Well Child Care

allergic diseasebreast feeding may *decrease* incidence and severity of _____ _____ including *eczema, asthma, and food allergies*mother-infant bondingwhat does great feeding *promote*?convenientbreast feeding is _____- no warming of bottles, no refrigeration, no boiling water, less to carry outinexpensivewhat is an advantage financial wise for breast feeding?better nutrition_____ _____- may have less mineral but *bioavailability is high* (for example iron)contract mom's uterusbreast feeding can help _____ _____ _____ to *stop bleeding* and helps return uterus to pre-pregnancy size more rapidlyovarian cancer breast cancerbreast feeding shows a *decreased* incidence of _____ _____ and premenopausal _____ _____ in women who have nursedchildhood obesitybreast feeding shows *decreased* incidence of _____ _____ in breast fed infants according to a 1999 German study -effect was greatest in infants who were nursed *>6 months* -various other studied have shown an *increased in insulin and protein intake in bottle fed infants* -subsequent studies have also shown a decreased incidence of _____ _____ in those who were breast fedneurodevelopmentalbreast feeding can have an *improved* _____ outcome1) active disease 2) galactosemia 3) primary lactase deficiency of newborn 4) drugs4 contraindications of breast feeding?active diseasecontraindications: _____ _____ such as *TB, CMV, HIV, hepatitis, Syphillis, Herpes Simplex Virus lesions on breast*galactosemiacontraindications =: _____ which is *autosomal recessive*; pt *lack enzyme to convert galactose to glucose*primary lactase deficiency of newborncontraindications: _____ _____ _____ _____ _____- rare condition in which pt *lack enzyme* to *break down lactose into glucose and galactose*drugscontraindications: _____- street drugs, immunosuppressant, chemo, lithium, chloramphenicol, tetracyclines, anti thyroid, anti diabetic medicationsmethadonemothers on _____ for treatment without the use of other drugs including alcohol generally have *no ill effect on the baby*; if the dose if <40mgfrequentbreast feelings basics -feedings should be _____ in the beginning5 minutesbegin with _____ _____ *each breast* every 2-5hrs, ad lib -longer intervals between feedings at night (if you're lucky)8-10breast feeding: -approximately _____-_____ *feedings per day*10 minutes 15 minutes*increase feedings* to _____ _____ each on *day 2* and _____ _____ each breast after that4 minutes*80%* of milk consumed in first _____ _____; available milk within 5-7 minutesVitamin D (available as Vitamin A,D,C drops)*supplement breast fed baby* with _____ _____all of the nipple and most of the areolagreat feeing technique: what should be in the baby's mouth?widely*stimulate the rooting reflex* and wait for the baby's mouth to be opened _____alternate which breast is used first at each feeding alternate the position of feelingshow should moms be alternating during breast feeding? (2)break suction*to separate*- put finger inside of baby's mouth to _____ _____cradle holdname the green positioncross cradle holdname the yellow positionlyding downname the pink positionfootball holdname the blur positionsoreness, engorgement, cracking/bleeding3 breast feeding problems?alternate starting side and position air dry nipples apply lanolin Tylenol PRN may help dont allow the baby to suckle too long (15 minutes max) may beed to express milk/pump the breastprevention method for breast feeding problems?mastitis-*flu like illness* -*breast tenderness/swelling* -fever/chills -malaise -*discharge* -*breast lump* possible -rednesstreatment options for Mastitis-*continue nursing!