1. Preventive Pediatrics
♦ Immunizations
• Indications and schedules
o Be aware of the special needs of children traveling outside the US, including immunizations and
other forms of prophylaxis, their indications and contraindications
 Most important to make sure they are up to date on their routine immunizations
 Meningococcal vaccine if travelling to areas of sub-Saharan Africa, Saudi Arabia
 Yellow fever vax if older than 9mos and going to S. America or Africa
 Typhoid if older than 2yrs and may have prolonged exposure to contaminated food in
areas endemic for S. typhi (Asia, Africa, C. America and S. America)
 Japanese encephalitis if ilder than age 1 and will be in parts of Asia for more than 1
month
 Rabies vaccine if going to areas with high endemic rates of rabies and where
immediate health care may be difficult to obtain; endemic areas include Brazil, Bolivia,
Colombia, El Salvador, Guatemala, India, Mexico, Nepal, Peru, Philippines, Sri Lanka,
Thailand, Vietnam
 Malaria ppx depends on the region of travel
∗ Should be started 1 week before going there and continued after returning
home
∗ Mefloquine if going to S. America, Africa, Indian subcontinent, Asia, S. Pacific
 Contraindicated if kids have sz d/o, psych d/o, cardiac conduction abns
∗ Chloroquine and hydroxychloroquine works for travel to areas of Mexico, Haiti,
Dominican Republic, C. America, Mid East and Eastern Europe
 Use cautiously for kids with liver d/o, psoriasis, G6PD
∗ Primaquine if going to area with malaria caused by P vivax or P facliparum for a
prolonged time
 Taken once a day and continued for 2 weeks after leaving the area
 Contraindicated if they have G6PD
o Know the indications for using hep A and hepB vaccines

2.  Hep B is universally recommended for all infants (at birth), as is Hep A (age 12 months)
 Hep A is also recommended for
∗ Travelers to countries with high hep A rates
∗ Children with chronic hep A or hep C infections or other chronic liver disease
∗ Children with clotting factor disorders
∗ Homosexual or bisexual males
∗ Persons with occupational exposure to hep A
∗ Illegal drug users
 Hep B should be given to older kids if they were born before the universal
immunization recommendation; adolescents can get a 2 dose series
o Know the indications for using meningococcal vaccine
 All 11-12 year olds
 Kids age 2-10 with terminal complement deficiency, anatomic or functional asplenia,
certain other high risk groups
 College freshmen living in the dorm, or people in other “crowded” conditions, like
military barracks
 Boosters needed for those at prolonged risk (asplenia, complement deficiency, etc)
o Know that DTaP immunization is based on postnatal age rather than on postconceptual age
o Know the indications for and the schedule for tetanus vaccine (e.g. need for rutine booster at
the time of injury)
 Tetanus vaccine should be routinely given to everyone and is part of DTaP, TdaP, Td
 Should be given at ages 2, 4, 6 and then 15-18months and 4-6 years
 For adolescents age 11-12 years another dose of Tdap or Td; adults need boosters
every 10 years
o Know when a tetanus booster is necessary
 Boosters are needed roughly every ten years
 If there is a clean, minor wound or any other wound and the pt had fewer than 3 shots
of tetanus then they need a shot
 If the wound is clean and minor and they have 3 or more tetanus shots then they do

3. not need one unless has been more than 10 years since their last one, but if the wound
is dirty or more significant then they need a shot if it has been more than 5 years since
the last one
o Know the recommendations and the schedule for varicella vaccine
 Given to all kids at one year of age and then a second dose given later in childhood, at
least 3 months after the first shot
 Efficacious 80% of he time after one dose
 A mild rash can develop in 5% of kids 4-6 weeks after the shot, if they develop within
2-3 weeks after the shot they should be considered to have wild type and treated as
such
 The rash from the vaccine is as contagious to unvaccinated kids as the wild type
• General contraindications
o Understand that not all egg based vaccines are contraindicated for children after anaphylactic
reaction to eggs
 Egg containing vaccines are: influenza, MMR, rabies and yellow fever vaccines
 Measles is okay to give b/c of the medium on which it is grown, it can be given as a
whole dose
 Flu can be given if the reaction was not anaphylactic and if the benefit would outweigh
the risk (i.e. the kid has asthma and risk of complications if they got flu would be
higher), it can be given at a dose of 105, monitor the kid and then give the rest of it
o Know when it is appropriate to administer measles vaccine to a patient with egg allergy
 The AAP Red Book states that all children who have egg allergy routinely may be given
MMR
o Know that patients with a h/o anaphylactic reaction to eggs should generally not receive
inactivated influenza vaccine
 They shouldn’t get the shot or the intranasal
• Prevention by active immunization
o Know which serotypes are contained in meningococcal vaccine
 Meningococcal serogroups A, C, Y and W-135
 Serogroups B, C, and Y are the predominant cause of invasive disease in the US, in
developing countries it is A and C

