Pediatrics

Pediatrics
Kirsten H. Ohler, Pharm.D., BCPS, BCPPS

University of Illinois Hospital & Health Sciences System
Chicago, Illinois
Pediatrics
Pediatrics
Kirsten H. Ohler, Pharm.D., BCPS, BCPPS
University of Illinois Hospital & Health Sciences System
Chicago, Illinois
ACCP Updates in Therapeutics® 2016: Pharmacotherapy Preparatory Review and Recertification Course
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Pediatrics
Learning Objectives 3. Which is the most accurate statement about pro-

phylaxis of bacterial meningitis?
1. Describe the most common pathogens associated A. Close contacts of patients with pneumococcal
with neonatal and pediatric sepsis and meningitis. meningitis should receive prophylaxis.
2. Describe current therapeutic options for the man-
B. Close contacts of patients with Haemophilus
agement of neonatal and pediatric sepsis and
influenzae meningitis need prophylaxis only if
meningitis.
their immunizations are not up to date.
3. Identify the drugs available for preventing and
treating respiratory syncytial virus. C. Rifampin is a first-line agent for prophylaxis
4. Describe the most common causative organisms of against meningococcal meningitis.
otitis media and potential treatment options. D. Prophylaxis against bacterial meningitis is no
5. Identify the recommended pediatric immunization longer recommended regardless of the caus-
schedule and barriers to routine immunization. ative organism.
6. Discuss the differences in anticonvulsant pharma-
cokinetics and adverse effects between children 4. A 6-month-old baby who was born at 24 weeks’
and adults. gestation is brought to the clinic in October for a
7. Describe the current drug therapy for treating routine checkup and immunizations. Which is the
patients with attention-deficit/hyperactivity disorder. best recommendation to make for this patient’s
immunization schedule?
A. Only two of the five immunizations due should
Self-Assessment Questions be given at the same time; schedule another
Answers and explanations to these questions can be appointment for the next week to administer
found at the end of this chapter. the rest.
B. Oral polio vaccine should be used to reduce
1. A 15-year-old boy with a history of exercise-in-
the number of injections needed to complete
duced asthma presents with fever, tachypnea,
the schedule.
headache, and myalgia. Which is most likely to be
isolated from this patient? C. Vaccines should be based on his corrected ges-
tational age rather than on his chronologic age
A. Respiratory syncytial virus (RSV).
because he was born prematurely.
B. Streptococcus pneumoniae.
D. Influenza vaccine should be administered with
C. Group B Streptococcus. all other scheduled vaccinations.
D. Pseudomonas aeruginosa.
5.
A physician asks for your recommendation for
2. Which is the best assessment of the risk of severe treating a 5-year-old child with his first case of
RSV infection and subsequent need for prophylaxis acute otitis media (AOM). Which statement is the
in a 3-month-old girl born at 30 weeks’ gestation? best advice?
A. This patient should receive prophylaxis if she A. A blood culture should be obtained to identify
is 6 months or younger at the beginning of the causative organism.
RSV season. B. Antibiotics may not be warranted at this time.
B. This patient is at risk only if she has chronic C. Initiate azithromycin to treat atypical organ-
lung disease (i.e., necessitating more than 21% isms (e.g., mycoplasma).
oxygen for at least the first 28 days of life).
D. Administer intramuscular ceftriaxone.
C. All neonates born during RSV season should
receive prophylaxis. 6. A 16-year-old girl with asthma, a history of ven-
D. This patient should receive prophylaxis only if tricular septal defect, and attention-deficit/hyper-
she has additional risk factors such as day care activity disorder (ADHD) was initially treated
attendance or school-aged siblings. with methylphenidate immediate release, but her
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Pediatrics
ADHD symptoms persisted at home and at school. 10. An 8-month-old, former 36-week gestational-age
Her therapy was then changed to methylpheni- infant with hypoplastic left heart disease is admit-
date OROS (Concerta). The dose was maximized ted during RSV season for stage II (of III) repair of
during the next several weeks; however, her symp- his heart defect. Which statement is most accurate
toms were still not well controlled throughout the about the use of palivizumab for RSV prophylaxis
day. She and her family report adherence to the in this patient?
treatment regimen. Which is the best recommen- A. He is not at significant risk of severe RSV
dation to make for treating her ADHD? infection; therefore, palivizumab is not
A. Switch to clonidine. indicated.
B.
Switch to extended-release mixed amphet- B. Palivizumab is indicated to reduce nosocomial
amine salts (i.e., Adderall XR). transmission of RSV in high-risk patients.
C. Switch to methylphenidate transdermal sys- C. Palivizumab is not indicated because he has
tem (i.e., Daytrana). undergone surgical repair of his heart defect.
D. Switch to atomoxetine. D. A dose of palivizumab should be administered
postoperatively and continued throughout the
7. A 7-year-old child with absence seizures is having RSV season.
breakthrough episodes on ethosuximide. Which is
the most appropriate alternative therapy?
A. Valproic acid.
B. Phenytoin.
C. Phenobarbital.
D. Gabapentin.
8. In a retrospective study of the risk of appetite loss

in adolescents taking a specific stimulant agent for
ADHD management, 7 of 200 patients exposed
to the stimulant showed appetite loss, compared
with 1 of 198 control subjects (unexposed). Which
choice best reflects the correct odds ratio of devel-
oping loss of appetite for the case subjects com-
pared with the control subjects?
A. 3.
B. 6.
C. 7.
D. 8.
9. An investigator wants to establish a causal relation-

ship between the use of ceftriaxone in premature
neonates and the incidence of kernicterus. Which
study design is best to use?
A. Case series.
B. Randomized controlled.
C. Retrospective cohort.
D. Crossover.
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Pediatrics
BPS Pharmacotherapy Specialty Examination Content Outline

This chapter covers the following sections of the Pharmacotherapy Specialty Examination Content Outline:
1. Domain 1: Patient-specific Pharmacotherapy
a. Tasks 1, 2, 3, 5, and 6
b. Systems and Patient Care Problems
i. Sepsis/Meningitis
ii. Respiratory Syncytial Virus (RSV) Infection
iii. Otitis Media
iv. Immunizations
v. Pediatric Seizure Disorders
vi. Attention-Deficit/Hyperactivity Disorder
2. Domain 2: Retrieval, Generation, Interpretation and Dissemination of Knowledge in Pharmacotherapy, Task 2
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Pediatrics
I. SEPSIS AND MENINGITIS
A. Clinical Presentation
1. Signs and symptoms
a. Neonates
i. General: Temperature instability, feeding intolerance, lethargy, grunting, flaring, retractions,
apnea
ii. More likely to be associated with meningitis: Bulging fontanelle and seizures
b. Children
i. General: Fever, loss of appetite, emesis, myalgias, arthralgias, cutaneous manifestations
(e.g., petechiae, purpura, rash)
ii. More likely to be associated with meningitis: Nuchal rigidity, back pain, Kernig sign,
Brudzinski sign, headache, photophobia, altered mental status, and seizures
2. Early versus late neonatal sepsis
a. Onset
i. Early: Within 3 days of birth
ii. Late: After the first 3 days of life
b. Risk factors
i. Early: Very low birth weight, prolonged rupture of amniotic membranes, prolonged labor,
maternal endometritis, or chorioamnionitis
ii. Late
(a) Unrelated to obstetric risk factors
(b) Usually related to iatrogenic factors (e.g., endotracheal tubes, central venous catheters)
c. Incidence
i. Early
(a) 0.7–3.7 of 1000 live births (8 of 1000 very-low-birth-weight infants)
(b) Meningitis occurs in less than 10% of cases.
ii. Late
(a) 0.5–1.8 of 1000 live births
(b) Meningitis occurs in 60% of cases.
3. Cerebrospinal fluid findings (Table 1)
Table 1. Cerebrospinal Fluid Findings

Laboratory Value Normal Child Normal Newborn Bacterial Meningitis Viral Meningitis
WBC (cells/mL) 0–6 0–30 >1000 100–500
Neutrophils (%) 0 2–3 >50 <40
Glucose (mg/dL) 40–80 32–121 <30 >30
Protein (mg/dL) 20–30 19–149 >100 50–100
RBC (cells/mL) 0–2 0–2 0–10 0–2
RBC = red blood cell count; WBC = white blood cell count.
Adapted with permission from the American Academy of Pediatrics. Wubbel L, McCracken GH. Management of bacterial meningitis: 1998.
Pediatr Rev 1998;19:78-84.
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Pediatrics
Patient Case
1. A baby born at 36 weeks’ gestation develops respiratory distress, hypotension, and mottling at 5 hours of life.
The baby is transported to the neonatal intensive care unit, where he has a witnessed seizure, and cultures are
drawn. Maternal vaginal cultures are positive for group B Streptococcus, and three doses of penicillin were
given to the mother before delivery. Which is the best empiric antibiotic regimen?
A. Vancomycin.
B. Ampicillin plus gentamicin.
C. Ampicillin plus ceftriaxone.
D. Ceftazidime plus gentamicin.
B. Common Pathogens for Sepsis and Meningitis (Table 2)
Table 2. Common Pathogens

Age Organism
0–1 month Group B Streptococcus
Escherichia coli
Listeria monocytogenes
Viral (e.g., herpes simplex virus)
Coagulase-negative staphylococcus (nosocomial)
Gram-negative bacteria (e.g., Pseudomonas spp., Enterobacter spp.; nosocomial)
1–3 months Neonatal pathogens (see above)
Haemophilus influenzae type B
Neisseria meningitidis
Streptococcus pneumoniae
3 months–12 years H. influenzae type Ba
N. meningitidis
S. pneumoniae
>12 years N. meningitidis
S. pneumoniae
a
H. influenzae is no longer a common pathogen in areas where the vaccine is routinely used.
C. Potential Empiric Antibiotic Regimens for Sepsis and Meningitis (Table 3)
Table 3. Potential Antibiotic Regimens

Age Regimen
0–1 month Ampicillin + gentamicin or ampicillin + cefotaxime
1–3 months Ampicillin + cefotaxime/ceftriaxone
3 months–12 years Ceftriaxone ± vancomycina
>12 years Ceftriaxone ± vancomycina
a
Addition of vancomycin should be based on the regional incidence of resistant Streptococcus pneumoniae.
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Pediatrics
Patient Cases
2. Culture results for the patient in question 1 reveal gram-negative rods in the cerebrospinal fluid. Which rec-
ommendation regarding antibiotic prophylaxis is best?
A. The patient’s 5-month-old stepsister is at high risk because she is not fully immunized; the patient should
therefore receive rifampin.
B. The patient should receive rifampin to eliminate nasal carriage of the pathogen.
C. Antibiotic prophylaxis is not indicated in this case.
D. All close contacts should receive rifampin for prophylaxis.
3. A 6-year-old boy presents to the emergency department with a temperature of 104°F, altered mental status,
and petechiae. There is no history of trauma. A toxicology screen is negative. A complete blood cell count
reveals 32 × 103 cells/mm3 with 20% bands. Culture results are pending. The patient has no known drug aller-
gies. Which antibiotic regimen provides the best empiric coverage?
A. Ampicillin plus gentamicin.
B. Cefuroxime.
C. Ceftriaxone plus vancomycin.
D. Rifampin.
D. Sequelae of Meningitis
1. Hearing loss
2. Mental retardation and learning deficits
3. Visual impairment
4. Seizures
5. Hydrocephalus
E. Chemoprophylaxis of Bacterial Meningitis

1. Purpose: Prevent the spread of H. influenzae and Neisseria meningitidis
2. High-risk groups
a. Household contacts
b. Nursery or day care center contacts
c. Direct contact with index patient’s secretions
3. Regimens (Table 4)
Table 4. Regimens for Chemoprophylaxisa

Drug Neisseria meningitidis Haemophilus influenzae
Rifampin <1 month old: 5 mg/kg/dose PO every 12 hours × 2 days 20 mg/kg/dose (maximum 600 mg)
≥1 month old: 10 mg/kg/dose PO every 12 hours × 2 days PO daily × 4 days
Adults: 600 mg PO every 12 hours × 2 days
Ceftriaxone <15 years old: 125 mg IM × 1 dose Not indicated
≥15 years old: 250 mg IM × 1 dose
a
Ciprofloxacin and azithromycin are possible alternatives but not routinely recommended.
IM = intramuscularly; PO = orally.
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Pediatrics
II. RESPIRATORY SYNCYTIAL VIRUS INFECTION
1. Seasonal occurrence: Typically November through April, depending on geographic location
2. Signs and symptoms
a. Neonates and infants: Lower respiratory tract symptoms (e.g., bronchiolitis and pneumonia),
wheezing, lethargy, irritability, poor feeding, and apnea
b. Older children: Upper respiratory tract symptoms (e.g., rhinorrhea, cough)
B. Risk Factors for Severe Disease

1. Premature birth
2. Chronic lung disease or bronchopulmonary dysplasia
3. Cyanotic or complicated congenital heart disease
4. Immunodeficiency
5. Airway abnormalities or neuromuscular conditions compromising the handling of respiratory secretions
6. Other
a. Lower socioeconomic status
b. Passive smoking
c. Day care attendance
d. Siblings younger than 5 years
Patient Case
4. You are screening babies during the current respiratory syncytial virus (RSV) season for risk factors asso-
ciated with the development of severe RSV infection. Which is the best recommendation about the use of
palivizumab for RSV prophylaxis?
A. Palivizumab should be prescribed for an 18-month-old, former 26-week premature infant with a history
of chronic lung disease who has not received oxygen or medications during the past 8 months.
B. Palivizumab should be prescribed for a 5-month-old, former 28-week premature infant with a history of
chronic lung disease who was discharged from the hospital without oxygen or medications.
C. Palivizumab should be prescribed for a 41-day-old baby, born at 31 weeks’ gestation, without a history of
chronic lung disease who will attend day care.
D. Palivizumab should be prescribed for a 10-month-old baby, born at 37 weeks’ gestation, with a surgically
repaired congenital heart defect.
C. Prophylaxis
1. Nonpharmacologic: Avoid crowds during RSV season and conscientiously use good handwashing practice.
2. Palivizumab (Synagis)
a. Dosing: 15 mg/kg/dose intramuscularly, given monthly during RSV season
b. Effects on outcomes
i. A 55% reduction in hospitalizations for RSV
ii. Safe in patients with cyanotic congenital heart disease. There is a 58% decrease in palivi-
zumab serum concentration after cardiopulmonary bypass; therefore, a postoperative dose of
palivizumab is recommended as soon as the patient is medically stable.
iii. No reduction in overall mortality
iv. Does not interfere with the response to vaccines
v. Not recommended for the prevention of nosocomial transmission of RSV
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Pediatrics
c. American Academy of Pediatrics (AAP) recommendations for use were updated in 2014 (Table 5)
and contain several significant changes from their 2009 policy statement.
i. Routine prophylaxis is no longer recommended for neonates born at 29 weeks’ gestation or
later; previously all neonates born at less than 32 weeks’ gestation were recommended to
receive routine prophylaxis.
ii. Risk factors for RSV infection such as day care attendance or siblings younger than 5 years of
age are no longer considered when determining the need for prophylaxis.
iii. Prophylaxis is not recommended in the second year of life based on a history of prematurity
alone; previously neonates born at less than 28 weeks’ gestation could be considered for pro-
phylaxis during their second RSV season.
iv. Prophylaxis should be discontinued if an RSV hospitalization occurs; previously palivizumab
was continued to complete five monthly doses regardless of hospitalization.
Table 5. AAP Guidelines for Palivizumab Use

Gestational Age Age at Start of RSV Other Required Criteria Maximal
(weeks) Season (months) Doses
<29 + 0 days <12 5
29–32 + 0 days <12 Chronic lung disease necessitating more than 5
21% oxygen for at least the first 28 days of life
<32 + 0 days <24 Consider prophylaxis for a second RSV season if 5
chronic lung disease necessitating medical ther-
apy within the 6 months preceding the start
of RSV season
Any <12 Patient with hemodynamically significant 5
acyanotica congenital heart disease receiving
medication for congestive heart failure and will
need cardiac surgery
Any <12 Moderate to severe pulmonary hypertension 5
Any <12 Congenital abnormalities of airway or 5
neuromuscular disease
Any <24 Profound immunocompromise 5
Infants with cyanotic heart defects may be considered for prophylaxis after consultation with a pediatric cardiologist.
a
AAP = American Academy of Pediatrics; RSV = respiratory syncytial virus.
Patient Case
5. An 18-month-old baby with a history of premature birth and chronic lung disease is admitted to the pediatric
intensive care unit with fever, respiratory distress necessitating intubation, and a 3-day history of cold-like
symptoms. A nasal swab is positive for RSV. Which is the best intervention?
A. Palivizumab.
B. Dexamethasone.
C. Cefuroxime.
D. Intravenous fluids and supportive care.
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Pediatrics
D. Treatment
1. Supportive care
a. Hydration
b. Supplemental oxygen
c. Mechanical ventilation as needed
2. Ribavirin
a. Active against RSV replication
b. Not shown to reduce mortality in immunocompetent patients
c. Not shown to reduce ventilator days, stay in the intensive care unit or hospital, or hospital cost
d. The AAP states that ribavirin “may be considered” in a select group of high-risk patients
(e.g., those with complicated congenital heart disease, chronic lung disease or bronchopulmonary
dysplasia, immunocompromise).
3. β2-Agonists, racemic epinephrine
a. Not shown to improve outcome measures
b. Some practitioners may give a trial of these therapies, but this is not considered the standard of
care, nor is it recommended by the current AAP guideline.
4. Corticosteroids
a. Not shown to improve outcome measures
b. Use is not recommended.
5. Hypertonic saline
a. Should not be administered in the emergency department
b. May be considered for hospitalized patients; however, the evidence supporting use is weak.
6. Antibiotics: Not indicated unless secondary bacterial infection develops
III. OTITIS MEDIA
1. Definitions
a. Acute otitis media (AOM): Presence of middle ear effusion and evidence of middle ear inflammation
i. Middle ear effusion may be indicated by bulging tympanic membrane, decreased or no mobil-
ity of the tympanic membrane, purulent fluid in the middle ear.
ii. Inflammation of the middle ear may be indicated by erythema of the tympanic membrane or
otalgia.
b. Otitis media with effusion (OME): Fluid in the middle ear without evidence of local or systemic
illness
c. Recurrent AOM: Three or more episodes of acute otitis within 6 months or four episodes within
1 year
2. Risk factors
a. Day care attendance
b. Family history of AOM
c. Positioning during feeding (e.g., supine position during bottle-feeding allows reflux into eustachian
tubes)
d. Lower socioeconomic status
e. Smokers in the household
f. Craniofacial abnormalities or cleft palate
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Pediatrics
B. Common Pathogens
1. Viral
2. S. pneumoniae
3. Nontypeable H. influenzae
4. Moraxella catarrhalis
C. Treatment
1. General principles
a. Clinical resolution will occur in a significant number of cases without antibiotic therapy.
b. Immediate antibiotic therapy is warranted for AOM with bulging tympanic membrane, perfora-
tion, or otorrhea.
c. Delayed antibiotic prescribing (i.e., treatment only if otalgia persists for more than 48–72 hours
or temperature greater than 39°C in past 48 hours) is an acceptable strategy in children older than
2 years with AOM without severe systemic symptoms.
i. Analgesics are more beneficial than antibiotics for relieving otalgia within the first 24 hours
and are recommended regardless of antibiotic use.
ii. Antibiotics also may be deferred in otherwise healthy children between 6 months and 2 years
of age if their symptoms are mild and otitis media is unilateral (as opposed to bilateral).
iii. Caregiver must be reliable to recognize worsening of condition and gain immediate access to
medical care, if needed.
iv. Not recommended for infants younger than 6 months
d. Persistence of middle ear fluid is likely after treatment for AOM and does not warrant repeated
treatment.
e. Antibiotics are not generally warranted for OME because of the high rate of spontaneous resolution.
i. Antibiotics are recommended only if bilateral effusions persist for more than 3 months.
ii. Corticosteroids, antihistamines, and decongestants are not recommended.
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Pediatrics
2. Suggested treatment algorithm (Figure 1)
Confirmed AOM
NO Otorrhea or severe symptoms?