* -*warm compresses* -*antibiotic* to cover *Beta lactamase* producing organisms especially gram positive (Augmentin or 2nd generation cephalosporin) -Tylenol or Tylenol with codeineabscessif *mastitis* is NOT treated may progress to breast _____ which may require *I&D*-cover Beta lactamase producing organisms -gram POSITIVEs -use *Augmentin* or 2nd generation cephalosporinwhat type of antibiotic coverage do you want for mothers with mastitis?2-3 hours 6-8 times weight 4 timesis the baby getting enough? should be adequate if... -baby is *satisfied* with feeding and *remains satisfied* for _____-_____ hours -*voids* _____-_____ times per day -adequate _____ gain -*loose, yellow "seedy" stool* at least _____ times per daygastrocolic reflex_____ _____ is when putting food into a baby causes them to have a BM shortly after3 hoursfor *formula fed babies* the *first feeding* usually around _____ _____ of lifeincrease from 0.5-1.0oz per feeding --> to 1.5-2.0oz per feeding day 3 2-3oz every 2-3hours for 2-3 weekshow should the *formula* be *increasing* per each feed?boilfor formula feeding babies, _____ water until *6-12 months*dishwasher_____ *OK* for bottles instead of sterilization48 hours*open formula* must be *refrigerated* and used within _____ _____microwaveswarm bottle but *caution* parents on use of _____; can result in unequal "hot areas"waterfeedings in general: *no need to supplement with _____*1 year old*no cows milk* until _____ _____ -harder to digest -has more solutes which puts. greater demand on the *kidneys* -has more iron but the iron is much less absorbed and may also cause *intestinal blood loss* --->could result in *milk anemia*whole, 2%*switch* to _____ or at minimum _____ *milk* at *1 year old*nervous system*whole and 2% milk* are a good source of *fat* for developing _____ _____low fatat *2 years old switch* to _____ _____ *milk*30% (fat) 10% (saturated fat)no more than _____% of calories should be from *fat*; no more than _____% from *saturated fat*- just like in adultsformula intolerance_____ _____ may present with: -excessive spitting up -gas -constipation -irritability -may be due to milk protein, lactose intolerance, iron content, and or other componentstry lactose free --> soy --> elemental formula until one is toleratedwhat should you do if the infant has a *formula intolerance*?4-6 monthssolids: start with *single grain (usually RICE) cereal* at about _____-_____ months oldironsolids, such as single grain / *rice cereal are a good source* of _____ in infants as stores of _____ from mother are being depleted -AAP and WHO recommend d starting solids at *6 months*3-5 daystry a *new food* for _____-_____ days before adding another to look for *reactions/intolerance*4-6 monthswhat age... *fruits and vegetables*; usually yellow or orange8-9 monthswhat age... *finger food* now that coordination between front and back of mouth is betterformula or breast milkwhen *solids are started*, _____ or _____ _____ is still the *main source of nutrition*28-32ozaround *6 months old*, infants average _____-_____oz of *formula per day*after 1 year old_____ _____ _____, *solids becomes the main source of nutrition* -at that time *only 3 serving of milk* needed to get calcium and some vitamins, children do not need as much milk as they did formulaover weightrecent studies show that *15% of US children 6-19* years old are _____ _____use body mass index (BMI) -ratio of weight and heighthow to diagnose child hood obesity?raw numberin *adults BMI* is a _____ _____ which has a direct correlation to overweight and obesityage and genderin *children, MBI* must be placed on _____ and _____ specific *percentile curves*underweight at risk for overweight overweight / obseseBMI <5% BMI 85-95% BMI >95%between the 5-85th percentilewhat is a *normal healthy BMI in children*?prevention of childhood obesity-*breast feed at least 6 months* -*avoid feeding infants extra *when they just need to suck for pacification -*limit fruit juices* to 4-6oz per day (infants limited to 4oz per day and juice is not started until after 6 months) -use age appropriate portion sizes -*change to skim milk after 2 years old* -do not force children to eat; they often recognize hunger and satiety cues better than adults; encourage them ti recognize these cues as they are getting older -do *not graze* on food; encourage 3 meals per day with only healthy snacks in between if necessary -avoid bad habits (eating snacks in front of the TV); do *not use food as a reward* -*limit screen time* (TV, video games, computers) to 1-2hrs per day; AAP recommends no tv before 2 years of age -no TV in the bedroom -encourage active family life from infancy -encourage