Preventive Pediatrics

Question 1

A child lives with an HIV-infected sibling in the household.

Should the child receive the OPV vaccine?

Answer 1

No

Even though we never use OPV anymore, this could still be tested on exams. You should never use OPV in an immunocompromised child or in one who has an immunocompromised household member.

Question 2

A 4-year-old boy with sickle cell disease has never received an influenza vaccine.

What are the recommendations for the influenza vaccine in this patient?

Answer 2

2 Doses of Inactivated Influenza Vaccine (IIV),

Separated by ≥ 4 weeks; 1 Annual Dose Thereafter

IIV is recommended for all children ≥ 6 months of age. For children < 9 years of age who have never been vaccinated, 2 doses of vaccine, separated by ≥ 4 weeks, are required to achieve adequate antibody levels. Thereafter, 1 annual vaccine is recommended. Annual vaccination is important due to antigenic drift, which occurs continuously and results in new strains of influenza viruses. Vaccination is especially important in high-risk groups, including those with chronic pulmonary or hemodynamically significant cardiac disease, functional asplenia (e.g., sickle cell disease or other hemoglobinopathy), anatomic asplenia, chronic renal dysfunction, or metabolic disease (including diabetes mellitus).

Question 3

A 10-year-old’s permanent tooth is knocked out while playing in the back yard. The mother calls you and asks you what to do. She is not able to reimplant the tooth because the child is uncooperative. You get in touch with a dentist on call, who will meet them soon at his office.

You tell her to bring the tooth in what common household liquid?

Answer 3

Cold Milk

If the tooth cannot be reimplanted, it should ideally be kept in Hank’s Balanced Salt Solution (HBSS) or Save-A-Tooth solution. If these are not available, then cold milk, followed by saliva, physiologic saline solution, or any available isotonic solution is best.

Question 4

In what population and at what age(s) is hepatitis A vaccine routinely recommended?

Answer 4

Universally Recommended at 12–23 Months;

2^nd Dose ≥ 6 Months After the 1^st

Virtually all those completing the series develop protective levels of antibody to Hepatitis A virus (anti-HAV). The vaccine can also be used for postexposure prophylaxis (for those ≥ 12 months of age) in a household or other setting and is as equally protective as immunoglobulin.

Question 5

A 2 1/2-year-old boy who underwent emergent splenectomy at 16 months of age following an automobile accident has received a total of 4 doses of PCV13. His last dose was at 25 months of age.

What are the recommendations for PPSV23 in this patient?

Answer 5

A Single Dose at This Visit, a 2^nd Dose in 5 years

Children at risk for invasive pneumococcal infections should receive a single dose of PPSV23 after completing a 4-dose series of PCV13. PCV13 should be administered at 2, 4, 6, and 12–15 months of age; catch-up immunization is recommended for all children ≤ 59 months of age. PPSV23 is administered with a minimum interval of 8 weeks between the last dose of PCV13 and the 1^st dose of PPSV23. A 2^nd dose of PPSV23 is recommended 5 years after the 1^st dose in children with sickle cell disease or other hemoglobinopathies, functional or anatomic asplenia, HIV infection, chronic renal failure, nephrotic syndrome, or other immunodeficiency disorder. No more than a total of 2 PPSV23 doses should be administered.

Question 6

Can someone with egg allergy receive MMR?

Answer 6

Yes

Although measles and mumps vaccines are grown in chick embryos, the vaccines do not contain significant amounts of cross-reacting egg proteins. Therefore, severe egg allergy is not a contraindication to vaccination with MMR or any of its components.

Question 7

According to the 2014 AAP Bright Futures guidelines, at what age should routine hemoglobin or hematocrit screening be performed?

Answer 7

12 Months of Age

The guidelines also recommend a schedule of ongoing risk assessments for iron deficiency anemia throughout childhood and adolescence, with more frequent testing, as appropriate, for children identified as high risk (e.g., premature, low birth weight, exclusively breastfed without iron supplementation, strict vegans, kids with malabsorption disorders).

Question 8

Is the inactivated influenza vaccine (IIV) safe to administer during pregnancy?

