Primary Care Midterm

immunzation

process of developing immunity to a disease

vaccination

process of introducing a pathogen into the body to stimulate an immune response

immunogenicity

ability of a vaccine to trigger an immune response

efficacy

extent to which the vaccine produces a beneficial response in ideal conditions

effectiveness

extent to which the vaccine produces a beneficial response under real-life conditions

conjugate vaccines

pathogens modified with proteins to be recognizable by immune system

—conjugate proteins help break down polysacharide coating so body can recognize/respond

eg. Hib, PCV

inactivated vaccines

killed pathogens, prevents pathogens from mutating back to active state

more stable and safer

weaker activation of cellular and antibody response, requires more doses

eg. Dtap, IPV

live attenuated vaccines

live microbe-attenuated to reduce virility

strongest response, only need 1-2 doses for lifelong immunity

rare risk of disease state

contraindicated in immunocompromised kids

eg. varicella, mmr, OPV

VFC program

ACIP-recommended vaccines free of cost for children <19 years of age

must be medicaid eligible or uninsured

ACIP

body that makes recommendations to CDC director on immunizations for all ages

CDC

publishes annual recommendations for routine vax schedules

RFK June 2025

removed all members of ACIP, appointed 8 nenw members

Trump 2025

fires CDC director

FL surgeon general 2025

proposed ending state vaccine mandate

2025-2026 acip updates

changed focus from controlling preventable disease to evaluating vax safety

CDC director responsible for governance

no more scheduled meetings

• thimerosal containing multidose flu vax removed

• MMRV eliminated as option for first dose for children <3 years

• Hep B birth dose changed to “shared decision mkaing” for newborns of HB neg moms

  • CDC removed hep A, B, meningococcus, rotavirus, RSV, flu, COVID from routine ped vax recommendations

Hep B vaccine

3 dose series: birth, 1-2 months of age, 6-18 months of age

Energix-B, Recombivax-B

Transmitted through body fluids—liver disease/cancer and death

*doesn’t cause fever in newborns

**catch-up: minimum 4 weeks between 1 and 2

minimum 8 weeks between 2 and 3, minimum 16 weeks between 1 and 3

Pediarix

Dtap, IPV, Hep B

RSV vaccine (nirsevimab)

• newborn-8 months of age born in RSV season

• monoclonal antibodies

• alternative for maternal vaccine between 32-36 weeks gestation

• Beyfortus (50 ml <5kg; 100 ml >5 kg) or Enflonsia (not weight based)

• fever, cough congestion, bronchiolitis

  • greates risk for panea in infants <2mo or preemies

PCV

• 4 dose series: 2, 4, 6, 12-15 months

• may be given as young as 6 weeks—high risk

• Prevnar (PCV 20)

• pneumococcal disease caused by streptococcus pneumoniae—>AOM, pneumonia, meningitis, sepsis

PPSV23

• Pneumovax

• Children > 2 years with chronic medical conditions or who are immunocompromised

• CKD, diabetes, sickle cell, HIV, malignancy, cochlear implants

  • *functional asplenia from sickle cell—encapsulated bacteria (s pneumionae and Hib type B)

DTAP

diptheria and tetanus toxoids, acellular pertussis

5 dose series: 2, 4 6, 15-18 mo, 4-6 years

*plus Tdap at 11 years

containdicated with recent cerebral edema

Vaxelis

DTAP, IPV, Hib, Hep B

Pentacel

DTAP, Hib, IPV

Pediarix

DTAP, IPV, Hep B

Kinrix, Quadracel

DTAP and IPV

Adacel

stand alone DTAP

boostrix

stand alone TDAP booster

DTAP patho

diptheria—strains of bacteria release toxin, causes a biofilm that coats mucosal surfaces

tetanus—gram positive spore forming bacteria that creates neurotoxin tetanospasmin; causes paniful muscle spasms, difficulty breathing/swallowing, seizures

pertussis

• catarrhal stage—first 1-2 weeks, mild URI and cough, infants may experience apnea

• paroxysmal stage—1-6 weeks, paroxysms, whooping cough, color change

• convalescent stage—weeks to months

HiB

4 dose series: 2, 4, 6, 12-15 months

max age for admin is 71 months

ActHIB, PedvaxHIB, component of Pentacel

conjugate vaccine

gram-negative bacteria, encapsulated—>AOM, pneumonia, epiglottitis, meningitis, arthritis, sepsis

S. pneumoniae and HiB most common causes of meningitis in kids <5 before vax

IPV

4 dose series: 2, 4, 6-18 mo, 4-6 years

killed polio—not as effective as OPV, but adequate in non-endemic areas, no risk of VAPP

