Week 2: Growth, Development, & Vaccines

Question 1

What are normal growth parameters for the infant?

Answer 1

INFANT

• By 1 year: birth-weight should have tripled and height should have increased by 50%
• neurologic development progresses centrally to peripherally
• 3 months: infant should be able to lift their head (no “head-lag”), clasp hands, coo
• 6 months: infant should be able to roll over, reach for objects, turn to voices, babble, and possibly sit with support
• 9 months: infant should have a neat pincer grasp (self-feed), indicate wants; have usually developed “stranger danger:
• 12 months: infants should be able to stand, say 1-3 words

Question 2

What are normal growth parameters for the child?

Answer 2

EARLY CHILDHOOD (1-4 YEARS)

• rate of growth slows by about half
• preschool years, children grow 3.5 inches and gain 4 lbs on average
• chubby, clumsy toddlers transform into leaner, mroe muscular preschoolers
• almost all children walk by 15 months, run well by 2 years, and pedal a tricycle and jump by 4 years
• toddlers move from sensorimotor learning (through touching and looking) to symbolic thinking, solving simple problems, remembering songs, and engaging in imitative play
• 18 months: 10-20 words
• 2 years: 2-3 words
• 3 years: converses well
• 4 years: complex sentences
• impulsive and have poor self regulation, temper tantrums
• preoperational: WITHOUT sustained, logical thought process

MIDDLE CHILDHOOD (5-10 YEARS)

• grow steadily but slowly
• concrete operational: capable of limited lgoic and more complex learning
• little ability to understand consequences or abstractions
• school, family, and environment greatly influence learning
• major develomental task is self-efficacy
• guilt and self-esteem emerge
• clear sense of wrong and right

Question 3

What are normal growth parameters for adolescents?

Answer 3

• puberty begins on average at age 10 years in girls and 11 years in boys (sometimes younger for girls, but if younger than 7, work them up for precocious puberty)
• on average, girls end pubertal development with a growth spurt by age 14 years and boys by age 16 years
• age of onset and duration of puberty vary widely, although the stages follow the same sequence in all adolescents
• concrete to formal operational thinking: acquiring an ability to reason logically and abstractly and to consider future implications of current actions
• wide variability in cognitive development
• brain development continues well into twenties
• transition from family-dominated influences to increasing autonomy and peer influence
• struggly for identity, independence, and eventually intimacy leadsto stress, health-related problems, and high-risk behaviors

Question 4

In considering abnormal growth, which children should be prioritized for evaluation?

Answer 4

• variations beyond 2 standard deviations for age
• children above the 95% or below the 5% are indications for more detailed evaluation
• reduced growth velocity, shown by a drop in height percentile on a growth curve
• drop >2 quartiles in 6 months
• weight for length < 5th percentile
• head circumference above the 95% or below 5%

Question 5

What are the 5 domains of infant/child development?

Answer 5

1. Gross motor
2. Fine motor
3. Cognitive (or problem-solving)
4. Communication
5. Personal/social domains of development

Question 6

How do you correct for prematurity when considering growth and development?

Answer 6

Must correct for prematurity up until 24 months

Question 7

What are the various cognitive stages that children progress through?

Answer 7

Early childhood: preoperational (without sustained, logical thought process)

Middle childhood: concrete operational (capable of limited logic and more complex learning)

Adolescents: concrete to formal operational thinking (acquiring an ability to reason logically and abstractly and to consider future implications of current actions

Question 8

What is the difference between active and passive immunity?

Answer 8

Active immunity: protection that is produced by the person’s own immune system

• usually lasts for many years or a lifetime
• vaccines
• obtaining illness itself and develpoping antibodies

Passive immunity: protection by products produced by an animal/human and transferred to another human, usually by injection

• immunity generally wanes
• mother to baby: Tdap during 3rd trimester
• can come from blood products (IVIG, antitoxin)

Question 9

What are the 2 types of vaccines and how do they work?

