1
Q
list risk factors for babies born to adolescent mothers
A
at greater risk for low birth weight…
- lower birth weight
- vertically acquired STIs (due to higher incidence of STIs in adolescent population)
- poorer developmental outcomes
- increased risk of fetal death
**infants born to adolescent mothers DO NOT have increased incidence of chromosomal abnormalities; trisomy 21 is more likely in older mothers
2
Q
what are the risks of tobacco use in pregnancy
A
maternal tobacco use increases risk for low birth weight in the fetus
NO characteristic facies associated
3
Q
is there any safe amount of alcohol in pregnancy
A
no–always risk of FAS
4
Q
what is FAS
A
distinct pattern of facial abnormalities, growth deficiency and evidence of CNS dysfunction
in addition to cognitive disability, victims of fetal alcohol syndrome exhibit other neurobehavioral deficits such as poor motor skills and hand-eye coordination and learning problems (difficulties with memory, attention and judgement)
5
Q
have distinctive effects of marijuana on the fetus been identified
A
no
6
Q
what is the effect of cocaine use on the fetus
A
causes vasoconstriction leading to placental insufficiency and low birth weight
may lead to subtle yet significant later deficits in some kids including in cognitive performance, information processing and attention tasks
7
Q
list maternal factors that limit fetal growth in utero
A
- poor weight gain in the third trimester
- preeclampsia
- maternal prescription or illicit drug use
- maternal infections
- uterine abnormalities
8
Q
list placental factors that limit fetal growth in utero
A
- placenta previa
- placental abruptions
- abnormal umbilical vessel insertions
9
Q
list fetal factors that limit fetal growth in utero
A
- fetal malformations
- metabolic disease
- chromosomal abnormalities
- congenital infections
10
Q
what does it mean for an infant to be SGA
A
newborns noted to be smaller than expected for their gestational age
not synonymous but often used interchangeably with–
fetal growth restriction
IUGR
intrauterine growth retardation
11
Q
list factors that increase the risk of transmission of HIV from mother to infant
A
- frequent unprotected sex during pregnancy (increases risk of chorioamnionitis which, along with other STIs, increase risk of HIV transmission)
- advanced HIV maternal disease (may indicate high viral load)
- membrane rupture greater than 4 hours prior to delivery if mother not on ARVs
- vaginal delivery
- breastfeeding
- premature delivery (before 37 weeks GA)
12
Q
what are the components of the APGAR score
A
Appearance (skin color) Pulse (HR) Grimace (reflex irritability) Activity (muscle tone) Respiration
score of 0, 1 or 2 for each component with final score ranging from 0-10
13
Q
define SGA
A
weight below the 10th percentile for GA
14
Q
define microcephalic
A
head circumference below 10th percentile for GA
15
Q
what is a term infant
A
born at more than 37 weeks GA
16
Q
describe the Ballard gestational age assessment tool
A
uses signs of physical and neuromuscular maturity to estimate gestational age
can be helpful if there is no early US to help date the pregnancy or if the GA is in questions because of uncertain maternal dates
17
Q
list the risks that face SGA newborns
A
- hypoglycemia
- hypothermia
- polycythemia
18
Q
why are SGA infants at risk for hypoglycemia and what are the symptoms
A
happens because-- decreased glycogen stores heat loss possible hypoxia decreased gluconeogenesis
commonly asymptomatic, though may exhibit poor feeding and listlessness
19
Q
why are SGA infants at risk for hypothermia and what are the symptoms
A
happens because-- cold stress hypoxia hypoglycemia increased surface area decreased subQ insulation
commonly asymptomatic, though may exhibit poor feeding and listlessness
20
Q
why are SGA infants at risk for polycythemia and what are the symptoms
A
happens because–
chronic hypoxia
maternal-fetal transfusion
“ruddy” or red color to skin, respiratory distress, poor feeding, hypoglycemia
*infants with slugging blood flow (hyperviscosity) because of a critically elevated Hb/Hct may have resp distress secondary to inadequate oxygenation of end organ tissues
21
Q
what are TORCH infections
A
refers to prenatal or congenital infections
Toxoplasmosis
Rubella
CMV
HSV2
now also… HIV, Hep B, human parvovirus, syphilis
22
Q
what would you expect to see on brain imaging in an infant with congenital CMV
A
- intracranial calcifications (appear as bright areas on CT)
- diminished number of gyri and abnormally thick cortex (lissencephaly/agyria-pachygyria)
- enlarged ventricles
23
Q
what does congenital CMV cause?
