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2009 NY/NJ Pediatric Board Review Course

2009 NY/NJ Pediatric Board Review Course. General Pediatrics Alan J. Meltzer, MD FAAP Goryeb Children’s Hospital Atlantic Health Morristown, NJ. Disclosure. I will not be discussing any investigational or unlabeled uses of a product.

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2009 NY/NJ Pediatric Board Review Course

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  1. 2009 NY/NJ Pediatric Board Review Course General Pediatrics Alan J. Meltzer, MD FAAP Goryeb Children’s Hospital Atlantic Health Morristown, NJ

  2. Disclosure • I will not be discussing any investigational or unlabeled uses of a product. • I do not have a financial interest or relationship with any manufacturer of any commercial product I may discuss.

  3. Outline • Immunizations • Growth • Breastfeeding • Injury Prevention and Anticipatory Guidance • Child Abuse

  4. Immunizations

  5. Why Vaccinate?Pre vaccine 2006

  6. They Work!!!

  7. Case #1 Question 1 A 12 year old girl presents to your office for a regular checkup for school entry. She is a recent immigrant from Columbia. Her mother states that she does not have an immunization record. She denies any significant past medical history or history of allergies. Physical exam is unremarkable. Which immunizations would you give her at this time?

  8. A. Td, IPV, MMR, Varicella, Hep B, MCV B. Td, IPV, MMR, Varicella, Hep B, MPSV C. Td, IPV, MMR, Varicella, Hep B, Hep A, HPV D. Tdap, IPV, MMR, Varicella, Hep B, MPSV E. Tdap, IPV, MMR, Varicella, Hep B, MCV, Hep A, HPV

  9. Case 1 Based on the catch up schedule and requirements of 12 year old female. A. Td, IPV, MMR, Varicella, Hep B, MCV4 B. Td, IPV, MMR, Varicella, Hep B, MPSV4 C. Td, IPV, MMR, Varicella, Hep B, Hep A, HPV D. Tdap, IPV, MMR, Varicella, Hep B, MPSV4 E. Tdap, IPV, MMR, Varicella, Hep B, MCV, HepA, HPV

  10. Case #1 Question 2 Before you give the Tdap vaccine, the patient asks you what is a true contraindication for the vaccine?

  11. A. Temperature greater than 105 F within 48 hours of a previous DTP/DTaP B. Collapse or shock like state within 48 hours of a previous DTP/DTaP C. History of encephalopathy within 7 days of previous DTP/DTaP D. Latex Allergy E. Pregnancy

  12. Common Side Effects • Fever • Local redness and swelling • Rash 1-2 weeks after MMR • Rash 1-4 weeks after Varicella

  13. Pertussis Containing VaccinesTrue Contraindications • Anaphylaxis to vaccine component • Encephalopathy ≤ 7days after dose

  14. Pertussis Containing VaccinesPrecautions • Seizure within 3 days of vaccine • Crying for 3 or more hours within 48 hours of vaccine • Collapse or shock-like state within 48 hours of vaccine • Temp ≥ 40.5C/105F unexplained within 48 hours of vaccine • Progressive neurologic disorders

  15. Tdap Vaccines • Boostrix • Approved for 10-18 years of age • Adacel • Approved for 11-64 years of age • Indications • 11-12 year old booster • Adolescents who received Td, can receive Tdap at interval <5yrs in 09 recommendation • Single dose in primary catch up series in adolescent. • Contraindications –same as DTaP • Precautions –Guillain-Barré within 6 weeks of tetanus containing vaccine, progressive neuro disorder, Arthus hypersensitivity reaction, moderate to severe acute illness

  16. TdapPrecautionsNot Contraindications • Temperature > 105F within 48 hrs of DTP/DTaP • Collapse or shock-like state within 48 hrs of DTP/DTaP • Persistent crying for 3 hrs or longer within 48 hrs of DTP/DTaP • Convulsions with or without fever within 3 days after DTP/DTaP • History of entire or extensive limb swelling after vaccination with DTP/DTaP/Td • Stable neurological disorder

  17. TdapPrecautionsNot Contraindications • Brachial neuritis • Latex allergy other than anaphylaxis (BOOSTRIX single dose and ADACEL are latex free) • Pregnancy and breastfeeding • Immunosuppression • Intercurrent minor illness • Antibiotic use

  18. A. Temperature greater than 105 F within 48 hours of a previous DTP/DTaP B. Collapse or shock like state within 48 hours of a previous DTP/DTaP C. History of encephalopathy within 7 days of previous DTP/DTaP D. Latex Allergy E. Pregnancy

  19. Case #1 The patient heard that there are two different meningococcal vaccines. What’s the difference?

  20. MPSVA,C,Y,W-135 • MPSV • Polysaccharide vaccine • Shorter lived, T-cell independent response • No booster response with subsequent challenge • No reduction in nasopharyngeal carriage

  21. MCVA,C,Y,W-135 • 11-55 years old • T-cell dependent response, long lasting memory • Booster response • Eradication of nasopharyngeal carriage which contributes to herd immunity • Routinely recommended at ≥ 11 years old (recent change) • Recommended to increased risk 2-10 years old • History of Guillain-Barré - should not receive

