Remember the contraindications to diphtheria, pertussis, and tetanus (DPT) immunizations and usealternatives recommended by the American Academy of Pediatrics (AAP) and the U.S. Public Health Service
Remember the contraindications to diphtheria, pertussis, and tetanus (DPT) immunizations and usealternatives recommended by the American Academy of Pediatrics (AAP) and the U.S. Public Health Service: Excerpt from Avoiding Common Pediatric Errors
Author:
Esther Forrester, MD
What to Do - Make a Decision, Take Action
The overall goal of immunizations is to prevent disease. This revolution in
science began with the invention of the smallpox vaccine by Jenner in 1796
and has evolved to include prevention of more than 12 diseases. The use
of vaccines has actually led to the eradication of diseases (smallpox, wild-
type poliomyelitis). Following the AAP and Centers for Disease Control and
Prevention (CDC)–recommended immunization guidelines, however, is difficult. The CDC currently estimates that only two thirds of all 2-year-old
children in the United States have received all appropriate immunizations.
This can be further complicated when dealing with preterm (PT) and low-
birth-weight (LBW) infants. There are many challenges to successful immunization. In fact, the increase in vaccine-preventable illnesses presents a
challenge in and of itself.
Vaccine shortages pose another problem. From 2000 to 2005, there were
shortages for nine of 12 of the recommended childhood immunizations.
Millions of people were affected by prolonged shortages. The low supply
resulted partly from a reduction in the number of manufacturers. The rising
cost and financial barriers are additional challenges. Despite the increase in
cost,vaccinationisacost-effectivepublichealthintervention.Unfortunately,
children with fragmented health care often have incomplete immunizations.
There is also increasing public concern regarding adverse events occurring secondary to vaccination. Two of the most common public fears are: (a)
the association between the measles, mumps, and rubella (MMR) vaccine
and autism, and (b) thimerosal-containing vaccines and autism. In addition,
the Vaccine Adverse Event Reporting System was established to scrutinize
vaccine safety after U.S. Food and Drug Administration licensure. Clinicians may present a challenge when coupling medical liability concerns with
vaccineadministration.Public and professional lack ofknowledge(schedule,
necessity) also expounds the problem. As mentioned earlier, special populations may cause increasing concerns and intensified challenges.
Due to the many complications faced by PT and LBW infants, they are
at greater risk for amplified morbidity from diseases that can be prevented
by vaccine administration. Despite this fact, they are less likely to receive
timely immunizations. This is due to clinician's concern for the patient to
develop protective immunity after routine administration, and the patient's
overall fragile state. The safety, immunogenicity, and durability of immune
responsehave beenextensively studiedforhepatitisBvaccine (HBV), inactivated poliovirus (IPV), Haemophilus influenza type b (Hib), and pneumococcal and influenza viruses. PT and LBW infants should receive full doses
of all routinely recommended childhood vaccines at a chronological age
consistent with the schedule for full-term (FT) infants, with the exception
of Hepatitis B.
The AAP recommends that the first dose of HBV be delayed in infants
weighing<2,000gandborntohepatitisBsurfaceantigen(HBsAg)-negative
mothersuntiltheinfantachievesaweightof2,000goris2monthsofage.The
recommendationresultsfromstudiesthatshowedlowerseroconversionrates
and antibody levels in very LBW (<1,500 g) and extremely LBW (<1,000
g) infants immunized with HBV shortly after birth, when compared to FT
infants and PT infants immunized at a later age. Chronological age of the
medically stable PT infant at first dose administration is the best predictor
of successful seroconversion regardless of birthweight or gestational age at
birth. It is very important to remember that all PT and LBW infants born to
HBsAg-positive mothers must receive hepatitis immune globulin (HBIG)
within 12 hours of birth as well as HBV at different sites. If maternal status is
unknown, PT and LBW infants should follow the same guidelines as infants
born to HBsAg-positive mothers (HBV and HBIG at birth).
The safety and immunogenicity of DTP, diphtheria and tetanus toxoids
and whole-cell pertussis (DTwP), Hib, and IPV has been proven by several
studiesandtheyarerecommendedtobegiventoPTandLBWinfantsbeginning at a chronological age of 2 months. Despite this fact, significant delays
persist. There is no increase in adverse events when the before-mentioned
vaccines are given to PT and LBW infants, with one exception. There have
been reports of cardiorespiratory events occurring within 72 hours of DTwP
administration in extremely LBW infants younger than 31 weeks gestation,
but not after the administration of DTP. The episodes were not found to
have detrimental effects on the patient's medical course.
PT and LBW infants are at increased risk for morbidity associated with
influenza and respiratory syncytial virus (RSV). Because of this, it is recommended that this population receives 2 doses of the inactivated influenza
vaccine, given 1 month apart, beginning at 6 months' chronological age.
Household contacts, child care providers, and hospital nursery personnel of
PTinfants youngerthan6 monthsandthose with complications ofprematurity(i.e.,chroniclungdisease),shouldreceivethevaccineyearly.Palivizumab
(respiratory syncytial virus monoclonal antibody) should be given to all PT
infants younger than 32 weeks gestational age, and/or with chronic lung
disease, and/or specific cardiac conditions. This is a monthly vaccination
given during RSV season.
Anatomic limitations of PT and LBW infants should be taken into
consideration when administering vaccines in this population. The anterolateral thigh is the site of choice, and muscle mass, or the lack thereof, should
guide the choice of needle length. The appropriate size may be less than the
standard needle length (7/8 to 1 inch) used in FT infants.
Suggested Readings
Abramson J, Baker C. Immunization of preterm and low birth weight infants. Pediatrics.
2003;112(1):193–198.
Cohn AC, Broder KR, Pickering LK. Immunizations in the United States: a rite of passage.
Pediatr Clin North Am. 2005;52:669–693.
Pfister RE, Aeschbach V, Niksic-Stuber V, et al. Safety of DTaP-based combined immunization
in very-low-birth-weight premature infants: frequent but mostly benign cardiorespiratory
events. J Pediatrs. 2004;145:58–66.
>>>
Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
More About Immune disorders
More Medical Textbooks Online about Immune disorders
Review other book chapters online related to Immune disorders:
Medical Books Excerpts
- Anaphylaxis
- "Professional Guide to Diseases (Eighth Edition)" (2005)
- [ read ]
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
|
|
More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
|
|
» Next page:
Allergic Child (The 5-Minute Pediatric Consult)
Rate This Website
What do you think about the features of this website?
Take our user survey and have your say:
Website User Survey
Medical Tools & Articles:
Next articles:
Tools & Services:
Medical Articles:
Forums & Message Boards
- Ask or answer a question at the Boards:
