Lecture 1: Models of Pediatric Primary Care & Promoting Health Equity 1. What are general criteria for effective screening tests? - (1) Condition should be an important health concern that is usually not clinically present until irreversible damage occurs (2) Effective treatment should be available (3) Simple, reproducible testing methods (4) High benefit-to-cost ratios (5) Means of follow-up for abnormal results (6) Evidence-based 2. How would you distinguish between surveillance, screening, and assessment? SURVEILLANCE: continual process of skilled observation and history-taking of all children at each healthcare visit - Identification of “at risk” individuals SCREENING: application of a test to an asymptomatic population to determine those who most likely do not have a problem from those who most likely do have a problem - Criteria: - Condition should be an important health concern that is usually not clinically present until irreversible damage occurs - Effective treatment should be available - Simple, reproducible testing methods - High benefit-to-cost ratios - Means of follow-up for abnormal results - Evidence-based - Recommendations: - History, surveillance/screening, and physical assessment at each visit - Newborn screening - Physical measurements - Laboratory screening: Hgb, Pb, non-fasting lipid panels - Developmental / Behavioral surveillance and screening - Infancy and childhood are dynamic phases of growth and development - Neurodevelopment is sequential and predictable - AAP recommends forma screening at age 9, 18, and 30 months + regular/annual surveillance - Gross motor - Fine motor - Cognitive - Interpersonal or social - Language - Screening Tools: Ages & Stages (ASQ, ASQ-SE), SWYC (child wellbeing), M-Chat (autism), pediatric symptom checklist, CRAFFT (substance use), HEADDSS (assessment of adolescent) - Sensory screening: hearing, vision ASSESSMENT: identification of problem/diagnosis (in conjunction with family and/or child) 3. What are examples of the different levels of prevention? PRIMARY SECONDARY TERTIARY Specific protection to prevent illness or disease Immunizations Treating infants with PKU with a low phenylalanine diet to prevent complications Minimizing residual effects of illness Pediatric emergency access/referrals Reduction in risk factors Car seat laws Early treatment to prevent complications Lead abatement programs or treatment for IDA Helping to live with residual illness or chronic conditions Promotion of health and removal of barriers so that children can live up to full potential 4. When are children routinely screened for anemia, elevated lead (Pb) levels or plumbism, and dyslipidemia? - Hematocrit/Hemoglobin levels → screen for anemia and IDA (iron-deficiency anemia) - When: 12, 18, 24 months + yearly in at-risk children - Standard: - - - Hgb of 11.0 gm/dL age <3 - Hgb of 11.5 gm/dL age 3+ - WIC (women, infants, children) requires annual screening age 2-5 Lead levels → screen for elevated Pb levels and plumbism - When: 12, 24 months - Risk Factors: - Hand-to-mouth behaviors - Exposure to lead paint or dust - Standard or Acceptable Lead Level: <3 mcg/dL Lipid levels (non-fasting lipid panels) → screen for dyslipidemia - When: age 9-11; 17-21 → start at age 10 5. According to Mistry (2012), what are four core foundations of children’s health? - (1) Responsive caregiving (2) Safe and secure environments (3) Adequate and appropriate nutrition (4) Health-promoting behaviors Lecture 2: Perinatal History / Newborn Screening / Common Newborn Problems 1. What are signs of congestive heart failure in newborns? - - Assessment: - Respiratory rate and effort - Oxygen saturation - Cardiac auscultation and palpation - Brachial and femoral pulses - General color and appearance - Ability to feed and gain weight Signs & Symptoms: *main S/Sx: tachypnea, poor feeding, slow growth* - Tachypnea, difficulty breathing - Tachycardia - Slow growth, poor feeding at 3 to 6 weeks, difficulty eating or may not eat as fast or as well as other babies - Small, wasted appearance - Delays in reaching developmental milestones - Sleeping more or having less energy than other babies because their heart has to work harder - Right-Sided HF: - Liver may also be enlarged due to congestion on the right side of the heart → may be more easily palpated - There may be puffiness of the eyes or feet FETAL CIRCULATION: - Fetal circulation derives O2 + removes CO2 through the placenta Vast majority of right ventricular blood bypasses the lungs Multiple fetal shunts (ex: foramen ovale, ductus arteriosus, ductus venosus) direct blood to the aorta + ultimately the placenta to be oxygenated BIRTH CHANGES: - At birth, the placenta disconnects + lungs inflate to become source of oxygenation - Ductus arteriosus begins to close over the next few days - Foramen ovale closes - Ductus venosus closes Cardiac output is divided between both ventricles CONGENITAL HEART DEFECTS: - (1) LEFT → RIGHT SHUNTS: - - (2) LEFT HEART OBSTRUCTION: - - - (3) CYANOSIS: - - 2. What are key factors of assessment and counseling for the parent of a 3-day old who develops jaundice after 24 hours of life? - - - Etiology: - Increased rate of hemolysis - ABO incompatibility (DAT testing) - Rh incompatibility - Abnormal red cell shapes - Red cell enzyme deficiencies - Decreased rate of conjugation - Immaturity of bilirubin conjugation or ‘physiological’ jaundice - Physiological: appears on day 2-3 of life → usually expected and not considered pathologic unless other issues arise - Usually due to normal transition from the placenta removing bilirubin to the infant’s liver removing bilirubin - Typically followed up in outpatient - Pathological: occurs within first 24 hours of life → usually indicates some problem or disease process that needs to be addressed → could be an issue with liver or an ABO incompatibility - Serum bilirubin will be compared to normal value based on hours of life - Decrease in albumin binding sites - Inborn errors of metabolism - Abnormalities of excretion and absorption - Sepsis - Hepatitis - Biliary atresia Assessment → Laboratory Evaluation: - Total serum bilirubin - Blood types of infant and mother - ABO, Rh, DAT on infant’s blood - Hemoglobin, hematocrit, reticulocyte count Management: - Rule out pathophysiology - Monitor total serum bilirubin levels → higher levels at 24- and 36-hours are acceptable - Assess for yellow pigmentation in the mucus membranes and or the skin - Increase frequency of feedings - In this case, because it is over the 24-hour mark, it is most likely a feeding issue - Breast milk jaundice: condition that causes a newborn's skin to turn yellow due to a buildup of bilirubin in the blood → substances in the mother's milk prevent the baby's liver from processing bilirubin - How is the feeding going? - How many stools is the baby producing? - Phototherapy → bili lights → help break down bilirubin so it can be excreted in feces - Ensure the EYES + GENITALS are covered! - Serum bilirubin levels should be monitored during the phototherapy every 6-12 hours - Temperature + voiding patterns should be monitored closely for hyperthermia and dehydration - Exchange transfusion → used in critical scenarios usually in sickle cell anemia 3. What are important aspects of anticipatory guidance for the parent or caretaker of a thriving infant who was born premature? - - Preterm: birth before 37 weeks of gestation - Late preterm: 34w0d - 36w6d - Mid preterm: 28w - 31w - Early preterm: <28w Premature Infant by Weight: - Low Birth Weight: <2500 g - Very Low Birth Weight: <1500 g - Small for Gestational Age (SGA): <10% weight for age - Large for Gestational Age (LGA): >90% weight for age PHYSIOLOGICAL HANDICAPS OF PRETERM INFANTS: - Coordinated suck-swallow-breathe mechanism does not get established until 34-36 weeks of gestation - Decreased ability to maintain body temperature - Pulmonary immaturity - Immature control of respiration - Persistent patent ductus arteriosus (PDA) - Immature cerebral vasculature - Impaired gastrointestinal absorption - Immature renal function Increased susceptibility to infection Immaturity of metabolic processes predisposing infant to hypoglycemia and hypocalcemia CARE OF PRETERM INFANT: - - - - - - Thermoregulation - abdominal skin temperature of 36.5 ° C Careful Monitoring: - Vital signs - Pulse oximetry to measure oxygen saturation - Transcutaneous PO2 and PCO2 - Umbilical arterial catheter (UAC for arterial blood gasses and chemistries) Fluid & Electrolyte Therapy Nutrition - Feeding Progression: - Nasogastric Tube feedings - Nipple / Breast - Time to feed / Respiratory effort → should not exceed ~15 min on each breast because it expends too many calories/energy - Weight gain → goal: 15-30 g/day - Coordination of sucking-breathing-swallowing is difficult Monitor Growth & Development by Corrected Age: - Head circumference, weight, height - Infants <1500 g at birth have the highest risk for developmental issues - Neuromuscular abnormalities may resolve in time - Refer to birth-to-three for assessment and stimulation - Diet: - Encourage breastfeeding (may need augmentation) - Supplement with multivitamins (A, D, E, K, folic acid) + iron - Solids when infant (a) consumes >32 oz, (b) weighs> >6 kg, and (c) is a corrected age of 6 months Intraventricular Hemorrhage (IVH): periventricular (grade I-IV) or intraventricular bleed - Causes: hypoxia, increased cerebral blood flow, increased ICP - Assessed by serial cranial ultrasounds - Long-term implications for neurodevelopment Discharge (usually when weight ~2000-2500 g) → NICU Guidelines: - When infant can eat and take medications orally - Show consistent weight gain: 15-30 g/day - Maintain normal body temperature in open crib - No significant apnea or bradycardia - Parents are ready to care for infant: home safety, support (especially for multiples) Screenings: - Vision: retinopathy of prematurity (ROP), amblyopia, retinal detachment - Retinopathy of Prematurity - Risk of retinopathy is inversely proportional to gestational age - Higher PO2 of room air suppresses normal retinal vessel growth - Balancing act of need for O2 vs stimulation of retina - Need for ophthalmoscopy by skilled ophthalmologist - Laser surgery + corrective lenses may help sight - - - - Amblyopia (lazy eye): vision disorder that occurs when the brain + one or both eyes don't work together properly → results in decreased vision in one or both eyes, even though they may appear normal in other ways Hearing: newborn hearing screening done prior to discharge → there are multiple risk factors for hearing loss in preterm infants Dental: - Prolonged orotracheal intubation affects the palate + teeth - Dental eruption may be delayed - No fluoride supplementation for 6 months Cardiovascular: blood pressure screening for HTN Safety: - Car seat adjustment to prevent obstruction → test for car seat problems before discharge - General Car Seat Guidelines: - Blanket roll for lateral head + body support → should never be put behind the baby though! - Shoulder harness straps are snug at baby’s shoulders - Chest clip is in correct position at the axillary line - Blanket roll to fill space between harness buckle and infant’s groin to prevent slouching - Risk of apnea or SIDS → Rx: education → parent CPR - Sleep position → Rx: lay baby on the back for sleeping Immunizations: - Given at chronological age - Synagis for RSV protection in infants <32 weeks of age 4. What are the primary categories of inborn disorders commonly screened for in the newborn period? (A) Metabolic Disorders → ex: classical PKU - (1) Phenylketonuria (PKU): rare, inherited metabolic disorder that prevents the body from metabolizing the amino acid phenylalanine → amino acid disorder due to enzyme deficiency (phenylalanine hydroxylase) - Failure to convert phenylalanine to tyrosine - Screening Tests: - 1950s - early detection of PKU could prevent/minimize neurologic consequences - 1962 - bacterial inhibition assay for phenylalanine - Mid-1960s - PKU became routine newborn screening test - S/Sx: developmental delay, neurological disorders, seizures, autism - Treatment: - Phenylalanine-restricted diet by 3 weeks of age - Frequent monitoring of blood levels and diet adjustments - Outcomes: - Early Rx prevents and mitigates neurologic problems - Learning disabilities may persist - (2) Galactosemia: inability to fully break down the simple sugar galactose due to deficiency of galactose-1-phosphate uridyltransferase - S/Sx: lethargy, feeding intolerance, vomiting, hyperbilirubinemia, liver dysfunction - Treatment: - Dietary lactose restriction - Evaluate and monitor for complications → ex: sepsis, cataracts, cirrhosis - Outcomes: speech abnormalities, behavioral problems, visual/perceptual learning difficulties - (3) Maple Syrup Urine Disease (MSUD): inheritable condition that prevents your body from breaking down the amino acids leucine, isoleucine and valine → due to deficiency of ketoacid dehydrogenase → leads to accumulation of leucine, isoleucine, and valine - S/Sx exhibited by the end of 1st week of life: feeding intolerance, vomiting, lethargy - Can progress into ketoacidosis, encephalopathy, neurological impairments, and death - Specimen Collection: dried filter paper blood spots - When? → at <72 hours of age and preferably after 24 hours of protein feeding - Obtain prior to blood transfusion - Technology has improved from bacterial inhibition assays → tandem mass spectrometry → genetic sequencing (B) Hematologic Disorders → ex: sickle cell disease (C) Endocrinopathies → ex: congenital hypothyroidism - Diagnostics: measure T4/TSH levels → if low, repeat test → 10% of most cases are missed by sampling errors - S/Sx: developmental delay, neurological abnormalities - Treatment: L-thyroxine to maintain T4 levels within first 3 months of life 5. What are the primary principles of and criteria for newborn screening? - - - Principles of Newborn Screening: - Disorders not clinically present until irreversible damage occurred - Effective treatment was available - Simple, reproducible collection method - High benefit-to-cost ratio - Means of follow-up for abnormal results Criteria (HRSA): - Is the condition well-defined and detectable 24-48 hours after birth when it would not be detected clinically? - Is there a good screening test available to all with appropriate sensitivity and specificity? - Can the condition be confirmed by diagnostic testing? - Is early treatment available? - Does screening do no harm to the baby? Issues: - Addition of newer disorders (ex: muscular dystrophy, neuroblastoma) adds additional layers of complexity to an integrated system - Advances in molecular genetics - Issues related to false positives/negatives - Problems with early discharge and inadequate follow-ups - Balancing privacy rights - creating uncertainty if reliability of tests and availability of treatment if limited Lecture 3: Breastfeeding Basics - Lactation 101 1. What are the benefits of breast/chest feeding for the lactating parent and for the breastfed infant? Benefits For Lactating Parent Benefits for Breastfed Infants -Reduce risk for: Breast cancer ● Ovarian cancer ● Type 2 diabetes ● High blood pressure ● -Improved birth spacing (exclusive) -Breastmilk does not require ‘preparation’ -Debate over whether breastfeeding helps parents return to pre-pregnancy weight sooner (occurs for some people and not others) -Reduce risk for: SIDS ● NEC ● Allergies (including cow’s milk protein allergy) ● Chronic health conditions (ex: asthma, type 1 diabetes, obesity) ● -Production of early gut health/immune protection -Breastmilk contains antibodies and other living immune cells helping to strengthen infant’s immune system CAFFEINE: - Can pass from mother to infant in small amounts through breast milk - Low to moderate intake is ok! … Rx: <300 mg/day (2-3 cups of coffee) - Very high intakes of caffeine (>10 cups/day) can lead to the following S/Sx in infants: irritability, poor sleeping patterns, fussiness, jitteriness - Preterm and younger newborn infants break down caffeine more slowly - Common Dietary Sources: coffee, soda, energy drinks, tea, chocolate 2. What are symptoms of early hunger feeding cues in a newborn? - EARLY “I’m hungry” MID “I’m really hungry” LATE “I’m upset, please calm me” Stirring Mouth opening Head turning Turning head Stretching Movement Hand to mouth Crying Agitation Turning red Easier to latch an infant at the breast with early feeding cues → more effort needed to calm infants with late cues For Parents: - Teach parents to recognize early feeding cues: - Lip smacking/lip licking - Hand-to-mouth movements - Early waking behaviors - REM sleep (light sleep behavior) - Teach parents typical feeding behaviors (frequency and duration): - - - Frequency of feeds: on-demand (ideal), typically q2-3h - Feeding should not be ‘timed and stopped’ Better to teach parents to look for nutritive vs non-nutritive feeding behaviors Offer both breasts with each feeding → alternate which side feed starts on Solid Foods: - Semi-Solid: sits, watches spoon, opens for spoon, closes lips over spoon, swallows - Thicker, Lumpier: moves food to sides of mouth, munches (chews up and down) - Lumpy, Soft: bites off food, chews (grinds jaw), closes lips around cup - Finger-Foods: picks up food with fingers/palms, puts food in the mouth, chews - Always start with rice-cereal foods first! 