YES
Age 6 mo–2 yr?
NO YES
Antibiotic therapy
Delayed antibiotic • First-line agents
Bilateral • Amoxicillin 80–90 mg/kg/day
prescribing
• Not recommended if child Unilateral or Bilateral • Amoxicillin/clavulanate –
is <6 months unilateral Consider if amoxicillin taken
• Antibiotics prescribed only AOM? within past 30 days
if child worsens or does not • Alternatives (if penicillin allergic)
improve within 48–72 hours • Cefdinir
— OR — • Cefuroxime
Antibiotic therapy • Cefpodoxime
• If child is < 6 months old or • Ceftriaxone
if reliable follow-up cannot
be ensured
Reevaluate at 48–72 hours

Failure of initial treatment strategy?
YES
NO
• Start antibiotic if prescribing was delayed
• Continue current treatment strategy • Consider changing antibiotic regimen

• Amoxicillin/clavulanate 90 mg/kg/day
• Antibiotic duration • Ceftriaxone x 3 days
• Optimal duration is unknown • Clindamycin ± 3rd-generation cephalosporin
• <2 yr or severe symptoms: 10 days • Consider tympanocentesis
• 2–5 yr with mild–moderate symptoms: 7 days
• >6 yr with mild–moderate symptoms: 5–7 days • Consider tympanostomy tubes
• Most beneficial for children with persistent
OME and significant hearing loss (e.g., >25-dB
hearing loss bilaterally >12 weeks)
Figure 1. AOM suggested treatment algorithm.
D. Prevention Strategies
1. Antibiotic prophylaxis
a. Reduces occurrence by about one episode per year
b. The risk of promoting bacterial resistance may outweigh the slight benefit.
c. AAP recommends against routine use for children with recurrent AOM.
2. Immunization: Pneumococcal and influenza vaccines should be administered according to the AAP
and Advisory Committee on Immunization Practices (ACIP) recommendations.
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Pediatrics
Patient Cases
6. A 5-month-old infant who was born at term and is otherwise healthy was treated for her first case of otitis
media with amoxicillin 45 mg/kg/day for 7 days. On follow-up examination, her pediatrician noticed fullness
in the middle ear and a cloudy tympanic membrane with decreased mobility. She is now afebrile and eating
well. Which is the best recommendation for her treatment?
A. No antibiotics at this time.
B. High-dose (90 mg/kg/day) amoxicillin for 7 days.
C. Decongestant and antihistamine daily until resolution.
D. Azithromycin.
7. A 4-year-old boy receives a diagnosis of his fourth case of otitis media within 12 months. He has not shown
evidence of hearing loss or delay in language skills. Which is the best intervention at this point?
A. Giving long-term antibiotic prophylaxis.
B. Inserting tympanostomy tubes.
C. Administering high-dose amoxicillin and ensuring that he is up to date on his pneumococcal and influ-
enza vaccines.
D. No antibiotic therapy is warranted.
IV. IMMUNIZATIONS
A. Recommended Schedule
1. Few major changes have been made to the routine childhood schedule since 2009.
a. Replacement of 7-valent conjugated pneumococcal vaccine with 13-valent conjugated pneumococ-
cal vaccine (PCV13, Prevnar 13) for all children younger than 6 years
b. Human papillomavirus vaccine (HPV4, Gardasil) received a U.S. Food and Drug Administration
(FDA) label-approved indication in males 9–26 years old for prevention of genital warts. Now rec-
ommended for routine vaccination of adolescent males.
c. For children and adolescents who have a delayed start to immunizations, a catch-up schedule exists.
d. Refer to the National Immunization Program Web site (www.cdc.gov/vaccines).
Patient Case
8. A 1-year-old boy with a history of Kawasaki disease treated 4 months ago with intravenous immunoglob-
ulin (IVIG) is being seen by his pediatrician for a well-child checkup. He is due for the measles, mumps,
and rubella (MMR) and varicella vaccines. He has no known drug allergies, but he has many food allergies,
including peanuts, eggs, and shellfish. His mother has several concerns about administering these vaccines.
Which concern is the best reason to defer administering vaccines in this patient?
A. Association between MMR vaccine administration and the development of autism.
B. Allergic reaction after MMR administration in a patient with an egg allergy.
C. Many concurrent vaccines can overload the patient’s immune system.
D. Decreased vaccine efficacy because of previous IVIG administration.
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Pediatrics
2. Combination vaccines
a. Main advantage: Reduction in the number of injections needed to complete recommended schedule
b. The FDA mandates that the safety and efficacy of combination products not be less than those of
the individual components.
c. The measles, mumps, and rubella (MMR) and varicella combination vaccine (ProQuad)
i. Research from the Centers for Disease Control and Prevention and manufacturer indicated a
higher incidence of febrile seizures in children 12–23 months of age who received the combi-
nation product compared with those who received the separate MMR and varicella vaccines.
ii. Since June 2009, ACIP has expressed a preference for separate MMR and varicella vaccines
as the first dose given to children 12–47 months of age. The combination product may be used
for the second dose at any age and for the first dose in children 48 months or older.
d. Adding hepatitis B vaccine (HepB) to combination products may result in an extra dose being pro-
vided (e.g., monovalent HepB given at birth and then combination products at 2, 4, and 6 months);
however, ACIP states that this is a safe practice.
3. Interchangeability of products
a. ACIP recommends that the same product be used throughout the primary series; however, if the
previous product’s identity is not known or is no longer available, any product may be used.
b. For diphtheria, tetanus, and pertussis vaccine (DTaP): The current standard of care is to use the
same product for at least the first three doses of the five-dose series; however, if the product used
previously is not known or is unavailable, any product may be used.
c. For tetanus, diphtheria, and pertussis vaccine (Tdap): Boostrix or Adacel may be used for the
booster dose, regardless of the manufacturer of the DTaP product administered during the primary
immunization series.
d. For HepB: It is acceptable to use ENGERIX-B and RECOMBIVAX HB interchangeably.
e. For polio: Oral polio vaccine and inactivated poliovirus vaccine provide equivalent protection
against paralytic poliomyelitis; however, because the only cases of polio in the United States since
1979 have been vaccine associated (i.e., from the live virus in oral polio vaccine), oral polio vaccine
is no longer recommended.
f. For Haemophilus influenzae type b vaccine (Hib): These products may be used interchangeably;
however, if the regimen is completed using PedvaxHIB exclusively, only three doses are needed;
regimens using HibTITER or ActHIB include four doses.
g. For HPV: The products differ in the HPV types against which they provide protection. HPV4
(Gardasil) protects against types 6, 11, 16, and 18. HPV2 (Cervarix) protects against types 16 and
18. HPV types 6 and 11 are associated with genital warts; types 16 and 18 are associated with gyne-
cologic, anal, and penile cancers.
B. Barriers to Routine Immunization

1. Contraindications
a. Anaphylactic reaction to vaccine or any of its components
i. Inactivated poliovirus vaccine, MMR, and varicella contain neomycin.
ii. Influenza vaccine: Live attenuated influenza vaccine (LAIV) should be avoided in patients with
severe egg allergy; inactivated influenza vaccine may be administered with close monitoring.
iii. Severe egg allergy is not considered a contraindication to MMR, which is grown in chick
embryo tissue.
b. Acute moderate to severe febrile illness
c. Immunodeficiency: Oral polio vaccine, MMR, varicella
d. Pregnancy: MMR, varicella
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Pediatrics
e. Recent administration of immune globulin: MMR, varicella

i. Delay administration of vaccine product.
ii. Interval between immune globulin dose and administration of vaccine depends on indication
for and dose of immune globulin.
f. Encephalopathy within 7 days after administration of a previous dose of DTaP
g. History of intussusception: Rotavirus vaccine
2. Misconceptions about contraindications (i.e., these are not contraindications)
a. Mild acute illness
b. Current antimicrobial therapy
c. Reaction to DTaP involving only soreness, redness, or swelling at the site
d. Pregnancy of the mother of the vaccine recipient
e. Breastfeeding
f. Allergies to antibiotics other than neomycin or streptomycin
g. Family history of an adverse effect after vaccine administration
3. Other factors associated with underimmunization
a. Low socioeconomic status
b. Late start of vaccination series
c. Missed opportunities
i. Provider unaware that vaccination is due
ii. Failure to provide simultaneous vaccines
iii. Inappropriate contraindications (see previous discussion)
d. Concern about potential adverse reactions
i. Autism: The association with MMR vaccine has not been proven.
ii. Guillain-Barré syndrome: The association with meningococcal conjugate vaccine has not
been proven.
(a) 15 reported cases in adolescents after receiving meningococcal vaccine
(b) ACIP continues to recommend the routine use of meningococcal vaccine.
iii. Intussusception: An association with rotavirus vaccine led to the market withdrawal of
RotaShield; two products are currently available.
(a) Live, oral human-bovine reassortant rotavirus vaccine (RotaTeq, licensed in 2006)
(b) Live, attenuated human rotavirus vaccine (Rotarix, licensed in 2008)
(c) Neither product has been associated with intussusception.
iv. Safety concerns about any vaccine product should be reported through the Vaccine Adverse
Events Reporting System (VAERS).
Patient Case
9. The following patients are seeing their pediatrician today and are due for immunizations according to the
routine schedule. For which patient would it be best to recommend deferring immunizations until later?
A. A 12-month-old boy who recently completed a cycle of chemotherapy for acute lymphocytic leukemia.
B. A 6-month-old girl receiving amoxicillin for otitis media.
C. A 12-month-old HIV-positive boy whose most recent CD4 count was greater than 1000.
D. A 12-year-old girl completing a prednisone “burst” (1 mg/kg/day for 5 days) for asthma exacerbation.
1-17
Pediatrics
C. Considerations in Special Populations

1. Preterm infants
a. Immunize according to chronologic age.
b. Do not lower vaccine doses.
c. If birth weight is less than 2 kg, delay HepB vaccine because of reduced immune response until the
patient is 30 days old or at hospital discharge if it occurs before 30 days of age (unless the mother
is positive for HepB surface antigen).
2. Children who are immunocompromised
a. Should not receive live vaccines
b. Inactivated vaccines and immune globulins are appropriate.
c. Household contacts should not receive oral polio vaccine; however, MMR, influenza, varicella, and
rotavirus vaccines are recommended.
3. Patients receiving corticosteroids
a. Live vaccines may be administered to patients receiving the following:
i. Topical corticosteroids
ii. Physiologic maintenance doses
iii. Low or moderate doses (less than 2 mg/kg/day of prednisone equivalent)
b. Live vaccines may be given immediately after discontinuation of high doses (2 mg/kg/day or more
of prednisone equivalent) of systemic steroids given for less than 14 days.
c. Live vaccines should be delayed at least 1 month after discontinuing high doses (2 mg/kg/day or
more of prednisone equivalent) of systemic steroids given for more than 14 days.
4. Patients with HIV infection
a. MMR should be administered unless patient is severely immunocompromised.
b. Varicella should be considered for asymptomatic or mildly symptomatic patients.
c. Inactivated vaccines should be administered routinely.
1-18
Figure 1. Recommended immunization schedule for persons aged 0 through 18 years – United States, 2016.
(FOR THOSE WHO FALL BEHIND OR START LATE, SEE THE CATCH-UP SCHEDULE [FIGURE 2]).
These recommendations must be read with the footnotes that follow. For those who fall behind or start late, provide catch-up vaccination at the earliest opportunity as indicated by the green bars in Figure 1.
To determine minimum intervals between doses, see the catch-up schedule (Figure 2). School entry and adolescent vaccine age groups are shaded.
19–23
Vaccine Birth 1 mo 2 mos 4 mos 6 mos 9 mos 12 mos 15 mos 18 mos 2-3 yrs 4-6 yrs 7-10 yrs 11-12 yrs 13–15 yrs 16–18 yrs
mos
Hepatitis B1 (HepB) 1st dose 2nd dose 3rd dose
Rotavirus2 (RV) RV1 (2-dose See

