The 7 th Annual Metropolitan New York/New Jersey Pediatric Board Review Course

1. The 7thAnnual Metropolitan New York/New Jersey Pediatric Board Review Course General Pediatrics Andrew D. Racine, M.D., Ph.D. April 22, 2012

2. Outline • Screening • Immunizations • Breastfeeding and nutrition • Anticipatory Guidance • Psycho-social issues • Ethics and Professionalism in primary care • Patient Safety and Quality Improvement

3. Screening

4. Case #1 A 9 month old female is brought to your office for her regular health care maintenance visit. The components of developmental surveillance that you perform include all the following except: • Eliciting and attending to parental concerns • Obtaining relevant developmental history • Administering a validated instrument to identify developmental delays • Accurately observing the child/parent interaction in the examination room

5. Answer C • Surveillance is, “… a flexible continuous process whereby knowledgeable professionals perform skilled observations of children during the performance of health care.” • It includes attending to parental concerns, obtaining a history, making accurate and informed observations, and sharing opinions and concerns with other relevant professionals. • It does not involve the application of validated tools – that is the definition of screening. Source: AAP Committee on Children with Disabilities, Pediatrics; 2001

6. Screening Appropriate criteria for a useful screening tool include all of the following except: • It is valid, i.e. it is sensitive and specific • It is reliable • It is inexpensive to administer • The condition being screened for is prevalent • The tool is acceptable to screened subjects • There are effective interventions available for conditions identified by the tool

7. The correct answer is D • Screening tools should be valid and reliable meaning that they accurately identify the condition of interest and that in repeated applications they give the same result. The tools should be inexpensive to administer in times of time and other costs, they should be acceptable to patients and the conditions identified should be amenable to intervention. • We screen for rare as well as prevalent conditions

8. You and your colleagues are thinking of adding routine developmental screening to you office practice. In looking into this possibility you have discovered that: • Developmental surveillance should occur at the 9, 18, and 30 month visits. • The goal of developmental screening is to arrive at a diagnosis and a treatment plan. • The diagnosis of a specific developmental disorder is necessary to make an EI referral. • Sensitivity and specificity rates of 70%-80% are acceptable for developmental screening tests. • Subsequent screening is not necessary after a child passes two screening tests. 6 Countdown

9. Screening The correct answer is D sensitivity and specificity rates of 70%-80% are acceptable for developmental screening tests. A variety of screening tools with different psychometric properties are available for screening purposes but, in general, they have lower sensitivity and specificity than medical screening tests because of the underlying variability of the construct being measured and the absence of specific curative treatments for some conditions.

10. Screening The American Academy of Pediatrics, in its 2006 policy statement on Identifying Infants and Young Children With Developmental Disorders recommends surveillance at every preventive care visit and the use of a standardized tool to screen low risk children at the 9, 18, and/or 30 month visits.

11. Screening • Early Intervention services are valuable for children identified at high risk. They can provide evaluation services, developmental therapies, service coordination, transportation support, etc. • The diagnosis of a specific developmental disorder is not necessary to refer a child deemed at risk to receive EI services.

12. Summary • Surveillance is the process of recognizing children who may be at risk for developmental delays and should take place at every well child visit; • Screening is the use of a standardized tool to identify and refine the recognized risk; • Evaluation is a complex problem to identify a specific developmental disorder in a child.

13. Update on Immunizations

14. A 12 year old girl presents to your office for a regular checkup for school entry in September. She is a recent immigrant from Mexico. Her mother states that she does not have an immunization record. She denies any significant past medical history. There is no history of allergies. Physical exam reveals no abnormalities.Which immunizations would you give at this time? • Td, IPV, MMR, Varicella, Hep B, MCV4 • Td, IPV, MMR, Varicella, Hep B, MPSV4, Influenza • Td, IPV, MMR, Varicella, Hep B, Hep A, HPV • Tdap, IPV, MMR, Varicella, Hep B, MPSV4 • Tdap, IPV, MMR, Varicella, Hep B, MCV4, Hep A, HPV, Influenza

17. Pertussis Vaccine (Tdap) Two tetanus toxoid, reduced diphtheria toxoid and acellularpertussis vaccines are approved by the FDA for: Adolescents aged 11-18 years who completed their primary series of DTP/DTaP and have not received a Td booster dose Adolescents who have not received DTP/DTaP/Td/Tdap vaccination (or have no documentation) For wound management in adolescents who have not received Tdap before Children 7-10 with undocumented immunization status

18. Before you give the Tdap vaccine to the patient you ask your attending what is a true contraindication for the vaccine. Your attending responds that: • Temperature greater than 105 F within 48 hours of a previous DTP/DTaP • Collapse or shock like state within 48 hours of a previous DTP/DTaP • History of encephalopathy within 7 days of previous DTP/DTaP • Latex Allergy • Pregnancy

