Preventive Pediatrics

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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  Lipid screening  if obese

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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)

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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

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F. EXPANDED PROGRAM ON IMMUNIZATION (EPI) BY THE DOH

VACCINE

MINIMUM AGE

DOSE (number)

VACCINE ROUTE OF MINIMUM INTERVAL DESTROYED ADMINISTRATION BETWEEN DOSES BY

0.05 ml for NB BCG - 1

Birth; or any time after birth

DTP

6 weeks

0.1 ml for infants (1)

0.5 ml (3)

Intradermal deltoid R arm

IM Upper outer portion of thigh

Heat sunlight

4 weeks

Heat Freezing

ADDITIONAL NOTES  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  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 Paracetamol (1-2 doses as analgesic)

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 Previous Adverse Reactions: 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 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 Reactions: flu-like, fever, chills

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 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 /Trina 