Transcript Primary Health Care

Evidence –based care guidelines that include:
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Screening tests
Immunizations
Preventative counseling/Anticipatory
guidance
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American Academy of Pediatrics(AAP)
Bright Futures: National Guidelines for
Health Supervision of Infants, Children,
and Adolescents (U.S. Department of
Health and Human Services)
Guidelines for Health Supervision
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U.S. Preventative Task Force
◦ A Government-appointed expert panel that
developed recommendations for primary care
clinicians on the appropriate content of periodic
health examinations
◦ Clinician’s Handbook of Preventative Services
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EPSDT (Early and Periodic Screening,
Diagnostic, and Treatment) service
◦ Medicaid’s comprehensive and preventative
child health program for individuals under age
21
◦ aimed at identifying and correcting medical
conditions before the conditions become serious
and disabling
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Includes:
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Immunizations
Developmental/Periodic Screening
Vision screening
Hearing services
Dental services
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A set of health objectives for the Nation to
achieve over the first decade of the new
century.
To be used to develop programs to improve
health
Builds on initiatives pursued in Surgeon
General’s Healthy People 2000
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Leading Health Indicators
◦ Used to measure the health of the Nation over the next 10 years
◦ Reflect the major health concerns in the U.S. in the first decade of
the 21st century
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Physical Activity
Overweight and Obesity
Tobacco Use
Substance Abuse
Responsible Sexual Behavior
Mental Health
Injury and Violence
Environmental Quality
Immunization
Access to Health Care
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Assessment
Systematic screening for growth and
development
Periodic health screening
Physical exam
Immunizations
Anticipatory guidance
Patient and parent education
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Newborn to 2 weeks
1, 2, 4, 6, 9, and 12 months
15 and 18 months
2-18 years annually
Immunizations and Screening incorporated at
different time intervals based on guidelines
and insurance providers
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Patient Identifying Information along with
relationship of caregiver to patient
Chief complaint
History of present illness
Past medical history
(Observe Caregiver/Child Interaction while
obtaining health history)
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Prenatal, natal, postnatal
Past illnesses, surgeries, hospitalizations
Allergies
Accidents
Immunization history
Nutrition history
Growth and Development
Review of Systems
Family history (genogram?)
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Family composition/Occupations
Parenting/Caregiver schedule/time spent
Discipline
Family stressors/supports/coping
Substance Abuse
Nutrition
Sleep
Elimination
Activities at home/outside the home
Safety
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Growth Charts
Incorporate Developmental Screening onto
physical examination forms
Denver Developmental Testing (Denver II)
Prescreening Developmental
Questionnaire(PDQ-II)
Ages and Stages questionnaire
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Children who fail to progress developmentally or
deteriorate developmentally
◦ Etiologies
 CNS dysfunction/ Genetic syndromes
 Mental health problems, i.e., depression, ADHD
 Chronic disease affecting either functional abilities or activity
tolerance
 Child abuse or neglect
 Maternal/Paternal stress
 Developmentally inappropriate environment
 Lack of parent knowledge of development
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Base referral on H&P, Developmental testing,
hearing and vision screening,
Intervention is based on etiology
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Parental counseling
Educational programs
Physical/Occupational/Speech Therapy
Neurology
Social Services
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of rapid growth and
development in all areas
 Basic trust with primary
caregiver critical
◦ Trust vs. Mistrust
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Gestational Age
Overall State
Color
Tone (symmetry)
Reflexes
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Rooting
Sucking
Moro
Stepping
Tonic Neck
Palmar grasp
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Dysmorphic facies
Red reflex
Polydactyly
Jaundice
Heart murmur
Weight loss (10% in first few days)
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Weight
◦ 5-7 oz weekly 1st 6 months (0.5-1 oz/day)
◦ 3-5 oz weekly 2nd 6 months
◦ Birth weight doubles by 4-6 months, triples by
12
◦ Average weight of a 1 year old is 10 kg or 21-22
lbs.
