PREVENTIVE PEDIATRICS Ma. Philomena G. Lopez, MD
Department of Pediatrics
* with notes from the lecture. If anything, just refer to the book.
PREVENTIVE PEDIATRICS ENCOMPASSES:
1. health supervision of infants, children and adolescents
2. frequent concerns during health visits 3. future challenges
A. Health Supervision of Infants, Children and Adolescents Guidelines must be made to prevent morbidities to:
o childhood injuries o educational failures o child abuse and neglect o family violence o teenage pregnancy o media influence o obesity
o risk behaviors (tobacco, alcohol, drugs) Principles of Health Supervision
o health promotion
o establish partnership with each child and the family
o establish communication:
- demonstrate respect and empathy - listen to concern of patients
- use nonjudgmental questions to promote dialogue
- establish relationship with children by communicating directly to them Periodic Health Supervision Visits
o history and physical examination o screening tests
o immunizations
o surveillance of developmental milestones o observe parent-child interaction
o anticipatory guidance and counseling B. Frequent concerns during health visits
child’s behavior parenting
common issues on growth and development TEETHING:
o there is no correlation between teething and diarrhea. During teething, child bites at a lot of thing that might be a source of the infection
o 8 or 9 mo old has no teeth? Is it normal? o Not related to development of infection, fever
and mood disturbances
SLEEP PROBLEMS (night terror vs. nightmares) o Nightmares
- more common
- vivid, exciting scary events - the child can recall the dream o Night terror
- not common, 10-15 mins
- frightening circumstances, also vivid, exciting and scary
- child cannot recall the dream TOILET TRAINING
o Must start when the child is ready, not at less than 2 y/o
o Readiness – when the child is able to
communicate that he wants to go to the toilet
TEMPER TANTRUMS
o Although temper tantrums maybe normal, physician must investigate the presence of family violence or parental depression, since it may contribute to temper tantrums
DISCIPLINE
o Approach with firmness and consistency o Positive – (reinforcement) remove prize if
child did not perform well
o Negative – verbal rather than soank C. Future challenges in Preventive Pediatrics
o new immunizations
o improved screening tests / tools o tobacco use
o violence O OBESITY:
- overweight - BMI 85th to 95th %ile - obese - BMI > 95th %ile
o early hypertension o hypercholesterolemia o media influence on behaviors o parental health needs o literacy promotion
o reducing cardiovascular diseases
- starting 3 y/o: blood pressure monitoring every visit
- if high risk: can take BP at less than 3 y/o - encourage child to participate in active
physical activity
- starting 2 y/o: educate parents on appropriate use of dietary fats PROCEDURES FOR PREVENTIVE PEDIATRIC HEALTH CARE A. General Procedures
Hereditary / Metabolic Screening o Congenital Hypothyroidism o Congenital Adrenal Hyperplasia o Galactosemia
o Glucose 6-phosphate dehydrogenase deficiency (G6PD Deficiency) o Homocystinuria
o Phenylketonuria
if positive, can offer treatment as early as possible
Immunization Tuberculin test
o Ag = PPD; 5TU commonly used
o Inject 0.1 ml @ volar surface, read result in 42-72 hrs measure induration.
o Interpret: 0-4 = negative 5-9 = equivocal
10mm & above = positive Iron supplementation
o Start at 6 mos o If high risk: 1-4 mos Vitamin A supplementation
o 6-11 mos = 100,000 units o 12-24 mos = 200,000 units Deworming
o 1/year from 2 years old onwards B. Procedures for patients at risk
Hearing screening prior to discharge
Hemoglobin/hematocrit 1yr up; 10-19 adolescent Urinalysis 1-2/year; detect UTI
Lead tests not done routinely; only for suspected patients
ANTICIPATORY GUIDANCE injury prevention
nutrition and eating behaviors developmental expectations oral health
parental health and relationships environmental exposures media education school problems sexuality and puberty
family violence and substance abuse LEVELS OF PREVENTION
A. Primary Prevention
measures directed at avoiding disorders before they begin, often with a special emphasis on those who are at increased risk to develop a condition or disease
eg:
o chlorination and fluoridation of water o immunization
o mother’s classes
o counseling parents of toddlers about keeping poisons and drugs out of reach of children o pasteurization
B. Secondary Prevention
measures in which the condition or precursor is identified early and effective treatment instituted for remediation of condition before progression or for elimination of precursors
eg:
o treatment with antibiotics for streptococcal sore throat
o screening for lead levels
o screening for scoliosis among adolescents
C. Tertiary prevention
measures are directed in ameliorating or halting disabilities from the established diseases eg:
o chest physiotherapy for a child with cystic fibrosis
o physical therapy for patients with Rheumatoid arthritis or with cerebral palsy
ROLES OF PEDIATRICIANS IN PROTECTING CHILDREN’S HEALTH AT ALL THREE LEVELS:
as direct providers of clinical prevention services as coordinators of services
as leaders in developing community based programs as advocates for child health
IMMUNIZATION Ultimate goal: eradication of disease Immediate goal: prevention of disease TYPES OF PROTECTION INDUCED:
o Complete protection for life o Partial protection (booster doses) A. GOALS CAN BE ACHIEVED IN 2 WAYS:
ACTIVE IMMUNIZATION
o Involves administration of all or part of a microorganism or a modified product of that microorganism (toxoid, purified antigen, antigen produced by genetic engineering) to evoke an immunologic response mimicking that of the natural infection but which usually presents little or no risk to the recipient administration of microorganism or toxoid, purified antigen so the body can produce antibody against it
PASSIVE IMMUNIZATION
o the administration of preformed antibody to a recipient for the prevention and
amelioration of infectious diseases o types of prodcucts:
- Normal (standard) human Ig for general use gammaglobulin --> little
protection from measles, HepaA - Specific Human Ig HepaB, rabies, VZ for immediate protection
Igs are short-lived – 3mos supplement antibodies
Vaccination – administration of vaccine or toxoid (inactivated toxin) for prevention of disease B. ACTIVE IMMUNIZATION
live attenuated viral vaccine more reactions Measles
MMR OPV Varicella
Inactivated viral vaccine less reactions Flu vaccine
Hep A IPV
Hep B (recombinant DNA)
Detoxified exotoxin (Toxoid) local reaction diphtheria
tetanus
Purified protein antigens acellular pertussis, Hep B
Whole cell pertussis vaccine DTP
Inactivated acellular pertussis vaccine DTaP
Capsular polysaccharide Typhoid
Protein conjugated polysaccharide vaccine Hib
Pneumococcal
Live attenuated bacterial vaccine BCG (Bacille Calmette Guerin)
C. Contraindications to ALL LIVE VACCINES: immunocompromised patients
o patients with HIV, malignancy, aplastic anemia, nephritic syndrome, in chemotherapy and prolonged steroid, pregnant
patients given immunoglobulins and blood products for the past 3 months
o blood has small amounts of IgG which can interfere with globulin production
pregnancy and possibility of getting pregnant within 3 months
household contacts of immunocompromised patients o give OPV via IM instead
o Baby may pass out virus in the stool – may spread bacteria and affect the
immunocompromised patient
D. Simultaneous administration of Multiple Vaccines no contraindications for multiple vaccines routinely
recommended
immune response to one vaccine generally does not interfere with other vaccines
o must administer at different sites, using different syringes at the right route There should be an interval of 28 days between
administration of live vaccines
After 7th birthday, Td is recommended for both primary and booster vaccination
o Td – tetanus diptheria
Interchangeability of Vaccine Products is allowed for primary and booster doses
E. Lapsed immunizations
in general, intervals between vaccine doses that exceed those that are recommended do not
adversely affect the immunologic response, provided immunizations series is completed
o if immunization status is not known treat it as the start of the immunization again
VACCINE MINIMUM AGE DOSE (number) ROUTE OF ADMINISTRATION MINIMUM INTERVAL BETWEEN DOSES VACCINE DESTROYED BY ADDITIONAL NOTES BCG - 1 Birth; or any time after birth
0.05 ml for NB 0.1 ml for infants (1) Intradermal deltoid R arm Heat sunlight
live attenuated bacterial vaccine vs TB
at birth or any time after birth (prior to discharge 48 hrs after normal delivery, 3 days after delivery by cesarean section)
0.05 ml ID birth – 4 weeks at R upper deltoid; 0.1 ml ID beyond 1 month
booster dose given at school entry, 0.1 ml ID L upper deltoid
vaccine stored in amber bottle and in freezer because it is freeze-dried live bacterial vaccine given as early as possible
BCG does not prevent primary complex. Instead, it prevents extrapulmonary type TB contraindications immunodeficiency states
Reactions: abscess or ulcer at the site; axillary lymphadenopathy Usual Reactions Accelerated rxns
Induration 2 – 4 weeks 2-3 days Pustule formation 5-7 weeks 5-7 days Scar formation 2-3 months 2-3 weeks
