خدا نام خدا به نام به

Preventive PediatricsPreventive Pediatrics

Dr. Mehran karimiDr. Mehran karimi

What does mean What does mean preventionprevention??

PrimaryPrimary SecondarySecondary TertiaryTertiary

Child’s health

Smoking

Repeated infections

Genetic

???????AccidentMedia

Malnutrition

Violence

Family Environment hazards

Health supervision visitHealth supervision visit

AssessAssess

Cognitive developmentCognitive development

SocialSocial

Family lifeFamily life Traditional well child visitTraditional well child visit

Principles of health supervision Principles of health supervision visitvisit

Health promotionHealth promotion Health means:Health means: Health is not merely the absence of Health is not merely the absence of

disease but includes many dimentions of disease but includes many dimentions of well-being including physical’ mental’ well-being including physical’ mental’ social’ environmental and personal. social’ environmental and personal.

PartnershipPartnership Continuity and coordinationContinuity and coordination Media influences behaviorMedia influences behavior Active or passive smokingActive or passive smoking

Suggested Periodic health Suggested Periodic health supervision visitsupervision visit

TeetingTeeting

First teeth erupt at 6-8 mo.First teeth erupt at 6-8 mo. No association between teething No association between teething

and:and:

fever’ diarrhea’ drooling’ mood fever’ diarrhea’ drooling’ mood disturbances’ appearance of illness’ disturbances’ appearance of illness’ sleep disturbances’ red cheek sleep disturbances’ red cheek

Sleep problemsSleep problems

Frequent night awakening(1th year of Frequent night awakening(1th year of life)life)

Night walking’ Night terror’ Night mare’ Night walking’ Night terror’ Night mare’ Restless legs’ Noisy breathing’ Restless legs’ Noisy breathing’ Parasomnia’….Parasomnia’….

Regular bedtime routine starting with a Regular bedtime routine starting with a quiet interaction (Reading a bedtime quiet interaction (Reading a bedtime story’..)story’..)

Toilet trainingToilet training

Average age of successful toilet training Average age of successful toilet training is 35-39 mo.is 35-39 mo.

Early training (<2 y/o) discouraged Early training (<2 y/o) discouraged (constipation’ encopresis..) (constipation’ encopresis..)

Readiness of child is importantReadiness of child is important Readiness is present if child Readiness is present if child

communicate with parents before urine communicate with parents before urine or stool passageor stool passage

Positive reinforcement and Regular Positive reinforcement and Regular toilet time is important toilet time is important

Temper tantrumsTemper tantrums

Is a normal part of child developmentIs a normal part of child development May be due to anger ‘ stress’ hunger’ May be due to anger ‘ stress’ hunger’

unreasonable demand’ Parental unreasonable demand’ Parental depression’ Family violence depression’ Family violence

Growth & Development Growth & Development monitoringmonitoring

MalnutritionMalnutrition

ObesityObesity

UnderweightUnderweight

StuntingStunting

WastingWasting

FTTFTT Developmental delay (DQ)Developmental delay (DQ)

Parental health needs (Depression Parental health needs (Depression ’Disability ’ Addiction’..)’Disability ’ Addiction’..)

Reducing cardiovascular diseases:Reducing cardiovascular diseases:

Obesity: Monitor obesity starting at 2 y/oObesity: Monitor obesity starting at 2 y/o

Fat: No more than 30% of caloriesFat: No more than 30% of calories

Saturated fat: less than 10% of total Saturated fat: less than 10% of total caloriescalories

Dietary cholesterol: less than 300 mg/dayDietary cholesterol: less than 300 mg/day

BP: In every visit starting at 3 y/o BP: In every visit starting at 3 y/o

Screening testScreening test Newborn screening:Newborn screening: Metabolic screening: Metabolic screening: newborn newborn

(PKU’Hypothyroidism’Galactosemia’..)(PKU’Hypothyroidism’Galactosemia’..)