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Height
◦ 1 inch monthly 1st 6 months
◦ ½ inch monthly 2nd 6 months
◦ Birth height increases by 50% by 12 months
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Head Circumference
◦ 0.5 cm per month in first year
◦ Posterior fontanel closes by 2 months, AF may
begin closure by 9 months, should close by 18
months
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Teeth
◦ Teething begins around 6-8 months– 2 lower
central incisors
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Hearing
◦ Fully developed at birth (turn to sound or voice)
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Smell - well developed at birth
Vision
◦ Newborn – visual acuity poor
◦ 1-3 months – follows moving objects
◦ 4-7 months – color vision, distance vision 20/50
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Reflexive to conscious behavior
Cephalo-caudal development- head to foot
Proximo-distal development – central to peripheral
Primitive reflexes disappear by:
◦ Rooting - 4 months
◦ Sucking – 10-12 months
◦ Moro - 4 months
◦ Stepping – Before walking
◦ Tonic neck – 4-6 months
◦ Palmer grasp - 4 months
◦ Plantar - 9-12 months
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Birth
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7-9 Months
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1-4 months
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8-12 Months
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5-6 Months
◦ Reflex controlled
◦ Flexed position
◦ Lift head off bed
◦ Head control
◦ Rolls back to side
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Intentional rolling over
Supports weight on arms
Sits with support
Creeping
◦ Sits unsupported
◦ Crawls
◦ Pulls to stand
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Walks with help
Cruising
May stand alone
Can sit down from stand
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Birth to 1 month
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◦ Rakes at objects
◦ Pincer grasp
◦ Preference for dominant
hand
◦ Grasp and voluntarily let
go, will look
◦ Grasp Reflex
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1-4 Months
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Hand to Mouth
Plays with hands
Reaches, misses
Grasps objects
5-6 Months
◦ Grasp and voluntarily let
go, won’t look
◦ Plays with toes
◦ Transfers toys from hand
to hand
7-9 months
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8-12 Months
◦ Finger feeds
◦ Bangs cubes together
◦ Puts objects into a
container
◦ Imitates scribbling
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Erikson’s “Trust VS Mistrust”
“Can I trust my environment AND Can
I have an impact on my
environment?”
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Piaget’s Sensorimotor Phase ◦ “Reflexive” 0-1 month
◦ “Primary Reactions” 1-3 months
◦ “Secondary Reactions” 4-7 months
 Separation
 Cause and effect
 Object permanence – exist even when not in sight
◦ Curious - finding out how the world works
◦ Goal directed
◦ Object permanence - separation anxiety &
Stranger Anxiety
◦ Name and identify objects
◦ Associate symbols with events
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Play:
◦ Solitary
◦ Interactive – practice play….”what will happen
if?”
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Imitate sounds and gestures (older
infants)
Crying and communication
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Record weight, length, and head circumference; plot on growth
curve
Apical HR & RR while quiet
Exam on flat surface or parent’s lap
Distraction is very effective
Save invasive exam until last
Orient and explain everything to parent
Allow parent to use soothing measures to calm infant
Provide toys to occupy/distract infant
Use a calm voice and gentle, yet firm, handling
Screening and immunizations
Safety and injury prevention
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Experience separation anxiety more frequently
Limited ability to understand
Can become easily frustrated because still have
limited ability to express themselves
Keep contact to a minimum until child is
acquainted
Allow to handle equipment before use (Safety is
always first)
Autonomy vs. Shame & Doubt
Always offer a choice (acceptable)
Lying down position is last
◦ Weight
 Average weight gain is 4-6 lbs/year
 Average weight of a 2-year old is 27 lbs
 Birth weight quadrupled by 2 ½ years
◦ Height
 Average growth is 3 inches/year
 Adult height is usually 2X height at 2 years
 Average height of a 2 year old is 34 inches
◦ Head circumference
 1 inch from age 1-2
 ½ inch from age 2-3
 Anterior Fontanel closed by 18 months
◦ Teeth
 16 teeth by 24 months
 All 20 teeth by 30 months
◦ Bowel and Bladder Control
 By 30 months may have daytime control
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15 months
◦ Walks unassisted –
13 months
◦ Throws ball, falls
◦ Stairs, creeping
18 Months
◦ Throws ball w/o
falling
◦ Jumps in place
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24 Months
◦ Stairs – 1 foot first
◦ Kicks ball forward
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30 Months
◦ Stand on one foot
◦ Jumps from step
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15 months
◦ Scribbles
◦ Builds tower 2 blocks
◦ Holds crayon with fist
18 Months
◦ Builds tower 3-4 blocks
◦ Turns 2-3 pages of book
at a time
◦ Imitates lines when
drawing
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24 Months
◦ Builds tower 6-7 cubes
◦ Turns pages of book
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30 Months
◦ Builds tower 8 cubes
◦ Holds crayon with fingers,
not fist
◦ Imitates more complex
lines when drawing
Erikson’s “ Autonomy vs Doubt and Shame”
“Can I gain some independence from my
parents?”