Usual reaction: 2-4 wks after immunization, erythema on induration, may form pustule which may burst and exude pus and leave a permanent scar. Do not put antibacterial meds
Accelerated rxn: 2-3 days in duration, there is early formation of pus and scar. It means that the patient has already been exposed to or with TB
Axillary lymphadenitis abnormal (investigate prior to injection, patient may have signs and symptoms of TB)
Not given at buttocks because it has high SC fats
DTP 6 weeks 0.5 ml (3) IM Upper outer portion of thigh 4 weeks Heat Freezing
Diphtheria, Tetanus & Pertussis DTaP
o DT are toxoids
o P is acellular pertussis vaccine DTP or DTwP
o DT are toxoids
o P is killed or inactivated whole cell bacteria Usual dose: 0.5 ml, no 3 e.g. 6-10-14
Route and site:
IM Deep – the whole needle must be embedded; otherwise, antigenic cyst will form. If at buttocks can affect sciatic nerve
Usual Side Effects:
o fever up to 72 hours (low to moderate) rarely reaches 400C, usually about 38-38.5OC o restlessness and irritability because of pain. Baby is fuzzy, wants to be carried. o local reaction: pain and swelling at the site of injection May be prevented by
o change in sensorium: drowsiness, lethargic, stuporous, convulsion, coma o anaphylactic shock
o incessant crying >3 hrs within 48 hours after receiving the vaccine
o continuous high grade fever 39 to 40.5°C and above within 48 hours after vaccination before giving next dose, investigate baby’s reaction after 1st dose. A serious reaction indicates contraindication to DTP (w/c has whole cell pertussis component). Therefore, give DTaP (w/c is acellular preparation)
DTP – P100/dose. DTaP – P800/dose
NOTE: if doses are missed, do not start again from the 1st dose. Give the next dose already. Contraindications to DTP or DTwP
o high grade fever
o ongoing neurologic illness: seizure disorders
o previous adverse reactions to DTP (as mentioned above) DTP is not contraindicated but given with precaution in the following:
o a single high temperature <40°C immediately relieved by antipyretics o history of febrile convulsions
POLIO 6 weeks 2 drops (3) PO
Mouth 4 weeks
Easily by Heat (store
in freezer)
Live attenuated Two types of vaccines:
1. Oral Polio Vaccine (OPV) - live attenuated (Sabin)
- 0.5 ml orally; or 2 drops (using multiple dose) Absolute contraindications:
- altered immune states (malignancies [lymphoma, leukemia], therapy with alkylating agents, metaboltes, high dose steroids, radiation, HIV/AIDS) - pregnancy, household contacts of immunocompromised patients Relative contraindication:
vomiting may just vomit the vaccine; defer vaccination for a few days diarrhea
Adverse Reaction:
- Paralytic Polio Myelitis very rare, if it happens, recommend IPV
- IPV was recommended to decrease the incidence of Vaccine-associated paralytic polio (VAPP)
2. Inactivated or Killed Polio Vaccine (IPV) - given intramuscularly
Available products: individual dose 0.5 ml plastic individual pipette & multiple dose TOPV trivalent oral polio vaccine. 3 strains: PV1, PV2, PV3
Other CI anaphylactic rxns to neomycin, kanamycin, ptertomycin. Anaphylactic rxns to previous dose
HEP B 6 weeks or at birth Follow manufacturer instructions (3 – 0, 1, 6 mos) IM Anterolateral aspect Thigh 4 weeks Heat Freezing
0 (at birth), 1 mo old & 6 mo old, 0.5 ml IM if mother is HBsAg(+):
- give HBIg & Hep B #1 within 12 hours of birth inject at 2 diff sites using 2 diff synringes
- Hep B #2 at 1 month - Hep B #3 at 6 months of age
children and adolescent who have not been vaccinated with Hep B may begin series during any visit
Contraindications: anaphylactic reaction to previous dose Reactions: pain and swelling at site, fever
plasma-derived, genetically-engineered, yeast-derived
given monthly for patients at high risk: dialysis, medical and lab personnel, px receiving regular blood transfusions
MEASLES 9 months 0.5 ml (1)
SC Outer part of the
thigh
Easily by Heat
live attenuated
0.5 ml SC confers lifelong immunity w/ 1 dose
given at 9 months but may be given as early as 6 months during epidemics Reactions:
- fever with or without rashes (5-12 days after administration) maculopapular - hypersensitivity reaction
Contraindication: immunocompromised patients those taking high dose steroid, blood profucts, Ig during past 2 months
Relative Contraindication: untreated active tuberculosis
other contraindications: anaphylactic reaction to kanamycin & neomycin, acute febrile illness, pregnancy BCG - 2 At school entry whether or not child has BCG scar 0.1 ml (1) ID L deltoid Heat Sunlight Same reactions as BCG -1 TETANUS TOXOID Women of childbearing age 0.5 ml (5) IM Deltoid region TT1 at 1st contact TT2 at least 4 wks after TT1 TT3 at least 6 wks after TT2 TT4 at least 1 yr after TT5 at least 1 yr after Heat Sunlight;
