What are the key components of a 6-month well child check, including assessments, vaccinations such as DTaP (diphtheria, tetanus, and pertussis), Hib (Haemophilus influenzae type b), IPV (inactivated poliovirus), and PCV (pneumococcal conjugate vaccine), safety evaluations, and monitoring for a healthy 6-month-old child?

6-Month Well Child Check: Assessment, Safety, Vaccinations, and Monitoring

Vaccinations at 6 Months

At the 6-month visit, administer the third doses of DTaP, Hib (if using certain brands), IPV, PCV, and hepatitis B vaccines, along with the first dose of influenza vaccine if during flu season. 1, 2

Core Vaccine Schedule

• DTaP (Diphtheria, Tetanus, Pertussis): Administer the third dose at 6 months as part of the primary series 1, 2

• Hib (Haemophilus influenzae type b): The third dose at 6 months depends on the vaccine brand used 1

  • If PRP-OMP (PedvaxHIB® or ComVax®) was given at 2 and 4 months, a dose at 6 months is NOT required 1
  • If other Hib conjugate vaccines were used, administer the third dose at 6 months 1

• IPV (Inactivated Poliovirus): Give the third dose at 6 months (the fourth dose will be given at 6-18 months) 1, 2

• PCV (Pneumococcal Conjugate Vaccine): Administer the third dose at 6 months 1, 2

• Hepatitis B: Complete the third dose at 6 months (must be at least 16 weeks after the first dose and at least 8 weeks after the second dose, and not before 24 weeks of age) 1, 2

• Influenza Vaccine: Starting at 6 months of age, administer the first dose of influenza vaccine if during flu season 1, 2

  • Infants receiving influenza vaccine for the first time require two doses separated by at least 4 weeks 1
  • Use 0.25 mL dose for children aged 6-35 months 1

Combination Vaccines

Use FDA-approved combination vaccines when available to reduce the number of injections. 1, 3

• Pentacel® (DTaP-IPV/Hib): Can be used for the 6-month dose, combining five vaccines into one injection 1, 4
• Pediarix® (DTaP-HepB-IPV): Another option that combines five antigens 1
• Hexaxim® or Infanrix hexa (DTaP-IPV-HepB-Hib): Fully liquid hexavalent vaccines that combine all six antigens in one injection 5, 6

Simultaneous Administration

All vaccines due at the 6-month visit should be administered simultaneously during the same visit. 3

• Simultaneous administration increases vaccination completion rates and provides timely protection 3
• The immune response to one vaccine is not negatively affected by simultaneous administration of other vaccines 3
• Administer each vaccine at separate anatomic sites using different syringes 3
• Never mix vaccines in the same syringe unless specifically FDA-approved for mixing 1, 3

Developmental Assessment at 6 Months

Motor Skills to Evaluate

• Gross motor: Rolls over in both directions, sits without support, bears weight on legs when held upright, may begin to rock back and forth on hands and knees
• Fine motor: Reaches for and grasps objects, transfers objects from hand to hand, uses raking grasp to pick up small items

Social/Cognitive Milestones

• Recognizes familiar faces and begins to know if someone is a stranger
• Responds to own name
• Responds to emotions of others and often seems happy
• Enjoys looking at self in mirror
• Babbles and makes consonant sounds (e.g., "ba," "da," "ma")

Red Flags Requiring Further Evaluation

• Does not reach for objects
• Shows no affection for caregivers
• Does not respond to sounds around them
• Has difficulty getting things to mouth
• Does not make vowel sounds
• Does not roll over in either direction
• Does not laugh or make squealing sounds
• Seems very stiff with tight muscles or very floppy

Safety Counseling

Injury Prevention

• Fall prevention: Never leave infant unattended on elevated surfaces; use safety gates at stairs 2
• Car seat safety: Continue rear-facing car seat in back seat; ensure proper installation and harness fit
• Burn prevention: Test bath water temperature (should be <120°F); keep hot liquids and foods away from edges; install smoke detectors
• Choking prevention: Avoid small objects, coins, balloons, and foods like nuts, grapes, hot dogs, and popcorn
• Drowning prevention: Never leave infant alone in bath; empty all containers with standing water; fence pools with self-latching gates

Safe Sleep Practices

• Continue placing infant on back to sleep on firm surface
• Keep crib free of blankets, pillows, bumper pads, and toys
• Room-sharing without bed-sharing is recommended

Poison Prevention

• Store medications, cleaning products, and toxic substances in locked cabinets
• Keep poison control number readily available (1-800-222-1222)

Nutrition Guidance

Feeding Recommendations

• Breast milk or formula: Continue as primary nutrition source (24-32 oz per day if formula-feeding)
• Introduction of solid foods: Begin at 6 months if developmentally ready (can sit with support, shows interest in food, has lost tongue-thrust reflex)
  • Start with iron-fortified single-grain cereals, pureed vegetables, and fruits
  • Introduce one new food at a time, waiting 3-5 days between new foods to monitor for allergic reactions
  • No honey before 12 months (botulism risk)
  • No cow's milk before 12 months

Vitamin Supplementation

• Vitamin D: 400 IU daily for breastfed infants or those consuming <32 oz formula daily
• Iron: Exclusively breastfed infants should receive 1 mg/kg/day iron supplementation starting at 4-6 months

Growth Monitoring

Measurements to Obtain

• Weight, length, and head circumference
• Plot on WHO growth charts (0-24 months)
• Calculate weight-for-length percentile

Growth Concerns

• Weight loss or failure to gain weight appropriately
• Crossing two major percentile lines (upward or downward)
• Head circumference >2 standard deviations above or below mean

Post-Vaccination Monitoring

Expected Reactions

• Local reactions: Redness, swelling, and pain at injection site (common with DTaP and PCV) 5, 6, 7
• Systemic symptoms: Low-grade fever, fussiness, decreased appetite, drowsiness (usually mild to moderate) 5, 6
• Symptoms typically resolve within 24-48 hours

Management of Common Reactions

• Acetaminophen or ibuprofen for fever >100.4°F or significant discomfort
• Cool compress to injection site
• Encourage fluids and rest

When to Seek Medical Attention

• Fever >105°F
• Seizures
• High-pitched, unusual crying lasting >3 hours
• Severe allergic reaction (hives, swelling of face/throat, difficulty breathing, rapid heartbeat, dizziness)
• Lethargy or unresponsiveness

Documentation Requirements

• Record all vaccines administered in the child's permanent medical record, including vaccine name, manufacturer, lot number, expiration date, site of administration, and route 3
• Provide parents with updated immunization record 3
• Report any adverse events to the Vaccine Adverse Event Reporting System (VAERS)

Follow-Up Planning

• Schedule 9-month well child visit
• Discuss any remaining vaccine doses needed at future visits 3
• Address any parental concerns about development, feeding, or behavior