Answer 8

Yes

IIV is recommended and considered safe during any stage of pregnancy. Pregnancy increases the risk of complications and hospitalization from influenza. Pregnancy is a contraindication to administration of all live-virus vaccines. IIV is not a live-virus vaccine and is only rarely associated with major systemic reactions. Mild systemic symptoms, such as fever, nausea, lethargy, headache, myalgia, and chills, may occur.

Question 9

A child is to have a PPD and MMR today.

Can you give both today at the same office visit?

Answer 9

Yes

The problem comes if you give the MMR today and do not give the PPD today, then you must wait 4–6 weeks before placing the PPD. This is because the measles vaccine can suppress tuberculin reactivity. This suppression is not immediate, however, so it is fine to give both today.

Question 10

At what age should routine BP screening begin in healthy children with no coexisting medical condition predisposing to HTN?

Answer 10

3 Years of Age

BP should be measured in children < 3 years of age with a coexisting medical condition predisposing to HTN (e.g., history of prematurity, very low birth weight, neonatal complications requiring intensive care/umbilical lines, congenital heart disease, recurrent UTIs, chronic renal disease or renal malformations, family history of congenital renal disease). Normal BP requires both systolic and diastolic blood pressure to be < 90^th percentile for age. HTN is defined as systolic and/or diastolic blood pressure ≥ the 95^th percentile for sex, age, and height percentile on at least 3 occasions over a period of days to weeks.

Question 11

What are the first teeth to typically emerge?

Answer 11

Mandibular Incisors

The first teeth to emerge are typically the mandibular incisors (lower anterior) followed by the maxillary incisors (upper opposing). Tooth eruption rates and locations can vary greatly, but the first tooth typically erupts by 6 months of age, with 6 teeth present by 1 year of age. There are 20 baby teeth, all of which have generally erupted by 33 months of age.

Question 12

A child comes in for his routine immunization. You learn that the mother is pregnant, and the child is still breastfeeding.

What vaccines can you not give to the child today?

Answer 12

None

There are no contraindications to immunizing a child whose mother is pregnant and/or breastfeeding. All routine vaccines may be given to the child today.

Question 13

At what age(s) is nonfasting screening, with total and high-density lipoprotein cholesterol (HDL-C) levels, universally recommended for children and adolescents?

Answer 13

Once Between 9 and 11 Years of Age and

Once Between 17 and 21 Years of Age

The AAP recommends these screenings for all children and adolescents in these age groups, regardless of risk factors. If non-HDL-C ≥ 145 mg/dL and/or HDL-C < 40 mg/dL, then get 2 fasting lipid panels and average the results. Routine lipid screening is not recommended in children 2–8 years of age or 12–16 years of age.

Question 14

A child receives MMR and experiences joint pain 10 days after the vaccination.

What component of the vaccine is likely responsible for this?

Answer 14

Rubella

Common adverse events of MMR include:

• Fever to 103.0° F (39.4° C)
• Rash occurring 6–12 days after MMR
• In adolescents, joint pain (secondary to the rubella component) 7–21 days after MMR

Question 15

What is the cut-off age for giving a DTaP?

Answer 15

< 7 Years of Age

Do not give DTaP to children ≥ 7 years of age. After that, Tdap is recommended at 11–12 years of age, followed by a Td booster every 10 years thereafter or if a dirty wound has occurred. Children 7–10 years of age who have not completed their primary immunization schedule should receive a single dose of Tdap; if additional tetanus and diphtheria toxoid doses are required, use Td.

Question 16

A previously unimmunized child presents at 4 months of age.

Which routinely recommended vaccine is now too late to give to her?

Answer 16

Rotavirus Vaccine

If a child is not given their first rotavirus vaccine by 14 weeks 6 days of age, then the CDC recommends not to give it at all. Also, do not administer the final dose if the child is > 8 months 0 days of age.

Question 17

Varicella vaccine is contraindicated in children or adolescents receiving what dose—and for how long—of systemic corticosteroids?

Answer 17

> 2 mg/kg/Day (or 20 mg/Day if > 10 kg) for ≥ 14 Days

A patient taking oral corticosteroids at higher doses or for longer duration should not receive varicella (or MMR) vaccine for at least 1 month after discontinuation of corticosteroid therapy. Inhaled and nasal corticosteroid therapy is not a contraindication to administering varicella (or MMR) vaccine.