For those not given primary immunization in infancy and childhood For women of childbearing age
G. AMERICAN ACADEMY OF PEDIATRICS Hepatitis B
o Inactivated viral antigen o Number, minimum interval:
- 1st dose – birth - 2nd dose – 1-4 mos - 3rd dose – 6-18 mos DTaP
o More expensive, less reactions
o 3 doses; start at 2 months, 2 months apart o 1st DtaP booster: 15-18 months (1 year after
the 3rd dose)
o Booster can be given earlier than 1 year after the 3rd dose of series as long as there is a 6-month interval
o 2nd Booster: 4-6 years o Booster Td: after 10 y/o
- Reaction: very mild fever Haemophilus influenzae b (Hib)
o Bacterial, severe pneumonia
o polysaccharide protein conjugate to develop immunity, it has to be imminuty to the polysaccharide
o shots: If given <1yr: 2 doses; If given >1yr: 1 dose only
o 0.5 ml IM
o Hib titer (Hboc) and anti-Hib (PRP-T) given at 2,4,6 months, then 12-15 months
o Contraindications: anaphylaxis by prior dose o Reaction: low grade fever (2%) pain and
swelling (10-15%) Inactivated Poliovirus
o 2 doses, etc (refer to table given) Measles, Mumps, Rubella (MMR) Vaccine
o live attenuated o 0.5 ml SC
o given at 12-15 months; a booster dose is recommended at 4-6 years old
o Reactions: transient
- Measles: fever with or without rashes (5-12 days after administration),
anaphylaxis, swelling of mouth
- Mumps: fever, swelling of parotid gland - Rubella: fever, mild rash, transient
arthritis or arthralgia, post-auricular lymphadenopathy
- German measles: fever (6-14 days after administration), rash, post auricular lymphadenopathy
o Reasons for giving 2 doses of MMR: - only 87-90% of children actually receive
the measles vaccine
- 5% of children who receive the first vaccine won’t develop immunity
- children who had an immune response to the first dose could get a “booster” effect o must not be given to women who are
expecting to be pregnant within 6 months may develop congenital rubella syndrome o Contraindications: same as measles,
pregnancy within 3 mos
o HIV positivity is not CI in MMR unless severely CI; MMR is not CI if PPD test was done correctly
Varicella
o live attenuated o 1st dose: 0.5 ml SC
o routinely given 12 months and up but can be given as early as 9 months
o can be given within 5 days of exposure o a patient given Varicella vaccine can also
develop shingles although the incidence is less frequent and less severe as compared to the actual Varicella infection
o Varicella vaccine is designed to prevent moderate to sever cases
o Recommendations:
- single dose for ages 1-12 years - 2 doses 6-10 wks apart in children >13
years
o Safety of Varicella vaccine:
- the virus is so weak that it is not transferred from someone who got the vaccine to another person
- it can be given to children who are living in the home of someone whose immune system is weak
- may also be given to patients whose mother is pregnant
o Reactions:
- may develop few Varicella-like lesions about 1 month after vaccination deadly in immunocompromised patients.. severe pneumonia, enchepalitis
CI pregnancy, possible within 1 month Pneumococcal vaccine
o polysaccharide protein conjugate o 0.5 ml IM
o Indications:
- patients undergoing splenectomy - sickle cell disease
- asplenia - HIV Flu Vaccine o inactivated vaccine o dose: - 6 – 36 months: 0.25 ml IM or SC - 3 years and above: 0.5 ml IM or SC o should be administered before the start of flu
season every year, a new strain causes the flu.. determined around June (US)/February (Phils)
o Recommendation:
- prophylaxis in children older than 6 months and adults over 60 years - suffer from disease of cardiovascular
system, metabolic disease, cystic fibrosis, chronic respiratory disease, chronic renal insufficiency
Hepatitis A Vaccine
o inactivated viral antigen o given 2 years and above
o not routinely given, only among selected individuals recall: fecal-oral route transmission of HepaA
o 2 doses:
- first dose: anytime after 2 years - 2nd dose: (booster) 6-12 months after
first dose
o 2-18 years: 0.5 ml IM (720 U) o >19 years: 1 ml IM (1440 U) o Indications:
- persons traveling to areas with high prevalence of Hepatitis A
- occupational hazards
- hemophiliacs – contacts of infected persons
o Reactions: pain and local swelling o CI: anaphylaxis to prior dose
ADDITONAL NOTES: Combination Vaccine:
DTaP, IPV, Hib, HepB DTaP, IPV, Hib DTaP, IPV
HepA, HepaB (must follow 0,1,6 mos) Salmonella T. vaccine:
2 preparations:
alive – oral, 2 years old and above, 3 doses every other day
inactive – 1 dose, 0.5ml IM
Mild illness w/o fever safe to give immunization moderate to severe w/ or w/o fever contraindicated to give any vaccines