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Independence
Egocentrism
Negativism – part of the quest for autonomy
Ritualism
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Piaget’s - Sensorimotor Phase “Tertiary
Reactions”
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Active experimentation
Causal relationships
Object classification
Object permanence
Piaget’s – Preoperational stage (2+)
◦ Egocentrism
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Body image
Language development is very rapid
Negativism
Rituals and limits
Play is:
◦ Parallel play
◦ Imitation
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Allow parent to remain as close as possible
Communicate mostly with parents, use
simple language with toddler
Use of distraction techniques during exam
Screening and immunizations
Safety and injury prevention
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Preschoolers are very imaginative and like to show
off
Increased inquisitiveness and questioning
◦ Loves to participate (handle the equipment)
MAGICAL THINKING
◦ Fears begin to develop (e.g. the dark, monsters)
Keep parent present
Leave underpants and socks on
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Weight
◦ Average wgt gain is 5 lbs/year
◦ Average wgt of 3 yr old is 32 lbs;
◦ 5 yr old is 41 lbs
Height
◦ Grows ~ 2.5 to 3 inches/year
◦ Average 4 year old is ~ 40.5 inches
◦ Length at birth doubles by 4 years
Teeth
◦ Eruption of permanent teeth may start at end of 5th year
Bowel and Bladder Control
◦ Daytime by 3 years and nighttime by 5
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3 years
◦ Rides Tricycle
◦ Stands on 1 foot – few seconds
◦ Climbs stairs alternate feet
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4 Years
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5 Years
◦ Skips and hops
◦ Throws overhand
◦ Down stairs alternate feet
◦ Catches ball
◦ Jumps rope
◦ Balance on 1 foot, eyes closed
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3 years
◦ Tower 9-10 cubes
◦ Copies circle, Circle with facial features
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4 Years
◦ Scissors
◦ Lace shoes
◦ Copies square, stick figures
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5 Years
◦ Ties shoelaces, dresses self
◦ Copies diamond, triangle, makes letters, numbers
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Erikson’s “Initiative vs Guilt”
“Can I do everything I want without
overstepping my bounds?”
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Piaget’s Preoperational Phase
“Preconceptual”
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Switch from egocentric to social awareness
Causality
Time
Magical thinking
Piaget’s Preoperational Phase
“Intuitive Thought”
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Language
◦ By 4 years, using full sentences
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Body image
◦ Recognize differences in others
◦ Body is a whole
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Play
◦ Cooperative
◦ Imaginary friends
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everything to child (in
simple terms). May use dolls and
puppets
 Allow child to make some choices
 Anticipatory guidance
 Safety and injury prevention
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Incorporate into history
School is the most important activity
Likes explanation of exam
Give child a gown to wear
A time of “doing”
Feeling of mastery, being productive and
accomplishments crucial to self-esteem and selfworth
More interested in peer group, therefore less
anxiety away from parents
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Height
◦ 2 inches/ year
◦ Growth spurt – 10-12 years
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Weight
◦ Steady weight gain (6 ½ lbs/yr), obesity**
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Teeth
◦ Lose baby teeth, about 4/year
◦ Molars erupt - 28 teeth by 12
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Secondary sex characteristics
◦ May start developing around growth spurt
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Average weight gain is 4.5 to 6.5 lbs/year
Grow ~ 2 inches/year
Female Growth Spurt = 9.5 – 14.5 yrs
Male Growth Spurt = 10.5 – 16 yrs
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Gross Motor
◦ Large muscle activities
◦ More graceful and coordinated
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Fine Motor
◦ Hand-eye coordination complete
◦ Fine motor control smoother
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Erickson’s “Industry vs Inferiority”
“What can I accomplish?
How good am I?”
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Piaget’s “Concrete
Operations”
◦ Classification
◦ Conservation
◦ Reversibility
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Self Image
◦ Based on appearance and accomplishments
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Play
◦ Games with rules
◦ Clubs
◦ Same sex friends
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all procedures, what you
are doing.