Ipol-stand alone IPV, also part of Pentacel, Pediarix, Vexalis, Kinrix, Quadracel

spread via food, water, resp. droplets—>fever, fatigue, headache, nausea, vomiting, sore throat, myalgias, paralysis

ipol

stand alone IPV

OPV

live attenuated virus, primarily used in endemic areas

risk of VAPP

if child immigrates and has hsitory of OPV, requires full IPV series

Rotavirus

2-3 dose series: 2, 4, *6 months

Rotarix-RV1: 2 and 4 months, monovalent of live attenuated human strain, higher immediate IgA but waning at 2 years

Rotateq-RV5: 2, 4, 6 months, pentavalent live attenuated human strains, lower immediate IgA, better immunity at 2 years

Disease: viral gastroenteritis, severe diarrhea and dehydration

***do not give with hx or intussusception

immunocompromised family should not change diaper for 10 days bc of viral shedding

MMR

2 dose: 12 months, 4-6 years

can give >6 months if traveling to high risk area, require full series despite early dose

can be given as prophylaxis or post-exposure for up to 72 hours after known exposure

live-attenuated virus; measles rash 10-14 days post injection

subQ

MMR II or MMRV (combo with varicella)

MMRV

MMR and varicella combo

only for children 4 years+ d/t risk of febrile seizure

MMR patho

measles—high fever, rash, cough, congestion, potential for AOM, pna, encephalitis, cephalocaudal rash, koplik spots

mumps—fever, headache, parotidits, can cause orchitis, oophoritis, pancreatitis, hearing loss, meningitis, miscarriage

rubella-rash, fever, congestion, headache, sore throat, myalgia, arthritis, birth defects/stillbirth

varicella

2 dose series: 12 months, 4-6 years

postexposure 96hrs-10 days after exposure

live attenuated, may have rash 7 days later

subq

Varivax, Proquad (MMRV combo)

Varicella disease—fever and progressive rash, can cause pna, HSV encephalitis, Reye’s

**must be stored frozen, must be given with MMR and/or other vax, no other live vax for 1 month, cannot give to immunocompromised or kid with transfusion/IG therapy wihtin 5 months

Hep A

2 dose: 12-23 months of age, spaced at least 6 months apart

Havrix, Vaqta

hep a disease—flu like symptoms, abd pain, liver issues, fecal-oral

Havrix

Hep A

Vaqta

HepA

Proquad

MMRV

Varivax

varicella

HPV

2-3 dose series: as young as 9 years of age, 2 doses if start before 15, 3 dose after 15 years

Gardasil 9—9 valent: 6 and 11 warts, 16 and 18 cervical cancer, 5 other strains high risk

**dizziness and syncope post-admin, have patients stay seated or supine 5-10 mins

Gardasil 9

HPV

Meningococcal

MCV AWY-2 dose series at 11 and 16

Men B—shared decision making for high risk adolescents

ACWY (MenQuadfi, Menactra, Menveo); Men B (Trumenba, Bexsero), MenABCWY (Penbraya, Penmenvy—for patients 10-25)

Meningococal disease: fever, fatigue, headache, photophobia, nucchal rigidity, purpuric rash, sepsis

***contraindicated in kids with hx of guillan barre

Flu vaccine

sep-april annually

children 6 months and older, first dose requires booster in 1 month if less than 8 years old

Trivalent (2 type A, 1 type B) or quadvalent (2 type A, 2 type B)

all brands have Flu in them

**do not administer if history of guillan barre, febrile in last 24 hours, or moderate to severe illness

egg free prep for children with severe egg allergies

MenQuadfi, Menactra, Menveo

MCV ACWY

Trumenba, Bexsero

Men B

Penbraya, Penmenvy

MenABCWY

flu disease

respiratory virus

those with chronic condiitons at higher risk-**asthma

complications inc pna, AOM, sinusitis, dehydration

antigenic drift (small changes) and shift (major changes causing pandemic level strains)

COVID vaccine

6 mo-23 mo with risk of severe disease should get vax, previously vax should get booster

6mo-18 years: moderately or severely immunocompromised should get 2 doses

2-18 years should get 1 dose if high risk, resident of congregate setting, never vax before, or have high risk household contacts

2-18 years with no risk factors can get 1 dose if parents want

vaccine adjuvants

chemicals added to vaccines to enhance the magnitude and durability of the immune response—do not themselves confer immunity

aluminum salts—vaccines with subunit antigens or toxoids (DTAP, TDAP, hep A/B, Hib, HPV)

live vaccines do not contain adjuvants

vaccine preservatives

help prevent microbial contamination

all pediatric vaccines are offered thimerosal free

general contraindications for vaccine admin

acute illness

febrile illness within past 24 hours

trauma/non-intact skin at injection site

previous allergic reaction to vaccine or vaccine component

hypersensitivity to neomcyin

DTAP, IPV, Varicella contraindicationhy

allergy to streptomycin, polymixin B

contraindication to IPV

allergy to baker’s yeast

contraindicated to Hep B

allergy to gelatin

contraindicated to MMR, varicella

Criteria for early discharge

• uncomplicated pregnancy/delivery course

• 38-42 weeks gestation, AGA

• VS stable for 12 hours prior to discharge

• voiding and stooled at least once

• normal physical exam

• no risk for EOS (gestational age, maternal fever, ROM, maternal GBS, intapartum antibiotics, infant stability)

