- Chapter 14: Introduction to Health Promotion and Health Protection (pp. 161-163)
- Chapter 20: Sleep (pp. 283-284)
- Chapter 22: Immunizations (pp. 306-317)
- Chapter 44: Common Pediatric Injuries and Toxic Exposures (pp. 919-933)
Nurse Practitioner Roles:
- Pediatric Nurse Practitioner (PNP): Focuses on health promotion, protection, and disease prevention in children.
- Primary Care Nurse Practitioner (PCNP): Manages well-child care, including prevention and management of common pediatric acute illnesses and childhood diseases.
- Acute Care Nurse Practitioner (ACNP): Specializes in caring for children who are acutely, chronically, or critically ill. These patients may be unstable, experiencing life-threatening conditions, or medically fragile and technology-dependent.
Prevention Strategies:
- Primary Prevention: Aimed at preventing diseases before they are established by eliminating causes or increasing people’s resistance to illness. This includes two main strategies:
- Health Promotion: Efforts such as encouraging lifestyle changes, proper nutrition, and maintaining safe environments.
- Specific Protection: Actions targeted at specific diseases, like immunizations, anti-malarial prophylaxis, and environmental modifications (e.g., adding fluoride to water supplies).
- Secondary Prevention: Involves early diagnosis and prompt treatment to interrupt the progression of a disease. This often includes screening for early detection and initiating treatment early to reduce symptoms or prevent disease progression.
- Tertiary Care: Focuses on improving survival rates and quality of life for those already affected by disease. It includes:
- Disability Limitation: Managing early symptoms to prevent further disability.
- Rehabilitation: Managing later symptoms to enhance patient recovery and quality of life.
- Quaternary Care: Involves the use of highly specialized expertise and equipment for managing rare or complex medical conditions.
Immunizations
Barriers to Vaccination: Several factors contribute to vaccine hesitancy among parents. Common concerns include beliefs that vaccines are unsafe, may cause autism, could overload or weaken a child’s immune system, or might be traumatic for the child. Some parents may also perceive a lack of threat from the diseases that vaccines prevent, leading them to undervalue the importance of immunization. Additional barriers include poverty and a lack of education.
Strategies to Encourage Vaccination:
- Acknowledge and Respect: It is crucial to recognize and respect the trusted relationship between the healthcare provider and the parent. This relationship is foundational in addressing vaccine hesitancy.
- Communicate Commitment: Clearly express a strong, shared commitment with the parent to the health and well-being of their child. Reinforcing the mutual goal of protecting the child can help build trust.
- Listen and Address Concerns: Take the time to listen to parents’ reasons for refusing or delaying vaccines. Understanding that not all vaccine-hesitant individuals have the same concerns allows for tailored communication that addresses specific issues.
- Educate on Misconceptions: Be well-informed about common misconceptions and controversies surrounding vaccines, such as the debunked link between vaccines and autism. Be prepared to discuss these topics and provide evidence-based information (e.g., thimerosal-free vaccines).
- Emphasize Vaccine Safety: Highlight the rigorous testing that vaccines undergo before licensure, as well as the ongoing safety surveillance programs after they are approved. Explain the severe consequences that can arise from not vaccinating.
- Discuss Simultaneous Vaccination: Educate parents about the safety of administering multiple vaccines at once. Reassure them that a healthy child’s immune system can effectively manage exposure to 2000 to 6000 antigens daily through normal activities like playing, eating, and breathing. The number of antigens in vaccines is much lower, with the entire schedule containing around 150 antigens, which is minimal compared to daily exposures.
Live Vaccines:
Live vaccines contain an attenuated (weakened) form of a virus that induces immunity without causing the disease. These vaccines generally provide broader and longer-lasting immunity. A mild fever or rash is a common side effect, indicating that the immune system is responding appropriately.
- Age Restrictions: Live vaccines should not be administered before a child is 1 year old. If two live vaccines are needed, they should be given on the same day, or a four-week interval must be maintained between them to ensure efficacy.
- Pregnancy Precautions: Live vaccines should not be administered to pregnant women or within 28 days before pregnancy.
- Immunocompromised Individuals: Extra caution is required when administering live vaccines to immunocompromised individuals. Recommendations for these patients vary depending on their specific condition.