3. What are indicators that a two-week-old infant is getting enough breast milk? - - - - - Wet or soiled diapers: ≥1 wet diaper + 1 diaper w/ stool per day for every day old until day 4-5 - Once mature milk comes in, anticipate seeing ≥6 wet diapers + 2-3 diapers w/ stool per day - At 2 weeks of birth, stools should be yellow, seedy, and lose - Days of life should equal the number of diapers a day Rhythmic sucks and swallows - can hear baby swallow Baby’s jaw is moving when sucking at breast Baby’s behavior and length of feeding - Baby is active and alert with a strong cry - Baby is happy and sleepy after feeding - Mouth and lips are wet and pink Number of feedings during 24-hours period (usually 8-12 times or more) All babies lose weight after birth - Maximal acceptable weight loss: 10% - Weight loss >7% from birth weight may indicate possible breastfeeding problems - Babies should regain birth weight by 2 weeks (latest) Newborn Stomach: Size and Volume Milk volume consumed per feeding varies by age, and until ~4 weeks old, by weight → also varies feeding to feeding - Full-term babies take no more than 30-60 mL per feed by ~1 week of age - At ~4-5 weeks, babies reach a PEAK of 90-150 mL per feed and 900 mL (30 oz)/day Until an infant starts eating solid food ~6 months of age, the feeding volume and daily milk intake will not vary by much - Although an infant’s rate of growth slows down during the first 6 months of age, the amount of milk they need stays about the same → breast milk has the unique ability to adapt to the needs of an infant over time - Formula-fed babies, in contrast, consume more volume as they grow → greater risk for obesity 4. What is the expected pattern of weight gain in a newborn, and in an infant during the first year of life? - - - Expected Pattern of Weight Gain: - 0-3M = 30 g - 3-6M = 20 g - 6-9M = 15 g - 9-12M = 12 g - 1-3 yr = 0.25 kg - Formula-fed babies have an accelerated growth velocity compared w/ breastfed infants → no data indicating that this persists past the 2nd year Cluster feeds correlate with growth spurts - First period of 12-24 hours after delivery - 2-week growth spurt at about 10-14 days old - Common in first year: - 1-3 weeks, 6-8 weeks, 3, 6, or 9 months - 2x birth weight by 6 months - 3x birth weight by 12 months Avoid supplement without breast/breast milk stimulation 5. What practical suggestions would you make to a chest feeding parent? GENERAL SUGGESTIONS: - Join a breastfeeding support group - Newborns (0-2 months): watch for cues, calm baby, and feed in a continuous, smooth fashion → pay attention to cues of timing, amount, and tempo - Give no food or drink other than breast milk unless medically indicated - Stress importance of exclusive breastfeeding for 6 months + continuation of breastfeeding after the introduction of complementary foods - Breastfeeding should continue for at least the first year of life → if mutually desired, can go beyond first year - How to know if baby’s getting enough: - At the breast, by the diaper, by weight trends - Baby feeding at least 8x in 24 hrs - Baby’s jaw is moving when sucking at the breast - Hear baby swallowing - Baby is active and alert with a strong cry - Baby is happy and sleepy after feedings - Mouth and lips are wet and pink - Baby has enough wet and dirty diapers - Rx: antenatal hand expression if mother encounters difficulty with milk production - When to Start Bottles/Pumping: - If breastfeeding is going well, start around 3-4 weeks + 1-2x/day after breastfeeding - If breastfeeding is NOT going well, protect milk supply, pump 15-20 min, and pump whenever baby gets a bottle - Always use paced bottle feeding and slow-flow nipple - Common Problems: - Maternal sore nipples - Review latch/position - Reverse pressure softening - Nipple care: expressed breast milk, cold compress, lanolin, gel pads ‘smoothies’ - Engorgement - Prevention: feed on cue → 8-12x within 24 hours → if infant separated from mother, do milk expression - Tx: brief warmth/cold, gentle massage, hand expression, reverse pressure softening, frequent milk removal - Maternal Diet: - Increase of 330-400 kcal/day - Food in natural state, unprocessed foods - Try to refrain from caffeine - Vegans may need B12 supplementation - Multivitamin - Seafood → eat in moderation - Family Support: - Bring nursing mom food, water, snacks - Skin-to-skin time - Change diapers, clean house, manage visitors - Track feed/diapers INFANT NUTRITIONAL NEEDS: - Infants should be encouraged to eat frequently and on-demand at least 8-12x/day to decrease weight loss, decrease the need for supplements, and decrease the risk for clinically significant hyperbilirubinemia - Exclusive breastfeeding on demand should continue without addition of any other foods or liquids until 6 months of age - Complementary foods should be introduced around 6 months of age for most infants - Breast Milk Production & Intake: - By 8 days postpartum, lactating parent should be making 650 mL (21.67 oz) of breast milk per day - If exclusively pumping, have a goal of pumping 750-960 mL (25-32 oz) of breast milk per day to sustain breastfeeding and/or exclusively provide EBM (expression of breast milk) - From 1-6 months of lactation, infant should be taking in about 750-800 mL (25-26.67 oz) of breast milk per day HOW TO MAXIMIZE MILK PRODUCTION: - Skin-to-Skin Contact: - Immediately after delivery allows for uninterrupted access to the breast + promotes the innate 9 steps to encourage a successful first feed - Innate 9 Steps: - (1) Birth cry: The newborn cries out loud to signal that they are breathing well - (2) Relaxation: The newborn relaxes after the birth cry - (3) Awakening: The newborn awakens - (4) Activity: The newborn is active - (5) Rest: The newborn rests - (6) Crawling: The newborn approaches the breast for short periods of time - (7) Familiarization: The newborn becomes familiar with the breast and nipple - (8) Suckling: The newborn self-attaches to the nipple and begins to suckle - (9) Sleep: The newborn and sometimes the mother fall into a restful sleep - Promotes bonding between parent and infant - Increases early release of lactation-supporting hormones → thus increasing milk production - Can be used ongoing after discharge and throughout lactation to help calm infant + promote ongoing successful latch and access to the breast - Feedback Inhibitor of Lactation: - Many hormones play a role in the production and release of breast milk - Feedback Inhibitor of Lactation plays a role in the “demand-and-supply” chain during breast milk production - ↓ ‘demand’/ ↓ breastfeeding/ ↓ less draining of breast ⇒ ↑ FIL in breast ⇒ ↓ milk production - ↑ ‘demand’/ ↑ breastfeeding/ ↑ draining of breast ⇒ ↓ FIL in breast ⇒ ↑ milk production - Milk Removal ⇒ Milk Production: - Milk removal tells the body to continue to make milk → remember: the breast is never ‘empty’! - Letdown: increased flow of milk triggered by breast stimulation, suckling at the breast, and breast massage - Hand expression of the milk before feeding or pumping has been shown to increase overall milk production by up to 50-80% more milk than from simply feeding or pumping to remove milk - Hand Expression Techniques: - Purpose: to capture milk and store for later use - Supplies: use a clean feeding bottle, wide-mouth jar, or bowl - (1) use moist heat (warm water, washcloth, or shower) to promote milk release (letdown) - Alternative: gently massage breast in circles + towards areola (2) shape your hand in a “C” + place thumb in 12:00 position + first 2 fingers in the 6:00 position about 1-2 inches behind the nipple (3) press your fingers and thumb back against the chest wall, trying not to stretch the skin around the nipple and areola (4) squeeze your breast gently by bringing your thumb and fingers together → avoid pulling or sliding on the breast surface! (5) compress your breast several times in this position (6) rhythmically repeat compressions, moving your thumb and fingers all the way around the breast (including areas near your chest and armpits) (7) repeat