Полезные материалы за все 6 курсов / Учебники, методички, pdf / Kaplan Pediatrics USMLE 2CK 2021

HiB Conjugated Vaccine

•Does not cover nontypeable Haemophilus

•Depending on the vaccine brand, the recommended primary series consists of 3 or 4 doses.

•After the primary series, an additional booster dose is recommended at 12–15 months of age, regardless of which regimen was used for the primary series.

•If immunization is not initiated (i.e., child is behind) until age 15–59 months, then there is catch-up (1 dose), but not given after age 5 years in normal children

•Invasive disease does not confirm immunity; patients still require vaccines if age appropriate, i.e., age <5 years.

Pneumococcal Vaccines

•Pneumococcal conjugate vaccine (PCV13)

–Purified polysaccharides of 13 serotypes conjugated to diphtheria protein

–Routine administration as a 4-dose series for all children age 15 months and younger

–If no dose given yet between age 15–59 months, then there are catch-up doses

•23-valent pneumococcal polysaccharide vaccine (PS23)—given as additional protection to the PCV13 in some high-risk children (e.g., functional/anatomic asplenia) age >2 years

•Age ≥65 years (PPSV-23)

Varicella

•Recommended at age 12 months or older for healthy people who have not had varicella illness, with second dose at age 4–6 years

•Catch-up dosing: both doses should be given for proper immunity

•May still have breakthrough varicella; milder than unimmunized, rarely spreads

•Has been associated with the development of herpes zoster after immunization (rare)

•Most people age >18 years, even without a reliable history of varicella infection, will still be immune.

MMR

•Live attenuated vaccine: issues are similar to those for varicella

•First dose given at age 12–15 months

•Second dose given at preschool age, 4–6 years

•Catch-up with 2 doses

•Documented egg allergy is not a contraindication to the MMR. MMR is derived from chick embryo fibroblast tissue cultures but does not contain significant amounts of egg cross-reacting proteins.

•HIV: varicella and MMR should be given if CD4 showing >15 CD4/total lymphocytes AND no AIDS-related illness at vaccination time

•Immunoglobulin-containing products: if given recently, must wait to administer varicella and MMR, as IG may inactivate the live vaccine

Note

Advantages of conjugated polysaccharide vaccines (HIB, PCV13, MCV4) over nonconjugated:

•Effective <2 years of age

•Effect from booster doses

•Long-term immunity

Note

MPSV4 is the older, pure polysaccharide vaccine, while MCV4 is the newer, conjugated vaccine.

Hepatitis A Vaccine

•Recommended for all children age >1 year (12–23 months)

•Two doses, 6 months apart

•Also recommended routinely for chronic liver disease patients, homosexual and bisexual men, users of illegal drugs, patients with clotting-factor disorders, and those at risk of occupational exposure

•Can give with other vaccines

Meningococcal Conjugate Vaccine (MCV4)

Administer MCV4 to

•All children at the age 11–12 visit and booster at age 16

•All college freshmen living in dormitories, if not vaccinated

•There is now a vaccine for serotype B for high risk patients and during outbreaks (status post concurrent type B outbreaks at Princeton and UC Santa Barbara)

•Meningococcal B vaccine is recommended only for those at increased risk for meningococcal B disease—persistent complement component deficiencies (C3, C5-C9, properdin, factor D, factor H); anatomic or functional asplenia,

including sickle cell disease; and those residing in a community with a serogroup B meningococcal disease outbreak per the local health department on the basis of

CDC criteria (college students not considered at increased risk since the incidence is not greater than that of the same-aged general population)

Influenza Vaccine

•Inactivated influenza vaccine (typical flu shot)

–Administered intramuscularly

–Inactivated influenza vaccine has been deemed safe in egg-allergic patients

–Given annually during flu season for children age >6 months (A strains, B strains, and H1N1)

•Live influenza vaccine

–Live attenuated vaccine has recently had only 3% effectiveness so has not been used in last 2 seasons; the AAP has stated that it may be used in 2019 season, but the preferred vaccine is the quadrivalent inactivated vaccine

•Influenza vaccine contains egg protein but studies have shown that, like reactions secondary to any component in any vaccine, there are only rare instances of severe reaction in people who truly have an egg protein allergy. As a result, the American Academy of Pediatrics states that children with egg allergy can receive influenza vaccine with no additional precautions than those considered for any vaccine. This means that for any vaccine administration, the patient should be observed postadministration and any severe allergic manifestations should be anticipated and treated appropriately with medication should they occur.

These recommendations must be read with the notes that follow. For those who fall behind or start late, provide catch-up vaccination at the earliest opportunity as indicated by the green bars. To determine minimum intervals between doses, see the catch-up schedule (Table 2). School entry and adolescent vaccine age groups are shaded in gray.