- Measles, Mumps, and Rubella (MMR) Vaccine: The MMR vaccine is a trivalent vaccine given in two doses, starting at 12 months of age. After the two doses, the efficacy of the MMR vaccine is approximately 98%.
Side Effects and Precautions:
- Rash and High Fever: After receiving certain vaccines, such as the MMR vaccine, children may experience a rash and high fever 5 to 12 days post-vaccination. This is a normal response indicating the immune system is reacting to the vaccine.
- Seizure Risk with Varicella Vaccine: When the varicella vaccine is administered as part of a quadrivalent vaccine, the risk of febrile seizures doubles. However, this risk can be minimized by giving the varicella vaccine at the same time as other vaccines, but in different injection sites.
- Pregnancy Precautions: Live vaccines, including the varicella vaccine, should not be administered during pregnancy or within 28 days prior to becoming pregnant.
Vaccine-Specific Information:
- Varicella Vaccine: Administered in two doses, the varicella vaccine is 98% effective after the second dose. Severe cases of chickenpox have become rare due to widespread vaccination.
- Rotavirus Vaccine: Given in two doses, the rotavirus vaccine is effective but carries a small risk of intussusception, a condition where part of the intestine folds into itself. This vaccine is an exception to the general rule that live vaccines are not given before the age of 1 year.
- Smallpox Vaccine: Smallpox has been eradicated, so this vaccine is no longer routinely administered.
Passive Immunization:
- Overview: Passive immunization involves administering an exogenous antibody, such as immunoglobulin, to provide immediate protection against specific infections.
- Respiratory Syncytial Virus (RSV) Prophylaxis:
- Palivizumab (Synagis): This is the only product available in the U.S. for preventing RSV infection in infants at high risk for severe outcomes. It is a humanized monoclonal antibody administered intramuscularly (IM) in five monthly injections during the RSV season, usually from November to March or April. It has been shown to reduce RSV hospitalizations in high-risk infants by 39% to 82%.
- Candidates for RSV Prophylaxis:
- Preterm Infants: Infants born at 29 weeks of gestation or earlier during the RSV season, up to 12 months of age.
- Chronic Lung Disease (CLD): Children born at or before 32 weeks of gestation who are under 2 years old and have chronic lung disease requiring treatment within 6 months of the RSV season onset. Prophylaxis can also be given to 2-year-olds with CLD of prematurity who need medical support within 6 months prior to the RSV season.
- Congenital Heart Disease: Infants up to 12 months old with significant cyanotic or complicated congenital heart disease.
- Neuromuscular Disorders or Congenital Anomalies: Infants up to 12 months old with conditions that impair the clearing of respiratory secretions.
Killed (Inactivated) Vaccines:
- Overview: Killed or inactivated vaccines offer systemic protection by stimulating the production of immune globulin G (IgG) antibodies. However, they may not trigger local mucosal immunity (IgA antibodies), which could result in local colonization or infection during an epidemic.
- Common Inactivated Vaccines: These include vaccines for diphtheria-tetanus-pertussis (DTaP), polio, Haemophilus influenzae type B (Hib), hepatitis A, hepatitis B, human papillomavirus (HPV), meningococcus, and pneumococcus.
Common Side Effects:
- General Reactions: Common side effects from vaccines often include mild to moderate fever, local swelling, pain, and erythema (redness) at the injection site. These symptoms typically occur within the first 24 to 72 hours after vaccination and are seen with vaccines such as DTaP, tetanus-diphtheria (Td), tetanus-diphtheria-acellular pertussis (Tdap), Haemophilus influenzae type B (Hib) conjugate, hepatitis B virus (HBV), and pneumococcal conjugate (PCV-13).
- Allergic Reactions: While uncommon, there is a concern for allergic reactions following vaccination. Healthcare providers should monitor for these reactions, especially after administering vaccines known to cause systemic reactions, such as Tdap, meningococcal, and HPV vaccines.
- Syncope: Fainting (syncope) is a common reaction, particularly associated with the Tdap, meningococcal, and HPV vaccines. Other side effects of the meningococcal vaccine may include headache and irritability.
Vaccine-Specific Information:
- Diphtheria-Tetanus-Acellular Pertussis Vaccine (DtAP): Administered in 4 doses to children under the age of 7. The pertussis component is not long-acting, necessitating multiple doses to maintain immunity.
