The 2 Month Appointment: Expectations & Immunizations

If you read James’ 2 month update, you’ll know I published it just before I was taking him for his 2-month well baby & vaccination appointment. I promised I’d update about how those went but I also wanted to include some information about this first appointment: what to expect, what the vaccinations are, and more.

If you’re looking on information on how to prepare for a childhood immunization appointment, I have written a post previously on that topic! From the perspective of a mom and a nurse who worked in family practice.

*Disclaimer: This blog is intended for informational purposes only. The information on this blog should not be used as a substitute to medical advice or medical treatment. As always, your Primary Care Provider, a doctor, or another health professional is your best resource for specific questions and medical advice. If you believe you or a loved one are experiencing a medical emergency, please contact 911.*

What to Expect at the 2 Month Appointment

At 2 months, your baby should see their primary care provider (PCP) – whether that be a general practitioner, a paediatrician, or a nurse practitioner. This may be your baby’s first visit to their PCP if you were seeing midwives who followed baby to 6 weeks, or it may be there second (or third, or fourth) visit, depending on the circumstances.

If you saw an OB or your GP for delivery, your baby would usually be seen in their first week of life. If there were any concerns, or if any concerns arose in the interim, your baby may have seen them more than once!

The 2 month visit is part of the regular visit schedule for babies, known as well baby checks, who are usually seen at 2, 4, 6, 12, 15 and 18 months. Again, there may be additional visits for follow ups (weight checks for example) or other concerns (illness, injury, etc.).

Well baby or well child visits usually include a physical examination; growth check (including weight, length and head circumference); a check in on developmental milestones, nutrition/feeding, and health teaching as needed.

Got growth chart anxiety? Check my post on the topic and ease your mind.

Your provider will ask you questions about your little one and examine them. Some questions you might be asked include (and this is not exhaustive or necessarily exact, but just an overview of what may be asked or what you can think about if you have concerns to bring up during your visit):

  • – How are you feeding your baby? And hopefully – how is that going, is there any way in which you need support, any resources I can give you, etc.
    • – If you are breastfeeding – are you giving vitamin D drops? How often are you breastfeeding? How is their sucking?
    • – If you are formula feeding – how much is your baby eating?
  • – Questions about stool/urine output – wet diapers, any concerns?
  • – Questions about sleep – how much sleep night and day, how much is baby waking at night, where is baby sleeping, etc.
  • – Questions about development
    • – Does your baby follow your/an objects movement with their eyes (aka tracking)?
    • – Does your baby coo and gurgle?
    • – Does your baby do tummy time and lift up their neck for a short period of time?
    • – Is your baby easily calmed by known methods (rocking, nursing, cuddles)?
    • – Is your baby sucking & swallowing effectively?
    • – Do they smile in response to your face, talking, etc?
    • – Do you have any concerns?

Your provider will also examine your baby. They will look at things like: their fontanelles; their eyes (for the red reflex); ask if they’ve had their hearing test (usually done in hospital or arranged for outpatient at discharge); check their skin for any issues (jaundice, etc); examine their neck and head shape; listen to their heart and lungs and abdomen; and check their hips and muscle tone.

Well baby appointments are an opportunity for parents to ask questions or voice concerns, and they’re also when the first round of childhood immunizations are offered! I’ll discuss those more about those below – but know that the best resource for questions/concerns/education about childhood immunizations is your provider (or often – their clinic nurse!) or even your local public health unit.

If your child requires any follow up care or referrals, these things would also be discussed and arranged at this appointment.

2 Month Immunizations

There are usually 3 immunizations offered in Ontario at the 2 month appointment. Please refer to your region/province/states immunization schedule to see what your appointment will be like. Generally, they are *pretty* similar across Canada, but I know the US schedules often vary slightly from ours (I have linked the CDC immunization schedule below, but cross reference with any local information).

Note: since the vaccinations mentioned here are given at 2 and/or 4 and/or 6 months – I will write my next post on immunizations at 12 months, but expect 4 and 6 month visit expectation posts!

DTaP-IPV-Hib (Diphtheria, Tetanus, Pertussis; Polio; Haemophilus influenzae type B)

Phew, there is a lot going on in this one. This is just one immunization. One needle – at least in Canada. It’s a combination and it’s a great one! Let’s break it down.

Note: if Hep B is given, this may be a slightly different combination initially (containing Hep B). In Ontario, Hep B isn’t on the routine schedule though – so I will not be discussing this. You can read more about it on this page (Canada) or here (US) as it is offered routinely in the US. Additionally, some people may opt not to receive the pertussis vaccine and so on and so forth. Refer to those pages & your healthcare provider.