*can be used in this age group

Pediatrics λ CK 2 Step USMLE

Learning Objectives

Define physical, sexual, and psychological abuse

Describe the epidemiology of child abuse

INTRODUCTION

Table 7-1. Scope of Child Abuse and Neglect

Definitions

•Child maltreatment: abusive actions or acts of commission and lack of action, or acts of omission that result in morbidity or death

•Physical abuse: intentional injury to a child by a caregiver that results in bruises, burns, fractures, lacerations, punctures, or organ damage; may be accompanied by shortor long-term emotional consequences

•Psychological maltreatment: intentional verbal/behavioral acts or omissions such as withholding emotional responsiveness, isolating, terrorizing that result in adverse emotional consequences

•Sexual abuse: any act intended for sexual gratification of an adult

•Factitious disorder: intentionally giving poisons or toxins, or any other deceptive action to simulate a disorder

The consequences of child abuse and neglect are severe. Failure-to-thrive (FTT) (nutritional neglect) is the most common cause of underweight infants (>50% of all cases of FTT). Additionally, developmental delay and learning disabilities are common. Physical disabilities may occur, and possibly death.

Note

In all 50 states, physicians and child care providers are required to report suspected abuse/neglect. Failure to report may result in penalties or malpractice claims for damages.

•Affords lawsuit protection to those who report in good faith

•Allows for all clinical and lab evaluation and documentation without parents’ permission

Note

Certainty is not required to file a report to Child Protective Services (CPS). However,

one must determine whether parents have an understanding of disease processes and

the intellectual, emotional, economic, and physical resources to provide for the child.

Note

Battered child syndrome is suggested by bruises, scars, internal organ damage, and fractures in various stages of healing.

Epidemiology

There is a higher likelihood of abuse with caregivers who have history of abuse or violence:

•Young parental age

•Closely spaced pregnancies

•Lower socioeconomic status

•On military bases

•Spousal abuse

•Substance abuse

•Single parent (mother)

•Intellectually disabled child

•High stress level

•Preterm, low-birth-weight infants

PHYSICAL ABUSE

A 2-year-old boy presents to the emergency department with a skull fracture that the mother states resulted after he fell from the sofa onto a carpeted floor. On physical examination the child is alert. He is noted to have old bruising on the buttocks and back, as well as a cigarette burn on his palm. The mother states that the child “falls a lot” and is always touching things he should not.

Diagnosis

•When to suspect

–Injury is unexplained or implausible

–Injury is incompatible with the history given or with child’s level of development

–There are no reports of death or serious brain injury from witnessed falls <10 feet.

Clinical Findings

Bruises

•Most common

•Accidental: thin, leading surfaces overlying bone edges (e.g., shins)

•Nonaccidental: buttocks, genitals, back, back of hands, thoracoabdominal

•Shape of injury suggests object used: suspect with bilateral, symmetric, or geometric injuries

•Staging: bruises in various stages are not compatible with a single event

•Consider cultural issues, e.g., coining, cupping

Fractures

•Wrenching or pulling an extremity → corner chip or bucket handle fracture of metaphysis

•Inflicted fracture of bone shaft → more likely are spiral fractures from twisting rather than transverse from impact

•A spiral fracture of the femur before child can walk independently has usually been inflicted by someone else.

•Accidental impact rarely causes rib fracture or retinal hemorrhage in children

•Highly specific for abuse

–Rib fractures in infants

–Fractures of different stages of healing

–Bilateral fractures

–Complex skull fracture

Burns

•Cigarette burns → circular, punched-out lesions of uniform size

•Immersion burns (most common in infants)

–Glove-stocking pattern of extremity

–Dipping into bathtub water:

°Demarcation is uniform and distinct

°Flexion creases spared; hands and feet spared

°No splash burns

°Incompatible with falling into tub or turning on hot water while in tub

Intentional head trauma

•Most common cause of death

•Consider when injured infant presents with coma, convulsions, apnea, increased ICP

•A subdural hemorrhage in which there are no scalp marks or skull fracture is possibly from a hand blow.

•Retinal hemorrhages

•Shaking—acceleration-deceleration; may have no external marks; 85% associated with retinal hemorrhage

Intra-abdominal injuries

•Impacts

•Recurrent vomiting, abdominal distension, absent bowel sounds, localized tenderness, shock

•If struck with fist → row of 3–4 teardrop-shaped, 1-cm bruises in a slight curve

•May rupture liver or spleen

•Laceration of small intestine at sites of ligamental support

•Intramural hematoma → temporary obstruction

•Free air

Note

Differential Diagnosis

With osteogenesis imperfecta or severe osteomalacia, there is an increased incidence of pathologic fractures, but they are rarely of the metaphysis.

Note

Always obtain a CT scan for intracranial bleeding and an eye exam for retinal hemorrhages.