procedure with other breast (8) stop when milk slows down ENSURING GOOD LATCH: How to Achieve Comfortable Latch w/ Wide Gape (Open) Mouth at Breast - Promoting Wide Latch: - Shallow Latch: when baby does not have enough breast in their mouth to transfer milk → can lead to nipple soreness - Deep Latch: more effective; when baby’s mouth is open wide, lips flared out, and chin is touching breast → can see and hear sucking and swallowing - Promoting Asymmetric Latch: - (1) Start infant off-positioned belly-to-belly or belly-to-body with lactating parent - (2) Position the infant so that their ear, shoulder, and hip are in alignment → so the infant is facing the breast - (3) Place the infant in a ‘sniffing’ position so that their nose starts across the nipple vs starting with their mouth across from the nipple - Starting at ‘sniffing’ position will encourage a wider gape + more comfortable latch - By promoting a wide-open mouth, where infant’s chin will be in contact with the breast below the nipple and at the areola, the baby will have taken more of the nipple and areola into the mouth for a more comfortable latch DO’s DO NOT’s -Wide-open mouth latch -Lower lip should make contact w/ breast first -Upper lip should go up + around/over the nipple -Widely flanged lips -Infant’s chin should be in contact w/ breast below the nipple + at areola -Baby takes more of nipple + areola into mouth for more comfortable latch -Infant’s head should be tilted up at breast -Areola should be more visible above than below the nipple -Chin should not be tucked down or into neck when latching or while attached to breast -Infant should not look like they are sliding on/off the breast with each suckle BREASTFEEDING POSITIONS: - Promoting Nutritive Suckling: - Hands on stimulation of the breast with massage + gentle compressions while infant is latched can promote more milk transfer to the baby and more active suckling time at the breast - Active suckling will look like several sucks with a pause + swallow - S/Sx of Poor Suckling: - Clicks - Dimpling to cheeks - Infant is coming on/off the breast repeatedly - Parents often do not realize that once a newborn is at the breast, they need to continue to be held close - Even for parents who have breastfed before, it is difficult to remember the difference between a newborn vs an older infant or toddler - Each age group can present its own challenges (ex: sustaining an active latch) NIPPLE CARE: - Do not use vaseline on the nipples → if you wouldn’t eat it, it should not be applied to the breast - Expressed Breast Milk vs Lanolin vs Hydrogels - Everyone should be encouraged to use their own milk on their nipples as it contains their cells to promote healing of their own skin - Lanolin: topical ointment that can be used, similar to chapstick, on the skin of the nipple and areola - Lanolin should not be used by individuals who are allergic to wool - Other options are available if patient is sensitive to lanolin - Always use products marketed for use on the nipple alone vs other skin areas - Hydrogels: used as constant gel pad on the breast → moisture does not wash away and most products can be used/reused for ~24 hours - Lactating patients should be encouraged to follow up with their OB or with a Lactation Consultant if the nipple irritation is not improving within 24-48 hours of using any products on it - Broken skin that is not healing can be a source of bacterial or other breast infections if not addressed - Concerns of bacterial skin infection or yeast infection - Ongoing broken skin needs to be seen by a provider → may need topical treatment beyond OTC options 6. What are contraindications to human feeding? - Infants: Classic Galactosemia - Rx: use non-lactose-containing formula → either soy or elemental formula MOTHERS - CONTRAINDICATIONS: - (1) Infection with human T-cell lymphocytic virus type I or II (HTLV 1 or 2) - (2) Illicit drug use → ex: opioids, PCP, cocaine - Prenatal OPIOID Use & Breastfeeding: - Active use of substances (opioids, cocaine, phencyclidine) are considered contraindications to breastfeeding! - Potential effects on infant’s long-term neurobehavioral development - However, in most cases, it is recommended that mothers with prenatal opioid use initiate breastfeeding + exclusively breastfeed to mitigate the impact of potential withdrawal in the newborn infant - Maternal rooming-in and continued breastfeeding is desirable even if additional pharmacologic treatment is required → may depend on workplace policies - Monitor these infants for appropriate weight gain + signs of withdrawals - PCP, COCAINE: - Concern about long-term neurobehavioral development - Cannabis: Strongly discouraged but not a contraindication - METHADONE: - “Adequately nourished, narcotic-dependent mothers can be encouraged to breastfeed if enrolled in the supervised methadone maintenance program and have negative screenings for HIV and illicit drugs” - No specified methadone dose limitations - ALCOHOL: - Highest level of alcohol in breast milk presents within 30-60 min of consuming the alcoholic beverage - Up to 1 standard drink/day is not known to be harmful to the infant … especially if waiting 2 hours after a single drink to nurse or express milk - Consuming >2 standard drinks daily is discouraged! - NICOTINE/SMOKING: - Avoid second-hand smoke exposure + stop smoking during pregnancy and lactation - Second-hand smoke exposure for infant is associated with: ↑risk of SIDS, asthma, and other respiratory illnesses - If unable to quit, minimize smoking - NEVER smoke while breastfeeding! - NEVER smoke inside the home or car - Ideally, breastfeed BEFORE smoking or vaping to minimize exposure - Use of nicotine can reduce production of breastmilk + shorten the duration of lactation - Nicotine cessation products may be used during lactation - (3) Suspected or confirmed Ebola virus disease - (4) HIV + not on antiretroviral therapy and/or does not have suppressed viral load during pregnancy (at minimum throughout 3rd trimester), delivery, and postpartum - 2023: Breastfeeding with HIV w/ Undetectable Viral Load - Replacement feeding with properly prepared formula or pasteurized donor milk from milk bank can eliminate the risk of postnatal HIV transmission to the infant - Rx for people with HIV that are not on ART and/or do not have suppressed viral load - Viral suppression via antiretroviral therapy during pregnancy and postpartum can decrease risk of transmission but does not completely eliminate risk - Mothers with HIV who choose to breastfeed need close follow-up → goal is to minimize risk of transmission to infant - Does not warrant CPS - Need to stress importance of adherence to ART and sustained viral suppression Direct Breastfeeding is Contraindicated But Providing Expressed Breast Milk is Safe: - Untreated, active Tuberculosis - May resume breastfeeding once treated appropriately for 2 weeks + no longer contagious - Active case of Varicella (chickenpox) that developed within 5 days prior to delivery to the 2 days following delivery Temporary Contraindications (No Breastfeeding and No Expressed Milk): - Untreated brucellosis infection - Active herpes simplex virus (HSV) infarction with lesions present on the breast - However, it is ok to breastfeed directly from the unaffected breast if lesions on affected breast are covered completely to avoid transmission - MPox virus infection - Certain medications → ex: chemotherapy - Mothers with hepatitis C with cracked or bleeding nipples should refrain from breastfeeding from affected breast or from feeding expressed milk from that breast until the nipple has healed - However, Hep C infection is not considered a contraindication - Hep B infections are not a contraindication either → Rx: initial vaccine within 12 hours of delivery - No reason to delay breastfeeding - No evidence of transmission via maternal milk Breastfeeding Myths: (things that are ok to still give when lactating but people believe are not) - Maternal use of medications or certain substances - In general, most medications are safe for breastfeeding/lactating parent → weight risks vs benefits - Need for drug? - Potential effects on milk production? - Amount of drug excreted into human milk? - Extent of oral absorption by infant? Potential adverse effects? Age of infant? - Always consider an alternative medication if original medication is less than ideal - Never just immediately recommend discontinuing breastfeeding - Radioiodine contrast