Paediatrics Vaccinations Flashcards
What do vaccinations do?
Provide immunity to full version of the pathogen
Give some examples of inactivated vaccines?
Polio
Flu vaccine
Hepatitis A
Rabies
What do subunit and conjugate vaccines contain?
Parts of the organism used to stimulate an immune response
Safe for immunocompromised patients
What are some examples of subunit and conjugate vaccines?
Pneumococcus
Meningococcus
Hepatitis B
Pertussis (whooping cough)
Haemophilus influenza type B
HPV
Shingles (herpes-zoster)
What do live attenuated vaccines contain?
Weakened version of the pathogen
Give some examples of live attenuated vaccines?
Measles, mumps and rubella vaccine: contains all three weakened viruses
BCG: contains a weakened version of tuberculosis
Chickenpox: contains a weakened varicella-zoster virus
Nasal influenza vaccine (not the injection)
Rotavirus vaccine
What are toxin vaccines?
Toxin which is normally produced by a pathogen
What kind of immunity do toxin vaccines produce?
Immunity to the toxin and not to the pathogen itself
What are some examples of toxin vaccines?
Diphtheria
Tetanus
What vaccines are given at 8 weeks?
6 in 1 vaccine (diphtheria, tetanus, pertussis, polio, haemophilus influenzae type B (Hib) and hepatitis B)
Meningococcal type B
Rotavirus (oral vaccine)
What vaccines are given at 12 weeks?
6 in 1 vaccine (again)
Pneumococcal (13 different serotypes)
Rotavirus (again)
What vaccines are given at 16 weeks?
6 in 1 vaccine (again)
Meningococcal type B (again)
What vaccines are given at 1 year?
2 in 1 (haemophilus influenza type B and meningococcal type C)
Pneumococcal (again)
MMR vaccine
Meningococcal type B (again)
What vaccines are given yearly from age 2 - 8 years?
Influenza vaccine (nasal vaccine)
What vaccines are given at 3 years 4 months?
4 in 1 (diphtheria, tetanus, pertussis and polio)
MMR
What vaccine is given at 12-13 years?
HPV vaccine (2 doses given 6 to 24 months apart)
What vaccine is given at 14 years?
3 in 1 (tetanus, diphtheria and polio)
Meningococcal groups A, C, W and Y
What is the current NHS HPV vaccine?
Gardasil (against 6, 11, 16 and 18)
What strain of HPV causes genital warts?
Strains 6 and 11
What strains of HPV cause cervical cancer?
Strains 16 and 18
When is the BCG vaccine offered?
From birth to babies at higher risk of TB
What is sepsis the result of?
Systemic inflammatory response
In sepsis what is the causative pathogen recognised by? What do they release
Macrophages
Lymphocytes
Mast cells
They release cytokines e.g. interleukins and TNF leadint to further release of chemicals e.g. nitrous oxide which cause vasodilation
What effect fo cytokines have on the endothelial lining of the blood vessels?
Become more permeable - causing fluid to leak out of blood into extracellular space causing oedema and reduction in intravascular volume
What is the result of the oedema in sepsis?
Create space between blood and tissues reducing oxygen that reaches tissues
How does disseminated intravascular coagulopathy (DIC) occur in sepsis?
Activation of coagulation system leads to deposition of fibrin throughout the circulation - causing consumption of platelets and clotting factors as they are being used up to form the blood clots. Causes thrombocytopenia, haemorrhages and an inability to form clots and stop bleeding
Why does blood lactate rise in sepsis?
Result of anaerobic respiration in the hypo-perfused tissues with an inadequate oxygen - waste product is lactate
How should septic shock be treated?
Aggressively with IV fluids - for bp and tissue perfusion
If bp does respond then escalate to high dependency or ICU where inotropes e.g. noradrenaline can be considered
What are inotropes?
Medications which stimulate CVS and improve bp and tissue perfusion
What signs can indicate sepsis in children?
Deranged physical observation
Prolonged CRT
Fever or hypothermia
Deranged behaviour
Poor feeding
Inconsolable / high pitched crying
Reduced consciousness
Reduced body tone (floppy)
Skin colour changes (cyanosis, mottled pale or ashen)
What is the traffic light system for assessment of serious illness in child with fever?
