SPECIAL REPORT: Pediatric Vaccines

July 31, 2017

This Patient Care Special Report updates you on pediatric vaccines in a series of clever clinical scenarios. First, the intro and pretest.

Today I am an experienced pediatrician (“experienced” sounds so much better than “old”...[I completed my residency in 1979]), but I first practiced medicine in a time when a child from birth to age 5 years received a total of 6 shots (5 DTPs and 1 MMR) and 4 doses of oral polio vaccine. Today, a child could receive 6 shots at the two-month-of-age visit along with one dose of an oral vaccine if the provider does not use combination vaccines.

The early years

I joined a two-physician practice after residency and in my first 3 years of practice I hospitalized children with Haemophilus influenzae type B (Hib) epiglotitis, facial cellulitis, periorbital cellulitis, and septic arthritis. Somehow, we did not have a case of Hib meningitis, but I probably averaged two lumbar punctures per month looking for it. One in 200 children contracted invasive Hib disease prior to the introduction of the vaccine.

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Until the rotavirus vaccines were approved, I routinely hospitalized a couple of children every year with dehydration from vomiting and diarrhea. I assume these were mostly rotaviral infections since I think I have hospitalized one or maybe two children in the last decade since the FDA approval of RotaTeq in 2006.  Prior to the vaccine 1 in 70 children in the US were hospitalized with rotavirus infection.

Before the varicella vaccine was available, I would see children several times a year with so many pox on their trunk that I could not place my thumb anywhere without touching a lesion. Needless to say, those children were miserable. I have seen pox on about every possible body part including the eye. Girls with pox on their labia would cry with every urination. I saw a jaundiced child with varicella hepatitis. I cared for a toddler who developed cerebellar ataxia after contracting varicella. Fortunately, I never saw a case of transverse myelitis leading to permanent paraplegia, another possible neurologic consequence of varicella infection. Those opposed to childhood vaccines, the “anti-vaxers,” like to call varicella a mild illness that does not require a vaccine for prevention. Most of the time it is a mild illness, but even then a child is missing a week of school or a parent a week of work.

[[{"type":"media","view_mode":"media_crop","fid":"62082","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_3735003497246","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"7874","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"width: 245px; height: 245px; float: right;","title":"Varicella ","typeof":"foaf:Image"}}]]Prior to the Hib and Prevnar vaccines children under age two years with a fever greater than 103°F got blood work. CBCs and blood cultures were performed several times a week with some children needing IM ceftriaxone pending culture results. In that era, you didn't see many pediatricians in Las Vegas. We got to gamble every night we were on call and talking to parents about their sick child. Which toddler with a 104°F temperature at 10 pm did you send to the ER and which could you wait to see in the morning?  Which child with stridor at 2 am had croup and which one had epiglottis?

This is now

I have a “that-was-then” story for each of the infectious and often deadly diseases we now prevent with routine vaccination; but “this is now,” and the modern challenge is to stay current with knowledge of available vaccines and indications and to be prepared for whatever scenario may evolve in your office on any given day.

This is the first segment of a weekly, five-part series on pediatric vaccines and the diseases they prevent. The Patient Care Special Report on Pediatric Vaccination won’t offer a step-by-step review of the Advisory Committee on Immunization Practices (ACIP) annually updated schedule of vaccine recommendations. That’s available any time on the CDC's website

Instead you will be challenged in a series of creative, short case-based quizzes to use your clinical knowledge of the specific vaccination needs of a variety of pediatric patients in a variety of situations. Some of the answers will be readily apparent; other situations I hope will make you stop and think.

This introduction is followed by a pretest, to see what you already know. You will see the questions again in a posttest after the final installment. In the following weeks you will be quizzed on:

 â–º The diseases still most deadly to children under age 5 years

 â–º Measles and pertussis

 â–º HPV and meningococcus

 â–º The challenge of the “catch-up” vaccination plan

Images:
Viruses (L) Haemophilus influenzae
©Kateryna Kon/Shutterstock.com;
(R) Rotavirus ©decade3d - anatomy online mathagraphics/Shutterstock.com
Baby with varicella ©UbjsP/Shutterstock.com 

 

Continue to Pediatric Vaccination Special Report Pre-test

 

PRE-TEST

 

Question 1:

Pneumococcus is the vaccine-preventable disease responsible for the greatest number of deaths annually in the US.

Answer and Question #2 on Next Page »

 

The correct answer is D. 70,000 deaths per year from pneumococcus infections in the US

 

Question 2.

Answer and Question #3 on Next Page »

 

The correct answer is A. True

 

Question 3.

Following are 3 sequences of the top 6 most deadly diseases in children under the age of 5 years, worldwide.

Answer and Question #4 on Next Page »

 

The correct answer is A. Pneumococcus, hepatitis B, rotavirus, influenza, DTP, measles

 

Question 4.

Answer and Question #5 on Next Page »

 

The correct answer is B and C are off-label uses of Quadracel.

 

Question 5.

Answer and Question #6 on Next Page »

 

The correct answer is D. A 5-year-old boy needs his second MMR. He weighs 25 kg and has been on 25 mg oral prednisone QD for 6 months.

 

Question 6.

Answer and Question #7 on Next Page »

 

The correct answer is C. 5%

 

Question 7.

Answer and Question #8 on Next Page »

 

The correct answer is A. 80% and 9,000

 

Question 8.

Three vaccines are given at the 11-12-year-old well child visit: dTap, HPV, and meningococcus. Parental resistance is usually strongest to having the child receive the HPV vaccine.

Answer and Question #9 on Next Page »

 

The correct answer is C. Parents simply told the child would receive the 3 recommended vaccines and asked if they had any questions.

 

Question 9.

Answer and Question #10 on Next Page »

 

The correct answer is D. 3rd leading cause

 

Question 10.

An underimmunized child is in your office for his 12-month visit. He received 1 HIB shot at 4 months of age (type unknown). You give him a second one today, PedvaxHIB.

Answer on Next Page »

 

The correct answer is C. In 4 weeks (the child needs to return)

 

These questions will all be answered in the course of the next 4 installments of the Patient Care Pediatric Vaccines Special Report. Stay tuned for next week's discussion on which vaccine-preventable diseases continue to be most deadly to children.