agents → ex: gadolinium or iodinated contrast medium - Maternal illnesses: influenza, gastroenteritis, COVID, common cold, etc. - Breast milk provides antibodies and protecting with little to no direct evidence of virus causing infection to infants - Rx: hand hygiene or covering nose/mouth, limiting contact/exposure - Maternal breast infection → ex: mastitis - Immunizations - Live viruses in vaccines are not excreted in breast milk - All inactivated immunizations are safe - Influenza and COVID vaccine is recommended 7. What is a medical indication for the use of soy formula? - - - Medical indication: - Galactosemia - Hereditary lactase deficiency - For infants sensitive to lactase but without a true hereditary lactase deficiency best to use formula brands with reduced lactose “sensitive” versions - May also be used to treat cow’s milk allergy → mainly for economic reasons since hydrolysates are expensive - May also be recommended for acute gastroenteritis IF secondary lactose intolerance occurs - However, most can be rehydrated with human or cow’s milk Others indications: vegetarian or vegan diet (though there is no true vegan formulation) Contraindications/Not Recommended For: - Preterm infants - AVOID soy formula in PRETERM infant populations due to concern for bone health. Calcium and phosphorus are less bioavailable in soy formula - Infant fussiness or colic - Prevention of atopic disease in healthy or high-risk infants Controversy Over Safety: - In vivo and in vitro study raise possibility of estrogenic effects of isoflavones in soy formulas - Isoflavone serum levels are higher in infants fed with soy formula compared to those fed with cow’s milk or breastmilk - Animals study show that isoflavone decrease fertility - No human studies with adverse effects 8. How is the standard formula prepared and how many calories does it provide? - Total Calories: 20 kcal/oz (regular formula) - In some specialized brands, total calories: 22-24 kcal/oz - Babies need a minimum of 100-115 kcal/kg/day to gain weight 3 Formulations: - (1) powder - 1 scoop formula to 2 oz water - (2) ready-to-feed - - (3) liquid concentrate - 1 can water to 1 can formulation Steps for ALL Types of Formula: - (1) Check expiration date on label - (2) Wash the top of the container and lid before opening - (3) Wash hands with soap and water before preparing the bottle - (4) Make sure the countertop, bottle, and nipple are clean - (5) Use the exact measurements on the label - (6) Close the container ASAP - For concentrated or powdered formula with hot water: - (a) Follow the steps listed above - (b) Keep the formula lid and scoop clean. Wash them with hot water when necessary - (c) Use hot water (>158 ° F / >70 ° C) to make the formula. To do this, boil the water for 1-2 min and let it cool for <30 min after boiling - (d) Measure the required amount of hot water into the bottle. Then, add the exact amount of formula - (e) With the cap over the nipple, gently shake or swirl the bottle until the formula is mixed - (f) Cool the formula to ensure it is not too hot before feeding the baby. Put the capped bottle under cool running water or in an ice-water bath. DO NOT LET ANYTHING TOUCH THE NIPPLE, INCLUDING THE WATER! - (g) NEVER warm a bottle in the microwave! Instead, place it in a bowl of hot water or use a bottle warmer - (h) Test temperature by shaking a few drops on wrist Lecture 4: Immunizations 1. What are the routine recommendations for timing and routes of immunizations as part of the primary series (at birth, 2, 4 and 6 months)? Brief Overview: AT BIRTH 2 MO 4 MO 6 MO 12 MO HepB (Hepatitis B) (within 24 h of birth) HepB DTaP (diphtheria, tetanus, pertussis) Hib (haemophilus influenzae type b) Polio (IPV) Pneumococcal conjugate (PCV15/20) Rotavirus (RV) DTaP Hib IPV PCV15/20 RV DTaP Hib IPV PCV15/20 RV HepB (6-18 mo) Annual flu COVID-19 Hib PCV15/20 MMR Varicella HepA ***almost all these immunizations are IM injections*** EXCEPTION: Rotavirus is given PO by putting drops in the infant’s mouth Primary Series of Immunizations (Birth, 2-, 4-, 6-months) AT BIRTH Hepatitis B Vaccine IM INJECTION Brand Names: Engerix-B, Recombivax HB (in primary care settings, usually given as part of Pediarix) Indications: prevents infection caused by hepatitis B virus Particularly important for those at increased risk of exposure to hepatitis B virus → ex: baby born to parent who is infected with the virus If hep B surface antigen test is (+), also give HBIG as well as vaccine to the infant When: all ages, including newborns / birth + older → 0, 1-2, 6-18 months Common S/E: soreness/redness/swelling at injection site, irritability, fever, diarrhea, fatigue/weakness, loss of appetite, headache Transmission Route: body fluids infected with Hepatitis B enters the body of a person who is not infected Can lead to chronic hepatitis (liver inflammation), liver cancer, and death 2 MONTHS DTaP #1 (Diphtheria, Tetanus, and Pertussis) Vaccine IM INJECTION Brand Names: Vaxelis, Pediarix, Pentacel, Kinrix Indications: prevents bacterial infections diphtheria, tetanus (lockjaw), and pertussis (whooping cough) When: given as a series in infants + children age: 6 weeks to 6 years old (age <7) Primary 3-dose series: 2, 4, 6 months Booster 2-dose series: 15-18 months, 4-6 years Clinical Manifestations of Infections: Diphtheria - throat infection → thick covering that can lead to problems with breathing, paralysis or heart failure Tetanus - painful tightening (spasms) of muscles, seizures, paralysis, and death Pertussis - runny nose, sneezing, mild cough → cough can become more severe slowly Common S/E: fever, drowsiness, fussiness/irritability, redness, soreness, swelling at injection site Contraindications: Child is moderately or severely ill Swelling of brain within 7 days after a previous dose of vaccine Severe allergic reaction to previous shot HIB #1 (Haemophilus B Conjugate) Vaccine IM INJECTION Brand Names: ActHIB, PedvaxHIB Indications: prevents Haemophilus influenzae type B (HIB) invasive disease Complications of HIB disease: - Meningitis (children age <5): infection of tissue covering brain + spinal cords Can lead to lasting brain damage + deafness Pneumonia, severe swelling in throat Infections of blood, joints, bones, and tissue covering of the heart Death When: infants + children beginning at 2 months + through 18 months (ActHIB) and 71 months (PedvaxHIB) of age Primary 3-dose series: 2, 4, 6 months PedvaxHIB → Primary 2-dose series: 2, 4 months Booster 1-dose series: 12-15 months Common S/E: fussiness, sleepiness, soreness, swelling and redness at site of injection Contraindications: Child is moderately or severely ill Severe allergic reaction to previous shot Polio #1 (Inactivated Poliovirus) Vaccine IM INJECTION Brand Names: most often given as part of Pediarix or Pentacel Indications: prevents polio which can cause nerve injury leading to paralysis, difficulty breathing or death When: 6 weeks to 6 years Primary 4-dose series: 2, 4, 6-18 months, 4-6 years Last dose must be administered on/after age 4 and at least 6 months after previous dose Common S/E: redness/hardening/pain at injection site, fever, irritability, sleepiness, fussiness, crying Contraindications: Child is moderately or severely ill, including illness with a fever Severe allergic reaction to previous dose of vaccine or any component of the vaccine Allergic reaction to Abx neomycin, streptomycin, or polymyxin B Pneumococcal Conjugate #1 Vaccine (PCV15 or 20) IM INJECTION Brand Names: Vasneuvance, Prevnar Indications: prevent invasive disease caused by 13 different types of Streptococcus pneumonia Also approved for otitis media (ear infection) caused by 7 different types of this bacteria Complications of Pneumonia: infections of the blood, middle ear, meningitis, and pneumonia When: infants, children, and adolescents → ages 6 weeks through 17 years Primary 3-dose series: 2, 4, 6 months Booster 1-dose series: 12-15 months Common S/E: pain/redness/swelling at injection site, irritability, decreased appetite, fever Contraindications: Child is moderately or severely ill Allergic reaction to previous dose or component of the vaccine, including diphtheria toxoid (ex: DTaP vaccine) Pneumococcal Polysaccharide Vaccine (PPSV23) “Pneumovax” IM INJECTION Indications: Immunocompetent children and teens with underlying medical condition → ex: chronic heart disease, chronic lung disease, diabetes, CSF leakage, cochlear implants Children + teens with