1st dose 2nd dose footnote 2
series); RV5 (3-dose series)
Diphtheria, tetanus, & acellular
1st dose 2nd dose 3rd dose 4th dose 5th dose
pertussis3 (DTaP: <7 yrs)
Haemophilus influenzae type b4 See 3rd or 4th dose,
1st dose 2nd dose footnote 4 See footnote 4
(Hib)
Pneumococcal conjugate5
1st dose 2nd dose 3rd dose 4th dose
(PCV13)
Inactivated poliovirus6
1st dose 2nd dose 3rd dose 4th dose
(IPV: <18 yrs)
Annual vaccination (LAIV or Annual vaccination (LAIV or IIV)
Influenza7 (IIV; LAIV) Annual vaccination (IIV only) 1 or 2 doses IIV) 1 or 2 doses 1 dose only
Measles, mumps, rubella8 (MMR) See footnote 8 1st dose 2nd dose
Varicella9 (VAR) 1st dose 2nd dose
Hepatitis A1 0 (HepA) 2-dose series, See footnote 10
Meningococcal1 1 (Hib-MenCY
> 6 weeks; MenACWY-D >9 mos; See footnote 11 1st dose Booster
MenACWY-CRM ≥ 2 mos)
1-19
Tetanus, diphtheria, & acellular (Tdap)
Pediatrics
pertussis1 2 (Tdap: >7 yrs)

Human papillomavirus1 3 (2vHPV:
(3-dose
females only; 4vHPV, 9vHPV: series)
males and females)
See footnote 11
Meningococcal B1 1
Pneumococcal polysaccharide5
See footnote 5
(PPSV23)
Range of recommended Range of recommended ages Range of recommended ages Range of recommended ages for non-high-risk No recommendation
ages for all children for catch-up immunization for certain high-risk groups groups that may receive vaccine, subject to
individual clinical decision making
This schedule includes recommendations in effect as of January 1, 2016. Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and
feasible. The use of a combination vaccine generally is preferred over separate injections of its equivalent component vaccines. Vaccination providers should consult the relevant Advisory Committee
on Immunization Practices (ACIP) statement for detailed recommendations, available online at http://www.cdc.gov/vaccines/hcp/acip-recs/index.html. Clinically significant adverse events that follow
vaccination should be reported to the Vaccine Adverse Event Reporting System (VAERS) online (http://www.vaers.hhs.gov) or by telephone (800-822-7967). Suspected cases of vaccine-preventable
diseases should be reported to the state or local health department. Additional information, including precautions and contraindications for vaccination, is available from CDC online
(http://www.cdc.gov/vaccines/recs/vac-admin/contraindications.htm) or by telephone (800-CDC-INFO [800-232-4636]).
This schedule is approved by the Advisory Committee on Immunization Practices (http//www.cdc.gov/vaccines/acip), the American Academy of Pediatrics (http://www.aap.org), the American Academy of
Family Physicians (http://www.aafp.org), and the American College of Obstetricians and Gynecologists (http://www.acog.org).
NOTE: The above recommendations must be read along with the footnotes of this schedule.
Figure 2. Recommended immunization schedule for people aged 0–18 years, 2016.
For those who fall behind or start late, see the catch-up schedule at www.cdc.gov/vaccines/schedules/hcp/imz/catchup.html.
Footnotes — Recommended immunization schedule for persons aged 0 through 18 years—United States, 2016
For further guidance on the use of the vaccines mentioned below, see: http://www.cdc.gov/vaccines/hcp/acip-recs/index.html.
For vaccine recommendations for persons 19 years of age and older, see the Adult Immunization Schedule.
Additional information
• For contraindications and precautions to use of a vaccine and for additional information regarding that vaccine, vaccination providers should consult the relevant ACIP statement available online at
http://www.cdc.gov/vaccines/hcp/acip-recs/index.html.
• For purposes of calculating intervals between doses, 4 weeks = 28 days. Intervals of 4 months or greater are determined by calendar months.
• Vaccine doses administered 4 days or less before the minimum interval are considered valid. Doses of any vaccine administered ≥5 days earlier than the minimum interval or minimum age should not be counted as
valid doses and should be repeated as age-appropriate. The repeat dose should be spaced after the invalid dose by the recommended minimum interval. For further details, see MMWR, General Recommendations
on Immunization and Reports / Vol. 60 / No. 2; Table 1. Recommended and minimum ages and intervals between vaccine doses available online at
http://www.cdc.gov/mmwr/pdf/rr/rr6002.pdf.
• Information on travel vaccine requirements and recommendations is available at http://wwwnc.cdc.gov/travel/destinations/list.
• For vaccination of persons with primary and secondary immunodeficiencies, see Table 13, “Vaccination of persons with primary and secondary immunodeficiencies,” in General Recommendations on Immunization
(ACIP), available at http://www.cdc.gov/mmwr/pdf/rr/rr6002.pdf.; and American Academy of Pediatrics. “Immunization in Special Clinical Circumstances,” in Kimberlin DW, Brady MT, Jackson MA, Long SS eds. Red
Book: 2015 report of the Committee on Infectious Diseases. 30th ed. Elk Grove Village, IL: American Academy of Pediatrics.
1. Hepatitis B (HepB) vaccine. (Minimum age: birth) 3. Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine (cont’d)
Routine vaccination: Catch-up vaccination:
At birth: • The fifth dose of DTaP vaccine is not necessary if the fourth dose was administered at age 4 years or older.
• Administer monovalent HepB vaccine to all newborns before hospital discharge. • For other catch-up guidance, see Figure 2.
• For infants born to hepatitis B surface antigen (HBsAg)-positive mothers, administer HepB vaccine and 4. Haemophilus influenzae type b (Hib) conjugate vaccine. (Minimum age: 6 weeks for PRP-T [AC-
0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth. These infants should be tested THIB, DTaP-IPV/Hib (Pentacel) and Hib-MenCY (MenHibrix)], PRP-OMP [PedvaxHIB or COMVAX],
for HBsAg and antibody to HBsAg (anti-HBs) at age 9 through 18 months (preferably at the next well- 12 months for PRP-T [Hiberix])
child visit) or 1 to 2 months after completion of the HepB series if the series was delayed; CDC recently Routine vaccination:
recommended testing occur at age 9 through 12 months; see http://www.cdc.gov/mmwr/preview/ • Administer a 2- or 3-dose Hib vaccine primary series and a booster dose (dose 3 or 4 depending on
mmwrhtml/mm6439a6.htm. vaccine used in primary series) at age 12 through 15 months to complete a full Hib vaccine series.
• If mother’s HBsAg status is unknown, within 12 hours of birth administer HepB vaccine regardless of birth • The primary series with ActHIB, MenHibrix, or Pentacel consists of 3 doses and should be administered at
weight. For infants weighing less than 2,000 grams, administer HBIG in addition to HepB vaccine within 2, 4, and 6 months of age. The primary series with PedvaxHib or COMVAX consists of 2 doses and should
12 hours of birth. Determine mother’s HBsAg status as soon as possible and, if mother is HBsAg-positive, be administered at 2 and 4 months of age; a dose at age 6 months is not indicated.
also administer HBIG for infants weighing 2,000 grams or more as soon as possible, but no later than age • One booster dose (dose 3 or 4 depending on vaccine used in primary series) of any Hib vaccine should be
7 days. administered at age 12 through 15 months. An exception is Hiberix vaccine. Hiberix should only be used
Doses following the birth dose: for the booster (final) dose in children aged 12 months through 4 years who have received at least 1 prior
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• The second dose should be administered at age 1 or 2 months. Monovalent HepB vaccine should be used dose of Hib-containing vaccine.
for doses administered before age 6 weeks. • For recommendations on the use of MenHibrix in patients at increased risk for meningococcal disease,
• Infants who did not receive a birth dose should receive 3 doses of a HepB-containing vaccine on a
Pediatrics
please refer to the meningococcal vaccine footnotes and also to MMWR February 28, 2014 / 63(RR01);1-13,
schedule of 0, 1 to 2 months, and 6 months starting as soon as feasible. See Figure 2. available at http://www.cdc.gov/mmwr/PDF/rr/rr6301.pdf.
• Administer the second dose 1 to 2 months after the first dose (minimum interval of 4 weeks), administer Catch-up vaccination:
the third dose at least 8 weeks after the second dose AND at least 16 weeks after the first dose. The final • If dose 1 was administered at ages 12 through 14 months, administer a second (final) dose at least 8 weeks
(third or fourth) dose in the HepB vaccine series should be administered no earlier than age 24 weeks. after dose 1, regardless of Hib vaccine used in the primary series.
• Administration of a total of 4 doses of HepB vaccine is permitted when a combination vaccine containing • If both doses were PRP-OMP (PedvaxHIB or COMVAX), and were administered before the first birthday, the
HepB is administered after the birth dose. third (and final) dose should be administered at age 12 through 59 months and at least 8 weeks after the
Catch-up vaccination: second dose.
• Unvaccinated persons should complete a 3-dose series. • If the first dose was administered at age 7 through 11 months, administer the second dose at least 4 weeks
