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2012 NY/NJ Pediatric Board Review Course

2012 NY/NJ Pediatric Board Review Course. General Pediatrics Alan J. Meltzer, MD FAAP Goryeb Children’s Hospital Atlantic Health System Morristown, NJ. Disclosure. I will not be discussing any investigational or unlabeled uses of a product.

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2012 NY/NJ Pediatric Board Review Course

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  1. 2012 NY/NJ Pediatric Board Review Course General Pediatrics Alan J. Meltzer, MD FAAP Goryeb Children’s Hospital Atlantic Health System 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 2011

  6. They Work!!!

  7. Case #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.

  8. Question 1:Which immunizations would give her at this time? • Td, IPV, MMR, VZ, Hep B, MCV • Td, IPV, MMR, VZ, Hep B, MPSV • Td, IPV, MMR, VZ, Hep B, Hep A, HPV • Tdap, IPV, MMR, VZ, MPSV • Tdap, IPV MMR, VZ, Hep B, Hep A, MCV, HPV

  9. Question 2: Before you give the Tdap, the patient asks you what is a true contraindication for the vaccine? • Temperature >105 F within 48 hours of a previous DTP/DTaP • Collapse or shock like state within 48 hours of a previous DTP/DTaP • History of encephalopathy within 7 days of previous DTP/DTaP • Latex allergy • Pregnancy

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

  11. Pertussis Containing VaccinesTrue Contraindications • Anaphylaxis to vaccine component • Encephalopathy within 7days after dose

  12. 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

  13. Tdap Vaccines • Boostrix • Approved for 10-64 years of age • Adacel • Approved for 11-64 years of age • Indications • 11-12 year old booster • Adolescents who received Td, can receive Tdap regardless of interval after Td • Single dose in primary catch up series if >7 years old. • 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

  14. 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

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

  16. MPSVA,C,Y,W-135 • MPSV4 • Polysaccharide vaccine • Shorter lived, T-cell independent response • No booster response with subsequent challenge • No reduction in nasopharyngeal carriage

  17. MCVA,C,Y,W-135 • T-cell dependent response, long lasting memory • Booster response • Eradication of nasopharyngeal carriage which contributes to herd immunity • Routinely recommended at 11-12 years old with a booster at 16-18 y/o • Two doses 2m apart to increased risk 2-10 years old • Two doses 3m apart to increased risk 9-23m • History of Guillain-Barré - should not receive

  18. Question 3: Compared to the older polysaccarhide vaccine , all of the following are true except? • The conjugate vaccine produces an antibody response which lasts longer • The conjugate vaccine stimulates a booster response • The conjugate vaccine promotes herd immunity • The conjugate vaccine has less side effects • The conjugate vaccine reduces nasopharyngeal carriage

  19. 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 girls • Recommended for 9-21 year old boys • Three doses: 0, 2 mo, 6 mo

  20. Case #1 You ask your 12 year old patient to return in 4 weeks to continue the catch up schedule of vaccination.

  21. Question 4: At that visit you will administer? • Td, IPV, MMR, Hep B • Td, IPV, MMR, Hep B, VZ • Tdap, IPV, MMR, Hep B, MCV • Tdap, IPV, MMR, Hep B, VZ • Tdap, IPV, MMR, Hep B, VZ, MCV

  22. Catch-up Schedule • Tdap is for only one dose in primary series. 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 – next dose at 16y/o.

  23. MORE VACCINE STUFF!!!!

  24. 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

  25. 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

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

  27. MMRSide Effects • Redness, swelling, fever • Rash • Joint pain • Increased risk of febrile seizure if use MMRV

  28. VaricellaContraindications • Anaphylaxis to neomycin/gelatin • Pregnancy • Immunodeficiency (T-cell) • HIV +/- (CD4 >15% is OK) • High dose steroid use (wait 1 mo.)

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

  30. Influenza-inactivated • Indicated for all children 6mo-18y/o • 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

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

  32. 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

  33. Hepatitis B≥2Kg <2Kg

  34. 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

  35. Pneumococcal Vaccines • PPV23 - > 2 years old high risk group, repeat 5 year • PCV13 – routine 2m to 23m complicated 4 dose schedule. Complete with PCV 13 if started with PCV7 • PCV 13 – 1 dose to healthy children 14-59m if vaccinated with PCV 7 • PCV13 -1 dose to all healthy children aged 24 through 59 months who are not completely vaccinated for their age. • PCV 13 – 1 dose of PCV13 is recommended for all children aged 60 through 71 months with underlying medical conditions who have received an age-appropriate series of PCV7.

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

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

  38. Growth

  39. OK135S053

  40. OK135S057

  41. OK135S059

  42. BMI • Body mass index (BMI) = weight (kg)/height (m)2 • BMI is an effective screening tool; it is not a diagnostic tool • For children, BMI is age and gender specific, so BMI-for-age is the measure used • 85%-95% = overweight • >95% = obese

  43. BMI • BMI-for-age relates to health risks • Correlates with clinical risk factors for cardiovascular disease including hyperlipidemia, elevated insulin, and high blood pressure • BMI-for-age during pubescence is related to lipid levels and high blood pressure in middle age

  44. Can you see risk? • This girl is 4 years old. • Is her BMI-for-age • >85th to <95th percentile? • Is she overweight? Photo from UC Berkeley Longitudinal Study, 1973

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