Green (low risk)
Amber (intermediate risk)
Red (high risk)
What forms part of the traffic light system assessment?
Colour: normal vs cyanosed, mottles, ashen
Activity: happy, responsive vs abnormal, drowsy, inconsolable
Respiratory: normal vs respiratory distress, tachypnoea, grunting
Circulation and hydration: normal, moist membranes vs tachycardia, dry membranes or poor skin turgour
Other: fever > 5 days, non blanching rash, seizures or high temp < 6 months
Which infants need to be treated urgently for sepsis?
Infants under 3 months with a temperature of 38C or above
What is the immediate management of sepsis?
- Oxygen: if in shock / oxygen sats below 94%
- Obtain IV access (cannulation)
- Blood tests: including FBC, U&Es, CRP, clotting screen (INR), blood gas for lactate and acidosis
- Blood cultures: ideally before giving abx
- Urine dip: with cultures and sensitivities
- Abx according to local guidelines, within 1 hour of presentation
- IV fluids 20ml/kg IV bolus of normal saline if lactate above 2 mmol / L or there is shock
What investigations in suspected sepsis?
CXR if pnuemonia
Abdo and pelvic ultrasound if intra-abdo infection suspected
Lumbar puncture if meningitis suspected
Meningococcal PCR blood test
Serum cortisol if adrenal crisis suspected
How long to continue abx for if a bacterial infection is suspected?
5-7 days - alter abx if needed once organism is isolated
When should abx be stopped?
Low suspicion of bacterial infection - patient is well and blood cultures and two CRP results are negative at 48 hours
What is meningitis?
Inflammation of the meninges - lining of the brain and spinal cord (usually due to bacterial or viral infection)
What is neisseria meningitidis?
Gram negative diplococcus bacteria - circulae (cocci) that occur in pairs (diplo) aka meningococcus
What is meningococcal septicaemia?
Meningocuccus bacterial infection in the bloodstream - cause of classic non-blanching rash
What does a non-blanching rash occur?
DIC and subcutaneous haemorrhages
What is meningococcal meningitis?
When bacteria infects the meninges and the cerebrospinal fluid around the brian and spinal cord
What are the most common causes of bacterial meningitis in children and adults?
Neisseria meningitidis (meningococcus) and streptococcus penumoniae (pneumococcus)
What is the most common cause of meningitis in neonates?
Group B strep (GBS) contracted from birth from bacteria that lives harmlessly in mothers vagina
What are the typical features of meningitis?
Fever
Neck stiffness
Vomiting
Headache
Photophobia
Altered consiousness
Seizures
Do causes other then maningococcal septicaemia cause the non-blanching rash?
Not usually
How do neonates with sepsis present?
Non-specific signs
Hypotonia
Poor feeding
Lethargy
Hypothermia
Bulging fontanelle
When is a lumbar puncture performed for a child with fever?
Under 1 month with fever
1-3 months with fever and unwell
Under 1 year with unexplained fever and other features of serious illness
What two special tests look for meningeal irritation?
Kernig’s test
Brudzinski’s test
How is Kernig’s test performed?
Lie patient on back
Flex hip and knee to 90 degrees
Slowly straighten knee whilst keeping hip flexed
Stretch in the meninges produces spinal pain or resistance to movement
How is brudzinski’s test performed?
Lie patient on back
Use hands to lift their head and neck off the bed - flex chin to chest
Positive test = involuntary flex of hips and knees
How should bacterial meningitis be treated in GP?
If suspected meningitis and non-blanching rash should receive an urgent stat IM/IV benzylpenicillin prior to transfer to hospital - dose is age dependent
What if true penicillin allergy in GP with sepsis?
Transfer should be priority rather than finding alternative abx
What is the management of meningitis in hospital?
Blood culture and LP for CSF prior to starting abx (if acutely unwell then not to be delayed)
Blood tests for miningococcal PCR if meningococcal disease suspected - tests directly for meningococcal DNA can give result quicker than blood cultures
What is the typical abx for meningitis?