 Ask child questions, involve them
 Allow for privacy
 Recognize achievement and praise
 Healthy lifestyle choices
 Safety and injury prevention
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Alertness and Cooperation
Growth measurements and Vitals
Overall state of development (behavior)
Size (nutrition)
Hygiene (cleanliness)
Parent-child interaction
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Assess for “Red Flags”
Developmentally appropriate**
Head to toe approach
Gain trust
Assure privacy and safety
Anticipatory guidance
Save invasive until last
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Important visit before birth of baby
Use time to introduce yourself and discuss
issues like family history, circumcision,
feeding methods, car seats, home
preparation for infant, visit schedules, safety,
and etc.
Siblings and their preparation
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Newborn exam within first 12-24 hours of
birth
Screening-Newborn metabolic Screen
Review feeding methods
Discuss times when parents should call with
concerns
Discharge planning
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Physical Exam
Screening-Hearing, Vision, & Metabolic
Anticipatory Guidance
Very Important Visit to begin to establish a
long relationship with parents and child
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High risk pregnancy
◦ Increases risk of
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Abortion
fetal death
premature delivery prior to 37 weeks gestation
IUGR
congenital malformations
mental retardation
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Acquired health problems
◦ In utero exposure to
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Poor nutrition
Alcohol
Drugs/Tobacco
Viruses or Bacteria
HTN
DM
Maternal age <16 or >40
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Genetic Problems
◦ Chromosomal
abnormalities
◦ Congenital anomalies
◦ Inborn errors of
metabolism
◦ Mental retardation
◦ Familial diseases
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Perinatal Complications and Injuries
◦ Occur immediately before or during birth
 Prolonged or dysfunctional labor
 Prolonged ROM risk for chorioamnionitis
 Increase risk of infection for infant
 Ruptured placenta previa
 Increases risk of blood loss
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Birth injuries
◦ Mechanical and anoxic trauma incurred by infant in L&D
◦ 2-7 per 1,000 live births
◦ 2-3% of infant deaths
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Risk factors
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Macrosomia
Prematurity
CPD
Breech presentation
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Milia
◦ Multiple, firm, pearly, whitish/yellow papules
scattered over the forehead, nose and cheeks
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Epstein pearls
◦ Single or multiple superficial lesions that are
formed by tissues trapped during embryologic
growth occur in 80% of newborns, asymptomatic,
don’t enlarge, exfoliate within a few weeks
◦ Numerous yellow papules
and pustules surrounded
by large erythematous
rings usually on trunk,
face and extremities
◦ Develop 24-48 hours
after birth up to the 10th
day of life
◦ Increased eosinophils
noted on smear
◦ 50% of infants develop
◦ Fades spontaneously
within 5-7 days
◦ Patchy areas of
hyperpigmentation in
which the epithelial
cells contain increased
amounts of melanin
◦ Most commonly located
over the sacrum and
buttocks
◦ Fade with time usually
to traces by adulthood
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Cleft lip
◦ Failure of embryonic
structures and
surrounding the oral
cavity to join
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Cleft palate
◦ Failure of the palatal
shelves to fuse
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Various degrees of
clefts
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Genetic factors influence cleft lip
Cleft lip with or without cleft palate occur in 1
in1000 births
Cleft palate alone occurs in 1 in 2500 births
More common in males than females
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Surgical repair is indicated
Special nipples and feeding techniques are
used until surgery
Speech evaluation and therapy are needed
depending on the severity of the cleft
Speech evaluation are necessary in later years
Dental restoration is often needed
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Occur anterior to the
pinna
Result from imperfect
fusion of the tubercles of
the first and second
brachial arches during
gestational development,
Familial
More common in females
and African Americans
Excision if chronically
infected
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Common finding in African
American infants, premature
infants and congenital
thyroid deficiency
Defect of central fascia
beneath the umbilicus
Require no therapy
(attempts to reduce with
tape or coins are ineffective)
Spontaneous resolution
usually occurs in first years
of life
Surgical repair by 3-5 years
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Touch corner of
infant cheek and
infant turns head and
opens mouth
birth to 3-4months
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Place index finger
into palm from ulnar
side, infant
demonstrates flexion
of fingers to grasp
examiner’s index