functional or anatomic asplenia → ex: sickle cell disease or other hemoglobinopathies, congenital or acquired asplenia or splenic dysfunction Children + teens with immunocompromising conditions → ex: HIV, chronic renal failure, malignancy, congenital immunodeficiency When: approved for age 2+ Rotavirus #1 (RV) PO droplets Brand Names: Rotarix, RotaTeq Indications: prevents gastroenteritis caused by rotavirus infection RV is the leading cause of severe diarrhea + dehydration in infants worldwide Before vaccine was created, most children were infected before age 2 When: starting at 6 weeks of age Primary Series: 2-dose: 2, 4 months 3-dose: 2, 4, 6 months Common S/E: fussiness, irritability, cough, runny nose, fever, loss of appetite Contraindications: Illness with a fever Weakened immune system because of disease Blood disorder Any type of cancer GI problems or history of intussusception Dose #2 HepB vaccine (1-2 months) 4 MONTHS 6 MONTHS Dose #2 for the following vaccines: DTaP, Hib, IPV, PCV, RV COVID-19 IM INJECTION When: ≥6 months → 2-dose primary series Flu Vaccine (inactivated Influenza Virus) IM INJECTION Brand Names: Afluria, Fluarix, FluLaval, Fluvirin, Fluzone, Quadrivalent, FluLaval Quadrivalent, Fluzone Quadrivalent Indications: different vaccines are approved for different age groups to prevent influenza disease caused by the strains of influenza virus that are included in the vaccine When: 6 months (inactivated only) Common S/E: pain/redness/swelling at injection site, low-grade fever, muscle aches, headache, fatigue, malaise Contraindications: Child is moderately or severely ill Immune system problems Guillain-Barre Syndrome (GBS): neurological disorder that causes severe muscle weakness Severe allergies to eggs or any allergic reaction to previous dose of any influenza vaccine Clinical Presentation of Influenza: Commonly called the ‘flu’ → contagious respiratory virus that can cause mild to severe illness The elderly, young children, and people with certain health conditions (asthma, diabetes, or heart disease) are at high risk for serious influenza-related complications Complications: pneumonia, ear infections, sinus infections, dehydration, and worsening of certain medical conditions such as CHF, asthma, or diabetes Dangers of Influenza: Influenza is a serious disease and people of any age can get it “Flu season”: November to April Annual vaccination = best way to reduce circulation of flu Flu viruses change yearly Immunity built from having the flu caused by 1 virus strain does not always provide protection when a new strain is circulating Immunity to the disease declines over time + may be too low to provide protection after 1 year Dose #3 for the following vaccines: DTaP, Hib, IPV, PCV, RV Dose #3 for HepB (6-18 months) 2. After the primary series, at what age can the DTaP, Hib and PCV boosters be given? - - DTaP → booster: 2-dose series given at 15-18 months of age and again at 4-6 years of age - 1st booster may be given at age 12–15 months as long as there is an interval of at least 6 months from the preceding dose - TDap Booster every 10 years (IM) Hib → booster: 12-15 months of age → administer the booster dose at least 8 weeks after the most recent Hib shot (IM) PCV → booster: 12-15 months 3. When are the MMR and varicella vaccines usually given and by what route? The hepatitis A vaccine? Measles, Mumps, and Rubella (MMR) Vaccine SQ INJECTION Brand Names: M-M-R II Indications: prevents measles, mumps, and rubella Measles: respiratory disease that causes a skin rash all over the body, fever, cough, and runny nose Can be severe → manifestations: ear infections, pneumonia, seizures, swelling of the brain Mumps: fever, headache, loss of appetite Well-known S/Sx: swelling of salivary glands → swollen cheeks + jaw Rare complications: deafness, meningitis, orchitis/infertility Rubella: aka. German Measles → fever, rash, and possibly, arthritis Infection during pregnancy can lead to fetal birth defects When: 12+ months of age Primary 2-dose series: 12-15 months, 4-6 years Common S/E: fever, mild rash, fainting, headache, dizziness, irritability, and burning/stinging, redness/swelling, tenderness at the site of injection Contraindications: Child is ill and has a fever Allergic reaction to gelatin, the antibiotic neomycin, or a previous dose of the vaccine Immunodeficiency or malignancy MMR & Autism: Autism is a common developmental disability MMR vaccine is first given at age 12-15 months and the first sign of autism often appears at 15-18 months → raised concerns about possible link between vaccine + autism Studies proved no association Autism is a genetic- or environmental-based disorder Varicella Vaccine SQ INJECTION Brand Names: Varivax Indications: prevents varicella (chickenpox) When: usually given at 12-18 months + booster at age 4-6 Needs to be given at same time as MMR or at least 1 month apart Common S/E: soreness/pain/redness/swelling at the injection site, fever, irritability, chickenpox-like rash on the body or at site of injection Contraindications: Child is moderately or severely ill, including fever Weak immune system Has received a blood or plasma transfusion or immunoglobulin within the last 5 months Takes any medications Allergies, including any life-threatening allergic reaction to gelatin or the Abx neomycin Clinical Presentation of Varicella/Chickenpox: Hepatitis A Vaccine IM INJECTION Blister-like itchy rash, tiredness, headache, fever Can be serious, particularly in babies, adolescents, and adults with weak immune systems → though less common, more serious complications include: skin infection, scarring, pneumonia, brain swelling, Reye’s syndrome (encephalopathy, liver failure) Complications of Chickenpox: encephalitis, severe staph and strep secondary infections, hepatitis, and pneumonia Brand Names: Havrix, Vaqta Indications: prevent disease caused by hepatitis A virus When: approved for people age 12+ months 2-dose given some time between 12-23 months of age with a minimum interval of 6 months Common S/E: soreness and redness at injection site, loss of appetite Contraindications: Child is moderately or severely ill Severe allergic reaction to previous shot Clinical Presentation of Hepatitis A: May be asymptomatic Young children may not have any symptoms but may be infected if the caregiver is ill May have flu-like symptoms May have jaundice, tiredness, stomachache, nausea, and diarrhea Transmission Route: most often spread by an object contaminated with feces of a person with Hepatitis A → ex: parent does not wash hands properly after changing diapers or cleaning up the stool of an infected person 4. What counseling should be given when offering the flu shot? - Recommendations for Given Influenza Season (WHO): - When: - Annual event, typically around mid-late February - Strains of influenza virus frequently changes, so yearly vaccination is needed to protect against the viruses that are most likely to cause illness each winter - ≥6 months of age - Based on anticipated strains: - Trivalent vaccines: protection against 2 influenza type A + 1 influenza type B strains - Quadrivalent vaccines: protection against 2 influenza A + 2 influenza type B strains - Live-attenuated influenza vaccine (LAIV4, ‘Flumist’) is NOT recommended for the last several seasons due to low efficacy → for 2023-2024, one is not preferred over another Influenza Vaccine-Intranasal: - Brand Names: FluMist Quadrivalent - Indications: protects against 4 different strains of influenza virus included in the vaccine - This is a nasal spray that contains a weakened form of the influenza A and B viruses - It is the only non-injected flu vaccine available in the United States - When: age 2-49 - Common S/E: runny or stuffy nose, cough - Contraindications: - Child is moderately or severely ill - Weakened immune system - Asthma or recurrent wheezing - History of Guillain-Barre Syndrome (GBS) 5. When can the HPV be initiated, and what counseling should be given? - Cervical and Anogenital Cancers: - Highest risk: HPV 16, 18 - Significant risk: HPV 31, 33, 52, 56 - HPV-related Disease (problematic without malignancy risk): - Common warts - 2, 6 - Plantar warts - 1, 2, 4 - Flat cutaneous warts - 3, 10 - Genital warts - 6, 11 Human Papillomavirus (HPV) Vaccine: - Brand Names: Gardasil and Gardasil 9, Cervarix - Indications: prevents anal cancer and associated precancerous lesions caused by HPV 6, 11, 16, and 18 - Also approved for prevention of cervical, vulvar, and