Question 18

Assuming that the highest weight or height allowed by the manufacturer has not been reached, until what age should infants and toddlers ride in a rear-facing car seat?

Answer 18

2 Years of Age

If a premature infant needs more head support, place body blanket rolls on both sides of the infant. Use only the head support system that comes with the car safety seat. If a premature infant’s head still falls forward when the rear-facing car seat is at ∼ 45°, place a tightly rolled blanket or pool noodle under the car safety seat to maintain the recommended 45° angle. Toddlers and preschoolers ≥ 2 years of age or those

Question 19

All infants should have a hearing screen by what age?

Answer 19

3 Months of Age

The AAP recommends universal screening, and if needed, diagnostic testing of all infants by 3 months of age. In children this age, this is usually done with auditory brainstem response testing (ABR), which measures how CN 8 responds to sound. You can also use otoacoustic emissions analysis (OAE), which measures sound waves made in the inner ear as an echo in response to sound. Ideally, hearing screens should be performed before newborns leave the hospital.

Question 20

What is the only vaccine currently recommended at birth?

Answer 20

Hepatitis B

Administer monovalent Hep B vaccine to all newborns within 24 hours of birth. Administer a 2^nd dose 1–2 months after the 1^st dose (minimum interval of 4 weeks). Administer the 3^rd dose at least 8 weeks after the 2^nd dose and at least 16 weeks after the 1^st dose. The final dose in the series should be administered no earlier than 24 weeks of age.

Question 21

At what ages do the majority of state and federal screening programs and the AAP recommend universal screening for lead?

Answer 21

12 and 24 Months of Age

AAP/Bright Futures guidelines recommend that screening for lead poisoning follow federal, state, and local laws, which typically recommend universal screening at 12 and 24 months of age. Detectable blood lead levels are associated with irreversible neurocognitive deficits. A lower limit for lead toxicity has not been established. Because there is no known safe threshold for lead exposure, action should be taken in all children with blood lead levels ≥ 5 μg/dL (e.g., environmental assessment and eradication of lead).

Question 22

Within hours of his 1^st DTaP vaccination, a 2-month-old boy became irritable and had a febrile seizure with a temperature of 104.8° F (40.5° C).

Do these reactions represent an absolute contraindication to additional doses of DTaP?

Answer 22

No

Absolute contraindications to additional doses of DTaP include a history of encephalopathy within 7 days of dosing or an immediate anaphylactic reaction with a previous dose. Delay vaccination of a patient with a history of a progressive neurologic disorder until neurologic status is stable or the disease process is clarified. A history of irritability, fever > 104.8° F (40.5° C), or seizure within 3 days of receiving a prior dose are relative, not absolute, contraindications to receiving additional doses of DTaP.

Question 23

According to the AAP, at what age should you begin a discussion with children about “sex and drugs?”

Answer 23

10 Years of Age

With respect to health supervision, the well-child visit is one of the pediatrician’s most important tools. Always counsel and give guidance at each well-child visit, no matter what. In the early visits, most counseling revolves around feeding, injury prevention, developmental/behavioral issues, daily care, immunizations, and medical issues. As the child grows, a range of age-appropriate topics, from bicycle helmets to sex and drugs, becomes the focus of counselling. Be sure you know these topics and the recommended ages to discuss them at a well-child visit.

Question 24

A 2-year-old with a history of hives with no associated systemic symptoms following egg ingestion has never received an influenza vaccine.

What are the recommendations for influenza vaccination in this patient?

Answer 24

2 Doses of Vaccine, Separated by at Least 4 Weeks;

1 Dose Annually Thereafter

For children < 9 years of age who have never been vaccinated, 2 doses of inactivated influenza vaccine (IIV), ≥ 4 weeks apart, is recommended. Thereafter, 1 annual vaccine is recommended. Although most IIV vaccines are produced in eggs, the vaccine is well tolerated by most recipients with egg allergy; skin testing or a 2-step graded challenge is no longer recommended in egg-allergic patients. Refer to an allergist only with anaphylaxis or severe systemic reaction to eggs, not following a mild reaction with hives only. The most common adverse events after IIV administration are local injection site pain; tenderness; fever; and mild systemic symptoms such as nausea, lethargy, headache, myalgia, and chills.