• at least 2 successful feedings

• no excessive bleeding at circ site

• maternal and neonatal labs reviewed (syph, gonorrhea/chlamydia, HbsAG, HIV; DAT, bilirubin, NBS)

• Hearing screening

• CHD screening

  • Vitamin K, erythromycin, Hep B, RSV vaccine (Nirsivimab)

OAE

hearing test for well babies

ABR

hearing test for neonates in NICU, evaluates whole auditory pathway

abrysvo

RSV vax given to mom during pregnancy

Routine well-visits in first year of life

newborn

2 week

4 week

2 month

4 month

6 month

9 month

12 month

weight gain and hydration

expected loss up to 10% of BW

should regain by 7-14 days

gain 0.5-1oz/day

double weight by 4 months, triple by 1 year

100-120 kcal/kg/day

1 wet diaper for every day of life, up to 6 DOL

1 wet diaper every 6 hours

Stool changes: meconium—light brown-green—>yellow seedy (should stool at least once a day with evidence of transition)

Infant care

sponge bath until umbilical stump falls off

keep cord clean and dry

petroleum jelly on circ site with diaper changes

sleep 14-17 hours/day, wake every 2-3 hrs overnight to feed until back to BW

car seat guidance

rear facing, length limits per manufacturer

clip at nipple line

shoulder straps without an inch to pinch

no heavy jackets

anticipatory infant guidance—health promotion

ER—>difficult to rouse, rectal temp <95 or >100.4

safe sleep/SIDS prevention (ABCs of sleep, sleep at parent’s bedside until 6 months, reduce smoke)

breech delivery considerations

hip ultrasound at 6 weeks of life

macrocephaly consideration

HC > 95% requires head ultrasound

Newborn screening

errors of metabolism, endocrine disorders, hemoglobinopathies, hearing, CHD

newborn screening disorders

sickle cell

hearing loss

CF

congenital hypothyroidism

PKU

CAH

galactosemia

MSUD

PKU

PAH enzyme deficiency

failure to convert phenylalanine to tyrosine

sx: developmental delay, intellectual disability, seizures, autism, microcephaly, hypopigmentation and eczematous rashes

tx: diet restriction of phenylalanine by 3 weeks of age (alternate breastfeeding with phenylalanine free formula)

Congenital hypothyroidism

screened via TSH, if high, repeate NBS or thyroid studies

sx: devo delay and neuro abnormalities

tx: l-thyroxine within first 3 mo of life

galactosemia

inability to metabolize galactose, results from three types of enzymatic deficiencies

GALT (type 1)

GALK (type 2)

GALE (type 3)

sx: lethargy, feeding intolerance, vomiting, hyperbili, liver dysfx, ecoli sepsis

tx: lifelong galactose and lactose restriction—switch to soy-based formula

untreated disease leads to liver failure, brain damage, speech/behavior problems, death

MSUD

abnormal enzyme that metabolizes branched chain amino acids

altered gluconeogenesis

metabolite of isoleucine causes urine to smell sweat like maple syrup

sx: ketonuria, neonatal encepholpathy, lethargy, vomiting, dystonia, seizures, fatal wihtin 4 days

CF screening

1. IRT, pancreatic proenzyme, sensitive but not specific for CF

2. CFTR variant screening

3. Chloride sweat test is definitive

Newborn hemoglobinopathy screening

1. sickle cell

2. alpha thalassemia

3. beta thalassemia

sickle cell

(autosomal recessive)

trait =heterozygous, disease = homozygous recessive

alpha thal

(decreased production of alpha globin, results in excess accumulation of beta globin)

1. silent carrier (one affected gene)

2. trait/minor (two affected genes)

3. major (3 affected genes)

4. hydrops fetalis (all 4 affected genes)

beta thal

Decreased or absent beta globin production, results in excess accumulation of alpha globin)

• transfusion-dependent, severe anemia

• little-to-no beta globin—>little to no HbA

• becomes most prevalent 6-12 months after birth (when HbF is replaced by HbA)