Answer 9

Live Attenuated Vaccines

• produced by modifying a disease-producing virus/bacterium in a lab
• vaccine retains ability to replicate and produce immunity but usually does not cause illness (if does produce, illness is usually much milder)
• produce immunity in most recipients with 1 dose, except those administered orally
• may cause severe or fatal reactions in immunocompromised as a result of uncontrolled growth of vaccine

Inactivated Vaccines

• cannot replicate
• less affected by circulating antibody than live vaccine
• always require multiple doses… first “primes the immune system” and often “booster” doses

Question 10

What special consideration should you make about the interval between most live virus vaccines?

Answer 10

All vaccines can be administered at the same visit as all other vaccines
-except in persons without a spleen (or dysfunctional) for PCV13 and menactra brand meningococcal vaccines should not be given at the same visit; separate by at least 4 weeks

If live injected and/or intranasal vaccines are not administered at the same visit, they should be separated by at least 4 weeks

Live oral vaccines (rotavirus) may be given at any time before or after live parenteral vaccines or LAIV

Question 11

What are the various types of adverse vaccine reactions?

Answer 11

Adverse reaction: an untoward effect caused by a vaccine that is extraneous to the vaccine’s primary purpose of producing immunity

Local

• occur with up to 80% of vaccine doses
• occur within a few hours and are generally mild and self-limited
• pain, swelling, and redness at the injection site

Systemic

• more generalized events
• fever, malaise, myalgias, headache, loss of appetite, and others

Allergic

• due to vaccine or component
• are rare and risk is minimized by screening

Question 12

What are the only contraindications to receiving a vaccine?

Answer 12

• severe allergic reaction to a vaccine component or following a prior dose
• encephalopathy not due to another identifiable cause occurring within 7 days of pertussis vaccination
• severe combined immunodeficiency (SCID, genetic disease): rotavirus vaccine
• history of intussusception (rotavirus vaccine)
• live vaccines should not be administered to pregnant women
• live vaccines should not be administered to severely immunosuppressed persons
• if person has moderate-severe illness, vaccination with both live and inactivated vaccines should be delayed until patient recovers

Question 13

Diphtheria

Answer 13

Pathogen: Bacteria

Symptoms:

• can affect any mucus membrane
• insidious offset of pharyngitis
• within 2-3 days, membrane forms which can cause respiratory obstruction
• fever usually not high but patient appears toxic

Complications:

• myocarditis
• neuritis
• paralysis of the soft palate, eyes, and limbs
• death (5-10%, 40% in persons <5 and >40)

Vaccine:
DTaP: Children 6 weeks - 6 years: 2, 4, 6, 15-18 months, and 4-6 years, 11-12 years (TDap) and then every 10 years with TD or TDaP

Question 14

Haemophilus influenzae type B (Hib)

Answer 14

Pathogen: bacteria

Symptoms:

• meningitis
• epiglottitis
• pneumonia
• arthritis
• cellulitis

Complications:

• hearing impairment
• neurologic sequelae
• death (3-6%)

Vaccine:
-3 or 4 doses depending on the brand given at 2, 4, 15-18 months OR 2, 4, 6, and 15-18 months

Question 15

Hepatitis A

Answer 15

Pathogen: virus

Symptoms:

• abrupt onset of fever
• malaise
• anorexia
• nausea
• abdominal discomfort
• dark urine
• jaundice

Complications:

• immunologic, neurologic, hematologic, pancreatic, and renal extrahepatic manifestations
• death rate 0.3-0.6%

Vaccine:
-2 doses 1-18 years (generally given 6 months apart)

Question 16

Hepatitis B

Answer 16

Pathogen: virus

Symptoms:

• preicteric: insidious onset of malaise, anorexia, nausea, vomiting, RUQ abdominal pain, headache, fever, myalgia, skin rashes, arthralgia and arthritis, dark urine
• icteric: 1-3 weeks and is characterized by jaundice, light/gray stools, hepatic tenderness and hepatomegaly (splenomegaly is less common)

Complications:

• fulminant hepatitis (fatality rate 63-93%)
• hospitalization
• cirrhosis
• hepatocellular carcinoma death