Hemoglobin Electrophoresis:Hemoglobin Electrophoresis: newborn newborn

Hearing evaluation: Hearing evaluation: Before discharge of newbornBefore discharge of newborn Hearing evaluationHearing evaluation::’ ’ Speech and language Speech and language

developmentdevelopment’’ Vision:Vision: Evaluation of gross motorEvaluation of gross motor Anemia: Anemia: At birth if there is risk factors (such as LBW’..)’ At 9 At birth if there is risk factors (such as LBW’..)’ At 9

monthmonth In healthy child’ Adolescence (Once for boys and yearly for In healthy child’ Adolescence (Once for boys and yearly for

girls)girls)

Urinalysis:Urinalysis: 15 month is the preferred age15 month is the preferred age

Lead poisoning:Lead poisoning: 9-12 mo or 24 mo. or both9-12 mo or 24 mo. or both

Cholesterol:Cholesterol: Random cholesterol if one parent with high blood Random cholesterol if one parent with high blood

cholesterol or family history of premature CVD cholesterol or family history of premature CVD exist.exist.

Cholesterol > 200 mg/dl → Fasting lipoprotein Cholesterol > 200 mg/dl → Fasting lipoprotein analysisanalysis

Cholesterol 170 to 199 → Borderline →average of Cholesterol 170 to 199 → Borderline →average of two Cholesterol level assessedtwo Cholesterol level assessed

ImmunizationImmunization

Vaccination EradicationVaccination Eradication::

SmallpoxSmallpox PolioPolio TetanusTetanus DiphtheriaDiphtheria RubellaRubella MeaslesMeasles PertussisPertussis MumpsMumps

Hib InfectionHib Infection Pneumococcal Inf.Pneumococcal Inf. Hepatitis BHepatitis B VaricellaVaricella

اختصاري بيماري واكسنعالئم نام

BCG. ژ. ث سلب

DTP) ( ثالث گانه ديفتري،كزاز،سياسهسرفه ه DT خردساالن دوگانه

Td بزرگساالن گانه دو

OPV خوراكي اطفال پوليو فلج

IPV تزريقي پوليو

MMR- اوريون- سرخجه سرخك،سرخجه،سرخكاوريون

TT كزاز كزازتوكسوئيد

Hep.B ب ب هپاتيت هپاتيت

Vaccination programVaccination program

At Birth: BCG’ OPV’ Hepatitis B*At Birth: BCG’ OPV’ Hepatitis B* 2 Month: DPT’ OPV’ Hepatitis B2 Month: DPT’ OPV’ Hepatitis B 4 Month: DPT’ OPV4 Month: DPT’ OPV 6 Month: DPT’ OPV’ Hepatitis B6 Month: DPT’ OPV’ Hepatitis B 12 Month: MMR12 Month: MMR 18 Month: DPT’ OPV18 Month: DPT’ OPV 4-6 years old: DPT’ OPV’MMR4-6 years old: DPT’ OPV’MMR 14-16 years old: Td 14-16 years old: Td

ImmunizationImmunization

Active Immunization:Active Immunization:

Cellular Immune responseCellular Immune response

Vaccine Vaccine

Antibody productionAntibody production

Passive ImmunizationPassive Immunization

Administration of antibodyAdministration of antibody

Constituents of Immunizing Constituents of Immunizing AgentsAgents

VaccineVaccine ToxoidsToxoids AntitoxinsAntitoxins Immune globulinsImmune globulins

PreservativePreservative

StabilizerStabilizer

AntibioticAntibiotic AdjuvantAdjuvant Suspending fluidSuspending fluid

AAdverse dverse EEvents vents FFollowing ollowing IImmunizationmmunization

AEFIAEFI

EEvents or reactions observed following vents or reactions observed following immunization. Some of these events may immunization. Some of these events may be due to the vaccine, some due to error be due to the vaccine, some due to error

in the administration of the vaccinein the administration of the vaccine

AEFI ClassificationAEFI Classification

Vaccine reactionVaccine reaction Program errorProgram error Coincidental eventsCoincidental events Injection reactionInjection reaction UnknownUnknown

AEFIAEFI

Mild Reactions:Mild Reactions:

PainPain

SSwelling welling

FFeverever

IIirritabilityirritability

MalaiseMalaise

AEFIAEFI

Severe reactions:Severe reactions:

SeizuresSeizures

ThrombocytopaeniaThrombocytopaenia

Hypotonic hyporesponsive episodes Hypotonic hyporesponsive episodes

Persistent inconsolable screamingPersistent inconsolable screaming

AnaphylaxisAnaphylaxis

AEFIs (in some common AEFIs (in some common vaccines)vaccines)

Vaccine ReactionOnset Interval

Rates per million doses

Suppurative lymphadenitis 2-6 months 100 to 1000BCG osteitis 1-12 months 1 to 700Disseminated BCG-it is 1-12 months 2