A
- hearing loss(–>onset of hearing loss may be after newborn period, often progressive)
- microcephaly and intracranial calcifications(–> developmental delay, cerebreal palsy; require ongoing developmental assessment)
- hepatosplenomegaly(–> can be expected to resolve spontaneously within a few weeks)
- rash
24
Q
what feeding is recommended for premature infants
A
breastmilk plus fortifier
25
how often should mothers breastfeed their babies
when there are signs of hunger (about 8-12 times a day)
26
list the absolute contraindications to breastfeeding
1. maternal HIV infection
2. active HSV lesions on breast
3. active untreated tuberculosis
4. active maternal use of some non presecription drugs of abuse
5. infants with galactosemia
27
what are the benefits to the child of breastfeeding
1. stimulates GI growth and motiblity
2. decreases risk of acute illnesses during breastfeeding period
3. lower rates of diarrhea, acute and recurrent otitis media and UTIs
4. reduction in obesity, cancer, adult CAD, allergic conditions, T1DM and IBD
5. neurodevelopmental advantage
28
what are the maternal benefits to breastfeeding
decreased risk of breast and ovarian cancers, and decreased risk of osteoporosis
29
what are 4 common signs of an inborn error of metabolism and when do they tend to present
1. anorexia
2. lethargy
3. vomiting
4. seizures
tend to present 24-72 hr after birth
30
how common are inborn errors of metabolism in the neonate
1/5 sick full term neonates without risk factors for infection will have a metabolic disorder
31
what two things are neonates routinely screened for?
metabolic disorders and congenital deafness
**2010 guidelines recommend screening all newborns for significant congenital heart defects via pulse ox
32
what metabolic conditions are screened for in the neonate
1. PKU
2. hypothyroid
3. galactosemia
4. hemoglobinopathy
5. maple syrup urine disease
6. CAH
7. CF
8. G6PD deficiency
9. toxoplasmosis
**many states now screen for more than 30 diseases using tandem mass spectrometry
33
what is the leading cause of congenital infection in the US
CMV
*more than 90% of kids with CMV infection have no clinical evidence of disease as newborns
34
symptoms of congenital CMV in the neonate
1. skin--> petechiae, purpura, ecchymosis, jaundice
2. hepatobiliary--> high direct bilirubin, elevated ALT, hepatomegaly
3. hematopoietic--> thrombocytopenia, anemia, splenomegaly
4. CNS--> microcephaly, intracranial calcifications on CT, poor feeding, lethargy, seizures, increased CSF protein
5. auditory--> sensorineural hearing loss
6. visual--> chorioretinitis
35
what does a HEADDSSS interview consist of
```
Home
Education/employment
Eating disorder screening
Activities/affiliations/aspirations
Drugs
Sexuality
Suicidal
Safety
```
36
what are the standard elements of newborn resuscitation
1. warm and dry the infant and remove any wet linens immediately --> infants have large surface area relative to body weight and can thus experience significant hypothermia from evaporation
2. stimulate the infant to elicit a vigorous cry-->helps clear lungs and mobilize secretions
3. suction amniotic fluid from the infants nose and mouth--> this clears upper airway
4. initiate further resuscitation if required--> may include blow by oxygen, PPV/bag valve, chest compressions, meds
37
what % newborns require some assistance to initiate breathing
10%
fewer than 1% require extensive resuscitation
38
how can you stabilize infants temperature
skin to skin contact with mother
radiant warmer
incubator
39
define rooting reflex
newborn turns head towards your finger when you touch his cheek
40
define sucking reflex
newborn sucks on your finger when you touch the roof of his mouth
41
define startle/moro reflex
support newborns head with one hand and buttocks with other
with head in midline position, hand supporting it quickly dropped to position approximately 10 cm below starting position and head caught in new position
newborn should flex thighs and knees, fan and clench fingers, and arms first thrown outward then brought together as though embracing something
42
define palmar and plantar grasp reflexes
newborn grasps fingers when you stroke it against the palm of his hand or plantar surface of foot
43