• A 2-dose series (doses separated by at least 4 months) of adult formulation Recombivax HB is licensed for later and a third (and final) dose at age 12 through 15 months or 8 weeks after second dose, whichever is
use in children aged 11 through 15 years. later.
• For other catch-up guidance, see Figure 2. • If first dose is administered before the first birthday and second dose administered at younger than 15
2. Rotavirus (RV) vaccines. (Minimum age: 6 weeks for both RV1 [Rotarix] and RV5 [RotaTeq]) months, a third (and final) dose should be administered 8 weeks later.
Routine vaccination: • For unvaccinated children aged 15 months or older, administer only 1 dose.
Administer a series of RV vaccine to all infants as follows: • For other catch-up guidance, see Figure 2. For catch-up guidance related to MenHibrix, please see the
1. If Rotarix is used, administer a 2-dose series at 2 and 4 months of age. meningococcal vaccine footnotes and also MMWR February 28, 2014 / 63(RR01);1-13, available at
2. If RotaTeq is used, administer a 3-dose series at ages 2, 4, and 6 months. http://www.cdc.gov/mmwr/PDF/rr/rr6301.pdf.
3. If any dose in the series was RotaTeq or vaccine product is unknown for any dose in the series, a total of Vaccination of persons with high-risk conditions:
3 doses of RV vaccine should be administered. • Children aged 12 through 59 months who are at increased risk for Hib disease, including chemotherapy
Catch-up vaccination: recipients and those with anatomic or functional asplenia (including sickle cell disease), human
• The maximum age for the first dose in the series is 14 weeks, 6 days; vaccination should not be initiated for immunodeficiency virus (HIV ) infection, immunoglobulin deficiency, or early component complement
infants aged 15 weeks, 0 days or older. deficiency, who have received either no doses or only 1 dose of Hib vaccine before 12 months of age,
• The maximum age for the final dose in the series is 8 months, 0 days. should receive 2 additional doses of Hib vaccine 8 weeks apart; children who received 2 or more doses of
• For other catch-up guidance, see Figure 2. Hib vaccine before 12 months of age should receive 1 additional dose.
3. Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine. (Minimum age: 6 weeks. • For patients younger than 5 years of age undergoing chemotherapy or radiation treatment who received
a Hib vaccine dose(s) within 14 days of starting therapy or during therapy, repeat the dose(s) at least 3
Exception: DTaP-IPV [Kinrix, Quadracel]: 4 years) months following therapy completion.
Routine vaccination: • Recipients of hematopoietic stem cell transplant (HSCT) should be revaccinated with a 3-dose regimen
• Administer a 5-dose series of DTaP vaccine at ages 2, 4, 6, 15 through 18 months, and 4 through 6 years. of Hib vaccine starting 6 to 12 months after successful transplant, regardless of vaccination history; doses
The fourth dose may be administered as early as age 12 months, provided at least 6 months have elapsed should be administered at least 4 weeks apart.
since the third dose. • A single dose of any Hib-containing vaccine should be administered to unimmunized* children and
• Inadvertent administration of 4th DTaP dose early: If the fourth dose of DTaP was administered at least 4 adolescents 15 months of age and older undergoing an elective splenectomy; if possible, vaccine should
months, but less than 6 months, after the third dose of DTaP, it need not be repeated. be administered at least 14 days before procedure.
4. Haemophilus influenzae type b (Hib) conjugate vaccine (cont’d) 6. Inactivated poliovirus vaccine (IPV). (Minimum age: 6 weeks) (cont’d)
• Hib vaccine is not routinely recommended for patients 5 years or older. However, 1 dose of Hib vaccine • If both OPV and IPV were administered as part of a series, a total of 4 doses should be administered, regardless
should be administered to unimmunized* persons aged 5 years or older who have anatomic or functional of the child’s current age. If only OPV were administered, and all doses were given prior to 4 years of age, one
asplenia (including sickle cell disease) and unvaccinated persons 5 through 18 years of age with HIV dose of IPV should be given at 4 years or older, at least 4 weeks after the last OPV dose.
infection. • IPV is not routinely recommended for U.S. residents aged 18 years or older.
* Patients who have not received a primary series and booster dose or at least 1 dose of Hib vaccine after 14 • For other catch-up guidance, see Figure 2.
months of age are considered unimmunized. 7. Influenza vaccines. (Minimum age: 6 months for inactivated influenza vaccine [IIV], 2 years for
5. Pneumococcal vaccines. (Minimum age: 6 weeks for PCV13, 2 years for PPSV23) live, attenuated influenza vaccine [LAIV])
Routine vaccination with PCV13: Routine vaccination:
• Administer a 4-dose series of PCV13 vaccine at ages 2, 4, and 6 months and at age 12 through 15 months. • Administer influenza vaccine annually to all children beginning at age 6 months. For most healthy,
• For children aged 14 through 59 months who have received an age-appropriate series of 7-valent PCV nonpregnant persons aged 2 through 49 years, either LAIV or IIV may be used. However, LAIV should NOT
(PCV7), administer a single supplemental dose of 13-valent PCV (PCV13). be administered to some persons, including 1) persons who have experienced severe allergic reactions
Catch-up vaccination with PCV13: to LAIV, any of its components, or to a previous dose of any other influenza vaccine; 2) children 2 through
• Administer 1 dose of PCV13 to all healthy children aged 24 through 59 months who are not completely 17 years receiving aspirin or aspirin-containing products; 3) persons who are allergic to eggs; 4) pregnant
vaccinated for their age. women; 5) immunosuppressed persons; 6) children 2 through 4 years of age with asthma or who had
• For other catch-up guidance, see Figure 2. wheezing in the past 12 months; or 7) persons who have taken influenza antiviral medications in the
Vaccination of persons with high-risk conditions with PCV13 and PPSV23: previous 48 hours. For all other contraindications and precautions to use of LAIV, see MMWR August 7,
• All recommended PCV13 doses should be administered prior to PPSV23 vaccination if possible. 2015 / 64(30):818-25 available at http://www.cdc.gov/mmwr/pdf/wk/mm6430.pdf.
• For children 2 through 5 years of age with any of the following conditions: chronic heart disease For children aged 6 months through 8 years:
(particularly cyanotic congenital heart disease and cardiac failure); chronic lung disease (including asthma • For the 2015-16 season, administer 2 doses (separated by at least 4 weeks) to children who are receiving
if treated with high-dose oral corticosteroid therapy); diabetes mellitus; cerebrospinal fluid leak; cochlear influenza vaccine for the first time. Some children in this age group who have been vaccinated previously
implant; sickle cell disease and other hemoglobinopathies; anatomic or functional asplenia; HIV infection; will also need 2 doses. For additional guidance, follow dosing guidelines in the 2015-16 ACIP influenza
chronic renal failure; nephrotic syndrome; diseases associated with treatment with immunosuppressive vaccine recommendations, MMWR August 7, 2015 / 64(30):818-25, available at http://www.cdc.gov/
drugs or radiation therapy, including malignant neoplasms, leukemias, lymphomas, and Hodgkin disease; mmwr/pdf/wk/mm6430.pdf.
solid organ transplantation; or congenital immunodeficiency: • For the 2016-17 season, follow dosing guidelines in the 2016 ACIP influenza vaccine recommendations.
1. Administer 1 dose of PCV13 if any incomplete schedule of 3 doses of PCV (PCV7 and/or PCV13) were For persons aged 9 years and older:
received previously. • Administer 1 dose.
2. Administer 2 doses of PCV13 at least 8 weeks apart if unvaccinated or any incomplete schedule of fewer 8. Measles, mumps, and rubella (MMR) vaccine. (Minimum age: 12 months for routine vaccination)
than 3 doses of PCV (PCV7 and/or PCV13) were received previously. Routine vaccination:
3. Administer 1 supplemental dose of PCV13 if 4 doses of PCV7 or other age-appropriate complete PCV7 • Administer a 2-dose series of MMR vaccine at ages 12 through 15 months and 4 through 6 years. The
series was received previously. second dose may be administered before age 4 years, provided at least 4 weeks have elapsed since the first
4. The minimum interval between doses of PCV (PCV7 or PCV13) is 8 weeks. dose.
5. For children with no history of PPSV23 vaccination, administer PPSV23 at least 8 weeks after the most • Administer 1 dose of MMR vaccine to infants aged 6 through 11 months before departure from the United
1-21
recent dose of PCV13. States for international travel. These children should be revaccinated with 2 doses of MMR vaccine, the first
• For children aged 6 through 18 years who have cerebrospinal fluid leak; cochlear implant; sickle cell at age 12 through 15 months (12 months if the child remains in an area where disease risk is high), and the
second dose at least 4 weeks later.
Pediatrics
disease and other hemoglobinopathies; anatomic or functional asplenia; congenital or acquired