Hib Nil knownAnaphylaxis 0-1 hour 0 to 2

Guillain-Barrè Syndrome )plasma derived( 1-6 weeks 5Febrile seizures 5-12 days 333Thrombocytopaenia 15-35 days 33Anaphylaxis 0-1 hour 1 to 50

OPV Vaccine associated paralytic polio )VAPP( 4-30 days 1.4 to 3.4Persistent )>3 hrs( inconsolable crying 0 -24 hours 1000 to 60000Seizures 0 - 3 days 570Hypotonic, hyporesponsive episode 0-24 hours 570Anaphylaxis 0 - 1 hour 20Encephalopathy 0 - 3 days 0 to 1

Post-vaccination encephalitis 7-21 days

400 to 4000 )in infants <6 m(

Allergic/anaphylaxis 0-1 hour 5 to 20Yellow Fever

BCG

Hepatitis B

Measles/MMR

DTP

General contraindications & General contraindications & PrecautionPrecaution

contraindicationscontraindications Serious allergic reaction after a previous Serious allergic reaction after a previous

vaccine dosevaccine dose

Serious allergic reaction to a vaccine Serious allergic reaction to a vaccine componentcomponent

PrecautionPrecaution Moderate to severe illnessModerate to severe illness

No contraindicationsNo contraindications

Mild acute illness regardless of feverMild acute illness regardless of fever Low grade feverLow grade fever Convalescent phase of illnessConvalescent phase of illness Recent exposure to infectious diseaseRecent exposure to infectious disease Mild to moderate local reaction to previous Mild to moderate local reaction to previous

dosedose Low grade to moderate fever after Low grade to moderate fever after

previous doseprevious dose Current antimicrobial therapyCurrent antimicrobial therapy

No contraindicationsNo contraindications

Premature birth(except Hepatitis B)*Premature birth(except Hepatitis B)* MalnutritionMalnutrition Allergy to penicillin and other Allergy to penicillin and other

antibiotics(antibiotics(except neomycin & streptomycin)except neomycin & streptomycin)

Breast feedingBreast feeding Egg allergyEgg allergy

(*Premature birth with BW<2 kg At birth,1,2,6 (*Premature birth with BW<2 kg At birth,1,2,6 mo.) mo.)

: مهم :نكات مهم نكات

) ( در زرد وتب پوليو بجز زنده ويروسي هاي واكسن از ( استفاده ( در زرد وتب پوليو بجز زنده ويروسي هاي واكسن از استفادهعوارض بر ابتال خطر موارديكه بجز است ممنوع حامله عوارض زنان بر ابتال خطر موارديكه بجز است ممنوع حامله زنان

. باشد غالب .آن باشد غالب آن گرفته خوني محصوالت يا و عضالني گاماگلوبولين كودكي گرفته اگر خوني محصوالت يا و عضالني گاماگلوبولين كودكي اگر

باشد 33باشد باشد گرفته وريدي گاماگلوبولين اگر و بعد باشد ماه گرفته وريدي گاماگلوبولين اگر و بعد ماه ماه 66ماه. ) بگيرد ) را ليو پو بجز زنده ويروسي واكسن بايد .بعد ) بگيرد ) را ليو پو بجز زنده ويروسي واكسن بايد بعد

طي علتي هر به كودكي در طي اگر علتي هر به كودكي در واكسن 22اگر تزريق از پس واكسن هفته تزريق از پس هفته ) ( خوني محصوالت يا و گاماگلوبولين پوليو بجز زنده ( ويروسي ( خوني محصوالت يا و گاماگلوبولين پوليو بجز زنده ويروسيو عضالني گاماگلوبولين درمورد است الزم باشد شده و تزريق عضالني گاماگلوبولين درمورد است الزم باشد شده تزريق

از پس خوني محصوالت از يا پس خوني محصوالت پس 33يا وريدي گاماگلوبولين و پس ماه وريدي گاماگلوبولين و ماه.66از از شود تكرار واكسن .ماه شود تكرار واكسن ماه

مهم مهم نكات نكات

اي فاصله واكسن دوزهاي مابين صورتيكه اي در فاصله واكسن دوزهاي مابين صورتيكه درشروع به نيازي باشد شده توصيه مقدار از شروع بيش به نيازي باشد شده توصيه مقدار از بيشدوزهاي با تزريق ويا واكسيناسيون سري دوزهاي مجدد با تزريق ويا واكسيناسيون سري مجدد