19. Contraindications of Tdap • Anaphylaxis to any components of the vaccine • History of encephalopathy (coma or prolonged seizure) within 7 days of administration of a pertussis vaccine that cannot be attributed to a different cause

20. Precautions of Tdap • History of an Arthus-type reaction following a previous dose of tetanus- or diphtheria-containing vaccine • Progressive neurological disorder, uncontrolled epilepsy, or progressive encephalopathy • History of Guillain-Barre syndrome (GBS) within 6 weeks after a previous dose of tetanus toxoid-containing vaccine • Moderate or severe acute illness

21. Not Contraindications • Temperature > 105F within 48 hrs of DTP/DTaP • Collapse or shock-like state within 48 hrs of DTP/DTaP • Persistent crying for 3 hrs or longer within 48 hrs of DTP/DTaP • Convulsions with or without fever within 3 days of DTP/DTaP • History of entire or extensive limb swelling after DTP/DTaP/Td • Stable neurological disorder

22. Not Contraindications • Brachial neuritis • Latex allergy other than anaphylaxis-BOOSTRIX single dose and ADACEL are latex free • Pregnancy and breastfeeding • Immunosuppression • Intercurrent minor illness • Antibiotic use

23. Meningococcal Vaccine (MCV4) Introduced in 2005 the meningococcal conjugate vaccine is recommended in • Adolescents 11-12 years • Unvaccinated adolescents at school entry • College freshmen living in dormitories • Certain high risk groups • Booster dose now recommended at age 16 (as of January, 2011) FIGURE. Annual incidence of meningococcal disease by age , United States, 1999-2008

24. MCV4 Side effects include: Erythema, swelling and induration Guillain-Barre – 17 reported cases from March 2005 – September 2006. GBS incidence estimated at 0.20 per 100,000 person months after vaccine compared to 0.11 per 100,000 person months among 11-19 year olds generally.

25. Hepatitis A Vaccine In May of 2006 the ACIP broadened its recommendations for the use of Hep A vaccine to include all children between 1-2 years of age. The use of Hep A vaccine is also recommended for high risk groups including travelers to endemic areas, MSM, drug users, persons with chronic liver disease, those with clotting factor disorders

26. Human Papillomavirus • The most common sexually transmitted infection in the United States (6.2 million new cases annually). • HPVs are non-enveloped double stranded DNA viruses of over 100 types including several (16,18,31,33,35, and others) detected in 99% of cervical cancer cases. • Risk of HPV associated with number of sexual partners, partner sexual behavior, and immune status.

27. Human Papillomavirus • Most infections are transient, asymptomatic and clear within 1-2 years • Of the 6.2 million new cases per year, about 74% occur in women 15-24 • Acquisition occurs soon after sexual debut • Prevalence of HPV 16 may be as high as 40% • Consistent condom use may help prevent acquisition

28. Human Papillomavirus Vaccine Two HPV vaccines have been licensed by the FDA for use in girls: • A quadrivalent vaccine was approved in June 2006 (HPV4, Gardasil, Merke and Co.), and • A bivalent vaccine was approved in 2009 (HPV2, Cervarix, GlaxoSmithKlein). As of 2011, the quadrivalent vaccine is now recommended for boys as well

29. HPV Vaccine • Quadrivalent HPV vaccine (Gardasil®) targets HPV types 6, 11, 16 and 18 • Bivalent HPV vaccine (Cervarix®) targets HPV 16 and 18. • HPV types 16 and 18 cause approximately 70% of cervical cancers and types 6 and 11 cause approximately 90% of genital warts • Both vaccines are administered in 3 doses with 2nd and 3rd doses given 2 and 6 months after the first dose • Combined protocols indicate an efficacy of 98-100% in the prevention of CIN 2/3, AIS or genital warts caused by HPV 6, 11, 16 and 18.

30. Case # 2 In December of last year a mother comes into your office with her 4 month old infant daughter who is due for her health care maintenance visit. She brings along her 3 year old son as well. He has not yet received his flu vaccine for this year but did receive it last year. You advise this mother that:

31. Influenza Vaccine • Both children should receive seasonal flu vaccines; • Neither child should receive seasonal flu vaccine; • The three year old should receive seasonal flu vaccine but the four month old should not; • The 4 month old infant should receive seasonal flu vaccine but if the three year old gets a rash from eggs he should not receive it this year; • The three year old needs two doses of the seasonal flu vaccine because he is less than 9 years old.