Diphtheria

Do you remember the movie or story of Balto? Or the newer one Togo? Those tell the tale of the delivery of diphtheria antitoxin to a small community in Alaska (the treatment for those with diphtheria).

Although rare in North America today (thanks vaccination!), diphtheria is still a problem in many developing countries. It has a high fatality rate of 5-10% especially in the young population (like babies and children). Because it is rare here, diagnosis of this illness is often late – hence the fatality rate.

If you’re wondering what it can be like – it is a respiratory illness that sometimes also impacts the skin (though this form is less severe). Symptoms such as swollen lymph nodes and sore throat occur. This may seem benign (“just a cold” as some like to say about our newer viral friend, may be said by the same people here) – but because the bacteria that causes diphtheria releases a toxin, it kills the healthy tissues in these areas and leaves what is called a pseudomembrane or a grey coating that is thick making respirations and swallowing challenging. There is also a risk of it spreading via the blood to other locations to cause further damage to vital organs.

As I mentioned – it can be treated with an antitoxin in addition to antibiotics. However, it is not perfect and the death rate remains 1 in 10 with treatment.

The vaccine on the other hand, can be used to prevent diphtheria and when the full dose series is completed 95 out of 100 people are protected from the disease for about 10 years. It is not perfect, of course, but it’s pretty great! After every 10 years you can get a booster for further protection.

Schedule for Ontario: 2, 4, 6 month and 12 to 23 months (usually given at 18 months) – slightly different if pursuing Hep B as well; booster at 4-6 years

Schedule as per CDC: 2, 4, 6 month; 15-18 months; 4-6 year booster

Tetanus

I feel like most people have at least heard of tetanus. As a child, I remember it being associated with soil. As I grew up, I associated it with lockjaw.

Again – it is rare in North America because of vaccinations! Yay. It is an example of a vaccination that works very well – 99% of people who receive the primary series (minimum 3 doses) develop antibodies and protection against tetanus. However, it does only last about ten years so boosters are needed.

Fatality rate is high, ranging from 10 to >80%, with highest risk being – you guessed it – infants and older people.

Similar to diphtheria, tetanus is also caused by a toxin produced by a bacteria. This one is a neurotoxin. The bacteria produces spores which can be found in soil (childhood fears confirmed), but also in human and animal intestines and therefore, faces (yuck!). It enters through open wounds – so gardening gloves and shoes are important if you’re working with soil, and other protective methods if you’re around animal or human feces, or dust. It can also be transmitted via injection drug use and animal bites.

Unlike diphtheria, it is not contagious. It presents primarily with spasms of the muscles often starting with the jaw (hence the lockjaw association). These muscle spasms can impact major organ function and even break bones.

It is emergent and requires hospital treatment, including the administration of tetanus immune globulin, medications for the spasms, antibiotics and the vaccine. For this one – the benefit very clearly outweighs the risk.

Schedule for Ontario: 2, 4, 6 month and 12 to 23 months (usually given at 18 months); booster at 4-6 years

Schedule as per CDC: 2, 4, 6 month; 15-18 months; 4-6 year booster

Pertussis

A.K.A. whooping cough. It is a highly contagious illness caused by another bacteria. It impacts young infants the most – which is why the TDaP vaccine is recommended in pregnancy.

See my post on Vaccinations in Pregnancy here.

It is a respiratory illness that presents with cold symptoms like runny nose and in babies, apnea (pauses in breathing). There may be an occasional cough to start, so it’s easily mistaken for a cold. It eventually becomes much worse, with the classic “whooping” cough, often followed by vomiting and fatigue. In babies, this can be problematic and many under the age of 1 will require a hospital stay. Pneumonia, convulsions, and further apnea can result, and less commonly but in 1 out of 100 hospital cases, death.

Pertussis can be treated with antibiotics, however it is most effective when administered in the early weeks (when ironically, it is often mistaken for a cold). If a hospital stay is required, suctioning, oxygen, and IV fluids may be needed.

After the primary series of this vaccine and a booster, it is shown to be 90% effective in protecting against pertussis. That sounds better than a hospital admission to me.

Schedule for Ontario: 2, 4, 6 month and 12 to 23 months (usually given at 18 months); booster at 4-6 years

Schedule as per CDC: 2, 4, 6 month; 15-18 months; 4-6 year booster

Polio

I associate this one with an iron lung, and the few people left in the world still using them. But polio left many a mark on people’s lives, and continues to impact areas of the world (and have long-term impacts on those who get it).

Polio, once again, hits our young population the hardest. This time it impacts ages 5 and under the most, so it remains important to be protected through early childhood. The inactivated vaccine (not the oral which is no longer used in Canada or the US) is very effective after a full series and a booster, boasting almost 100% immunity. Although polo is not a problem in North America generally, because it is endemic in certain countries still you could contract it while travelling or coming into contact with it when someone else has brought it back (it is spread via fecal-oral routine, so this could happen as a result of poor hand hygiene, drinking water contamination, etc).