define asymmetrical tonic neck response
turning newborns head to one side causes gradual extension of arms towards direction of infants gaze with contralateral arm flexion like a fencer
44
define stepping response
newborns legs make stepping motion when hold him vertically above table and stroke dorsum of foot against table edge
45
ddx for SGA newborn with microcephaly and purpuric rash
1. TORCH infection
2. FAS--unlikely to be sole etiology
3. chromosomal abnormality--rash unlikely
4. prenatal tobacco exposure
5. HIV infection--most asymptomatic at birth
46
what tests are usually included in prenatal lab screening
serological screening to determine status for HIV, rubella, hep B
blood type and Rh
urine drug screen
47
test for hep B
maternal hep B surface antigen (HBsAg)
48
test for rubella
maternal and infant rubella titre
49
test for toxoplasmosis
infant toxo titre
50
test for CMV
infant urine culture
51
list methods of decreasing risk of vertical HIV transmission in positive mother
1. tx of mother with combo ARV therapy if viral load above 1000
2. cesarean delivery if possible prior to onset of labour at 38 weeks
3. no breastfeeding (if clean water is available...breastfeeding okay if poor water sources)
52
what are the routine newborn meds
vitamin K
hep B vaccine
erythromycin
53
why is vitamin K given to the newborn
IM injection to prevent hemorrhagic disease of the newborn
54
why is hep B vaccine given to newborns
regardless of maternal test resuts
immunoglobin only given to kids at risk of vertical transmission
55
why is erythromycin eye ointment given
to prevent gonococcal conjunctivitis
(chlamydia trachomatis conjunctivitis more common but occurs at 7-14 days after birth....neonatal prophylaxis does little to prevent it)
56
how do you treat congenital CMV and why
treat with either parenteral ganciclovir or oral valganciclovir
decreases progression of hearing impairment and diminished developmental impairment in infants with CMV infection and CNS involvement
treat for 6 months
(no data for tx of asymptomatic CMV infection)
57
how should congenital CMV infection be followed up
1. audiometry--> ABR or acoustic emissions until at least 12 months then age appropriate
2. ophthalmoscopy, vision function--> at newborn, 12 mo, 3 years, preschool
3. neuro exam/devel assessment by primary care physician--> at each check up until school age
4. neuro/neuropsych referral as indicated
58
list risk factors for neonatal respiratory distress
1. maternal diabetes
2. prematurity
3. maternal GBS infection
4. c section delivery
5. premature rupture of membranes more than 18 hours (prolonged PROM)
6. meconium in amniotic fluid
59
why is the following a risk factor for neonatal respiratory distress:
maternal diabetes
risk factor for respiratory distress syndrome among others
60
why is the following a risk factor for neonatal respiratory distress:
prematurity
predisposes to RDS caused by lung immaturity and lack of surfactant
most infants born at 36 weeks GA do not have RDS
61
why is the following a risk factor for neonatal respiratory distress:
maternal GBS infection
risk factor for neonatal sepsis-- > respiratory distress
62
why is the following a risk factor for neonatal respiratory distress:
c section
predisposes to transient tachypnea of the newborn (TTN)
63
why is the following a risk factor for neonatal respiratory distress:
premature rupture of membranes more than 18 hours before
risk factor for neonatal sepsis
64
why is the following a risk factor for neonatal respiratory distress:
meconium in amniotic fluid
risk factor for meconium aspiration syndrome
65
what does the apgar score describe
condition of the newborn infant immediately after birth and is a tool for standardized assessment
provides mechanism to record fetal to neonatal transition
affected by GA, maternal meds, resuscitation and cardiorespiratory and neuro conditions that may be present in the infant
poor neuro outcome is better associated with documented asphyxia--> important to obtain good arterial blood gasses to look for metabolic acidosis
apgar score alone correlated poorly with future neuro outcome of the term infant
66
can low apgar scores of 1-5 be conclusive markers or an acute intrapartum hypoxic event?