- Tdap Vaccine: This vaccine is given multiple times throughout life, including during pregnancy (recommended between 27-36 weeks gestation) and as a booster every 10 years in adults.
- Polio Vaccine: The polio vaccine is available in an inactivated form in the U.S., administered in 4 doses. It is particularly recommended for immunocompromised individuals.
- Haemophilus influenzae Type B (Hib) Vaccine: Given in 3 doses, the Hib vaccine has significantly reduced the incidence of infections like pneumonia, bacteremia, meningitis, and other serious conditions in children under age 4.
- Hepatitis A Virus Vaccine: Administered in 1 to 2 doses, this vaccine offers protection for 14-20 years and is recommended for children under 18 months.
- Hepatitis B Virus Vaccine: This vaccine is given in 3 doses, typically at birth, 1-2 months, and 6-18 months. Immunogenicity lasts up to 20 years, and routine booster doses are not generally recommended.
- Human Papillomavirus (HPV) Vaccine: Administered in 2 doses 6 months apart to individuals aged 9-26. The vaccine is safe with mild side effects but should not be given to pregnant women.
- Influenza Vaccine: Given yearly to individuals aged 6 months and older. Widespread vaccination helps achieve herd immunity, protecting those who are not immunized.
- Meningococcal Vaccine: Administered in 2 doses, typically starting at age 11-12, with a booster at 16 years. The vaccine is crucial for preventing a disease with high morbidity and mortality, especially in late high school and college-age individuals.
- Pneumococcal Vaccine: There are 91 known serotypes of pneumococcus. The PCV13 vaccine is given to children up to 59 months old, while the PCV23 vaccine is recommended for high-risk groups, including infants and the elderly.
Vaccine Schedule:
- Birth: Hepatitis B (Hep B)
- 2 Months: Hep B, Rotavirus, DTaP (Diphtheria, Tetanus, Acellular Pertussis), Hib (Haemophilus influenzae type B), PCV13 (Pneumococcal Conjugate), Polio (BDRHIP)
- 4 Months: Rotavirus, DTaP, Hib, PCV13, Polio (DRHIP)
- 6 Months: Hep B, DTaP, PCV13, Polio (BDRHIP again)
- 12 Months: Hib, Influenza (Flu), MMR (Measles, Mumps, Rubella), Varicella (Chickenpox), Hepatitis A (Hep A)
- 18 Months: (This interval typically includes a booster dose, but specifics vary based on the child’s vaccine history.)
- Age 4-6 Years: MMR, Varicella, Polio, DTaP
- Age 11-12 Years: Tdap (Tetanus, Diphtheria, Acellular Pertussis), Meningococcal, HPV (Human Papillomavirus)
- Age 16 Years: Meningococcal
Vaccines for Children (VFC) Program:
The VFC program allows primary care providers to offer Advisory Committee on Immunization Practices (ACIP)-recommended vaccines at no cost. This program is available to children under 19 years old who are eligible for Medicaid, uninsured, or who are Native American or Alaska Native. Additionally, children without insurance coverage for immunizations can receive vaccines at Federally Qualified Health Centers (FQHCs) and rural health clinics. The VFC program plays a significant role in reducing vaccination disparities among low-income children.
Sudden Infant Death Syndrome (SIDS) Prevention:
Sudden Unexpected Infant Death (SUID): This term encompasses any sudden and unexplained death during infancy, which can result from suffocation, asphyxia, entrapment, infection, ingestion, metabolic diseases, or trauma, whether accidental or non-accidental.
SIDS: After thorough investigation, many SIDS cases are linked to suffocation or overheating, particularly in infants who sleep on their stomachs or with unsafe bedding. About 90% of SIDS cases occur before 6 months of age, with a higher likelihood among premature or growth-restricted infants.
Recommendations for SIDS Prevention:
- Share a room with the baby but avoid bed-sharing.
- Avoid substances that could impair judgment, such as alcohol or drugs, especially during pregnancy and after the baby is born.
- Use a firm mattress without loose bedding or bumper pads.
- Keep the baby’s sleeping area cool to prevent overheating.
- Encourage breastfeeding and ensure the baby receives timely immunizations.
- Educate parents on safe sleep practices.