Childhood Well-Child Care (Case 9)

 A 2-month-old child you have followed since birth arrives for his rou-tine “baby shots.” His mother’s pregnancy was uncomplicated, and he has been healthy without significant problems.

What is the next step in the care of this patient?

Routine Well-Child Care

Summary: A healthy 2-month-old infant due for a routine well-child visit.

Next step: Gather interval history (feeding, sleep), obtain appropriate meas-urements (length, weight, and head circumference), review sensory and devel-opmental or behavioral screenings (ensure that he can see and hear, and that he is developing normally), perform a physical examination, perform general and specialized procedures (ensure that his neonatal state screen is normal and provide immunizations), and offer anticipatory guidance.

ANALYSIS

Objectives

1. Become familiar with the goals of the routine well-child (or health super-vision) session.

2. Become familiar with the American Academy of Pediatrics (AAP) Recommended Childhood and Adolescent Immunization Schedule.

3. Learn the side effects and contraindications of common childhood immu-nizations.

Considerations

Well-child care for this healthy infant is uncomplicated. For children with special needs, such as Down syndrome or sickle cell disease, guidelines outline their specific considerations. For children with multiple handicaps, such as those resulting from extreme prematurity, no specific guidelines exist; the providers adapt national “well-child care” guidelines as appropriate.

APPROACH TO 

Childhood Well-Child Care

CLINICAL APPROACH

Goals of a health supervision visit include evaluating a child’s physical, devel-opmental, psychosocial, and educational status to identify problems early; prompt intervention then can be instituted. Anticipatory guidance aims to fos-ter good health habits, prevent illness, and assist in family communication.

Most pediatric providers follow commonly available preventive health-care guidelines. The AAP periodically updates its Recommendations for Preventive Pediatric Health Care, which outlines questions, medical procedures, and coun-seling areas for children’s birth through 21 years. Other sources include guide-lines from the Agency for Healthcare Research and Quality and “Bright Futures” (National Center for Education in Maternal and Child Healthcare). Regardless of the source, guidelines are modified to fit local practice and to best serve the patients’ needs.

IMMUNIZATIONS

Immunizations are part of the well-child visit. They are cost-effective and effi-cacious in improving children’s general health and well-being. Vaccination pro-grams have eliminated smallpox and reduced the incidence of other diseases (Haemophilus influenzae type b [Hib], polio, measles, tetanus, rubella, and diph-theria) such that medical students and residents are unlikely to see a single case. The Recommended Childhood and Adolescent Immunization Schedule (Figure 9–1), updated annually and available on the Internet, is supported by a variety of organizations, including the AAP, the American Academy of Family Practice, and the Centers for Disease Control and Prevention.

Pediatric immunizations are extraordinarily safe. The side effects risk is extremely low, especially when compared to the benefit of preventing mor-bidity and mortality from communicable diseases. However, vaccine safety sometimes is scrutinized by the news media and by parents. The health-care provider must have access to scientifically sound and updated side effect data to allay these fears (Table 9–1).

Many American children are incompletely immunized because of a lack of access to immunizations, poor family understanding of the need for immu-nizations, cost, or fear of side effects. True contraindications to giving immu-nizations are rare. Mild upper respiratory infections, gastroenteritis, and low-grade fever are not contraindications.

True contraindications to a particular vaccine include immediate hyper-sensitivity reactions to the given vaccine, the vaccine component, or the pre-servative in the agent. True egg hypersensitivity is a contraindication to influenza and yellow fever vaccination (both grown in chick embryo tissue cultures) but not for measles-mumps-rubella (MMR) vaccination (contains only minute amounts of egg products). Patients having encephalopathy or encephalitis after receiving the diphtheria, tetanus, and pertussis vaccine do not receive subsequent doses. In general, live virus vaccines are not given to preg-nant and severely immunocompromised patients, but they are given to a child living in the home with a pregnant woman. Giving MMR or varicella to an asymptomatic patient with human immunodeficiency virus (HIV) is permitted. Expert consultation in some cases is warranted.

Table 9–1 VACCINE ADVERSE EVENTS, CONTRAINDICATIONS, AND PRECAUTIONS
AGENT	ADVERSE EVENT	CONTRAINDICATIONS OR PRECAUTIONS
H influenza type b vaccine	Pain, redness, and/or swelling at the injection site in 25% of recipients.	Anaphylactic reaction to vaccine.
DPT/DTaP∗ vaccine (In general, only the acellular (DTaP) pertussis vaccine is available; all of the adverse events listed are far more common with the cellular (DTP) form.)	Local and febrile reaction. Redness, edema, induration, and tenderness at the injection site. Drowsiness, fretfulness, anorexia, vomiting, crying. Slight to moderate fever. Bacterial or sterile abscesses at the site of injection (6-10 cases per million injections). Allergic reactions (2 cases per 100,000 injections), transient urticarial rash. Seizures (incidence occurring within 48 h is 1 case per 1750 doses). Hypotonic-hyporesponsive (also called “collapse” or “shocklike state”) episodes (1 case per 1750 doses). Fever ≥40.5°C (105°F) (0.3% of recipients). Persistent, severe, inconsolable screaming or crying (1 case per 100 doses).	Contraindications •        Anaphylactic reaction to vaccine or vaccine constituent. •        Moderate or severe illness with or without a fever. •        Encephalopathy within 7 d of administration of previous dose of DTP/DTaP. Precautions •        Fever ≥40.5°C (105°F) within 48 h of vaccination with a prior dose of DTP/DTaP. •        Collapse or shocklike state (hypotonic-hyporesponsive episode) within 48 h of receiving a prior dose of DTP/DTaP. •        Seizures within 3 d of receiving a prior dose of DTP/DTaP (acetaminophen given prior to administering DTaP or DTP and every 4 h thereafter for 24 h should be considered for children with a personal or family history of convulsions in siblings or parents). •        Persistent, inconsolable crying lasting >3 h within 48 h of receiving a prior dose of DTP/DTaP. •        Guillain-Barré syndrome within 6 wk after a dose of DTP/DTaP.
Hepatitis B vaccine	Pain at injection site and temperature >37.7°C (99.86°F) (1%-6% of recipients). Anaphylaxis reported to be 1 in 600,000 doses.	Contraindications •        Anaphylactic reaction to vaccine or vaccine constituent. •        Anaphylactic reaction to baker’s yeast. Precautions Moderate or severe illness with or without a fever.
MMR vaccine	Fever up to 39.4°C (103°F) occurs in 5%-15% of vaccines 7-12 d after injection, lasting 1-      2 d. Rash in about 5% of vaccines. Transient thrombocytopenia. Encephalitis and encephalo-pathy occurs in 1 per million doses, less often with revaccination. Allergic reaction: reactions to the MMR vaccine are rare even in children with documented egg allergy. Clinically apparent thrombo-cytopenia within 2 mo of the vaccine occurs in <1 per 25,000-40,000 vaccinated children, clustered about 2-      3 wk after the vaccine, and is generally transient and benign in nature. Subacute sclerosing panence-phalitis is possibly a rare complication.	Contraindications •        Anaphylactic reaction to neomycin or gelatin. •        Pregnancy. •        Known altered immuno-deficiency (hematologic and solid tumors, severe HIV infection, congenital immunodeficiency, and long-term immunosuppres-sive therapy). Precautions •        Recent immunoglobulin administration (within 3-11 mo depending on product). •        Thrombocytopenia or history of thrombocy-topenic purpura.
Inactivated Poliovirus vaccine (IPV)	None	Contraindications Anaphylactic reaction to streptomycin, polymyxin B, and neomycin. Precautions Pregnancy.
Varicella vaccine	Rash within 1 mo of immuni-zation, a mild maculopapular or varicelliform rash (median of about 2-5 lesions) at the injection site or elsewhere, develops in about 7% of children and about 8% of susceptible adolescents/adults. Pain, redness, and/or swelling at the injection site in 20% of children and 25%-35% of adolescents. Transmission of the vaccine virus from healthy vaccines to other persons is rare (<1%) and appears to occur only if vaccine develops rash. Transmission of this vaccine virus appears to cause mild or no disease. Zoster-like illness (rash and minimal or absent system symptoms) has been reported in vaccines (about 18 cases per 100,000 person years); no cases have been severe.	Contraindications •        Anaphylactic reaction to neomycin and gelatin. •        Infection with HIV. •        Known altered immuno- deficiency (hematologic and solid tumors, congenital immunodeficiency, and long-term immunosuppres-sive therapy). Precautions •        Recent immunoglobulin administration (within 5 mo). •        Family history of immunodeficiency.
Pneumococcal Vaccine	Up to about 1 of 4 infants had redness, tenderness, or swelling where the shot was given. About 1 of 3 infants had a fever38°C (>100.4°F), and up to about 1 in 50 had a higher fever >39°C (>102.2°F). Some children also became fussy or drowsy, or had a loss of appetite.	Known anaphylactic reaction.
Hepatitis A Vaccine	Soreness where the shot was given (about 1 of 2 adults and up to 1 of 5 children). Headache (about 1 of 6 adults and 1 of 20 children). Loss of appetite (about 1 of 12 children). Fatigue (about 1 of 14 adults). If these problems occur, they usually come 3-5 d after vaccination and last for 1 or 2 d.	Known anaphylactic reaction.

 

 

Abbreviations: DTaP, diphtheria and tetanus toxoids and acellular pertussis [vaccine]; DTP, diphtheria and tetanus toxoids and  pertussis [vaccine]; HIV, human immunodeficiency virus; MMR, measles-mumps-rubella.