no
67
what does a neonates birth weight indicate
the health of the intrauterine environment
68
define LGA
newborns with birth weight above 90th percentile
many infants are constitutionally large but most important pathologic etiology is maternal gestational diabetes
69
what are some potential clinical problems being LGA
1. often must be delivered by c section, forceps or vacuum extraction --> assoc complications
2. birth injuries are more common such as fractured clavicle, brachial plexus injury and facial nerve palsy
3. hypoglycemia is especially common in LGA infants born to diabetic mothers
70
define appropriate for gestational age infants
between 10th and 90th percentiles
71
define SGA
1. newborns with birth weights below either the 3rd or 10th percentile
2. may have low birth weight due to prematurity but low birth weight also results from many other causes--> up to 70% of SGA infants are small simply due to constitutional factors (maternal ethnicity, parity, weight or height)
3. dx with SGA at birth
4. differs from IUGR because IUGR is dx with pregnancy
72
what are some potential clinical problems with SGA
1. temperature instability
2. inadequate glycogen stores
3. polycythemia and hyperviscosity
73
from a blood flow perspective, what 4 things are essential for a successful transition to extrauterine life at birth?
1. removal of the low-resistance placental circulation by cutting the umbilical cord
2. initiation of air breathing by the newborn infant
3. reduction of the pulmonary arterial resistance
4. closure of the PFO and PDA
74
what happens physiologically when the infant takes its first breath
first breath results in replacement of the lung fluid by air --> fluid leaves the lungs by combo of being squeezed out during uterine contractions with vaginal delivery and absorption by pulmonary lymphatics
delayed absorption of pulm fluid results in TTN
75
what causes TTN
delayed absorption of pulmonary fluid by the pulmonary lymphatics at birth
76
HR and RR in first hour of life
160-180 bpm
60-80 resps per min
77
HR and RR in second hour of life assuming successful transition
120-160 bpm
40-60 rpm
78
what conditions will cause evidence of abnormal transition to extrauterine life?
TTN
persistent pulmonary hypertension of the newborn (PPHN)--persistence of fetal circulation
79
what are the signs of respiratory distress
tachypnea
retractions
grunting
intercostal and subcostal indrawing reflect increased WOB due to decreased lung compliance (from primary lung pathology or edema)
grunting is at end of expiration--air being expelled through partially closed glottis as infant attempts to increased transpulmonary pressures, increased lung volumes and improve gas exchange
80
respiratory ddx in the cyanotic newborn
common:
TTN
RDS
```
uncommon:
pneumothorax
diaphragmatic hernia
choanal atresia
pulmonary hypoplasia
PPHN
```
81
cyanotic congenital heart defects ddx in cyanotic newborn
common:
tetralogy of fallot
transposition of the great arteries
```
uncommon:
truncus arteriosus
tricuspid atresia
total anomalous pulmonary venous return
pulmonary atresia
```
82
what is transposition of the great arteries?
defect in which the aorta and pulmonary arteries are transposed resulting in resp distress and cyanosis as the ductus arteriosus closes shortly after birth
one risk factor is being born to a diabetic omther.