finger
Birth to 3-6 months
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Support head and
then let drop a few
cm or loud noise the
infants response is
symmetrical
abduction of the
upper extremities
and extension of the
fingers
Birth-3-5 months
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Interview
Physical Exam
Screening-Review results of Newborn Hearing
Tests, vision & Metabolic Testing
Anticipatory Guidance
Immunizations
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Interview
Physical Exam
Screening
Anticipatory Guidance
Immunizations
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Interview
Physical Exam
Screening- None specific at this visit
Anticipatory Guidance
Immunizations
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Interview
Physical Exam
Screening- Hemoglobin
Anticipatory Guidance
Immunizations
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Interview
Physical Exam
Screening-Assess Lead Risk and TB risk
Anticipatory Guidance
Immunizations
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Interview
Physical Exam
Screening-lead level, hemoglobin , PPD if risk
Anticipatory Guidance
Immunizations
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Interview
Physical Exam
Screening-Assess lead and TB risk
Anticipatory Guidance
Immunizations
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Interview
Physical Exam
Screening-Lead & TB Risk
Anticipatory Guidance
Immunizations
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Interview
Physical Exam
Screening-Lead & TB Risk, Hyperlipidemia
risk
Anticipatory Guidance
Immunizations
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Interview
Physical Exam
Screening-Lead & TB risk, hyperlipidemia
risk, vision and hearing
Anticipatory Guidance
Immunizations
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Interview
Physical Exam
Screening-Lead & TB risk, Hyperlipidemia
risk, Vision and Hearing
Anticipatory Guidance
Immunizations
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Interview
Physical Exam
Screening-Assess Lead & TB Risk, Assess
Hyperlipidemia, Vision, Hearing, Urinalysis
Anticipatory Guidance
Immunizations
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Interview
Physical Exam
Screening-Assess lead & TB Risk, Vision,
Hearing, Hyperlipidemia,
Anticipatory Guidance
Immunizations
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Recommendations for preventative pediatric
health care (AAP)
Newborn screening
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Phenylktonuria (PKU)
Congenital Hypothyroidism (CH)
Galactosemia
CongenitalAdrenal Hyperplasia(CAH)
Sickle Cell Disease
Cystic Fibrosis
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Initial newborn screening specimen should be
collected from all infants as close as possible
to time of d/c from hospital and not > 6 days
If initial specimen collected < 12 hours a 2nd
specimen should be collected before 2weeks
PCP should be identified prior to d/c for
appropriate f/u
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Completed with heel stick and the filter paper
circles should be completely filled with blood
Avoid overlapping circles
Allow to dry horizontally at least 4 hours
before mailing within 24 hrs of collection.
Complete all demographic information
◦ Normal Visual Developmental Milestones
◦ Visual Acuity Norms
◦ Pediatric Eye Evaluation Screening
Recommendations
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Neonatal Risks
Affected family member
Bilirubin>20md/dl
Congential CMV, herpes, rubella
Defects in ENT structure
Birthweight <1500gm
Use of ototoxic medications>5days(aminoglycosides,
furosemide, salicylates, naproxen)
◦ Mechanical ventilation for cardiopulmonary
disease>48hours
◦ Intracranial hemorrhage
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Neonatal screening
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Infant screening
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4-7months of age
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6-9months of age
◦ Evoked Otoacoustic Emissions (EOAEs)
◦ Brainstem Auditory Evoked Response(BAER)
◦ Open eyes, blink, startle, change sucking or breathing
patterns in response to sounds
◦ Look toward sound
◦ Look for decreased verbal output
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33 infants born a day in US with permanent
hearing loss
Avg. age child with congenital hearing loss
identified was 2.5 to 3 years of age
If not identified early may be difficult to
obtain fundamental language
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ABR-Auditory Brainstem Response-measures
how the brain responds to sounds.
OAEs-Otoacoustical Emisions-Measures
sound waves produced in the inner ear
Both tests are quick-5 to 10 minutes and
painless
Cost $25-$40
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No universal screening in children
Indications
Family Hx Premature CAD
A Parent with total Cholesterol
>240mg/dl
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Optional Indications for screening
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Cigarette smoking
Dietary History
Sibling with elevated serum cholesterol
Physical inactivity
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Iron deficiency is the most prevalent form of
nutritional deficiency in U.S.
