What are the recommended vaccinations and assessments for a 4-month well-child checkup?

4-Month Well-Child Checkup

At the 4-month well-child visit, administer the second doses of DTaP, Hib, PCV, IPV, and rotavirus vaccines, along with the third dose of hepatitis B if using a combination vaccine. 1, 2

Core Vaccinations at 4 Months

The following vaccines should be administered at this visit:

Standard Immunization Series

• DTaP (Diphtheria, Tetanus, acellular Pertussis): Second dose of the primary series 1, 2, 3
• Hib (Haemophilus influenzae type b): Second dose; note that if PRP-OMP formulation (PedvaxHIB or ComVax) was used at 2 months, this dose is still required, but the 6-month dose will not be needed 1, 2
• PCV (Pneumococcal Conjugate Vaccine): Second dose of the primary series 1, 2
• IPV (Inactivated Poliovirus): Second dose 1, 2, 3
• Rotavirus vaccine: Second dose; must be administered by 8 months of age, with the series not to be initiated after 14 weeks 6 days of age 1, 2, 4

Hepatitis B Considerations

• Hepatitis B vaccine: If using combination vaccines containing HepB (such as DTaP-IPV-HB-PRP-T hexavalent), a dose at 4 months is permissible as part of a 4-dose series 1
• If monovalent HepB was used for previous doses, no dose is needed at 4 months; the third dose should be given at 6-18 months 1, 2

Developmental and Health Assessments

Growth Monitoring

• Measure weight, length, and head circumference and plot on growth charts 5
• Assess growth trajectory from previous visits 5

Developmental Surveillance

• Perform developmental surveillance at this visit, though formal developmental screening tools are reserved for 9,18, and 30-month visits 5
• Observe for age-appropriate milestones including social smiling, head control, and visual tracking 5

Maternal Mental Health

• Screen for postpartum depression in mothers, as this is recommended for infants up to 6 months of age 5

Anticipatory Guidance

Feeding Recommendations

• Breastfeeding: Encourage exclusive breastfeeding through 6 months, as cessation before 6 months is associated with childhood obesity 5
• Solid foods: Advise against introduction before 6 months of age, as early transition is associated with childhood obesity 5
• Juice avoidance: Counsel that juice should be avoided before 1 year of age 5

Safety Counseling

• Car seat positioning: Ensure car seat remains rear-facing until at least 2 years of age or until height/weight limit for the seat is reached 5
• Safe sleep practices: Review safe sleep guidelines including supine positioning and avoiding soft bedding

Dental Health

• Discuss fluoride supplementation if water supply is not fluoridated 5
• Counsel on oral hygiene practices even before tooth eruption 5

Common Pitfalls to Avoid

Vaccine Timing Errors

• Do not delay rotavirus vaccination beyond the maximum age constraints, as the final dose must be completed by 32 weeks of age 1
• Ensure minimum 4-week intervals between doses have been maintained from the 2-month visit 2

Combination Vaccine Confusion

• When using hexavalent vaccines (DTaP-IPV-HB-PRP-T), recognize that this creates a 4-dose hepatitis B series rather than the standard 3-dose series 1, 6
• If PRP-OMP Hib vaccine was used at 2 months, document this to avoid unnecessary 6-month Hib dose 1

Missed Screening Opportunities

• Do not overlook maternal postpartum depression screening, as this visit represents one of the last opportunities within the recommended screening window 5