• can also be nontransfusion dependent

hemoglobinopathy screening interpretation

Hb reported in order of quantity

Normal at birth: 80% HbF, 20% HbA, 0% HbA2

HbA2 production turns on shortly before birth—delay measurement until 6-12 mo

After Hb F dies off, HbA becomes dominant with small amount HbA2

potential hemoglobinopathy screening results

• FAS (sickle cell trait)—confirmatory electrophoresis and again at 9 mo

• FAC— (sickle cell trait)—no repeat testing needed, routine CBC and lead at 9 mo

• FS (sickle cell disease)—CBC and electrophoresis

• Hb Barts (alpha thal)—confirm with electrophoresis and CBC, gene studies, refer to heme; for high risk get CBC at 4-6 mo and 9 mo and repeate electro at 9 mo

• ***can have alpha thal trait with normal Hb electrophoresis

CHD examples

left to right shunt: ASD, VSD, PDA

left heart obstruction: coarctation, pre/post ductal (bicuspid vs tricuspid aortic valve), aortic valve stenosis, hypoplastic left heart syndrome

cyanotic lesions: tetralogy of fallot, TGA, pulmonary valve stenosis

most common form of CHD

septal defects

associated with other defects (trisomy 21, turner syndrome)

presentation of heart failure in CHD

• poor feeding, extended feeding time

• early fatigue, sweating with feed

• irritiability

• tachypnea, weak pulses, prolonged cap refill

• brachiofemoral delay

• hepatomegaly

bilirubin metabolism

RBC breakdown in macrophage, hemolysis

heme—>biliverdin

biliverdin—>unconjugated bilirubin

unconjugated—>conjugated bilirubin (in liver via glucoronyl transferase)

conjugated bilirubin—>gut (via common bile duct)—>excretion in stool

hyperbilirubinemia etiology

• ABO/Rh incompatibility

• Red blood cell disorders—>G6PD deficiency, PK disease, herediatry spherocytosis/eliptocytosis

• hemoglobinopathies

• birth trauma

• liver disease

• errors of metabolism

• sepsis

Jaundice that persists past early postnatal life

• breastfeeding jaundice

  • reduced supply

  • poor feeding

• breast milk jaundice

  • components of breastmilk interfere with metabolism of unconjugaed bilirubin

  • low hepatic capacity

  • immature enzymatic activity

hyperbilirubinemia clinical presentation

• jaundice (cephalocaudal progression, opposite resolution)

• scleral icterus

• lethargy

• poor feeding, poor weight gain

• dehydration

  • dry mucous membranes

  • difficult to arouse

  • decreased urine output

  • tachypnea, tachycardia

hyperbili labs

transcutaenous bilirubin

serum bilirubin: measures total (direct/conjugated and indirect/unconjugated)

blood type of infant and mother

ABO, Rh, DAT of infant blood

Hemoglobin, hematocrit, reticulocyte

management of hyperbilirubinemia

rule out pathophys

monitor total serum bili

increase feeding frequency, supplement with formula PRN

phototherapy (12-24 hours under lights, monitor for rebound hyperbili)

exchange transfusion

preterm categorization by date

34-36 6/7 weeks, late preterm

32-34, moderately preterm

28-31 weeks, very preterm

<28 weeks, extremely preterm

infant categorization by weight

LBW <2500g

VLBW <1500g

ELBW <1000g

SGA <10% weight for age

LGA > 90% weight for age

physiological handicaps of preemies

coordinated suck/swallow/breathe not in place until 34-36 weeks gestation

decreased thermoregulation

pulmonary immaturity

immature control of respiration

persistent PDA

immature cerebral vasculature

impaired GI absorption

immature renal fx

increased infection risk

immature metabolism—>hypoglycemia and hypocalcemia

premature infant screening

• vision

  • ROP, myopia, amblyopia, retinal detachment

• hearing

  • ototoxic drugs, NICU stay > 5 days requires 6 months audio exam

  • OAE and ABR

• dental

  • intubation affects development

  • delayed dental eruption

  • no fluoride for 6 months

• BP screening for HTN

preemie growth and development

• monitor by corrected age

• Fenton preterm growth charts unitl 50 weeks PMA

• Infants <1500g at birth have highest risk for devo issues

  • refer to birth to 3

preemie diet

supplement with multivitamins (ADEK, folic acid), and IRON

Iron supplementation for all preemies for first year of life (2mg/kg/day)

100-120 kcal/kg/day

may need higher cal formula—>22kcal/day (Neosure, enfacare)

premature infant immunizations

given at chronological age

key components of pediatric primary care

• first contact (prenatally or first time patient receives care)

• longtitudinal

• family orientation

• integration of comprehensive care

  • coordinate services for medical complexity

changes in history of pediatric health promo

early 1900s-eradication of communicable diseases

mid 20th century-focus on changing individual behaviors

late 20th/early 21st century—shift to sociodemographic and sociopolitical focus