4.  Serogroup B has been difficult to create a vaccine against; it causes >50% of the cases
among kids under age 1year
o Know which newborn infants are at greatest risk for infection with HBV and the potential
consequences of such infection
 All pregnant women should be routinely screened for hep B surface antigen (HBsAg); if
they are positive then there is higher likelihood of vertical transmission
 Infants born oth HBsAg + moms should get both HepB and HBIg immediately after birth
 If the status is unknown, the HepB needs to be given within 12 hours after birth and
the mom’s status needs to be determined ASAP to decide whether baby also needs
HBIg
o Know that hep B vaccine is composed of recombinant DNA-produced HBsAg
o Know the recommended use of HB vaccine in premature infants
 Due to decreased seroconversion if they weigh less than 2kg, it is delayed
 Can be given when baby is one month of chronological age
 If the mom is HBsAg+ then the baby gets the vaccine regardless of weight, but if the
weight is less than 2kg this dose will not count toward the 3 total doses (gets 4 shots);
this baby would also need HBIG
o Know that the tetanus vaccine is a toxoid
 Is also safe in immunodeficient patients
o Know the appropriate use of the measles vaccine during an outbreak
 Control measures include immunization of susceptible individuals and the use of
immune globulin
 Susceptible individuals are those who lack evidence of immunity
∗ Evidence of immunity: documentation of two doses of MMR after the first
birthday, serologic evidence of immunity, documentation of measles dxed by a
physician, or birth before 1957
 MMR given within 72 hours of exposure may provide some protection and is preferred
to immune globulin
 Monovalent measles is used for those age 6-12 months (but they would need 2 more
doses after age 12 months)
 Infants younger than 6 months are usually protected by maternal antibodies

5.  Immune globulin is recommended for susceptible household contacts not vaccinated
within 72 hours of initial exposure, provided it is given within 6 days of exposure
 If a mother has measles then all kids not vaccinated after their first birthday should get
immune globulin if they didn’t get measles vaccine after 72 hours of exposure;
subsequent doses of vaccine must then be deferred for 5-6 months
o Know that infants who were immunized for measles when younger than 12 months of age may
not be protected
o Know the contraindications of the (live virus) measles vaccine
 Contraindicated in pregnant women or women intending to become pregnant in the
next 28 days, immunocompromised persons (unless they have asymptomatic HIV or
with HIV and not severely affected), anaphylaxis to neomycin or gelatin
 OKAY to give if egg allergy (even if anaphylactic)
o Know the recommendations regarding measles revaccination
 Any child who has not received a second dose after their first bday needs to receive a
dose at age 11-12
 May need repeat dose if titers have fallen
o Know that poliovirus infection is transmissible by the fecal-oral route
o Know the risks associated with the measles vaccine in children with anaphylactic egg sensitivity
 It is safe to give them
• Catch up immunizations
o Know that rabies vaccine should be administered with rabies immune globulin
o Know the safety of rabies vaccine
o Know the immunization schedule for rabies vaccine
• Live vs killed vaccines
o Know the side effects if intravenous immune globulin
♦ Screening
• Principles of screening tests
• Blood pressure
o Know when to screen for elevated blood pressure and how to interpret the results

6. o Know the range of normal blood pressure in children of all ages
o Know that a single elevated blood pressure reading requires repeat evaluation
o Know that the blood pressure cuff size should be appropriate for patient size
o
• Hematocrit
o Know that there may be a difference between centrally and peripherally drawn hct
• Lead
o Know the screening tests available for blood lead concentration
o Understand that a screening examination for lead can be incorporated into early periodic
screening
o Recognize that children may have multiple nondietary sources of exposure to lead
o Understand that lead poisoning may be the cause of cognitive difficulty
o Know the effects of chronic mildly increased blood lead concentration
• Hearing
o Understand that conductive hearing loss results from interference with the mechanical
transmission of sound in the inner ear
o Know the natural history of conductive hearing loss
o
• Vision
• Hypercholesterolemia/hyperlipidemia
♦ Disease prevention
• Heart Disease
• Osteoporosis
o Counsel families regarding the effects of diet, exercise and smoking on the natural h/o
osteoporosis
• Respiratory Disease
o Know that passive exposure to cigarette smoke in the home increases the chances, frequency,
and duration of lower respiratory tract illness in children

7. o Know that common indoor exposures can produce respiratory symptoms: wood fires and
stoves, cooking spray, hair spray, animal dander, cigarette smoke
•
♦ Anticipatory guidance
• Safety
o Know ways of preventing head injury
o Counsel parents regarding bicycle safety
• Poison prevention
• Burns
• Know how to counsel parents regarding hot water heaters
• Bites and stings
o Instruct families regarding the acute management of sting anaphylaxis at home
o Advise a parent on the appropriate method to remove a tick from their child
• Water safety
o Know how to counsel families regarding safe boat use (e.g. flotation devices, supervision)
• Sun exposure
o Counsel parents regarding sunscreen and exposure to sun
• Firearms
o Know how to counsel parents regarding the risks of having firearms in the home
• Know the epidemiology of firearms in US households
• Identify components of an injury prevention plan for firearms in a household (locked, unloaded,
discarded)