Question 25

A 3-month-old with severe combined immunodeficiency (SCID) presents for his first set of immunizations.

What routinely recommended immunization is contraindicated in this patient?

Answer 25

Rotavirus Vaccine

Rotavirus vaccine is a live attenuated virus vaccine and is contraindicated in children with SCID because it can cause prolonged diarrheal disease in these patients.

Question 26

A 24-month-old boy is taken into emergency protective custody due to medical neglect. His immunization record states that he received hepatitis B (HepB) vaccine at birth; at 2 months of age he received a combination vaccine (DTaP-HepB-IPV), Hib, and PCV13.

Do one or more of the vaccine series need to be restarted in this patient because he was last vaccinated > 1 year ago?

Answer 26

No

A vaccine series does not need to be restarted, regardless of the time that has elapsed between doses. Therefore, this patient has already received 2 doses of HepB and 1 dose each of DTaP, IPV, Hib, and PCV13. The number of catch-up doses required and the minimal interval between doses varies by vaccine and the age of the patient at the time catch-up is initiated. Give this child:

• 1 dose each of HepB, Hib, and PCV13,
• 4 doses of DTaP (1 dose now, another dose in 4 weeks, another in 6 months, and a final dose at 4–6 years of age), and
• 3 doses of IPV (1 dose now, another dose in 4 weeks, and a final dose at 4–6 years of age).

Question 27

What are the 4 subcutaneously administered vaccines?

Answer 27

MMR, Varicella, MMRV, and IPV

All the rest are IM, except for rotavirus, which is given orally. IPV and PPSV23 may be given either IM or subcutaneously.

Question 28

A 15-year-old boy with a cochlear implant presents for evaluation. You note that he received PCV7 and PPSV23 three years ago.

What pneumococcal vaccine, if any, should he receive today?

Answer 28

PCV13

A single dose of PCV13 may be given to children 6–18 years of age who have not received PCV13 previously and are at increased risk of invasive pneumococcal disease because of asplenia, sickle cell disease, HIV, or cochlear implant, regardless of whether they have previously received PCV7 or PPSV23. Administer this dose at least 8 weeks after the most recent dose of PPSV23. Remember to repeat PPSV23 five years after the first dose if the child remains at high risk.

Question 29

At what age(s) is meningococcal conjugate vaccine (MCV4) recommended for individuals without a medical condition placing them at increased risk for meningococcal disease?

Answer 29

11–12 Years of Age; Booster Dose at 16 Years of Age

MCV4 vaccines (Menactra and Menveo) each contain serotypes A, C, Y, and W-135. A single dose of either vaccine is recommended at 11–12 years of age, with a booster at 16 years of age to enhance protection during the period of highest risk (i.e., patients 18–23 years of age—especially college freshmen). Adolescents who receive their 1^st dose at 13–15 years of age should receive a booster dose at 16–18 years of age; 1 dose should be administered to previously unvaccinated college freshmen prior to school entry. Menactra, Menveo, and a 3^rd meningococcal conjugate vaccine (MenHibrix, a combination vaccine that contains Hib and serotypes C and Y) are licensed for high-risk infants and children but with different administration schedules.

Question 30

A preterm girl born at 26 weeks of gestation is now 2 months of chronologic age and remains in the NICU. She is clinically stable and has steady growth. She will likely stay in the NICU for several more weeks to gain additional weight.

List the vaccinations she may receive prior to discharge from the NICU.

Answer 30

Hepatitis B (HepB) Vaccine; DTaP; PCV13; Hib; IPV

All immunizations recommended at 2 months of age may be given simultaneously to preterm infants except for the live oral rotavirus vaccine. Defer this until discharge from the NICU to prevent nosocomial spread of the vaccine virus. Use combination vaccines to reduce the number of injections of the inactivated vaccines (HepB, DTaP, PCV13, Hib, IPV). If decreased muscle mass/limited injection sites make it difficult to administer 3 or 4 injections simultaneously, give the vaccines at 2-week intervals to avoid superimposing local reactions.