often associated with other congenital heart defects--> VSD--> murmur may be heard
83
what are the general classes of defects on the ddx for a cyanotic newborn
```
respiratory
congenital heart defect
CNS
infectious
other
```
84
CNS ddx in cyanotic newborn
hypoxic-ischemic encephalopathy
intraventricular hemorrhage
sepsis/meningitis
85
infectious ddx in cyanotic newborn
septic shock
| meningitis
86
other ddx in cyanotic newborn
respiratory depression secondary to maternal meds
hypothermia
polycythemia/hyperviscosity
87
what is the primary anabolic hormone for fetal growth
insulin
88
what is the effect of maternal hyperglycemia on the neonate
high maternal serum glucose--> hyperglycemia in the fetus--> stimulates fetal pancreatic beta cells and development of hyperinsulinemia
maternal insulin does not cross placenta
89
what is the effect of hyperinsulinemia in utero?
high levels in third trimester cause increased growth of insulin sensitive organ systems (heart, liver, muscle) and general increase in fat synthesis and deposition--> increased body fat, muscle mass, organomegaly--> LGA
brain and kidneys are not insulin sensitive and thus are not large
90
how are the first trimester HbA1c levels and risk for major malformations related
directly--> higher HbA1c, higher risk
infants born to women with HbA1c levels above 12% have at least a 12 fold increase in major malformations
91
is feeding a tachynpic infant by mouth contraindicated?
no, though many are reluctant
many infants with RR 60-80 tolerate oral feeds but some may need NG or IV fluids if resp distress worsens with feeds
RR above 80 usually causes difficulty with both oral and NG feeds --> IV
92
what should a mother do if kid is unable to breastfeed because of tachypnea
pump--> ensures milk production and adequate supply when baby is better
baby should be fed expressed breast milk supplemented with formula as needed
93
do we worry about asymptomatic hypoglycemia?
yes--can have negative consequences for long term neurodevelopment
94
which infants should be screened for hypoglycemia
```
SGA
LGA
late preterm
infants of diabetic mothers
--even if asymptomatic
```
95
what is the fetal blood glucose level in utero
approximately 2/3 of moms
96
when should glucose levels stabilize in the neonate
by 3-4 hours after birth
97
what is the dubowitz score
based on infants external physical characteristics and neurologic findings
requires infant be alert and active
98
what is the ballard score
shortened version of the dubowitz score
allows assessment in extreely premature infants
99
when should the gestational age assessment be done in an infant
every neonate between 12-24 hours of life
accuracy is about plus or minus two weeks
100
clinical features of developmental dysplasia of the hip (DDH)
partial or complete dislocation
instability of the femoral head
101
what are risk factors for DDH
breech position (30-50% DDH cases occur in infants born breech)
gender (9:1 female)
family history
102
how often and for how long will the typical breastfed infant feed?
on demand every 2-4 hours for 10-15 min on each side
103
what are the recommendations regarding vitamin D on discharge
exclusively breastfed infants receive a daily dose of 400 IU of vitamin D because human milk does not provide adequate intake
should continue until child weaned to cows milk or formula with vit D
104
ddx for tachypnea in the newborn
RDS
TTN
pneumothorax
hypoglycemia
CHF
neonatal sepsis
congenital diaphragmatic hernia
severe coarctation of the aorta
meconium aspiration
maternal drug exposure
hypothermia
105
what is RDS
respiratory distress syndrome
caused by deficiency of lung surfactant and delayed lung maturation
can occur as late as 37 weeks gestation
most common cause of respiratory distress in premature infants
remember that there may be surfactant deficiency and delayed lung maturation in infants of diabetic mothers
106
what is TTN
results of delayed clearance of fluid from the lungs following birth
much more common in infants born to diabetic mothers and by c section
often considered a disorder of term infants --> TTN does occur in premature infants
107
what causes a pneumothorax in a newborn
caused by collection of gas in pleural space with resultant lung collapse
common risk factors:
mechanical ventilation
underlying lung disease--> meconium aspiration or severe RDS
relatively uncommon but important to consider
more likely in premature infant with RDS
108
what most often causes neonatal sepsis
GBS
prolonged PRO (early membrane rupture) associated with increased risk of neonatal sepsis
109
what is a congenital diaphragmatic hernia?