immunodeficiencies; HIV infection; chronic renal failure; nephrotic syndrome; diseases associated • Administer 2 doses of MMR vaccine to children aged 12 months and older before departure from the
with treatment with immunosuppressive drugs or radiation therapy, including malignant neoplasms, United States for international travel. The first dose should be administered on or after age 12 months and
leukemias, lymphomas, and Hodgkin disease; generalized malignancy; solid organ transplantation; or the second dose at least 4 weeks later.
multiple myeloma: Catch-up vaccination:
1. If neither PCV13 nor PPSV23 has been received previously, administer 1 dose of PCV13 now and 1 dose • Ensure that all school-aged children and adolescents have had 2 doses of MMR vaccine; the minimum
of PPSV23 at least 8 weeks later. interval between the 2 doses is 4 weeks.
2. If PCV13 has been received previously but PPSV23 has not, administer 1 dose of PPSV23 at least 8 weeks 9. Varicella (VAR) vaccine. (Minimum age: 12 months)
after the most recent dose of PCV13. Routine vaccination:
3. If PPSV23 has been received but PCV13 has not, administer 1 dose of PCV13 at least 8 weeks after the • Administer a 2-dose series of VAR vaccine at ages 12 through 15 months and 4 through 6 years. The
most recent dose of PPSV23. second dose may be administered before age 4 years, provided at least 3 months have elapsed since the
• For children aged 6 through 18 years with chronic heart disease (particularly cyanotic congenital heart first dose. If the second dose was administered at least 4 weeks after the first dose, it can be accepted as
disease and cardiac failure), chronic lung disease (including asthma if treated with high-dose oral valid.
corticosteroid therapy), diabetes mellitus, alcoholism, or chronic liver disease, who have not received Catch-up vaccination:
PPSV23, administer 1 dose of PPSV23. If PCV13 has been received previously, then PPSV23 should be • Ensure that all persons aged 7 through 18 years without evidence of immunity (see MMWR 2007 / 56 [No.
administered at least 8 weeks after any prior PCV13 dose. RR-4], available at http://www.cdc.gov/mmwr/pdf/rr/rr5604.pdf ) have 2 doses of varicella vaccine. For
• A single revaccination with PPSV23 should be administered 5 years after the first dose to children with children aged 7 through 12 years, the recommended minimum interval between doses is 3 months (if the
sickle cell disease or other hemoglobinopathies; anatomic or functional asplenia; congenital or acquired second dose was administered at least 4 weeks after the first dose, it can be accepted as valid); for persons
immunodeficiencies; HIV infection; chronic renal failure; nephrotic syndrome; diseases associated aged 13 years and older, the minimum interval between doses is 4 weeks.
with treatment with immunosuppressive drugs or radiation therapy, including malignant neoplasms, 10. Hepatitis A (HepA) vaccine. (Minimum age: 12 months)
leukemias, lymphomas, and Hodgkin disease; generalized malignancy; solid organ transplantation; or Routine vaccination:
multiple myeloma. • Initiate the 2-dose HepA vaccine series at 12 through 23 months; separate the 2 doses by 6 to 18 months.
6. Inactivated poliovirus vaccine (IPV). (Minimum age: 6 weeks) • Children who have received 1 dose of HepA vaccine before age 24 months should receive a second dose 6
Routine vaccination: to 18 months after the first dose.
• Administer a 4-dose series of IPV at ages 2, 4, 6 through 18 months, and 4 through 6 years. The final dose in the • For any person aged 2 years and older who has not already received the HepA vaccine series, 2 doses of
series should be administered on or after the fourth birthday and at least 6 months after the previous dose. HepA vaccine separated by 6 to 18 months may be administered if immunity against hepatitis A virus
Catch-up vaccination: infection is desired.
• In the first 6 months of life, minimum age and minimum intervals are only recommended if the person is at risk Catch-up vaccination:
of imminent exposure to circulating poliovirus (i.e., travel to a polio-endemic region or during an outbreak). • The minimum interval between the 2 doses is 6 months.
• If 4 or more doses are administered before age 4 years, an additional dose should be administered at age 4
through 6 years and at least 6 months after the previous dose.
• A fourth dose is not necessary if the third dose was administered at age 4 years or older and at least 6 months
after the previous dose.
10. Hepatitis A (HepA) vaccine (cont’d) 11. Meningococcal vaccines (cont’d)
Special populations: 3. Menactra
• Administer 2 doses of HepA vaccine at least 6 months apart to previously unvaccinated persons who live o Children 9 through 23 months: Administer 2 primary doses at least 12 weeks apart.
in areas where vaccination programs target older children, or who are at increased risk for infection. This o Children 24 months and older who have not received a complete series: Administer 2 primary doses at
includes persons traveling to or working in countries that have high or intermediate endemicity of least 8 weeks apart.
infection; men having sex with men; users of injection and non-injection illicit drugs; persons who work Meningococcal B vaccines:
with HAV-infected primates or with HAV in a research laboratory; persons with clotting-factor disorders; 1. Bexsero or Trumenba
persons with chronic liver disease; and persons who anticipate close personal contact (e.g., household or o Persons 10 years or older who have not received a complete series. Administer a 2-dose series of Bexsero,
regular babysitting) with an international adoptee during the first 60 days after arrival in the United States at least 1 month apart. Or a 3-dose series of Trumenba, with the second dose at least 2 months after
from a country with high or intermediate endemicity. The first dose should be administered as soon as the the first and the third dose at least 6 months after the first. The two MenB vaccines are not interchange-
adoption is planned, ideally 2 or more weeks before the arrival of the adoptee.
able; the same vaccine product must be used for all doses.
11. Meningococcal vaccines. (Minimum age: 6 weeks for Hib-MenCY [MenHibrix], 9 months for
For children who travel to or reside in countries in which meningococcal disease is hyperendemic or
MenACWY-D [Menactra], 2 months for MenACWY-CRM [Menveo], 10 years for serogroup B
epidemic, including countries in the African meningitis belt or the Hajj
meningococcal [MenB] vaccines: MenB-4C [Bexsero] and MenB-FHbp [Trumenba]) • administer an age-appropriate formulation and series of Menactra or Menveo for protection against
Routine vaccination: serogroups A and W meningococcal disease. Prior receipt of MenHibrix is not sufficient for children
• Administer a single dose of Menactra or Menveo vaccine at age 11 through 12 years, with a booster dose at traveling to the meningitis belt or the Hajj because it does not contain serogroups A or W.
age 16 years. For children at risk during a community outbreak attributable to a vaccine serogroup
• Adolescents aged 11 through 18 years with human immunodeficiency virus (HIV ) infection should receive a • administer or complete an age- and formulation-appropriate series of MenHibrix, Menactra, or Menveo,
2-dose primary series of Menactra or Menveo with at least 8 weeks between doses. Bexsero or Trumenba.
• For children aged 2 months through 18 years with high-risk conditions, see below. For booster doses among persons with high-risk conditions, refer to MMWR 2013 / 62(RR02);1-22, available
Catch-up vaccination: at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6202a1.htm.
• Administer Menactra or Menveo vaccine at age 13 through 18 years if not previously vaccinated.
• If the first dose is administered at age 13 through 15 years, a booster dose should be administered at age 16 For other catch-up recommendations for these persons, and complete information on use of
through 18 years with a minimum interval of at least 8 weeks between doses. meningococcal vaccines, including guidance related to vaccination of persons at increased risk of infection,
• If the first dose is administered at age 16 years or older, a booster dose is not needed. see MMWR March 22, 2013 / 62(RR02);1-22, and MMWR October 23, 2015 / 64(41); 1171-1176 available at
• For other catch-up guidance, see Figure 2. http://www.cdc.gov/mmwr/pdf/rr/rr6202.pdf, and http://www.cdc.gov/mmwr/pdf/wk/mm6441.pdf.
Clinical discretion:
• Young adults aged 16 through 23 years (preferred age range is 16 through 18 years) may be vaccinated 12. Tetanus and diphtheria toxoids and acellular pertussis (Tdap) vaccine. (Minimum age: 10 years
with either a 2-dose series of Bexsero or a 3-dose series of Trumenba vaccine to provide short-term for both Boostrix and Adacel)
protection against most strains of serogroup B meningococcal disease. The two MenB vaccines are not Routine vaccination:
interchangeable; the same vaccine product must be used for all doses. • Administer 1 dose of Tdap vaccine to all adolescents aged 11 through 12 years.
Vaccination of persons with high-risk conditions and other persons at increased risk of disease: • Tdap may be administered regardless of the interval since the last tetanus and diphtheria toxoid-
Children with anatomic or functional asplenia (including sickle cell disease): containing vaccine.
1-22
Meningococcal conjugate ACWY vaccines: • Administer 1 dose of Tdap vaccine to pregnant adolescents during each pregnancy (preferred during 27
1. Menveo through 36 weeks gestation) regardless of time since prior Td or Tdap vaccination.
Pediatrics
o Children who initiate vaccination at 8 weeks: Administer doses at 2, 4, 6, and 12 months of age. Catch-up vaccination:
o Unvaccinated children who initiate vaccination at 7 through 23 months: Administer 2 doses, with the second • Persons aged 7 years and older who are not fully immunized with DTaP vaccine should receive Tdap
dose at least 12 weeks after the first dose AND after the first birthday. vaccine as 1 (preferably the first) dose in the catch-up series; if additional doses are needed, use Td vaccine.
o Children 24 months and older who have not received a complete series: Administer 2 primary doses at least For children 7 through 10 years who receive a dose of Tdap as part of the catch-up series, an adolescent
8 weeks apart. Tdap vaccine dose at age 11 through 12 years should NOT be administered. Td should be administered
instead 10 years after the Tdap dose.
2. MenHibrix • Persons aged 11 through 18 years who have not received Tdap vaccine should receive a dose followed by
o Children who initiate vaccination at 6 weeks: Administer doses at 2, 4, 6, and 12 through 15 months of age. tetanus and diphtheria toxoids (Td) booster doses every 10 years thereafter.
o If the first dose of MenHibrix is given at or after 12 months of age, a total of 2 doses should be given at • Inadvertent doses of DTaP vaccine:
least 8 weeks apart to ensure protection against serogroups C and Y meningococcal disease. - If administered inadvertently to a child aged 7 through 10 years may count as part of the catch-up
3. Menactra series. This dose may count as the adolescent Tdap dose, or the child can later receive a Tdap booster
o Children 24 months and older who have not received a complete series: Administer 2 primary doses at least dose at age 11 through 12 years.
8 weeks apart. If Menactra is administered to a child with asplenia (including sickle cell disease), do not - If administered inadvertently to an adolescent aged 11 through 18 years, the dose should be counted
administer Menactra until 2 years of age and at least 4 weeks after the completion of all PCV13 doses. as the adolescent Tdap booster.
Meningococcal B vaccines: • For other catch-up guidance, see Figure 2.
1. Bexsero or Trumenba 13. Human papillomavirus (HPV) vaccines. (Minimum age: 9 years for 2vHPV [Cervarix], 4vHPV
o Persons 10 years or older who have not received a complete series. Administer a 2-dose series of Bexsero, at [Gardasil] and 9vHPV [Gardasil 9])
least 1 month apart. Or a 3-dose series of Trumenba, with the second dose at least 2 months after the Routine vaccination:
first and the third dose at least 6 months after the first. The two MenB vaccines are not interchangeable; • Administer a 3-dose series of HPV vaccine on a schedule of 0, 1-2, and 6 months to all adolescents aged 11
the same vaccine product must be used for all doses. through 12 years. 9vHPV, 4vHPV or 2vHPV may be used for females, and only 9vHPV or 4vHPV may be used
Children with persistent complement component deficiency (includes persons with inherited or chronic for males.
deficiencies in C3, C5-9, properidin, factor D, factor H, or taking eculizumab (Soliriis®): • The vaccine series may be started at age 9 years.
Meningococcal conjugate ACWY vaccines: • Administer the second dose 1 to 2 months after the first dose (minimum interval of 4 weeks);
1. Menveo administer the third dose 16 weeks after the second dose (minimum interval of 12 weeks) and 24 weeks
o Children who initiate vaccination at 8 weeks: Administer doses at 2, 4, 6, and 12 months of age. after the first dose.
• Administer HPV vaccine beginning at age 9 years to children and youth with any history of sexual abuse or
o Unvaccinated children who initiate vaccination at 7 through 23 months: Administer 2 doses, with the assault who have not initiated or completed the 3-dose series.
second dose at least 12 weeks after the first dose AND after the first birthday.
Catch-up vaccination:
o Children 24 months and older who have not received a complete series: Administer 2 primary doses at • Administer the vaccine series to females (2vHPV or 4vHPV or 9vHPV) and males (4vHPV or 9vHPV) at age
least 8 weeks apart. 13 through 18 years if not previously vaccinated.
2. MenHibrix • Use recommended routine dosing intervals (see Routine vaccination above) for vaccine series catch-up.
o Children who initiate vaccination 6 weeks: Administer doses at 2, 4, 6, and 12 through 15 months of age.
o If the first dose of MenHibrix is given at or after 12 months of age, a total of 2 doses should be given
at least 8 weeks apart to ensure protection against serogroups C and Y meningococcal disease. CS260933-A
Pediatrics
V. PEDIATRIC SEIZURE DISORDERS
A. Treatment Options Based on Seizure Type (Table 6)
Table 6. Treatment Options Based on Seizure Type