If you do get it, the fatality rate is 2-5% in children and higher in adults. It is often asymptomatic but may present with flu-like symptoms such as a sore throat, fever or headache. Less than 1 in 100 people may develop complications from polio such as meningitis or paralysis. Something called post-polio syndrome can also occur with residual weakness and wasting of the muscles (almost like the polio version of long COVID which you are probably reading or hearing a lot about now).

The best way to deal with polio is to prevent it with vaccination.

Schedule for Ontario: 2, 4, 6 month and 12 to 23 months (usually given at 18 months); booster at 4-6 years

Schedule as per CDC: 4 dose series at 2, 4, 6-18 months; 4-6 years booster

Hib (Haemophilus influenzae type B)

Hib is another bacterial illness. Hib exists in the nose and throat where it is not problematic – but if it spreads to other parts of the body, it can cause issues. Because of where it lives, it is spread via respiratory droplets, so sneezing and coughing. Those under 5 years old and over 65 are considered high risk, alongside immune compromised people (this is the same for all illnesses like this – immune compromrised groups are often hit the hardest, which is why we need to do our best to protect them by getting vaccinated!).

It is usually diagnosed via lumbar puncture.

Depending on where Hib spreads to, it can cause pneumonia, meningitis or an infection in your blood. These all come with a variety of potential long-term complications, including death. As it is bacterial, it is treated with an antibiotic. It may require hospital admission for treatment.

If all 4 doses, including the booster, are received – 95% of children develop antibodies. It is considered to be 95-100% effective.

Schedule for Ontario: 2, 4, 6 month and 12 to 23 months (usually given at 18 months); booster at 4-6 years

Schedule as per CDC: 4 dose series at 2, 4, 6 months, 12-15 month booster or a 3 dose series at 2 and 4 months with a booster at 12-15 months, depending on the vaccination used

*Note: this is usually one combination vaccine with all of these in Ontario. As you can see, and if you look at the CDC website, it is different in the US in terms of combinations so there may be more than 1 needle to cover some of these.

Pneumococcal Conjugate 13

This vaccination works to prevent the bacterial infection Streptococcus pneumoniae. This bacteria actually has 100 different serotypes! This is another example of a bacteria we carry around in our respiratory tract as carriers, so it is therefore spread through coughs and sneezes.

Among adults, this often presents as pneumonia. However, among children (under 2) it is often seen as bacteremia. This may only present with a high fever, and the child will otherwise appear well. The case-fatality rate is still 20%, and even higher in older adults. Sometimes, pneumonia symptoms may also occur. Meningitis is another possible presentation that is common in children who get this, with a fatality rate of 8% as per CDC(5-7% as per Canadian data).

Finally it also causes ear infections in children, about 20% of cases of otitis media infections in that population.

Depending on how it presents, it is managed differently.

Schedule for Ontario: 2 and 4 months; 1 year

Schedule as per CDC: 4 dose series at 2, 4, 6 and 12-15 months

Rotavirus

The oral vaccine that your child will be offered at 2 months is for rotavirus, which causes the “stomach bug” or gastroenteritis (not the stomach flu – that is not a thing; true influenza and gastroenteritis are totally different). 7% of children infected with rotavirus end up hospitalized, plus it is just generally unpleasant so a vaccine is great!

Contrary to popular belief, just letting your kid “get it” won’t really necessarily help them – as most first time infections don’t build any permanent immunity.

Contraindications for this vaccine include immune compromise and history of intussusception (as there is a 1 in 7 chance this can occur in the 7 days after administration of the first and second doses). Please speak to your healthcare provider.

Schedule for Ontario: depends on type administered – Rotarix is 2 doses (2 and 4 months) while Rotateq is 3 doses at 2, 4 and 6 months.

Schedule as per CDC: same as above

And those are your 2 month routine vaccines – as I mentioned, Hep B may be given (2nd dose) in the US and a meningitis may be offered as well. In Ontario, this is not a part of the publicly funded schedule. I’ve covered quite a lot here – so stay tuned for a part two on side effects of these vaccines, what to look out for, and any after care. I already wrote a piece on how to prepare in advance for the vaccines here.

Additional Resources

Caring for Kids – Canadian Paediatric Society – Schedule of Well Baby Visits

Ontario’s Publicly Funded Immunization Schedule

Ontario Infant Hearing Program

CDC Immunization Schedule from Birth to 18 Years & CDC Parent Friendly Schedule

Canadian Immunization Guide

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