malformation resulting from defect in development of diaphragm
allows passage of organs from abdomen into chest cavity--> impairs lung development
most on left side
1/2200-5000 live births
110
what is the most common type of congenital diaphragmatic hernia
about 95% of all cases
Bochdalek hernia--> posterolateral
111
what are two important diagnostic clues for congenital diaphragmatic hernia
absent breath sounds or presence of bowel sounds on one side of the chest
112
what tests should be considered/ordered to evaluate a cyanotic newborn
1. arterial blood gases
2. blood and CSF culture
3. CBC with diff
4. chest radiograph
5. echocardiogram
6. oxygen challenge test
7. physical exam
8. pulse ox
113
why do you order this test to evaluate a cyanotic newborn?
| arterial blood gasses
show oxygenation, ventilation and acid base status
knowing pCO2 helps to understand cause
114
why do you order this test to evaluate a cyanotic newborn?
| blood and CSF cultures
ID infectious organisms if suspect sepsis
115
why do you order this test to evaluate a cyanotic newborn?
| CBC w diff
rule out neutropenia, leukopenia, abnormal immature-to-total neutrophil ratio, and thrombocytopenia
116
why do you order this test to evaluate a cyanotic newborn?
| CXR
integral part of initial assessment of newborn with resp distress
size and shape of heart
appearance of lungs--> pna? meconium asp? RDS? pneumothorax?
normal inspiratory films should have 8 or more intercostal spaces of lung fields on both sides
117
how many intercostal spaces should you be able to see on normal inspiratory films for a newborn
8
118
why do you order this test to evaluate a cyanotic newborn?
| echo
gold standard to diagnose CHD and PPHN
indicated when there is a persistent cyanosis and no indication of lung disease or when there are other signs suggesting heart defect (murmur, abnormal ECG, CXR with abnormal cardiac contour)
119
why do you order this test to evaluate a cyanotic newborn?
| oxygen challenge test (hyperoxia test)
can help differentiate between cardiac and pulm etiology in cyanotic newborns
oxygen will increase PaO2 of infant with respiratory etiology but will not really affect those with cardiac etiology
120
what tests should you order to evaluate a tachypnic newborn
1. CBC and diff
2. serum or plasma glucose
3. blood cx
4. CSF for culture
5. blood gas or pulse ox monitoring
6. CXR
121
why do you do this test to evaluate a tachypnic newborn?
| blood cx
may be the only sign of early sepsis or pna
122
why do you do this test to evaluate a tachypnic newborn?
| CSF for culture
part of eval of any infant with suspected sepsis or meningitis
very young infants with these conditions may have no localizing signs and only subtle clinical symptoms (i.e temp instability, lethargy, poor feeding)
123
newborn CXR with "wet" looking lungs, no consolidation and no air bronchograms--dx?
TTN
124
newborn CXR with diffuse reticulogranular appearance of lung fields ("ground glass") and air bronchograms--dx?
likely RDS
125
newborn CXR with air filled loop of bowel in the left side of the chest, displacing the heart and mediastinum to the contralateral side--dx?
diaphragmatic hernia
126
what would a newborn CXR for infant with pneumonia look like
findings may be similar to TTN on CXR but clinically more concerning for sepsis
127
TTN on CXR
"wet" looking lungs, no consolidation and no air bronchograms
128
RDS on CXR
diffuse reticulogranular appearance of lung fields ("ground glass") and air bronchograms
129
can glucometer testing be used to confirm hypoglycemia?