Risk is highest during infancy and
adolescence because of rapid growth
◦ Full term infants iron stores adequate until 4-6
months
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AAP-recommends Hct or Hgb screening :
◦ All infants 9-12 months
◦ Adolescent males during routine PE, during growth
spurt
◦ Adolescent females during all routine PEs
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More frequent screening for patients at risk
for anemia
At High Risk
◦ Infants and children in low income families
◦ Infants and children eligible for WIC (do at 6 mos)
◦ Infants and children who are migrants or refugee
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Risk factors for Iron Deficiency
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Preterm infants and low birth weight infants
Infants fed non-iron-fortified infant formula
Infants fed cow’s milk before 12 months
Breastfed infants who do not receive adequate iron
supplemental foods after 6 months
◦ Children with special health needs on medications
which lower iron absorption (antacids, calcium,
phosphorus, magnesium), chronic infection or
inflammation, restrictive diets, or extensive blood
loss
◦ Diet low in iron
◦ Children with limited access to food because of
poverty and neglect
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Lead poisoning is the presence of serum lead levels
that cause effects on multiple organ systems
Lead has an affinity for calcium binding proteins
and may affect any calcium-mediated process
Damage includes disruption of Hgb formation and
damage to the nervous system secondary to
damage to nerve cells and conduction interference
Current toxic level 10micrograms/dl
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Risk factors
◦ Living in/regularly visiting home built before 1950
◦ Living in a house built before 1978 undergoing
renovation
◦ Living with sibling or housemate with lead
>10mcg/dl
◦ Living with adult whose hobby/job involves lead
exposure
◦ Use of lead based pottery or home remedies with
lead
◦ Living near industry likely to release lead into
atmosphere
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Universal Screening
◦ In communities in which risk of lead exposure is
widespread
 Ages 1 and 2 years
 All children 36-72 months of age who have not been
screened
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Targeted screening
◦ Child resides in a geographic area (a specified zip
code) in which 27% or more housing was built
before 1950
◦ Child receives services from public assistance
◦ Child’s caretaker answers “yes” or “don’t know” to
any of the three basic personal-risk questionnaire
 Ask for all health supervision visits age 6mo-6yr
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AAP
◦ Urinalysis should be performed once at 5 years of
age
◦ Dipstick leukocyte esterase testing to screen for
STDs in adolescence
◦ Annually for sexually active adolescents
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AAP
◦ Annual Blood Pressure recordings after age 3 years
 Normal Blood Pressure <90th percentile
 High-normal >90th and <95th percentiles
 Hypertension >95th percentile (on 3 separate
occasions)
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Prevention of disease and illness
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Natural and acquired immunity
Active immunity
Passive immunity
Herd immunity
Vaccines cost effective
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Institute of Medicine-Immunization Review
Committee
Established in 2001 to address specific
vaccine safety issues
Produced independent reports about each
issue
Reports available at
http://www.iom.edu/CMS/3793/4705.aspx
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MMR Vaccine and Autism
Thimersol Containing Vaccines and
Neurodevelopmental Disorders
Multiple Immunizations and Immune Dysfunction
Hepatitis B Vaccine and Demyelinating Neurological
Disorders
SV40 Contamination of Polio Vaccine and Cancer
Vaccinations and Sudden Unexpected Death in
Infancy
Influenza Vaccines and Neurological Complications
New vaccines and complications (e.g. rotateq)
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Informed Consent
Parental information distributed once with
each type of shot
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Adverse Events
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Available at:
http://www.cdc.gov/nip/recs/childschedule.htm
Changes
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Divided in to 2 schedules
Rotavirus
Flu vaccine
HPV
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Summary of Recommendations from the ACIP
(Advisory Committee on Immunization
Practices)
Catch-up Schedule or Delayed Immunization
Schedule
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Blue card (California)
Yellow Pocket Card
California Immunization Registry (CAIR) and
Vaccines for Children (VFC)
Required for Daycare and WIC
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DTP is a trivalent vaccine composed of
diphtheria and tetanus toxoids and killed
whole-cell pertussis vaccine
DTaP is also composed of diphtheria and
tetanus toxoids but has an acellular pertussis
vaccine(preferred)
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DTaP
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Td
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Tdap (Tetanus, diptheria, pertussis)
◦ Usual dose 0.5ml IM
◦ 2, 4, 6, 15-18 mos & 4-6 yrs
◦ Smaller amount of diptheria toxoid given to patients older than 7
years (need less stimulation for antibody production)
◦ First vaccine for adolescents and adults to protect against all 3
illnesses
◦ For 11-18 yo
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Contraindications to DTP or DTaP
◦ Immediate anaphylactic reaction
◦ Encephalopathy within 7 days
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Precautions to further administration
◦ Convulsion with or without fever (within 3 days)
◦ Persistent inconsolable crying 3 or more hours within 48
hours
◦ Collapse or shock like state within 48 hours
◦ Unexplained temperature higher than 104.9 within 48
hours
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Usual reactions
◦ Moderate to high fever
◦ Local reactions
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Vaccination of febrile or children with
developmental delay can confuse the clinical
picture
◦ Work up of fever or neurological concern before
immunization-Consult pediatrician or ped neurolgist
◦ Minor respiratory illness is not a contraindication
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Live polio vaccine (OPV)- no longer used
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Inactivated polio vaccine (IPV)
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AAP recommends all IPV schedule for routine
childhood immunization
2,4, 6-18mos & 4-6 yrs
◦ Give OPV when:
 Mass vaccination needed to control outbreaks
 Unvaccinated child is traveling in less than 4 weeks to
area polio endemic
 A parent doesn’t accept recommended # vaccine
doses
 USE OPV for doses 3&4 (Check with 2008 schedule?)