Under 3 months - cefotaxime plus amoxicillin to cover listeria contracted during pregnancy
Above 3 months - ceftriaxone
Vancomycin - added if risk of penicillin resistent pneumococcal infection e.g. recent foreign travel or prolonged abx exposure
What is given to reduce frequency and severity of hearing loss and neurological damage?
Steriods - dexamethasone 4 times faily for 4 days to children over 3 month if the LP is suggestive of bacterial meningitis
Are bacterial meningitis and meningococcal infection notifiable diseases?
Yes, public health need to be informed of all cases
When is risk of catching meningococcal infections highest?
Close prolonged contact within the 7 days prior to the onset of the illness (risk decreases 7 days after exposure)
What is the recommended post-exposure prophylaxis after exposure to meningococcal infections?
Guided by public health - usually single dose of ciprofloxacin given asap (ideally within 24 hours of initial diagnosis)
What are the common causes of viral meningitis?
Herpes simplex virus (HSV)
Enterovirus
Varicella zoster virus
Sample of CSF from lumbar puncture sent for viral PCR testing
What is the management of viral meningitis?
Tends to be milder than bacterial requiring only supportive
Aciclovir can be used to treat suspected HSV or VZV infection
Complete this table:
What are some complications of meningitis?
Hearing loss is a key complication
Seizures and epilepsy
Cognitive impairment and learning disability
Memory loss
Cerebral palsy, with focal neurological deficits e.g. limb weakness or spasticity
What is encephalitis?
Inflammation of the brain - result of infective or non-infective causes
What are non-infective causes of encephalitis?
Autoimmune, meaning antibodies against brain tissue
What is the most common cause of encephalitis?
Viral
What is the most common cause of paediatric encephalitis in children and neonates respectively?
What are some other causes of paediatric encephalitis?
Why is it important to ask about vaccinations in paediatric encephalitis?
Measles, mumps, rubella and polio viruses can cause encephalitis
How does paediatric encephalitis present?
Altered consciousness
Altered cognition
Unusual behaviour
Acute onset of focal neurological symptoms
Acute onset of focal seizures
Fever
What investigations to establish the diagnosis of encephalitis?
Lumbar puncture sending CSF for viral PCR
CT scan if lumbar puncture contraindicated
MRI scan after LP to visualise the brain
EEG recording in mild or ambiguous symptoms - not always routinely required
Swabs of throat / vesicles
HIV in all patients with encephalitis
What are some contraindications to a lumbar puncture?
GCS below 9
Haemodynamically unstable
Active seizures
Post-ictal
What is the management of paediatric encephalitis?
IV antiviral medications:
- Aciclovir to treat HSV and VZV
- Ganciclovir to treat cytomegalovirus
Repeat lumbar puncture to ensure successful treatment prior to stopping antivirals
Aciclovir empirically until results available
Support with complications
What are the complications of encephalitis?
Lasting fatigue and prolonged recovery
Change in personality or mood
Changes to memory and cognition
Learning disability
Headaches
Chronic pain
Movement disorders
Sensory disturbance
Seizures
Hormonal imbalance
What is infectious mononucleosis (IM) caused by?
Infection with the Epstein Barr virus (EBV)
What is infectious mononucleosis also known as?
Kissing disease
Glandular fever
Mono
Where is EBV found?
Saliva of infected individuals (spread by kissing / sharing cups / toothbrushes)
What happens if patient with sore throat - misdiagnosed - takes amoxicillin?
Develops itchy rash - mononucleosis causes an intensly itchy maculopapular rash in response to amoxicillin or cefalosporins
What are the features of infectious mononucleosis?
Fever
Sore throat
Fatigue
Lymphadenopathy (swollen lymph nodes)
Tonsillar enlargement
Splenomegaly and in rare cases splenic rupture
What antibodies does the body produce in response to infectious mononucleosis? When?
Heterophile antibodies (multipurpose and not specific to the EBV antigens) - takes up to 6 weeks for these antibodies to be produced
How can heterophile antibodies be tested for?