no--> only for screening or ongoing monitoring
low reading by glucometer should be confirmed by serum or plasma glucose
130
tx of hypoglycemic baby who is asymptomatic
oral or NG feeds
131
tx of hypoglycemia in symptomatic infant
IV infusion of dextrose started immediately
132
example of a recombinant vaccine
guardasil--HPV
133
example of a protein vaccine
Menactra--meningococcus C
134
example of a polysaccharide vaccine
quadrivalent meningococcus vaccine
135
in what population can we use polysaccharide vaccines
over 2 years old because less immunogenic
136
what type of vaccines most often contain live microorganisms
vaccines against viruses
137
why do live vaccines have a particular advantage
small dose (virus replicates in the recipient)
stimulus more closely resembles that associated with a natural infection
138
what are the challenges of live vaccines
difficult to store
may potentially be inactivated
often difficult to know who is eligible for a live vaccine--> immunocompromised patients and pregnant people may be at risk
theoretical risk of viral shedding to immunocompromised contacts of live vaccine recipients
rare but live vaccines can reproduce some of the symptoms of the disease they are meant to prevent though at lower intensity
139
list reasons you should vaccinate
1. vaccines prevent uncommon diseases-->
smallpox eradicated worldwide, polio eradicated in the west; 12 000 cases and 1000 deaths per year due to diphtheria before vaccination--now only 5 cases and no deaths per year in canada
2. vaccines prevent uncommon diseases with devastating consequences -->
tetanus --death in 50%, whereas the vaccine is 5% may have fever
3. vaccination contributes to herd immunity -->
to obtain the benefits of vaccination, more than 95% of any given population must be vaccinated; outbreaks cannot be prevented without this
4. experts recommend it--> World Bank has stated that immunizations should be first among the public health initiatives in which governments around the world invest; considered the most cost-beneficial health interventions and one of the few that systematically demonstrate far more benefits than costs
140
do to many vaccines at once overwhelm the immune system
no evidence to support this
human immune system has redundancy built in to the point that the immune response to a vaccine given in isolation is similar to that same vaccine given in combination with other vaccines
141
which vaccines are recommended by the CPS
1. 6-in-1--> diphtheria, tetanus, pertussis, polio, Hib
2. MMR--> measles, mumps, rubella
3. varivax--> chickenpox
4. pneumococcus--> 13 valent is standard, protects against strep pneumo including meningitis and pneumonia
5. meningococcus--> Men-C is standard, protects against sepsis and meningitis caused by N. meningitidis
6. HPV--> strains 6, 11, 16, 18, protects against cervical cancer and genital warts
7. rotavirus--> oral vaccine
8. annual flu vaccine for all kids older than 6 mo
142
how do you take a history relevant to vaccines
1. present health
2. PMHx
3. current meds
4. alllergies--eggs, previous anaphylaxis
5. vaccine hx
- -which vaccines
- -when
- -where
- -how many doses
143
list contraindications to vaccines
1. cold
2. moderate to severe illness with or without fever--> defer
3. egg allergy if in the vaccine
4. pregnancy--only to live attenuated
*breastfeeding and allergic conditions (eczema/asthma) are not contraindications
144
what is the anaphylaxis risk of vaccines
1. egg--> varies among populations
2. more likely to occur in vaccines for yellow fever and flu (prepared from viruses grown in embryonated eggs)
3. MMR vaccines--> may contain trace avian proteins
4. anaphylaxis after measles vaccine is rare but reported in those with egg hypersensitivity
145
what are the cardinal features of anaphylaxis
1. itchy, urticarial rash (more than 90%)
2. progressive, painless swelling (angioedema) of the face and mouth which ay be preceded by itchiness, tearing, nasal congestion or facial flushing
3. respiratory symptoms--> sneezing, coughing, wheezing, laboured breathing, upper airway swelling--> potential for airway obstruction
4. hypotension--> develops later and can progress to shock and collapse
* involves at least two body systems
* uncommon for unconsciousness to be the only symptom
146
how do you manage anaphylaxis
(perform all together or in rapid sequence)
1. call for assistance including an ambulance
2. place patient in recumbent position, elevate feet if possible
3. establish oral airway if necessary
4. admin 0.01ml/kg (max 0.5 ml) of aqueous epinephrine 1:1000 by subQ or IM injection (in opposite limb to that in which vaccine was given)--> can be repeated twice at 20 min intervals in a different limb each time
- -> 50mg/ml benadryl can be given as an addition
5. monitor vitals and reassess patient frequently
6. should be transferred to ER for observation as 20% of anaphylaxis episodes follow biphasic course with recurrence after 2-9 hour asymptomatic period
Pediatrics 2
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