Question 31

During BP measurement, what is the recommended position of the patient and appropriate cuff size to minimize the risk of an inaccurate reading?

Answer 31

Seated; Cuff Covers ≥ 2/3 Length of the Upper Arm

and Wraps ≥ 3/4 of the Arm Circumference

BP is best measured with the child sitting, the arm held at heart level. The bladder of the blood pressure cuff should cover at least 2/3 the length of the upper arm and wrap around at least 3/4 of the arm circumference (thus, the cuff itself often overlaps). A cuff that is too small will yield an inaccurate and artificially elevated reading. The cuff should be inflated to 20 mmHg above the loss of the radial pulse and then deflated at 2–3 mmHg/second. The 1^st sound heard is a tapping sound, known as Korotkoff sound 1, which is recorded as the systolic blood pressure. The level at which all sound disappears is Korotkoff sound 5, which is the measured diastolic pressure.

Question 32

Administration of a pertussis-containing vaccine is contraindicated in a 15-month-old boy with developmental delay of unknown etiology associated with a poorly controlled seizure disorder. He has never received a pertussis-tetanus-diphtheria–containing vaccine.

What are the recommendations for immunization against tetanus and diphtheria in this patient?

Answer 32

2 Doses of DT ∼ 2 Months Apart; 3^rd Dose in 6–12 Months; 4^th Dose at 4–6 Years of Age

This schedule is recommended for previously unimmunized children 1–6 years of age with a medical contraindication to a pertussis-containing vaccine. The 4^th dose is recommended at 4–6 years of age unless the 3^rd dose is administered after the 4^th birthday. Td, rather than DT, is indicated at ≥ 7 years of age.

Question 33

The mother of an 18-month-old boy is concerned that his “eyes sometimes look crossed.”

Name 2 tests that may be used in this age group to evaluate for strabismus.

Answer 33

Corneal Light Reflex Test; Unilateral Cover Test

In toddlers and preschool age children, use the corneal light reflex test to confirm that the position of the corneal reflection is the same in both eyes. Perform the test by holding a light about 3 feet from both eyes. Displacement of the corneal light reflection in 1 eye suggests strabismus. Perform the unilateral cover test by covering and uncovering each eye while the child is looking straight ahead. Results are consistent with strabismus if there is movement in the uncovered eye when the opposite eye is covered vs. uncovered.

Question 34

What is the only live vaccine given before 12 months of age?

Answer 34

Rotavirus Vaccine

All other vaccines given before 12 months of age are either killed or recombinant.

Question 35

What temperature should the hot water heater be set at in the typical home?

Answer 35

≤ 120.0° F (48.8° C)

Other important child safety items you should review with parents:

• Smoke and carbon monoxide detectors installed at home
• Cabinet locks and plastic “plugs” for electrical receptacles
• Stair safety
• Poison prevention
• Firearm safety
• Choking prevention
• Drowning prevention

Question 36

At what age does the American Academy of Pediatric Dentistry (AAPD) recommend that children begin seeing a dentist?

Answer 36

By 1 Year of Age

All children should receive a dental referral at or near their first birthday. However, if dental providers in the area are unwilling to see children who are younger than 3 years of age, you may continue to provide preventive dental care and counseling for infants and children who are at low risk of developing dental disease and have no abnormalities on screening examination.

Question 37

What is the best way to reduce head and facial injuries while riding a bike?

Answer 37

Wear a Helmet

Prevention of bicycle injuries is an important topic to discuss with all age groups. Head injuries, which account for the majority of bicycle-related deaths and hospital admissions, can often be avoided with proper precautions and consistent use of bicycle helmets. Proper-fitting bicycle helmets should be worn at all ages. Adolescents are at increased risk of bicycle injury and death and should be strongly encouraged to wear bicycle helmets every time they ride.

Question 38

A child has not had any immunizations.

Assuming that the child is immunocompetent, what is the cut-off age for receiving a Haemophilus influenzae type b (Hib) vaccine?

Answer 38

> 5 Years of Age

Do not immunize children > 5 years of age because they are at much lower risk for serious sequelae. One dose of Hib is approved for those > 5 years of age if they have functional/anatomic asplenia, HIV, leukemia, or are immunocompromised.