vaginal cancer + the associated precancerous lesions caused by HPV 6, 11, 16, and 18 - Gardasil 9 covers 5 more HPV types than Gardasil → also prevents cervical, vulvar, vaginal, and anal cancers caused by HPV 16, 18, 31, 33, 45, 52, and 58 - Gardasil and Gardasil 9 are also approved for the prevention of genital warts caused by types 6 + 11 - When: age 9-26 - Common S/E: headache, fever, nausea, dizziness, fainting, pain/swelling/redness/itchiness/bruising at the injection site - Contraindications: (for Gardasil and Gardasil 9) history of allergic reaction to yeast or to a previous dose of vaccine 6. In addition to the HPV, what other vaccines should be given to a pre-teen child – usually at age 11? - COVID-19 and flu vaccines should also be given annually starting at age 6 months Tdap Vaccine(Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccine Adsorbed): - Brand Names: Adacel, Boostrix - Indications: prevent bacterial infections of diphtheria, tetanus, and pertussis - When: - 1 dose Tdap (adolescent booster) at age 11-12 - Pregnancy: 1 dose Tdap during each pregnancy (preferably early in gestation at weeks 27-36) - Common S/E: pain, redness, swelling at site of injection, headache, tiredness - Contraindications: - Child is moderately or severely ill - Swelling of brain within 7 days after a previous dose of vaccine - Severe allergic reaction to previous shot - Main difference: DTaP (recommended for age <7) vs Tdap (recommended for age 7+) Meningococcal Vaccine: - Brand Names: MenQuadfi, Menactra, Menveo, Trumenba, Bexsero - Indications: prevents certain types of meningococcal disease (life-threatening illness caused by Neisseria meningitidis that infects the bloodstream + the lining surrounding the brain and spinal cords (meningitis)) - Complications: brain damage or loss of limb or hearing - When: - MCV4, MenQuadfi → usually given at age 11 + booster at age 16 - Menactra → infants and children beginning at 9 months of age + adults age 55+ - Menveo → approved for as young as 2 months old (ex: infants with SCD) - Meningococcal Group B Vaccines → age 10-25; usually given at age 16 (often at same time as MCV4 booster) - Common S/E: tenderness/pain/redness/swelling at injection site, irritability, headache, fever, tiredness, chills, diarrhea, loss of appetite for a short while - Contraindications: - Child is moderately or severely ill - Severe allergic reactions to previous dose of meningococcal vaccine or diphtheria toxoid - Known sensitivity to vaccine components - History of Guillain-Barre Syndrome (GBS) 7. What immunizations are contained in Vaxelis? MMRV? Kinrix? - Vaxelis: DTaP, IPV, Hib, HepB Kinrix: DTaP, IPV - Prevents diphtheria, tetanus, pertussis, and polio in children age 4-6 (or age <7) MMRV: MMR, Varicella - aka. ProQuad → prevents measles, mumps, rubella, and varicella - Usually recommended at age 4 with separate MMR and Varivax at 12 months Pediarix: DTaP, HepB, IPV - Prevents diphtheria, tetanus, pertussis, hepatitis B and polio in children 6 weeks of age to 6 years of age (age <7) Pentacel: DTaP, IPV, Hib - Prevents diphtheria, tetanus, pertussis, polio and Hib disease in children 6 weeks of age to 4 years of age (age <5) Penbraya: MenABCWY - newly licensed; usually given at age 16 Summary of Immunizations VACCINATION MINIMUM AGE ROUTINE BOOSTER HepB Birth 3-dose: 0, 1-2, 6-18 months DTaP (diphtheria, tetanus, pertussis) 6 weeks 3-dose primary: 2, 4, 6 months 2-dose: 15-18 months, 4-6 years Hib (haemophilus influenzae type b) 6 weeks 3-dose primary: 2, 4, 6 months (PedvaxHIB) 2-dose primary: 2, 4 months 1-dose: 12-15 months Polio (IPV) 6 weeks 4-dose: 2, 4, 6-18 months, 4-6 years (last dose must be administered on/after age 4 and at least 6 months after previous dose) Pneumococcal conjugate (PCV15/20) 6 weeks (PCV15/20) 2 years (PPSV23) 3-dose: 2, 4, 6 months Rotavirus (RV) 6 weeks 2-dose: 2, 4 months 3-dose: 2, 4, 6 months 1-dose: 12-15 months IIV (inactivated influenza virus) 6 months (IIV) 2 years (LAIV4) Yearly MMR 12 months 12-15 months Varicella 12 months 2-dose: 12-15 months, 4-6 years HepA 12 months 2-dose given some time between 12-23 months of age with a minimum interval of 6 months Tdap 11 years (routine) 11-12 years MCV4 2 years 11-12 years HPV 9 years *If initial dose is given at age 9-14 → give a 2-dose series: 0 (starting date) + then 6-12 months after *If initial dose is given at age 15+ → give a 3-dose series: 0 (starting date) + then 1-2 after, and again 6 months after 2nd dose 4-6 years 16 years Lecture 5: Developmental Screening & Assessment 1. What is the general purpose of formal routine screening tests/procedures in pediatric health promotion? - Screen for developmental delays and provide guidance, help, and referrals when there is a delay Develop ongoing relationships with caregivers, and monitor development over time (including immigrants and refugees) Share the patient’s competencies as well as needs with suggestions and support for future development Witness caregiver/child interaction, praise, and educate Provide intervention opportunities for developmental concerns 2. What steps would you take if a toddler scores low on the Ages & Stages Questionnaire? - Get more data → OK to consult with a colleague for more input If sure of developmental issues: - Use screening tools to provide more standardized info; if still concerning: - Discuss with caregiver(s) - Refer to the appropriate service for the child’s age - Birth to Three Early Intervention - After 3 years → the local public school is responsible for assessment/services - If social-emotional is the main concern, seek local or online mental health services - Follow up to make sure further evaluation is done 3. At what ages does the American Academy of Pediatrics (AAP) recommend formal routine developmental screening? - Administer at 9, 18, and 24 or 30 months Specific motor evaluation at 48 months - Autism Spectrum evaluation at 18 and 24 months At any time If concerns with surveillance 4. What are the general components of assessing a child’s readiness for school? - - Developmental Screen/Surveillance Social Emotional Screening → important for school readiness - S-E screening is done up to 72 months of age: self regulation, compliance, social-communication, adaptive functioning, autonomy, affect, and interaction with people - S-E competence as child grows: self-esteem/self-confidence, self-efficacy, self-regulation, executive functioning, intrinsic motivation, conflict resolution, social and communication skills Motor Skills Evaluation 5. How should providers respond to parental concerns about their child’s development? - - Assessment: - APRN - if trained in assessment - Developmental or behavioral specialist - Geneticist - if there are genetic concerns - Psychologist - Psychiatrist - Social worker Do not wait for assessment before starting intervention: - Birth to Three, public school system, local programs, etc. - Provide suggestions to improve weak areas while waiting for assessment - - - PCP to follow up: assure evaluation is scheduled, review results and assist in finding appropriate interventions Support, monitor, screen, educate, and follow up! Concerning S-E (social-emotional) Scores in Older Children: - Review with the patient - separately from the parent - Review with parents - separately from the patient - Obtain a thorough history - Their concerns (patient and parent) - Are these new concerns? - Interventions attempted - Discuss options - ACCESS mental health – immediate - Counselor, social worker, group, psychiatrist – maybe wait - If urgent – suicidal, harm to others – refer directly to the emergency setting M-CHAT-R/F Modified Checklist for Autism in Toddlers, Revised, with Follow-up (M-CHAT-R): - 20 yes/no questions identify: #2, 5, 12 should be NO - High risk – immediate referral for full assessment ≥ 3 items refer - ≥ 2 critical items refer - Medium risk – do a follow-up interview - Low risk - rescreen at 24 months or continue to monitor 6. What is the definition of global developmental delay? - When a child takes longer to reach certain development milestones than other children their age Lecture 6: Mental Health Screening in Pediatric Primary Care 1. When assessing a child or adolescent for behavioral or physical health, how does the APRN determine whether observations and findings are within normal variation? - By gathering the following information: - Chief Complaint - History of presenting problem & current symptoms - Pediatric