family meal time -encourage 1 hours of active play each and every day1-2 hours per daylimit screen time (TV, video games, computers) to how long per day?NO TVAAP recommends _____ _____ *before 2 years of age*early childhood caries prevention-begin wiping baby mouth early to begin good habits; *when teeth erupt, wipe teeth with wet gauze or cloth before bed* -only *water in the bottle during night after teeth erupt* -wean off the bottle at *1 year old* -*fluoride supplementation at 6 months old* in areas where there is no fluorinated public water r1 year oldwean off the bottle at what age?tetracycline*no* _____ to mom when pregnant or in children until 12 years old; drug is incorporated into *teeth structure*streptococcus mutans and streptococcus sobrinuscaries caused by: -_____ _____ and _____ _____ (bacteria that produces *acid* when they *ferment carbohydrate*) -source of nutrient carbohydrate -tooth susceptible to *decalcification* genetic factors may play a role but *environment is more important*brush BID, especially before bed-takes 18-24hrs of bacteria to organize and produce acid tray affects the teeth -children <8 y/o do not have the dexterity to properly brush their own teethgood nutrition-restrict overall sugar and frequency of carbs -liquids generally better than sticky solids -limit juice 4-6 oz/day in 1-6 years old1 y/o or 6 months*routine dental visits* at _____ or _____ after eruption of first tooth per ADA and AAP, sooner if any problems -previous recommendation of 3 y/o was thought to allow significant progression of disease before treatmentfluoride, fluoride varnishconsider _____ until good habits and regular visits established; consider application of _____ _____IM injections at 90 degree angle in anterolateral thighuntil *12-15 months old* (text says 18 months) how should *immunizations be given*?deltoidafter 15-18 months where can *immunizations* be administered on the body?SC injections_____ _____ at *45 degree angle* in *thigh* until *1 y/o* then the middle of the *triceps*immunization statustake every opportunity to *check* _____ _____ and provide vaccines if needed"hold"*do not "_____" vaccines* for *mild illness* with or without feverrestart*no need* to _____ any series of a vaccine no matter how off schedule the pt isside effectsmultiple vaccinations can be given at the same visit *without an increase of _____ _____* or compromised efficacy28-30 daysif not given at the same visit, most recommendations will be to give the next set _____-_____ days laterNational Vaccine Injury Act of 1986-this was enacted to reduce the potential financial liability to vaccine makers and providers due to *vaccine related injuries* -aimed to ensure a stable market supply -also to provide cost effective arbitration for vaccine injury claimspolio-no cases of will _____ unthaw western hemisphere from 1991-2000 -none in the US since 1979 -in 2000, 19 cars of *acute flaccid paralysis* in Dominican Republic and 1 in Haiti; all pts were *inadequately vaccinated*; outbreak was caused by *oral polio virus* that recovered the neurovirulence transmissibility characteristics of wild polio virus type 1OPV and IPVwhat are the two types of *Polio vaccines*?OPV (oral polio virus)-benefits: ease of administration, compliance, intestinal immunity, *secondary immunization* -disadvantages: 8-10 cases of vaccine associated paralytic polio (VAPP) per year (1 case per 2.4 million doses of vaccine)IPV (inactivated polio vaccine)-benefits: *no chance of VAPP* -disadvantages: *extra injection*, less intestinal immunity, *no secondary immunization*IPV (inactivated polio vaccine)-1997, IPV first 2 doses, then IPV or OPV for last 2 doses; after the recommendation there were 4 cases of VAPP in 1997 and 1 in 1998 -ACIP voted to change recommendation to all _____ in the United States (polio vaccine) -OPV is still used in different areas of the worldchicken poxmany people feel _____ _____ is a totally benign childhood disease -- "a right to passage to adolescence*Varivax (Check Pox Vaccine)before its approval this was the *most studied vaccine in history*JapanVarivax/Chick Pox Vaccine: similar vaccine was used