NU 632 Unit 1 well-child visit with anticipatory guidance example

Nine-Month Well-Child Visit and Anticipatory Guidance for a Newly Crawling Infant

Student Name

Department of Nursing, Herzing University

NU 632: Healthcare of Infants, Children and Adolescents

Instructor Name

January 21, 2026

Nine-Month Well-Child Visit and Anticipatory Guidance for a Newly Crawling Infant

The Child and What the Family Came to Discuss

Mateo, a composite nine-month-old boy, attends with his mother and grandmother. He was born at 39 weeks after an uncomplicated pregnancy, weighing 7 pounds 6 ounces, and has had no hospitalizations. He is breastfed three times a day and eats pureed and mashed foods twice a day. He started crawling two weeks ago and pulls to stand on the couch. His mother's main question, asked before anything else: "He was sleeping through the night, and now he wakes up two or three times and only settles if I feed him. Is something wrong?" That question is recorded first because it is the one the family will remember whether it was answered.

Family and Social Context

Mateo lives with his mother, a dental assistant who returned to work part time at six months, his father, who works evenings, and his maternal grandmother, who cares for him three days a week while his mother works. No one in the household smokes or vapes. The family screened negative on a two-question food insecurity screen and reports stable housing. His mother screened negative for postpartum depression on the Edinburgh Postnatal Depression Scale, which is still relevant at nine months, and she says she feels supported but tired because of the night waking. Spanish is spoken at home with the grandmother and English with his parents; his mother asked whether two languages will slow his speech and was told that children raised with two languages reach language milestones within the typical range and that speaking to him in both is a benefit. The grandmother's role matters for the guidance below, because she is with him for much of the week and needs to hear the safety advice as well.

Measurements and Growth

Weight 20 pounds 2 ounces, length 28.5 inches, head circumference 45 cm. Plotted on the World Health Organization growth charts, which are recommended for children under two in the United States because they describe the growth of healthy breastfed infants (Grummer-Strawn et al., 2010). Weight is at the 60th percentile, length at the 55th, and head circumference at the 65th. At his four- and six-month visits, the corresponding percentiles were 55th to 60th for weight and 50th to 55th for length. He is tracking steadily, and weight for length is proportional. Interpretation: normal growth on a stable trajectory.

Development

Observed and reported: sits without support, crawls on hands and knees, pulls to stand, transfers objects between hands, uses a raking grasp and is beginning a pincer grasp, babbles with consonant sounds such as "mamama" and "bababa," responds to his name, looks for a toy dropped out of view, and is wary of strangers. The Ages and Stages Questionnaire, third edition, completed by his mother in the waiting room, showed all five domains above the cutoffs. A standardized developmental screening tool at the nine-month visit is recommended as part of developmental surveillance (Lipkin et al., 2020). Interpretation: typical development; his stranger wariness and night waking are consistent with a normal developmental stage.

Examination, Age-Specific Points

The examination was complete. Points specific to this age: anterior fontanelle open, soft, about 1.5 cm; red reflex present in both eyes and corneal light reflex symmetric, with no strabismus on cover testing; two lower central incisors erupted, with no visible decay; hips with symmetric skin folds and full abduction; normal male genitalia with both testes descended; and no bruising on the trunk, ears, or neck, which would be unexpected in a nonwalking infant.

Immunizations and Screening

His immunizations are up to date through the six-month visit. The third dose of hepatitis B vaccine is due between 6 and 18 months and is given today. It is influenza season, and because this is his first season, he receives the first of two doses today, with the second in four weeks. Fluoride varnish is applied to his teeth, and his family is advised that he should see a dentist by his first birthday. Lead screening and hemoglobin are planned at the 12-month visit.

Anticipatory Guidance, Prioritized

Guidance was chosen for what Mateo will do in the next three months, before his 12-month visit: pull to stand more confidently, cruise along furniture, possibly take first steps, and put everything he finds in his mouth. Four topics were prioritized rather than twelve, following the principle in Bright Futures that guidance be selected for the child's developmental stage and the family's concerns (Hagan et al., 2017).

First, the night waking. This is common around nine months, when separation awareness and new motor skills disturb sleep. His mother was reassured that nothing is wrong and was given a plan: a consistent bedtime routine, putting him down drowsy but awake, and at night waking, a brief check and comfort without feeding if he has fed well during the day, so he learns to settle himself. She was told it may take one to two weeks.

Second, mobility hazards. Gates at the top and bottom of stairs; anchoring furniture and televisions to the wall; covering outlets; and moving cleaning products and medications, including the grandmother's pills in her purse, up high and locked. The Poison Help number, 1-800-222-1222, was saved in both phones.

Third, choking and feeding. Finger foods in soft, small pieces; no whole grapes, nuts, popcorn, or hard raw vegetables; supervision while eating.

Fourth, water and car safety. Never leaving him alone in the bath, even for a moment; and keeping his car seat rear-facing, as long as he fits within the seat's limits, well beyond his first birthday.

Topics Deferred and Next Visit

Deferred to the 12-month visit: transition from bottle and breast to cup, whole milk introduction, and discipline and limit setting. Next visit at 12 months, with lead and hemoglobin screening, the measles, mumps, and rubella and varicella vaccines, and a check on how the sleep plan worked. His mother was asked to return sooner if night waking is accompanied by fever, ear pulling, or poor feeding.

References

Grummer-Strawn, L. M., Reinold, C., & Krebs, N. F. (2010). Use of World Health Organization and CDC growth charts for children aged 0 to 59 months in the United States. MMWR. Recommendations and Reports, 59(RR-9), 1-15.

Hagan, J. F., Jr., Shaw, J. S., & Duncan, P. M. (Eds.). (2017). Bright Futures: Guidelines for health supervision of infants, children, and adolescents (4th ed.). American Academy of Pediatrics.

Lipkin, P. H., Macias, M. M., & Council on Children With Disabilities, Section on Developmental and Behavioral Pediatrics. (2020). Promoting optimal development: Identifying infants and young children with developmental disorders through developmental surveillance and screening. Pediatrics, 145(1), Article e20193449. https://doi.org/10.1542/peds.2019-3449