In general, only the acellular (DTaP) pertussis vaccine is available; all of the adverse events listed are far more common with the cellular (DTP) form.

Data from Pickering LK, ed. 2006 Red Book: Report of the Committee on Infectious Diseases. 27th ed. Elk Grove Village, IL: American Academy of Pediatrics, 2006 and Centers for Disease Control and Prevention (available at www.cdc.gov).

Comprehension Questions

9.1     A healthy, well-developed 6-year-old child arrives as a new patient to your clinic. His immunization card reveals that he received an immu-nization at birth and some when he was 2 months old, but none since. Which of the following statements about him is correct?

A.       He should receive the live oral poliovirus vaccine rather than the inactivated (injectable) poliovirus vaccine (IPV).

B.       The pertussis vaccine is contraindicated at his age and is replaced with the tetanus-diphtheria vaccine.

C.      He is too old to receive the H influenzae type b vaccine.

D.      His vaccinations at birth and 2 months are repeated because too much time has elapsed for them to be effective.

E.       He is too young for the varicella vaccine.

 

9.2     Appropriate advice for a mother of a 2-week-old child here for a “well-child” visit includes which of the following?

A.       By age 1 month the child should be sleeping through the night.

B.       Children should be able to roll over by age 2 months and to sit by age 4 months.

C.      Half-strength fruit juices can be initiated at age 2 months.

D.      Potty training should begin at age 1 year.

E.       Sleep in the supine position is recommended.

9.3     During a “well-child” visit, the parents of a healthy 5-month-old offer a great amount of information. Which of the following bits of infor-mation is of most concern?

A.       A diet that includes baby cereal, five different baby vegetables, and one baby fruit

B.       Consuming 32 oz of infant formula per day

C.      Intermittent tugging on the ears

D.      Limited eye contact with parents

E.       Rolling from front to back but not back to front

 

9.4     Which of the following statements about “routine” screening tests is accurate?

A.       All children undergo tuberculosis skin testing at age 12 months.

B.       Lead testing is obtained on all 12- and 14-month-old infants.

C.      Pelvic examinations are part of the examination of a sexually active adolescent.

D.      Screening hematocrit levels are obtained on all infants at age 2 months.

E.       Universal cholesterol screening begins at age 11 months.        

 

ANSWERS

9.1     C. The Hib vaccine generally is not recommended for children 5 years of age or older.

9.2     E. Juices (undiluted) are avoided until approximately 6 months of age (in a cup and not in the bottle). At 1 month of age an infant should be able to fix and follow, but not be expected to sleep through the night by age 2 to 3 months. Realistic targets for development include rolling over at 4 months and sitting by 6 months. Potty training starts when the child shows interest, usually no earlier than age 2 years. Parents are told to place healthy children on their backs (or side) for sleep to reduce the incidence of sudden infant death syndrome.

9.3     D. Children fix and follow on the human face from birth. A 5-month-old child who does not engage in eye contact is abnormal.

9.4     C. Tuberculosis and lead testing are performed on at-risk children. Pelvic examinations are performed when girls become sexually active or by age 18 to 21 years. Screening hematocrits are done at age 9 to 12 months, and cholesterol tests are done for children with familial risk factors.

Clinical Pearls

➤       True contraindications for vaccinations are rare but include immediate hypersensitivity reactions to the vaccine, the vaccine component, or the preservative in the agent.

➤       Conditions that are not contraindications for vaccinations include mild upper respiratory infections, gastroenteritis, and low-grade fever.

➤       In general, pregnant and severely immunocompromised patients should not receive live virus vaccinations, but the vaccines are given to children liv-ing in the home with a pregnant woman. Measles-mumps-rubella (MMR) and varicella vaccinations can be given to asymptomatic patients with HIV.

REFERENCES

Agency for Healthcare Research and Quality. Guide to clinical preventive services.

Available at: http://www.ahrq.gov/clinic/cpsix.htm.

American Academy of Pediatrics. Recommendations for preventive pediatric health

care. Available at: http://www.aap.org.

Bright Futures. Guidelines for health supervision of infants, children, and adolescents.

Available at: http://www.brightfutures.org.

Centers for Disease Control and Prevention. Vaccine side effects. Available at:

http://www.cdc.gov/vaccines/vac-gen/side-effects.htm#dtap.

Halsey NA. Immunization. In: McMillan JA, Feigin RD, DeAngelis CD, Jones MD,

eds. Oski’s Pediatrics: Principles and Practice. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:118-134.

Orenstein WA, Pickering LK. Immunization practices. In: Kleigman RM, Behrman

RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, PA: WB Saunders; 2007:1058-1070.

Overby KJ. Pediatric health supervision. In: Rudolph CD, Rudolph AM, Hostetter

MK, Lister G, Siegel NJ, eds. Rudolph’s Pediatrics. 21st ed. New York, NY: McGraw-Hill; 2003:2-4, 19-30, 37-53.