in _____ for many years prior to the USVarivax (Check Pox Vaccine)the _____ vaccine does *not prevent all cases of chicken pox*; it is considered *successful if it prevents serious cases*; breakthrough cases are expected -in 1995 one dose of vaccine was recommended at 12 months -2006 a 2nd dose was recommended at 4-6 years old -85% decreased since adding 2nd vaccine in 2006mandated reportable disease in PAchicken pox is now a _____ _____ _____ in PANo. the vaccine does not prevent all causes of chicken pox; may prevent serious cases; breakthrough cases are expecteddoes the Varivax (Check Pox Vaccine) prevent chicken pox completely?Thimerosal-a *mercury* containing preservative that has been used for many years in *vaccines* -questions have been raised about the *accumulative amounts of mercury* from vaccines and the environment and potential long term health affects (including autism)methylmercury*bacteria* in the environment *change mercury* to _____ which makes its way though the food chain; has been shown to be *toxic to humans*ethylmercurythe *mercury compound in vaccines* is _____, which is *excreted much more rapidly* from the bodyThimerosalthere has been *no scientific evidence* linking _____ to any long term health problems; despite this AAP and CDC did recommend removing _____ from vaccinesinfluenza vaccinesthe *only continued use of Thimerosal* is in *multidose vials* of the _____ _____; the amount of mercury exposure from the _____ _____ is *less* than than is obtained from *breast fed*MMR vaccine and Autism-concerns have been raised about a *link between 2 symptoms* because of the timing of the vaccine -this vaccine is given at *12-15 months old* -this disorder's symptoms usually present at *15-18 months old*Dr. Andrew Wakefieldoriginal study that suggested MMR and Autism share a link was published by _____ _____ _____ in the Lancet in 1998; it was a retrospective look at *12 pts* that present to his office with *abdominal complaints*; all 12 also had a history of normal development with an acute loss of specific functionseverely flawedThe article/ paper and a second paper published by Dr. Wakefield have been challenged by the scientific community and have been found to be _____ _____; 10 out of the 13 original authors have *retracted findings*; on Feb 2, 2010 the Lancet officially retracted this article; subsequent studies have not supported Dr. Wakefeilds therapy or established any link between MMR vaccine and autismcombinationAAP recommends use of *approved* _____ _____ to *decrease* the number of *injections* given *Comvax* (Hep B/HIB) *MMRV* (measles, mumps, rubella, varicella) *Pentacel* (DTaP, IPV, HIB) *Pediarix* (DTaP, IPV, HBV)ComvaxHep B / HIBMMRVmeasles, mumps, rubella, varicellaPentacelDTaP, IPV, HIBPediarixDTaP, IPV, HBVtrivalent inactivated influenza vaccine (IIV)type: *inactivated split virus* or *purified surface antigen* (Influenza Types A and B) indication: Since 2010, universal immunization for all pts *>6 months* old is recommendedchildren 6months-4 years old age 50 and older chronic pulmonary, cardiovascular (except HTN), renal, hepatic, neurologic, hematologic or metabolic (including DM) immunocompromised (including medications and HIV disease) pregnant during the influenza season \\\\\\ age 6months-18 years old receiving chronic ASA therapy residents in nursing homes or chronic care facilities American Indians / Alaskan natives morbid obesity (BMI 40 or greater) health care professionals household contacts and caregivers of children <5 y/o or adults >50 y/o- particular attention to contacts of those <6 months old contacts and caregivers of persons with chronic medical conditions that put them at higher risk for complicationsimmunization of those at *highest risk* should still be the *focus* and the *target groups* in the event of vaccine shortages; what types of people would be considered a priority for *IIV*? -->trivalent inactivated influenza vaccineunder 9 years old -who were not previously vaccinated -have received only 1 lifetime dose prior to the current season*2 doses* given *4 weeks apart* in what age of pts?Route: IMages *6-35 months* give *0.25mL* dose