32. Influenza Vaccine • Both children should receive seasonal flu vaccines; • Neither child should receive seasonal flu vaccine; • The three year old should receive seasonal flu vaccine but the four month old should not; • The 4 month old infant should receive seasonal flu vaccine but if the three year old gets a rash from eggs he should not receive it this year; • The three year old needs two doses of the seasonal flu vaccine because he is less than 9 years old.

33. Influenza Vaccine • Influenza vaccine risk factors now include children with compromised respiratory function or children that have an increased risk of aspiration. • ACIP recommends immunizing all children 6 months to 18 years of age. Previously unvaccinated children 6 months to 8 years of age should receive 2 doses of this vaccine. • Available as Trivalent inactivated vaccine (TIV), or Live Attenuated Influenza Vaccine (LAIV) • Those with reported egg allergy may receive the vaccine unless they have had severe reactions (anaphylaxis)

34. Breastfeeding

35. Case # 1 A female infant presents for her two week check-up. She was born after a 38 week uncomplicated pregnancy via spontaneous vaginal delivery at a birth weight of 3 kg. Her mother is breastfeeding and asks whether breast milk alone is sufficient for her baby. What advice should you give her?

36. True or False? • The baby should receive oral iron supplements for the first 6 months of life. • The baby does not need vitamin K after birth so long as the mother is taking oral Vitamin K. • Starting shortly after birth, the baby will need 400 IU of vitamin D daily while she is exclusively breastfed.

37. True or False? • The baby should receive oral iron supplements for the first 6 months of life. • The baby does not need vitamin K after birth so long as the mother is taking oral Vitamin K. • Starting shortly after birth, the baby will need 400 IU of vitamin D daily while she is exclusively breastfed.

38. Question # 1 False

39. Iron • Iron stores at birth are proportional to birth weight or size. • Iron stores for term infants are sufficient to meet needs for the first 4-6 months of life. • Breast milk contains <0.1 mg/100cc of iron but it is in a highly bio-available form (50% of it is absorbed compared to 4% of iron in iron-fortified formulas). • Infants’ adequate intake of iron is approximately 0.27 mg/day for the first 4-6 months of life.

40. True or False? • The baby should receive oral iron supplements for the first 6 months of life. • The baby does not need vitamin K after birth so long as the mother is taking oral Vitamin K. • Starting shortly after birth, the baby will need 400 IU of vitamin D daily while she is exclusively breastfed.

41. Question # 2 False

42. Vitamin K Vitamin K is a fat soluble vitamin necessary for the posttranslational carboxylation of glutamic acid residues of coagulation proteins Factors II, VII, IX and X. lpi.oregonstate.edu/infocenter/vitamins/vitamink/kcycle.html

43. Vitamin K • Breast milk has inadequate amounts of Vitamin K to satisfy infant requirements. • All breastfed infants should receive 0.5 - 1.0 mg of Vitamin K IM after the first feeding and within the first 6 hrs of life. • Oral Vitamin K may not provide the stores necessary to prevent hemorrhage in later infancy and is not recommended at this time.

44. True or False? • The baby should receive oral iron supplements for the first 6 months of life. • The baby does not need vitamin K after birth so long as the mother is taking oral Vitamin K. • Starting shortly after birth, the baby will need 400 IU of vitamin D daily while she is exclusively breastfed.

45. Question # 3 True

46. Vitamin D • Vitamin D (calciferol) is available from certain dietary sources and can be synthesized in skin upon exposure to UV light. • Adequate intake of vitamin D for infants is 400 IU per day as per recent AAP guidelines (2008). • Vitamin D content of human milk is low (22 IU/L).

47. Vitamin D • Breastfed infants should receive supplements of 400 IU of vitamin D per day so long as the daily consumption of vitamin D-fortified formula or milk is below 1,000 ml. • The recommended routine use of sunscreen in infancy decreases vitamin D production in skin.

48. Case # 1 (cont’d) On further review of the mother’s history you discover that she is CMV positive, is taking anti-hypertensive medications, and has resumed her half-pack per day cigarette consumption since the baby was delivered. When asked whether any of these factors present a problem for her continuing to breastfeed, what should you advise her?

49. Breastfeeding and viruses Viruses can be transmitted into human milk but only the presence of certain viruses in the mother are contraindications to breasteeding in the United States. These include: HIV-1, HIV-2, HTLV-1, HTLV-2 and HSV if there are lesions present on the nipple. Hepatitis B, Hepatitis C, CMV, and rubella are not contraindications for breastfeeding.

50. Breastfeeding and medications Like viruses almost all medications taken by the mother are excreted into breast milk but only a very few are contraindications to breastfeeding. These include: Radioisotopes, anti-metabolites or immunosuppressive agents, lithium, chloramphenicol, iodides, bromocriptine, and ergot alkaloids.