Symptom Checklist (PSC): - Snapshot into a child’s mood, attentional capacity, and behaviors - Youth (suggested for those age 11+) and Parent Versions - Versions with different # of total items - PSC for ages 4-18 - 35 items - children ages 6-18: ≥28 indicates high risk - 35 items - children ages 4-5 ≥24 indicates high risk - Subscales: attention, anxiety/depression, conduct - Past History (medical & psychiatric) - Substance abuse history - Medical/surgical/mental health history patient & patient’s family - Social/cultural/developmental history - Review of systems - Physical Examination/Laboratory Tests - Mental Status Exam - Suicide risk factors/protective factors - Current: suicidal ideations - Assessment 2. Examine carefully the actual symptoms of ADHD found on pages 163-164 in the main required textbook. Do you believe that these symptoms can be easily elicited from the child? What additional, essential information do you need, other than core symptoms, in an assessment of ADHD? - - ADHD: chronic neurological disorder No, they are not easily able to be elicited from a child - Internalizing S/Sx → known to individual, may or may not be observed by others → corresponds to Anxiety/Depression subscale - Externalizing S/Sx → observed by others, may or may not be interpreted as a problem to the individual → corresponds to Conduct subscale and S/Sx of hyperactivity/impulsivity ADHD Assessment - Essential Information: (a) core symptoms of ADHD + (b) functional impairments - (a) Core Symptoms: - Inattention - Careless mistakes - Difficulty sustaining attention - Seems not to listen - - Fails to finish tasks - Difficulty organizing - Loses things - Easily distracted - Forgetful - Hyperactivity - Fidgety - Unable to stay seated - Moves excessively - “On the go” - Talks excessively - Impulsivity - Blurts answers - Difficulty awaiting turn - Interrupts or intrudes on others (b) Functional Impairments: - Social relationships - Educational Performance - Workplace Performance - Parenting Skills 3. At what point should a primary care APRN seek additional psychiatric care for a child that originally presents with anxiety and appears to be struggling with more complex problems? - - Screening: - Decline in academic functioning - School avoidance - Decline in interest - Psychosomatic complaints - Bullying - in person and cyber Anxiety Circuits: - Amygdala-centered: fear → panic, phobia - Cortico-striato-thalamo-cortical: worry → anxious misery, apprehensive expectation, obsessions Anxiety: fear-driven responsivity → includes deficiencies in dampening of the amygdala stress responses by the prefrontal region - - Medication (SSRI) → decrease anxious reactivity so children can have more opportunity to learn more adaptive ways to cope with stress When a patient scores 15 (severe anxiety) on their GAD-7 screening If SSRI (second-line treatment for mild to moderate anxiety (GAD-7 5 & 10) is not working at the maximum dose, refer to psychiatry for the possible start of other medications/treatments If the patient shows no signs of improvement 4. What are suicidal warning signs and risk factors in children and adolescents? - Risk Factors: - Family history of suicide - Previous suicide attempt - History of adoption - Male gender - - - - - - Parental mental health problems Lesbian, gay, bisexual, or questioning sexual orientation Transgender identification History of physical or sexual abuse Social and Environmental Risk Factors: - Bullying - Impaired parent-child relationship - Living outside home - Difficulties at school - Neither working nor attending school - Social isolation - Presence of stressful life events - Unsupported social environment for lesbian, gay, bisexual, and transgender adolescents Adolescent Suicide: Personal Risk Factors: - Sleep disturbance - Depression - Bipolar disorder - Substance intoxication - Psychosis - PTSD - Panic attacks - History of aggression - Impulsivity - Severe anger - Pathological internet use - Non-suicidal self injury Suicide Screening: - Risk Factors: - Recent psychosocial stressors - Psychiatric diagnosis - History of psychiatric hospitalization - Family history of suicide - Recent diagnosis of chronic medical condition Immediate Risk Factors in Adolescence: - Agitation - Intoxication - Recent stressful event - >90% of adolescents who commit suicide have a psychiatric disorder before their death Warning Signs: - Impulsive behaviors*** - Acute anxiety*** - Social isolation - Changes in sleep patterns - Lack of future-oriented thinking - Suicidal planning or gesturing (actions w/ intent &/or plan) - Anger, rage Protective Factors: religion or connection between adolescents, parents, school, and peers 5. How is the CRAFFT screening instrument used? - - CRAFFT is a well-validated substance use screening tool for adolescents aged 12-21 - Score one point for each "Yes" answer. A score of 2+ indicates the need for further assessment - Use the bar chart at the top of the CRAFFT card to interpret the probability of a patient having a substance use disorder - Depending on the patient's answers and CRAFFT score, the patient may be encouraged to stop using substances, given advice about the health effects of substance use, or given resources to help them stay safe. The CRAFFT has nine questions in two sections: - # 1–3: Ask about the number of days in the past year the patient used alcohol, cannabis, or other drugs - # 4–9: Y/N questions about risk indicators or problems the patient may have experienced from alcohol or drug use 6. What are general signs/symptoms of depression across the different pediatric age groups? - Major Depressive Disorder: 5+ symptoms presented within the same 2-week period + represents a change from previous functioning → at least 1 of the symptoms is either depressed mood or loss of interest/pleasure - Depressed mood - - - Loss of interest/pleasure - Changes in sleep - Changes in appetite or weight - Changes in activity - Guilt / worthlessness - Death / suicide - Fatigue / loss of energy - Decreased focus or concentration Screening: “SIGECAPS” = SIG + Energy + CAPsules - S - sleep disorder (either increased/decreased) - I - interest deficit - G - guilt (feelings of worthlessness, hopelessness, regret) - E - energy deficit - C - concentration deficit - A - appetite disorder (either increased/decreased) - P - psychomotor retardation or agitation - S - suicidality Pediatric S/Sx of depression differ from adult S/Sx: - Infants: withdrawn & lethargic - Toddler: “clingy” and protesting - School-Age: withdrawn, irritable, NOT interested in activities - Children and adolescents are more likely to be irritable (this can replace “depressed” mood) - Depressed mood most of the day → irritable or cranky - Decreased interest/enjoyment in once-favorite activities → loss of interest, isolation from friends - Significant weight loss or gain - Insomnia or hypersomnia → excessive late-night TV or refusal to wake for school in the morning - Psychomotor agitation or retardation → talking of running away from home - Fatigue or loss of energy → persistent boredom - Low self-esteem or feelings of guilt - Decreased ability to concentrate; indecisive → poor performance in school or frequent absences - Recurrent thoughts of death or suicidal ideation or behavior - Difficulty concentrating: look for sudden decline in school performance 7. What disorder can be screened for with the Patient Health Questionnaire (PHQ-2 and PHQ-9)? - - The PHQ-2, comprising the first 2 items of the PHQ-9, inquires about the degree to which an individual has experienced depressed mood and anhedonia over the past two weeks - Its purpose is not to establish a final diagnosis or to monitor depression severity, but rather to screen for depression → purpose of the PHQ-2 is to screen for depression in a “first-step” approach - Patients who screen positive (score 3+) should be further evaluated with the PHQ-9 to determine whether they meet criteria for a depressive disorder PHQ-2 and PHQ-9 are 2 validated tools for screening adolescents for depression - PHQ-2 is a 2-question screen widely used for adult patients. PHQ-9: score of 11+ = good → cutoff point is slightly higher for adults - Depressed mood (PHQ-2) - Loss of interest/pleasure or anhedonia (PHQ-2) - Changes in sleep - Changes in appetite or weight - Changes in activity - Guilt/ worthlessness - Death/ suicide - Fatigue/ loss of energy - Decreased focus or concentration
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