of Fluzone --*0.5mL of other brands* *0.5mL* dose to *3 years and older* for *teens 18 y/o and older*, ID version is avaible (Fluzone Intradermal)contraindications / precautions-allergy to egg -previous serious reactions -*GBS* within *6 weeks* of a previous vaccine -moderate to severe illnessside effects of trivalent inactivated influenza (IIV)-fever -malaise -myalgias (all immune response) -these occur usually within 6-12hrs and last 24-48hrs -this is NOT the flu!cytokine release*side effects* caused by _____ _____ as part of *immune response*live attenuated influenza vaccinetype: *Quadrivalent, live attenuated* influenza virus route: *intranasal* indication: *healthy* persons ages *2-49* schedule: annually2-8 year olds -not previously vaccinated -have no received 2 doses of seasonal influenza vaccine insure July 1, 2010*2 doses* (at least 4 weeks apart) in what age group?side effects of live attenuated influenza vaccine-allergy to eggs -those 18 y/o and older with egg allergy can receive recombinant influenza vaccine (RIVs) (Flublok) -previous serious reaction to influenza vaccine -*long term ASA* therapy -any chronic medical conditions -*pregnancy* -h/o *GBS wishing 6 weeks* of previous flu vaccine -*immune suppression* -received certain antivirals 48hrs prior to vaccinationside effects of live attenuated influenza vaccine-flu like symptoms -sinusitisStrep Pneumoniae_____ _____ is a significant cause of *morbidity and mortality* in the US; *bacterial meningitis #1 cause in US*resistancealso there is evolving _____ of this bacteria to antibiotics- *Strep Pneumoniae*Prevnar 13 (PCV13) (Conjugated Pneumococcal Vaccine)in 2010, _____ a *13-valent conjugate vaccine* was approved to REPLACE PrevnarPrevnar 13 (PCV13) (Conjugated Pneumococcal Vaccine)indications for WHICH vaccine? -all infants *2-59 months old* not previously immunized; # of doses depends upon the 1sr dose is given and whether the pt is healthy or at higher risk -children who previously starts PCV7 should complete the series with PCV13 -previously *unimmunized* children *60-71 months* who are at higher risk -*healthy children 14-59 months* who have previously completed the PCV7 series should receive one dose of PCV13 -children between *6 and 18 years old* who have previously completed the PCV7 series may receive *one dose of PCV13*pneumococcal diseasethose considered *high risk* for _____ _____ -sickle cell disease -anatomic or functional asplenia -chronic renal failure or nephrotic syndrome -CSF leaks -HIV -immunosuppression -diseases associated with immunosuppressive treatment or radiation, including cancer -asthma (if taking high dose corticosteroids) -solid organ transplantation -cochlear implant (have or will have) -also in 2-5 y/o; those with chronic cardiac or pulmonary disease or DMPrevnar 13 (PCV13) (Conjugated Pneumococcal Vaccine)type: *13-valent conjugated vaccine* schedule: *2, 4, 6, and 12-15 months* route* *IM*contraindications for Prevnar 13 (PCV13) (Conjugated Pneumococcal Vaccine)-anaphylactic reaction to any component of PCV7, PCV13, or any diphtheria toxoid containing vaccineside effects of Prevnar 13 (PCV13) (Conjugated Pneumococcal Vaccine)(within 7 days) -local irritation -mild fever -decreased appetite -irritability -increased or decreased sleep -anaphylaxis: extremely rarePneumovax (PPV)indications: *> 2 years old* at *higher risk for pneumococcal disease* -even if previously immunized with PCV7 or PCV13 -give at least 8 weeks after most recent dose of PCV13 adults *>65* years old adults *<65* years old with *chronic medical conditions*Pneumovax (PPV)type: *purified capsular polysaccharide antigen of 23 serotypes of pneumococcus* -responsible for 85% of illness due to pneumococcus schedule: 1 injection after 2 years old in high risk pts, 2nd dose in 5 years in adults if 1st dose was before 65 years old and it has been 5 years, repeat the vaccine after 65 years old route: *IM*contraindications and side effects of Pneumovax (PPV)-previous severe reactions to this vaccine -local pain and redness -<1% fever, myalgia -rare: anaphylaxishow should the

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