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Risks of Polio Vaccine
◦ Cases of vaccine-associated paralytic polio (VAPP)
have occurred
◦ In children the risk is 1 in 1.5 million doses
◦ In contact 1 in 2.2 million doses
 Risk is greater with administration of 1st dose and
when immunocompromised persons are exposed to
live polio virus
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Consists of purified bacterial protein joined
to a poly- or oligosaccharide that is linked to
a protein to enhance antibody stimulation
◦ Dose is 0.5ml IM
◦ 2, 4, 6* & 12-15 mos *see immunization schedule
◦ No severe side effects
 Low-grade fever and local pain reported
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MMR is 0.5ml (SQ) for either MMR or its
singular components
◦ Measles (Rubeola)
 Live attenuated chick-embryo-prepared virus
◦ Adverse reactions to MMR, is usually a result of the
measles component
◦ 12-15 mos & 4-6 yrs
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Measles adverse reactions
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A fever of 103 degrees
Transient rashes
Encephalopathy (rare)
Febrile seizures
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Contraindications:
◦ Pregnancy, women should not become pregnant 3
months after MMR
◦ Immunodeficiency or therapeutic
immunosuppression, may be given 3 months after
therapy has stopped
◦ MMR is recommended in symptomatic and
asymptomatic HIV patients who are not severely
immunocompromised
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MMR contraindications (cont)
◦ TB skin test
◦ Allergy to egg or neomycin
◦ Steroids
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Mumps
◦ Live vaccine
◦ Reactions are rare
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Reactions are:
◦ Febrile seizures, rash, pruritis, encephalitis,
purpura, orchitis reported
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Contraindications:
◦ Same as measles
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Rubella (German Measles)
◦ Live virus
 Reactions include
 Fever, lymphadenopathy, rash,-can occur 5-12 days after
vaccination
 arthritis, arthralgia, onset 7-21 days after immunization
 paresthesia, pain in extremities, morning knee pain
 Contraindications are the same as measles
 May be given postpartum, contraindicated in
pregnancy
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Inactivated vaccine
May be given with other vaccines
Contraindicated in those with anaphylactic
rxn to alum or 2-phenoxyethanol
2 doses b/t 12 & 24 mos (6 months apart)
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Recombinant vaccine
◦ Given IM
◦ Adverse reactions
 Rare but include,
 Pain and soreness at immunization site
 2-5% of children develop fever 102F and irritability
◦ Given at birth, 1-2 months and 6 months
 Some may used combined vaccines
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FDA approved 2006
Oral vaccine
Given at 2, 4, & 6 mos
Precautions
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Mod to severe illness
Acute GE mod to severe
Chronic GI disease
Intussuusception
Immunocompromised
Contraindications: Serious allergic reaction to a
vaccine component or prior dose
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Effective against 7 most common types of
pneumococcus
Given at 2, 4, 6 & 12-15 mos
Reactions:
◦ Local rxn
◦ Fever
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Research with more types
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Live-attenuated vaccine, Contains neomycin
Given at 12-15mos and 4-6 yrs
Reactions
◦ Local injection site rxn, rash
◦ 3-5% generalized rash maculopapular not vesicular
can occur 5-26 days after vaccine
◦ Varicella can be given with MMR (different syringe
and sites), if not together 4 week interval
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Contraindications:
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Allergy to neomycin and gelatin
Cellular immunodeficiencies
Pregnant women
Therapeutic immunosuppression
Immunocompromised 1st degree relative
May give with MMR (There is a combined
vaccine)
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A multivalent embryonic egg vaccine, contains
inactivated whole virus,with change periodically for
anticipation of prevalent strains in upcoming flu
season December-March
Immunize children with risk factors (asthma,
cardiac disease, sickle cell disease, HIV and
diabetes and those wanting immunity
If 8 years or less and not previously exposed need
two doses separated by 4 weeks
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Side effects
 Fever 6-12 hours after immunization in children less
that 24 months