Vaccine:
-3 doses: birth, 1-2 months, 6-18 months

Question 17

Human Papilloma Virus (HPV)

Answer 17

Pathogen: virus

Symptoms/Complications:

• anogenital warts
• respiratory papillmatosis
• cervical, anal, vaginal, vulvar, and penile cancers

Vaccines:

• routine schedule is 9-11 years: dosing at 0 (today), 1-2 months later, 6 months afterwards
• 2 dose series if started before 15 birthday, 2nd dose 6-12 months later
• series do not need to be restarted if the schedule is interrupted
• no therapeutic effect on HPV infection, genital warts, cervical lesions

Question 18

Influenza

Answer 18

Pathogen: virus

Symptoms:
-abrupt onset of fever, myalgia, sore throat, nonproductive cough, and HA

Complications:

• PNA
• secondary bacterial infections
• Reye syndrome
• myocarditis
• death is reported than less than 1 per 1,000 cases

Vaccine:

• IIV: annually, 6 month+; 2 doses, 4 weeks apart, the first year the child receives it up through the age of 8
• LAIV: anually for healthy, non-pregnant persons 2-49

Question 19

Measles

Answer 19

Pathogen: virus

Symptoms:

• Fever, which increases in stepwise fashion, often peaking as high as 103 F - 105 F
• onset of cough, coryza (runny nose), or conjunctivitis
• Koplik spots, a rash present on mucous membranes
• maculopapular eruption that usually lasts 5-6 days: begins at hairline, then face and neck, rash gradually proceeds downwards and outwards during the next 3 days… generally discrete, but may become confluent, particularly on the upper body

Complications:

• diarrhea
• AOM
• PNA
• encephalitis
• seizures
• death (0.2%)

Vaccine: MMR

• minimum age: 12 months
• mimum interval: 4 weeks apart
• CDC: 1st dose at 12-15 months, 2nd dose at 4-6 years (can be MMRV)

Question 20

Meningococcal disease (high risk in communal groups)

Answer 20

Pathogen: bacteria

Symptoms:

• sudden onset of fever, HA, and nuchal rigidity
• a/b nausea, vomiting, photophobia, and AMS

Complications:
-petechial or purpuric rash a/w hypotension, shock, acute adrenal hemorrhage, and multiorgan failure

Vaccine:

• MenACWY: 2 dose series; 11-12 years, booster at 16 years
• MenB: at 16 yo visit and may repeat 2nd dose in 1 month

Question 21

Mumps

Answer 21

Pathogen: virus

Symptoms:

• myalgia
• malaise
• HA
• low-grade fever

Complications:

• orchitis (testicular inflammation)
• parotitis (9-94%)

Vaccine:

• first dose after 12 months
• minimum dosing interval: 4 weeks
• CDC schedule: 1st dose at 12-15 months, 2nd dose at 4-6 years

Question 22

Pertussis

Answer 22

Pathogen: bacteria

Symptoms:

• onset of coryza, sneezing, low-grade fever, and a mild, occasional cough
• cough gradually becomes more severe, and after 1-2 weeks, the paroxysmal stage begins
• paroxysms, numerous rapid coughs, d/t difficulty expelling thick mucus from tracheobronchial tree
• at end of paroxysm, a long inspiratory effort is usually a/b characteristic high pitched whoop

Complications:

• secondary bacterial PNA (most common)
• neurologic complications - seizures, encephalopathy, AOM, anorexia, dehydration, pneumothorax, SDH
• hernias
• rectal prolapse

Vaccines:

• primary series (4 doses): 2, 4, 6, 15-18 months
• 5th dose (when 4th dose before 4th birthday: 4-6 years
• Tdap: single dose 11-18 years

Question 23

Pneuomococcal Disease

Answer 23

Pathogen: bacteria (streptococcus pneumoniae)

Symptoms:
-abrupt onset of fever and chills or rigors (classically there is a single rigor, and repeated shaking chills are uncommon, pleuritic chest pain)

Complications:

• bacteremia
• meningitis
• death

Vaccines: PCV13 and PPSV23
PCV13
-children: 2, 4, 6, and 12-15 months
-adults 65 years or older who have not received or is unknown should receive a dose… then 6-12 months later, a dose of PPSV23 should be given

PPSV23

• adults 65 and older
• single dose of vaccine is indicated for healthy people 2 years of age and older with a chronic illness
• the 2 vaccines should not be administered simultaneously and minimum acceptable interval is 8 weeks
• adults who previously received a dose of PPSV23 should receive PCV13 no early than 1 year afterwards

Question 24

Poliomyelitis

Answer 24

Pathogen: viral

Symptoms:

• up to 72% of all polio infections in children are asymptomatic
• approximately 24% of children have minor, nonspecific illness w/o clinical or laboratory evidence of CNS invasion
• nonparalytic aseptic meningitis (symptoms of stiffness of neck, back, and/or legs), usually following several days after a prodrome similar to that of minor illness, occurs in 1-5% of polio infections in children
• fever than 1% of children result in flaccid paralysis

Complications:

• paralytic polio
• death in 2-5% of cases

Vaccine:
-4 doses: 2, 4, 6-18 months, and one dose after 4 yo

Question 25

Rotavirus

Answer 25

Pathogen: viral

Symptoms:

• self-limited watery diarrhea to severe dehydrating diarrhea with fever and vomiting
• 1/3 of infected children have a fever greater than 102 F

Complications:

• severe diarrhea
• dehydration
• electrolyte imbalance
• metabolic acidosis

Vaccine:

• oral vaccine
• Rotateq: 3 doses: 2, 4, 6 months
• Rotrarix: 2 doses: 2 and 4 months
• Maximum age for first dose is 14 weeks 6 days

Question 26

Rubella

Answer 26

Pathogen: viral

Symptoms:

• 1-5 day prodrome with low-grade fever, malaise, lympadenopathy, and upper respiratory symptoms preceding rash
• rash is maculopapular and occurs 14-17 days after exposure; occurs initially on face and progresses to foot, lasts about 3 days and occasionally pruritic

Complications:

• arthralgia
• encephalitis
• hemorrhagic complications
• congenital rubella: fetal death, prematurity, deafness, eye and cardiac defects, microcephaly

Vaccine:

• first dose after 12 months
• 2nd dose usually 4-6 years
• given as MMR or MMRV
• ensure non-pregnant women of childbearing age are immune

Question 27

Tetanus

Answer 27

Pathogen: bacteria

Symptoms:

• trismus or lockjaw
• nuchal rigidity
• aphasia
• rigidity of abdominal muscles
• fever
• sweating
• HTN
• episodic tachycardia
• spasms may occur frequently and last for several minutes for 3-4 weeks

Complications:

• laryngospasm
• HTN
• PE
• fractures

Vaccines:

• DTaP (5 doses): 2, 4, 6, 15-18 months, 4-6 years
• Tdap: 11-12 years and then every 10 years (TD or Tdap)
• Tdap: given during 3rd trimester of pregnancy to protect baby from pertussis through passive immunity

Question 28

Varicella Zoster

Answer 28

Pathogen: viral, primary infection results in varicella (chicken pox), reactivation results in herpes zoster (shingles)

Symptoms:

• Varicella: mild prodrome may precede onset of a rash which starts from head and moves down to the extremities; highest concentration of lesions is on the trunk, vesicular, 1-4 mm, may rupture and crust
• Shingles: vesicular eruption of zoster generally occurs unilaterally in distribution of a sensory nerve… most ofen, involves trunk or 5th cranial nerve… 2-4 days prior to eruption, there may be pain and paresthesia

Complications:

• varicella: bacterial superinfection, PNA, CNA manifestations, Reye syndrome, death in 1:600,000
• shingles: postherpetic neuralgia (PHN)

Vaccine:

• Varicella: 1st dose after 12 months (use separate MMR and varicella), 2nd dose usually 4-6 yo…
• Shingles: single dose 60+