Seizure Type Drugs of Choice Alternatives
Focal (formerly VPA, CBZ, PHT PB, gabapentin, lamotrigine, tiagabine, topiramate,
“partial”) oxcarbazepine, zonisamide, levetiracetam, lacosamide
Generalized
Tonic-clonic VPA, CBZ, PHT Lamotrigine, topiramate, zonisamide, levetiracetam
Myoclonic VPA Topiramate, zonisamide, levetiracetam
Absence Ethosuximide, VPA Lamotrigine, zonisamide, levetiracetam
Lennox-Gastaut VPA, topiramate, lamotrigine Rufinamide, clobazam, felbamate, zonisamide
Infantile spasms ACTH Vigabatrin, lamotrigine, tiagabine, topiramate, VPA,
zonisamide
ACTH = adrenocorticotropic hormone; CBZ = carbamazepine; PB = phenobarbital; PHT = phenytoin; VPA = valproic acid.
B. Comparison of Available Antiepileptic Drugs (Table 7)
Table 7. Comparison of Available Antiepileptic Drugs

Drug Adverse Effects Pharmacokinetic Considerations Other Comments
Carbamazepine Rash Autoinduction Significant drug interactions
Hyponatremia ↓ Effectiveness of OCs
↓ Bone density
Teratogenic
Clobazam Somnolence Dose adjustment needed in hepatic
impairment
Dose adjustment needed in CYP2C19
poor metabolizers
Felbamate Anorexia, nausea, weight Clearance ~50:50 renal/hepatic Significant drug interactions
loss Aplastic anemia: Adults >
Insomnia, somnolence children
Aplastic anemia Requires signed informed
Hepatic failure consent
Gabapentin Somnolence ↑ Clearance in children <6 years Minimal drug interactions
Weight gain old Minimal cognitive effects
Dose adjustment needed in renal May worsen Lennox-Gastaut
insufficiency
Nonlinear pharmacokinetics
Lacosamide Prolonged PR interval Dose adjustment needed in severe Use with caution if severe
Dizziness renal insufficiency cardiac disease or
Headache conduction problems
Diplopia No clinically significant drug
interactions
Lamotrigine Rash Autoinduction Rash: Children > adults
Stevens-Johnson syndrome Minimal cognitive effects
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Pediatrics
Table 7. Comparison of Available Antiepileptic Drugs (continued)

Drug Adverse Effects Pharmacokinetic Considerations Other Comments
Levetiracetam Headache Linear pharmacokinetics Minimal drug interactions
Somnolence Renal excretion
Clearance 40% ↑ in children
No effect on CYP system
Oxcarbazepine Hyponatremia (>CBZ) Linear pharmacokinetics Hyponatremia more common
Rash (<CBZ) Clearance 40% ↑ in children in adults than in children
<6 years old Minimal cognitive effects
Induces CYP3A4
Inhibits CYP2C19
Phenobarbital Cognitive dysfunction Linear pharmacokinetics Significant drug interactions
Sedation ↓ Effectiveness of OCs
Rash
↓ Bone density
Phenytoin Rash Nonlinear pharmacokinetics Significant drug interactions
Gingival hyperplasia ↓ Effectiveness of OCs
Hirsutism
↓ Bone density
Teratogenic
Rufinamide Somnolence ↑ Level with concurrent VPA Somnolence: Minimized
Rash with slow dose titration
QT interval shortening Rash: All reported cases are
in children
Tiagabine Dizziness Clearance 50% ↑ in children Minimal cognitive effects
Nonconvulsive status
epilepticus (case reports)
Topiramate Cognitive dysfunction ↑ Clearance in children Weight loss more common in
Weight loss Dose adjustment needed in renal obese patients
Glaucoma insufficiency Children at higher risk of
Oligohidrosis oligohidrosis than adults
Valproic acid Weight gain CYP induction > in children Significant drug interactions
Menstrual irregularities Most cases of hepatotoxicity
Polycystic ovarian in children <2 years old
syndrome
Hyperandrogenism
Hepatotoxicity
Teratogenic
Thrombocytopenia
Vigabatrin Vision loss Available only through
Weight gain restricted distribution
program
Zonisamide Weight loss Linear pharmacokinetics Better tolerated by children
Rash Primarily renal excretion than by adults
Oligohidrosis No effect on CYP system
Somnolence
Agitation
Hallucinations
CBZ = carbamazepine; CYP = cytochrome P450; OC = oral contraceptive; PHT = phenytoin; VPA = valproic acid.
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Pediatrics
Patient Case
10. A 14-year-old moderately obese girl comes to the clinic with an erythematous pruritic rash. She was initiated
on oxcarbazepine about 3 weeks ago for the management of partial seizures. Her medical history is signifi-
cant only for seizures. She recently became sexually active with a male and admits inconsistent contraceptive
use. Which intervention is best for her?
A. Change to carbamazepine.
B. Change to levetiracetam.
C. Change to valproic acid.
D. No change in therapy is necessary.
VI. ATTENTION-DEFICIT/HYPERACTIVITY DISORDER
1. Diagnostic and Statistical Manual for Mental Disorders (DSM-V) criteria
a. Either (i) or (ii)
i. Six or more of the following symptoms of inattention have been present for at least 6 months
to a point that is disruptive and inappropriate:
Inattention
(a) Often does not give close attention to detail/makes careless mistakes
(b) Often has trouble keeping attention on tasks/activities
(c) Often does not seem to listen
(d) Often does not follow instructions
(e) Often has trouble organizing activities
(f) Often avoids or dislikes things that require long periods of mental effort
(g) Often loses things needed for tasks or activities
(h) Often is easily distracted
(i) Often is forgetful
ii. Six or more of the following symptoms of hyperactivity-impulsivity have been present for at
least 6 months to a point that is disruptive and inappropriate:
Hyperactivity
(a) Often fidgets or squirms
(b) Often is unable to remain seated when it is expected
(c) Often runs or climbs when and where it is not appropriate
(d) Often has difficulty with quiet play or activities
(e) Often is “on the go”
(f) Often talks excessively
Impulsivity
(g) Often blurts out answers
(h) Often has difficulty waiting one’s turn
(i) Often interrupts
b. Some symptoms were present before 7 years of age.
c. Some impairment from the symptoms is present in two or more settings.
d. Clear evidence of significant impairment exists in social, school, or work functioning.
e. No other mental disorder better describes the symptoms.
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Pediatrics
2. Comorbid disease states: 44%–87% of children with ADHD have at least one other disorder
a. Oppositional defiant disorder
i. Most common comorbid disorder in adolescents
ii. Presence of ADHD increases the odds of oppositional defiant disorder almost 11-fold.
b. Anxiety disorder: May exist in about 25% of children with ADHD
c. Tics
i. 21%–90% of children with Tourette syndrome may also have ADHD.
ii. May not be exacerbated by stimulant agents, as once thought
Patient Case
11. A 9-year-old boy has a new diagnosis of ADHD. At school, he is disruptive, talks when the teacher is talking,
and runs around the classroom. His parents report extreme difficulty in getting him to do his homework after
school. Which is best for his initial drug therapy?
A. Methylphenidate (OROS) (Concerta) given once daily.
B. Methylphenidate immediate release (Ritalin) given twice daily, with doses administered 4 hours apart.
C. Guanfacine given at bedtime.
D. d -Methylphenidate (Focalin) given twice daily, with doses administered 4 hours apart.
B. Classification: Based on DSM-V Criteria (see pages 1–17)

1. ADHD, Combined Type: Criteria (i) and (ii) both are met.
2. ADHD, Predominantly Inattentive Type: Criterion (i) is met, but (ii) is not met.
3. ADHD, Predominantly Hyperactive-Impulsive Type: Criterion (ii) is met, but (i) is not met.
C. Treatment Options: Combination of pharmacotherapy and behavioral therapy is more beneficial than either
intervention alone.
1. Factors affecting choice of pharmacologic agent
a. Desired length of coverage time for symptoms
i. Consider time of day when symptoms occur.
ii. Consider time of day when child’s activities occur (e.g., when is homework done, at what time
are teenagers driving, when is child’s bedtime).
b. Child’s ability to swallow pills or capsules
c. Concomitant disease states (e.g., tic disorders)
d. Adverse effect profile
e. Concerns about abuse or diversion potential
i. Children with ADHD are more likely to have a concurrent substance use disorder than those
without ADHD.
ii. Treatment with stimulant medication may reduce the risk of developing a substance use
disorder.
iii. Children treated with stimulants at a younger age are less likely to misuse or abuse substances
than those in whom treatment is delayed.
f. Expense
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Pediatrics
2.
Available pharmacologic agents
a. Stimulant medications: Some children with ADHD respond better to one stimulant type than
another; therefore, both methylphenidate- and amphetamine-containing products should be tried
before stimulant treatment is deemed a failure.
i. Methylphenidate-containing products
(a) Ramp effect: Behavioral effects are proportional to the rate of methylphenidate absorption
into the central nervous system.
(b) See Table 8 for a comparison of available products.
(c) Adverse effects and precautions
(1) Headache, stomachache, loss of appetite, and insomnia
(2) Use with caution in patients with glaucoma, tics, psychosis, and concomitant mono-
amine oxidase inhibitor use.
(3) Insomnia, anorexia, and tics occur more often with transdermal patch, also mild skin
reactions.
ii. Amphetamine-containing products
(a) See Table 8 for a comparison of available products.
(b) Adverse effects and precautions
(1) Loss of appetite, insomnia, abdominal pain, and nervousness
(2) May exacerbate preexisting hypertension and tic disorders
(3) Labeling change warns of potential association with sudden cardiac death (SCD);
therefore, not recommended for patients with known structural heart defects.
iii. Potential association with SCD
(a) No established evidence of causative relationship between stimulants and SCD
(b) The frequency of SCD is no higher in children taking stimulants than in the general pedi-
atric population.
(c) The AAP recommends targeted cardiac history and careful physical examination before
initiating stimulant therapy.
(1) Routine electrocardiography is not recommended unless history and physical exam-
ination suggest cardiac disease.
(2) For otherwise healthy children, stimulant therapy should not be withheld because of
the inability to obtain an electrocardiogram or assessment by a pediatric cardiologist.
b. Nonstimulant medications
i. Norepinephrine reuptake inhibitors (see Table 9)
(a) Adverse effects: Dyspepsia, decreased appetite, weight loss, and fatigue
(b) Labeling change warns of potential for severe liver injury, although routine monitoring of
hepatic function is not necessary.
(c) Black box warning about increased risk of suicidal ideation in children and adolescents
(d) Does not exacerbate tics
ii. α-Adrenergic receptor agonists: See Table 9 for a comparison of available products.
iii. Antidepressants: Non-FDA label approved for the treatment of ADHD
(a) Noradrenergic antidepressant (e.g., bupropion [Wellbutrin])
(1) May use immediate- or extended-release product given in two or three doses
(2) Contraindicated for children with active seizure disorder
(b) Tricyclic antidepressants (e.g., imipramine, nortriptyline)
(1) Baseline electrocardiogram is recommended before therapy initiation and after each
dose increase.
(2) Desipramine should be used with extreme caution because of reports of sudden death.
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Pediatrics
Table 8. Stimulant Agents for the Treatment of ADHD