  22. Question 3All the following are true except? A. The conjugate vaccine produces an antibody response which lasts longer B. The conjugate vaccine stimulates a booster response C. The conjugate vaccine promotes herd immunity D. The conjugate vaccine has less side effects E. The conjugate vaccine reduces nasopharyngeal carriage

  23. A. The conjugate vaccine produces an antibody response which lasts longer B. The conjugate vaccine stimulates a booster response C. The conjugate vaccine promotes herd immunity D.The conjugate vaccine has less side effects E. The conjugate vaccine reduces nasopharyngeal carriage

  24. Case #1 Question 4 The patient asks you why she should get the HPV vaccine?

  25. Human Papilloma Virus Vaccine • Costs 4 billion dollars/year in US to treat genital warts and cervical cancer • HPV types 16 and 18 cause approximately 70% of cervical cancers and types 6 and 11 cause approximately 90% of genital warts • Gardasil - licensed in 2006, • targets HPV types 6, 11, 16 and 18 • Recommended for 9-26 year old females • Three doses: 0, 2 mo, 6 mo

  26. Case #1 Question 5 You ask your 12 year old patient to return in 4 weeks to continue the catch up schedule of vaccination. At that visit you will administer?

  27. A. Td,IPV,MMR,Hep B B. Td,IPV,MMR,Varicella,Hep B C. Tdap,IPV,MMR,Hep B,MCV4 D. Tdap,IPV,MMR,Varicella,Hep B E. Tdap,IPV,MMR,Varicella,Hep B,MCV

  28. Catch-up Schedule • Tdap is for only one dose. Td is used for remainder of doses • Varicella- Two doses - 2nd dose in 3 mo. <13 years old and 4 weeks in ≥13 years old • MMR – Two doses 4 weeks apart • MCV only one dose is required.

  29. A. Td,IPV,MMR,Hep B B. Td,IPV,MMR,Varicella,Hep B C. Tdap,IPV,MMR,Hep B,MCV4 D. Tdap,IPV,MMR,Varicella,Hep B E. Tdap,IPV,MMR,Varicella,Hep B,MCV4

  30. MORE VACCINE STUFF!!!!

  31. Polio Vaccines • IPV- no serious adverse effects • contains trace amounts of neomycin/streptomycin/polymyxin B • 4 dose series except if dose 3 after 4 years old • OPV – No longer available in US due to vaccine associated paralytic polio

  32. MMRContraindications • Pregnancy • Anaphylaxis to first dose of vaccine/Neomycin/gelatin • Immunodeficiency (asymptomatic HIV is NOT contraindication) • Anaphylaxis to egg is NOT contraindication and skin testing not recommended

  33. MMRPrecautions • Recent Immunoglobulin (IG) administration • History of ITP • TB or (+) PPD

  34. VaricellaContraindications • Anaphylaxis to neomycin/gelatin • Pregnancy • Immunodeficiency (T-cell) • HIV +/- (CDC class 1 OK) • High dose steroid use (wait 1 mo.)

  35. VaricellaPrecautions • Recent Immunoglobulin (IG) • Salicylate use • Moderate to severe acute illness with or without fever

  36. Influenza-inactivated • Indicated for all children 6mo-18y/o • Indicated in targeted high risk children, not < 6 mo • Asthma, CF, cardiac, HIV, Sickle cell, ASA therapy, renal, diabetes, pregnancy • Close contacts of high risk – YOU! • Contraindicated in egg anaphylaxis • Guillain-Barré within 6 weeks is precaution • Requires 2 doses if not previously vaccinated and less than 9 years old • Dose 0.25ml if 6-35mo, 0.5ml if ≥3 years old • Multi-dose vial still with thimerosal

  37. Influenza-Live • Healthy 2 to 49 years old • not in high risk groups • Contraindicated in egg anaphylaxis, salicylate therapy, history of Guillain-Barré

  38. Hepatitis B • Universal immunization of all newborns • Preterm infant > 2kgs or > 1mo old in hospital, < 1mo old but going home • 3 dose except Recombivax 11-15 year olds – 2 doses • Do not give in buttocks • Does not cause SIDS, DM, MS

  39. Hepatitis B≥2Kg <2Kg

  40. Hepatitis A • 12-23 mo. universal immunization • 2 doses - 6 mo. apart, double dose ≥19 yr • High risk • Int’l travel, chronic liver, homo/bisexual, drug abuse, clotting factor def, job related • IG for pre and post exposure prophylaxis dependent on age and duration

  41. Pneumococcal Vaccines • PPV23 - > 2 years old high risk group, repeat in 3-5 year • PCV7 – routine 2 mo. to 23 mo., complicated schedule • PCV7 – high risk 24 mo. to 59 mo. (include cochlear implant) • PCV7 – 24-59 mo with incomplete series

  42. H. Influenza type B • Routine schedules require booster at 12-15 mo. • Can be given up to 59 mo.

  43. Rotavirus • Two formulations • Administer 2, 4, +/- 6 mo. • Start at 6 to 14weeks+6days • Final dose no later then 8mo+0 days

  44. Growth

  45. OK135S053

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