Monospot test: combine patients blood to RBC from horses - heterophile antibodies - if present will react and give positive result
Paul-Bunnell test: similar to monospot test but ises RBCs from sheep
Why are the monospot and paul-bunnell test only 70-80% sensitive but 100% specific for infectious mono?
Not everyone who has IM produces heterophile antibodies
How to test for specific EBV antibodies?
By targetting viral capsid antigen (VCA)
What does a rise in IgM and IgG suggest in mono?
IgM antibody rises early and suggests acute infection
IgG antibody persists after condition suggesting immunity
What is the management of infectious mono?
Usually self limiting - acute illness lasts around 2-3 weeks - can leave patient with fatigue several months once infection is cleared
Avoid alcohol as EBV affects liver
Avoid contact sports due to risk of splenic rupture
What are some complications of infectious mononucleosis?
Splenic rupture
Glomerulonephritis
Haemolytic anaemia
Thrombocytopenia
Chronic fatigue
What type of cancer is EBV associated with?
Burkitt’s lymphoma
What is mumps?
Viral infection spread by respiratory droplets
What is the incubation period of mumps?
14-25 days
What protection does the MMR vaccine provide against mumps?
80% protection
How does mumps present?
Prodrome of flu-like illness for a few days
Parotid swelling - unilateral or bilateral
Fever
Muscle aches
Lethargy
Reduced appetite
Headache
Dry mouth
How may mumps present with symptoms of the complication?
Abdo pain (pancreatitis)
Testicular pain and swelling (orchitis)
Confusion neck stiffness and headache (meningitis or encephalitis)
How is the diagnosis of mumps confirmed?
PCR testing on a saliva swab (also tested for antibodies to the mumps virus)
Is mumps a notifiable disease?
Yes, need to notify public health of any suspected and confirmed cases
What is the management of mumps?
Supportive, rest, fluids, analgesia
Self-limiting condition
What are the possible complications of mumps?
Pancreatitis
Orchitis
Meningitis
Sensorineural hearing loss
What is AIDS referred to as in the UK?
Late stage HIV
What type of virus is HIV? What are the types?
RNA retrovirus
HIV-1 is most common type
HIV-2 is rare outside west africa
What does HIV do?
Virus enters and destroys the CD4 T helper cells - initial seroconversion flu like illness occurs within a few weeks of infection - infection is then asymptomatic untul patient becomes immunocompromised and develops AIDS defining illnesses
How is HIV spread?
Unprotected anal, vaginal or oral sexual activity
Mother to child at any stage of pregnancy, birth or breastfeeding (vertical transmission)
Needle sharing, blood splashed in eye
What is the mode of delivery to prevent mother to child HIV transmission?
Normal vaginal delivery for women with viral load < 50 copies /ml
Caesarean section considered for patients with > 50 copies / ml and in all women with >400 copies / ml
IV zidovudine given during caesarean if >10000 copies /ml
For HIV, what prophylaxis treatment can be given to the baby?
Low risk (mums viral load < 50 copies per ml) = zidovudine for 4 weeks
High risk (mums viral load > 50 copies per ml) = zidovudine, lamivudine and nevirapine for 4 weeks
Is breastfeeding safe if HIV positive?
HIV can be transmitted during breastfeedig - even if mother’s viral load is undetectable - never recommended (if mum is adamant and viral load is undetectable then can be attempted with monitoring from HIV team)
When may a HIV test be falsely positive?
Due to maternal antibodies in children aged under 18 months
How is HIV testing performed?
HIV antibody screen: standard screening test - can take up to 3 months for antibodies to develop after exposure to the virus
HIV viral load: will never be falsely positive but may come back as“undetectable” in patients on antiretroviral therapy
When should HIV be tested for?
Babies to HIV positive
Immunodeficiency suspected
Young people who are sexually active - offered testing if concerns
Risk factors e.g. needle stick injury, sexual abuse or IV drug use
When are babies to HIV positive parents tested?
HIV viral load test at 3 months (if this is negative then not contracted HIV during birth)
HIV antibody test at 24 months (if they have contracted HIV since their 3 month viral load e.g. through breastfeeding)
What is the treatment of paediatric HIV?