 Local reaction in children > 13 years
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Contraindication
 Anaphylactic reaction to chickens or egg protein
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Given yearly from 6-59 months (see most
current recommendations – 2008)
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A serogroup-specific quadrivalent vaccine
against groups A, C, Y, and W-135
◦ Recommended for college/university students who
live in dorms 1 dose required
◦ Recently approved for use in children 2 and older,
however still only recommended/required for
tweens/teens
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Protects against cervical cancer
Effective in preventing 4 types of HPV
Side effects-local pain
3 doses over a 6 months
◦ Given to girls at 11-12 yrs
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General concerns
◦ Childhood overweight and obesity
◦ Vegetarian diets
◦ Food allergy and hypersensitivity
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Vitamins
◦ Vitamin supplements are usually not necessary for
healthy term infants who are breastfed or formula
fed and after 4-6 months receive mixed feedings of
cereal, fruits, vegetables and proteins
◦ Vitamin D supplements for breastfed infants whose
mother’s diets are low, or not exposed to sunlight
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Iron
◦ Iron deficency is the leading cause of anemia in children
◦ Term infants who are breastfed have adequate iron supplies
until 4-6 months
◦ Iron-fortified formulas are excellent sources of iron in
infants up to 12 months of age
◦ Iron-fortified cereals are excellent sources of iron in infants
6-12 months of age
◦ Premature infants who are exclusively breastfed beyond 46 months, or infant’s fed cows milk before age 12 months
are at high risk of Fe deficiency anemia
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Fluoride
◦ American Dental Association recommends
beginning fluoride treatment at 6 months of age
◦ See chart in Burns text, pg. 851 Table 33-2 for
fluoride supplementation
◦ Know fluoride information about local water
supplies, every county/city different.
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Infants
◦ 110 kcal/kg body weight
◦ Breast milk or formula only first 6 months
◦ Solids to be started at 6 months (4 months?)
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Toddlers
◦ 100 kcal/kg
◦ 3 meals and 2 snacks/day
◦ Choking hazards
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Preschoolers
◦ Average 1400-1800 calories/day
◦ Food jags
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School-age
◦ Average 1800-2200 calories/day
◦ Healthy food choices
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Human milk is preferred feeding for all
infants, with rare exceptions.
Exclusive breastfeeding 1st 6 months, then
gradually add solid foods.
Breastfeeding should continue 1st year, and
as long as mutually desired.
Dental Health
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Prevention of dental heath problems should
start early
PCP should provide education during well
child exams
Important to identify dental problems early
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Good dental health is related to total health
Dental problems may be associated with
other health problems
The mouth reflects the overall health and well
being of an individual
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Tooth decay is a problem in children esp. in
lower socioeconomic and minority
populations
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First visit by one year
Shortage of Pediatric Dentists
Those in lower socioeconomic status may not
have insurance or the ability to pay
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Eruption of teeth at 6- 7 months
20 primary teeth by age 3
Eruption of permanent teeth at 6
32 teeth by 13 or 14
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Role of infection
Overgrowth of Strep Mutans
Infant may be inoculated from the mother or
close caregiver
Diet high in sugar
Improper bottle feeding
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20% of children b/t 2 and 5 have caries
80% in poor children
17 % of children b/t 12 and 15 have caries
36 % of children lack dental insurance
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History
Risk Factors
Oral Exam
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Complete a risk assessment for caries
Discuss with parents
Refer to a pediatric dentist early
Provide education and regarding oral hygiene
Determine flouride content of water
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Gingivitis
Periodontal disease
Dental Malocclusions