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2014 NY/NJ Pediatric Board Review Course

2014 NY/NJ Pediatric Board Review Course. General Pediatrics Alan J. Meltzer MD, FAAP Goryeb Children’s Hospital Atlantic Health System Morristown, NJ. Disclosure. I have a bucket full of money and a house in Malibu just don’t tell my wife I actually have nothing.

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2014 NY/NJ Pediatric Board Review Course

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  1. 2014 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 have a bucket full of money and a house in Malibu just don’t tell my wife I actually have nothing

  3. Practice QuestionThe following is true of today’s speaker? • He has a bucket of money • He is the Chairman of Surgery • He thinks tie-dye is fashion • He loves white chocolate

  4. Outline • Immunizations • Growth, Breastfeeding, Nutrition • Injury Prevention and Anticipatory Guidance • Screening and Statistics • Ethical Terms • QI and Patient Safety • Child Abuse

  5. Immunizations

  6. Why Vaccinate?Pre vaccine 2012

  7. They Work!!!

  8. Vigilance!!Pre vaccine 2012 2013

  9. 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.

  10. 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

  11. 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

  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 within 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 10-64 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

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

  18. 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

  19. MCVConjugate Vaccines • 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 • Hi risk can vaccinate with Hib-MenCY starting at 6 weeks, MenACWY starting at 2 mo, MCV4 can be starting at 9mo. CHECK THE SCHEDULE • History of Guillain-Barré - should not receive

  20. 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

  21. 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 – HPV4 • 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 • Cervarix – HPV2 • Females only

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

  23. 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

  24. 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.

  25. MORE VACCINE STUFF!!!!

  26. 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

  27. 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

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

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

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

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

  32. Influenza-inactivated • Indicated for all children >6mo • 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

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

  34. 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

  35. Hepatitis B≥2Kg <2Kg

  36. 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 (<12 mo and >41 y/o)

  37. 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.

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

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

  40. Question 5A 7 year old was bitten by a raccoon. What should you do? • Administer RIG • Administer rabies vaccine • Administer rabies vaccine and RIG • Treat with amoxicillin/clavulanic acid

  41. Rabies • Bats, skunks, raccoons, foxes, woodchucks are high risk animals • Post exposure prophylaxis is recommended • Wash wound with soap and water • Rabies vaccine (HDCV) 4 dose series • RIG into the wound • Check tetanus status, consider abx as part of wound care

  42. Growth

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