Antiretroviral therapy (ART) to suppress the HIV infection, to achieve normal CD4 count and undetectable viral load
Normal childhood vaccines avoid / delay live vaccines if severely immunocompromised
Prophylactic co-trimoxazole (septrin) for children with low CD4 counts to protect against pneumocystis jirovecii pneumonia (PCP)
Treatment of opportunistic infections
What is the role of the paediatric HIV multidisciplinary team?
- Regular follow up to monitor growth and development
- Dietician input for nutritional support
- Parental education about the condition
- Disclose diagnosis when child is mature enough
- Psychological support
- Specific sex education in relation to HIV when appropriate
What type of virus is Hep B?
DNA virus - transmitted by direct contact with blood / bodily fuild
What is the prognosis of hep B infection?
Most fully recover within 2 months
Portion go on to become chronic hep B carriers (virus DNA has integrated into their own DNA and continue to produce viral proteins)
What is the risk of developing chronic hepatitis B after exposure?
90% for neonates
30% for children under 5
Under 10% for adolescents
What is the progression of chronic hep B infection?
Most are asymptomatic with normal growth and development
Less than 5% develop liver cirrhosis
Less than 0.05% develop hepatocellular carcinoma
What do the following antibodies and antigens signify?
Surface antigen (HBsAg)
E antigen (HBeAg)
Core antibodies (HBcAb)
Surface antibody (HBsAb)
Hepatitis B virus DNA (HBV DNA)
Surface antigen (HBsAg) – active infection
E antigen (HBeAg) – marker of viral replication and implies high infectivity
Core antibodies (HBcAb) – implies past or current infection
Surface antibody (HBsAb) – implies vaccination or past or current infection
Hepatitis B virus DNA (HBV DNA) – this is a direct count of the viral load
In what order should hep B be screened for?
Test HBcAb (previous infection) and HBsAg (active infection) if positive then do further testing for HBeAg and viral load (HBV DNA)
Which immunoglobulins are measured for HBcAb?
IgM and IgG
What does a high HBeAg imply?
Patient is in an acute phase of the infection wherev virus is activelly replicating
Which children to test for Hep B?
Children of hep B positive mums (screen at 12 months of age)
Migrants from endemic aread
Close contacts
How to reduce the risk of the baby contracting hep B at birth?
Within 24 hours given:
- Hep B vaccine (again at 1 and 12 months of age)
- Hep B immunoglobulin infusion
How to check if a baby has contracted hep B during birth?
Tested for HBsAg
Can hep B positive mothers breastfeed?
If is safe for hep B positive mothers provided the babies are properly vaccinated
What is the hep B vaccine? When is it given?
Injection of hepatitis B surface antigen - requires 3 doses and is part of the UK 6 in 1 vaccine
What is the management of chronic hep B?
Usually asymptomatic and do not require treatment
Regular follow up to monitor serum ALT, HbeAg, HBV DNA, physical examination and liver ultrasound
If evidence of hepatitis or cirrhosis then treatment with antiviral medication may be considered
What type of virus is hepatitis C?
RNA virus - spread by blood and bodily fluids
How is hep C treated?
Curable using direct acting antiviral medications (not yet available for children)
What is the progression of hep C in adults?
1 in 4 fight off virus
3 in 4 develop chronic hepatitis C
What are some complications of hep C?
Liver cirrhosis and associated complications
Hepatocellular carcinoma
Does hep C transmit from mother to baby in pregnancy?
Yes, 5-15% of the time
Hep C antivirals are not recommended in pregnancy
No additional measures are known to reduce risk of transmission
What is the testing of Hep C in children?
Hepatitis C antibody is the screening test
Hepatitis C RNA to confirm the diagnosis of hep C, calculate viral load and identify genotype
When are babies to hep C positive mothers tested?
18 months using the hep C antibody test
Is breastfeeding permitted in hep C?
Yes - but temporarily stop if nippled become cracked
What is the management of hep C infection in childhood?
Chronic hep B infection doesnt usually cause issues in childhood
Medical treatment in children over 3 years involved pegylated interferon and ribavirin
Treatment is typically delayed until adulthood