. نيست .باالتر نيست باالتر

Hepatitis BHepatitis B

Contraindication:Contraindication:

Severe allergic reaction after a Severe allergic reaction after a

previous doseprevious dose Precaution:Precaution:

Moderate to severe acute illnessModerate to severe acute illness

Infant weighting <2000 gramInfant weighting <2000 gram can be administered:can be administered:

pregnancypregnancy

Autoimmune diseasesAutoimmune diseases

AEFIAEFI within 48 hours of DTP within 48 hours of DTP vaccinationsvaccinations

Redness 1/3 Redness 1/3 doses doses

Swelling 2/5Swelling 2/5 Pain 1/2 Pain 1/2 Systemic Fever Systemic Fever

>=38°C 1/2>=38°C 1/2 Collapse 1/1 Collapse 1/1

750 750 Convulsions 1/1 Convulsions 1/1

750750

Vomiting 1/5 Vomiting 1/5 Anorexia 1/5Anorexia 1/5 Persistent,inconsoPersistent,inconso

lable crying lable crying (duration >=3 (duration >=3 hours) 1/100 hours) 1/100

Fever >= 40.5°C Fever >= 40.5°C 1/330 1/330

Drowsiness 1/3Drowsiness 1/3

DTPDTP

ContraindicationContraindication::

Severe AEFI after a Severe AEFI after a previous doseprevious dose

Encephalopathy Encephalopathy after a previous after a previous dosedose

Progressive Progressive neurologic disorder neurologic disorder

Precaution:Precaution:

Moderate to severeModerate to severe illnessillness After previous dose:After previous dose: Fever > 40.5 cFever > 40.5 c CollapseCollapse SeizureSeizure Persistent cryingPersistent crying

DTPDTP

Can be administeredCan be administered::

After previous dose After previous dose

T <40.5 c‘ Mild drowsiness’ FussinessT <40.5 c‘ Mild drowsiness’ Fussiness Family Hx ofFamily Hx of

Seizure’ SIDS’ AEFISeizure’ SIDS’ AEFI Stable neurologic conditionStable neurologic condition

DT ’ TdDT ’ Td

ContraindicationContraindication::

Severe allergic Severe allergic reaction after a reaction after a previous doseprevious dose

Precaution:Precaution:

Guillain-Barre Guillain-Barre syndrome after a syndrome after a previous doseprevious dose

Moderate to severe Moderate to severe illnessillness

MMR/MR/RMMR/MR/R

ContraindicationContraindication : : Severely ImmunocopromisedSeverely Immunocopromised Congenital ImmunodeficiencyCongenital Immunodeficiency HIV InfectionHIV Infection LeukemiaLeukemia Aplastic anemiaAplastic anemia Generalized malignancyGeneralized malignancy Antimetabolites TherapyAntimetabolites Therapy Large amount of Crticosteroids TherapyLarge amount of Crticosteroids Therapy RadiationRadiation

MMRMMR

ContraindicationContraindication::

Severe allergic Severe allergic reaction after a reaction after a previous doseprevious dose

PregnancyPregnancy Severe Severe

ImmunodeficiencyImmunodeficiency

PrecautionPrecaution:: Recent receipt of Recent receipt of

antibody-containing antibody-containing productproduct

Hx of Hx of Thrombocytopenia Thrombocytopenia or or Thrombocytopenic Thrombocytopenic purpurapurpura

Moderate to severe Moderate to severe illnessillness

MMRMMR

Can be administeredCan be administered: : + PPD+ PPD Simultaneous TB skin testingSimultaneous TB skin testing Breast feedingBreast feeding Pregnancy of mothersPregnancy of mothers Close household contactsClose household contacts Allergy to eggsAllergy to eggs Asymptomatic or mildly symptomatic Asymptomatic or mildly symptomatic

HIV infectionHIV infection

Immunization of Immunocompromised Immunization of Immunocompromised childrenchildren

BCG Contraindicated in:BCG Contraindicated in:

HIV/Aids’HIV/Aids’

Severely ImmunocopromisedSeverely Immunocopromised

AspleniaAsplenia

Renal failureRenal failure MMR/MR/RMMR/MR/R

Severely ImmunocopromisedSeverely Immunocopromised

شما توجه شما از توجه ازمتشكرممتشكرم