Methylphenidate-Containing Products
Duration
Doses Onset of of Effect
Medication per Day Effect (hours) Other Comments
Methylphenidate 2 or 3 20–60 3–5 50:50 racemic mixture of l-threo and d-threo isomers
immediate release minutes
(Ritalin)
Dexmethylphenidate 2 or 3 20–60 3–5 Only d-threo isomer, thought to be pharmacologically
(Focalin) minutes active enantiomer
d -Threo isomer has not been shown to hinder
effectiveness or increase adverse effects
Recommended doses are half those of methylphenidate
immediate release
Offers no proven pharmacoeconomic benefit over
methylphenidate immediate-release products
Methylphenidate 1 or 2 1–3 hours 2–6
sustained release
(Ritalin SR)
Methylphenidate 1 20–60 6–8 Contains 50% immediate-release and 50% extended-
extended release minutes release beads
(Ritalin LA) Capsule may be opened and sprinkled on applesauce
Efficacy may wane in after-school or late-afternoon
hours, necessitating addition of methylphenidate
immediate release for later-day coverage
Methylphenidate 1 20–60 6–8 Capsule contains 30% immediate-release and
modified release minutes 70% extended-release beads (slowly released about
(Metadate CD) 4 hours after ingestion)
Capsule may be opened and sprinkled on applesauce
Efficacy may wane in after-school or late-afternoon
hours, necessitating addition of methylphenidate
immediate release for later-day coverage
Methylphenidate 1 20–60 8
extended release minutes
(Methylin ER)
Dexmethylphenidate 1 20–60 8–12 Bimodal drug release results in peak serum concentrations
extended release minutes at 1½ and 6½ hours after dose administration
(Focalin XR) Shorter duration of action than methylphenidate OROS,
so afternoon symptom control is not as good
Methylphenidate 1 20–60 12 Outer capsule contains ~22% of the drug, allowing
OROS (Concerta) minutes immediate release; tablet core contains remainder of
drug, which is released over 10 hours, minimizing peak
to trough fluctuations
Swallow whole; do NOT chew, crush, or divide
Methylphenidate 1 60 11–12 Apply to hip 2 hours before effect is needed
transdermal system minutes Recommended to remove 9 hours after application; may
(Daytrana) be worn up to 16 hours
Duration of effect is ~3 hours after patch removal
May be worn while swimming or exercising
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Pediatrics
Table 8. Stimulant Agents for the Treatment of ADHD (continued)

Amphetamine-Containing Products
Doses Onset of Duration of
Medication per Day Effect Effect (hours) Other Comments
Mixed amphetamine 1 or 2 20–60 minutes 6
salts immediate
release (Adderall)
Mixed amphetamine 1 20–60 minutes 10 Contains 50% immediate-release and 50%
salts extended release extended-release beads (released 4 hours
(Adderall XR) after ingestion)
May be sprinkled on applesauce
Lisdexamfetamine 1 60 minutes 10–12 Prodrug with d-amphetamine covalently
dimesylate (Vyvanse) bound to l-lysine
Designed for less abuse potential than
amphetamine
No clinical evidence of superiority over other
amphetamine products
ADHD = attention-deficit/hyperactivity disorder.
Table 9. Nonstimulant Agents for the Treatment of ADHD

Norepinephrine Reuptake Inhibitor
Doses Onset of Duration of
Medication per Day Effect (weeks) Effect (hours) Other Comments
Atomoxetine 1 or 2 2–4 10–12 May be considered first-line therapy for
(Strattera) children with active substance abuse
problem, comorbid anxiety, or tics
Metabolized through cytochrome P450 2D6
α-Adrenergic Receptor Agonists
Clonidine extended 1 or 2 1–2 10–12 May be more effective for hyperactivity than
release (Kapvay) for inattention symptoms
Lessens severity of tics, especially when used
in combination with methylphenidate
Primary adverse effect is sedation
Guanfacine extended 1 1–2 10–12 Improves comorbid tic disorder
release (Intuniv) Less sedating than clonidine
Abrupt discontinuation may cause rebound
hypertension
ADHD = attention-deficit/hyperactivity disorder.
Patient Case
12. The patient in question 11 has been doing well in school since methylphenidate (OROS) (Concerta) was ini-
tiated 6 months ago. His late-afternoon symptoms are well controlled; however, he has had insomnia since
drug therapy initiation. Which is the best modification to his treatment regimen?
A. Administer the Concerta dose later in the day.
B. Change to methylphenidate modified release (Metadate CD) once a day.
C. Change to methylphenidate transdermal patch (Daytrana).
D. Change to atomoxetine at bedtime.
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Pediatrics
REFERENCES
Sepsis and Meningitis 4. Mendonca EA, Phelan KJ, Zorc JJ, et al. Clinical
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American Academy of Pediatrics (AAP). practice guideline: the diagnosis, manage-
Meningococcal infections. In: Pickering LK, ment, and prevention of bronchiolitis. Pediatrics
ed. 2012 Red Book: Report of the Committee on 2014;134:e1474-e1502.
Infectious Diseases, 29th ed. Elk Grove Village,
IL: American Academy of Pediatrics, 2012:500-9. Otitis Media
2. Brierly J, Carcillo JA, Choong K, et al. Clinical 1. American Academy of Pediatrics (AAP). Principles
practice parameters for hemodynamic support of of appropriate use for upper respiratory tract infec-
pediatric and neonatal septic shock: 2007 update tions. In: Pickering LK, ed. 2012 Red Book: Report
from the American College of Critical Care of the Committee on Infectious Diseases, 29th ed.
Medicine. Crit Care Med 2009;37:666-88. Elk Grove Village, IL: American Academy of
Pediatrics, 2012:802-5.
3. Dellinger RP, Levy MM, Rhodes A, et al. Surviving
sepsis campaign: international guidelines for man- 2.
Lieberthal AS, Carrol AE, Chonmaitree T, et
agement of severe sepsis and septic shock: 2012. al. Clinical practice guideline: diagnosis and
Crit Care Med 2013;41:580-637. management of acute otitis media. Pediatrics
2013;131:e964-e999.
4.
Polin RA; Committee on Fetus and Newborn.
Sepsis management of neonates with suspected 3.
Rettig E, Tunkel DE. Contemporary concepts
or proven early onset bacterial sepsis. Pediatrics in management of acute otitis media in children.
2012;129:1006-15. Otolaryngol Clin N Am 2014;47:651-72.
5. Wubbel L, McCracken GH. Management of bacte-
Immunizations
rial meningitis: 1998. Pediatr Rev 1998;19:78-84.
1. American Academy of Pediatrics (AAP). Active
Respiratory Syncytial Virus Infection and passive immunization. In: Pickering LK,
ed. 2012 Red Book: Report of the Committee on
1. American Academy of Pediatrics Committee on
Infectious Diseases, 29th ed. Elk Grove Village,
Infectious Diseases and Bronchiolitis Guidelines
IL: American Academy of Pediatrics, 2012:1-109.
Committee. Policy statement: updated guidance
for palivizumab prophylaxis among infants and 2. Wiley CC. Immunizations: vaccinations in gen-
young children at increased risk of hospitalization eral. Pediatr Rev 2015;36:249-59.
for respiratory syncytial virus infection. Pediatrics 3. Smith M. Vaccine safety: medical contraindica-
2014;134:415-20. tions, myths, and risk communication. Pediatr Rev
2. American Academy of Pediatrics Committee on 2015;36:227-238.
Infectious Diseases and Bronchiolitis Guidelines
Committee. Technical report: updated guidance Pediatric Seizure Disorders
for palivizumab prophylaxis among infants and 1. Anderson GD. Children versus adults: pharmaco-
young children at increased risk of hospitalization kinetic and adverse-effect differences. Epilepsia
for respiratory syncytial virus infection. Pediatrics 2002;43(suppl 3):53-9.
2014;134:e620-e638. 2. Asconape JJ. Some common issues in the use of
3.
American Academy of Pediatrics (AAP). antiepileptic drugs. Semin Neurol 2002;22:27-39.
Respiratory syncytial virus. In: Pickering LK, 3. Sarco DP, Bourgeois BFD. The safety and tolera-
ed. 2012 Red Book: Report of the Committee on bility of newer antiepileptic drugs in children and
Infectious Diseases, 29th ed. Elk Grove Village, adolescents. CNS Drugs 2010;24:399-430.
IL: American Academy of Pediatrics, 2012:609-18.
4. Sheth R, Gidel B. Optimizing epilepsy manage-
ment in teenagers. J Child Neurol 2006;21:273-9.
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Attention-Deficit/Hyperactivity Disorder
1.
American Academy of Pediatrics (AAP).
Subcommittee on attention-deficit/hyperactivity
disorder. ADHD: clinical practice guideline for
the diagnosis, evaluation, and treatment of atten-
tion-deficit/hyperactivity disorder in children and
adolescents. Pediatrics 2011;128:1007-22.
2. American Psychiatric Association. Diagnostic and
Statistical Manual of Mental Disorders, 5th ed.
Arlington, VA: American Psychiatric Association,
2013.
3. Cortese S, Holtmann M, Banaschewski T, et al.
Practitioner review: current best practice in the
management of adverse events during treatment
with ADHD medications in children and adoles-
cents. J Child Psychol Psychiatry 2013;54:227-46.
4. Harstad E, Levy S, and Committee on Substance
Abuse. Attention-deficit/hyperactivity disorder
and substance abuse. Pediatrics 2014;134:e293-301.
5. Kaplan G, Newcorn JH. Pharmacotherapy for child
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ANSWERS AND EXPLANATIONS TO PATIENT CASES
1. Answer: B would not be appropriate empiric coverage because

Group B Streptococcus, Escherichia coli, Klebsiella this patient’s presentation suggests he has meningitis.
spp., and Listeria are the most likely pathogens of neo- Rifampin would be the drug of choice for the prophy-
natal sepsis or meningitis. Ampicillin plus gentamicin laxis of close contacts if this patient receives a diagnosis
administered in meningitic doses would provide rea- of meningococcal meningitis; however, it is inadequate
sonable empiric coverage. Although coagulase-negative for treatment.
Staphylococcus is the most likely cause of nosocomial
neonatal sepsis, this patient’s early presentation makes 4. Answer: B
a hospital-acquired pathogen extremely unlikely. Palivizumab is the drug of choice for prophylaxis against
Therefore, vancomycin is unnecessary. Ampicillin plus RSV infection in high-risk patient populations, includ-
ceftriaxone would provide adequate empiric antimicro- ing those born before 29 weeks’ gestation, regardless
bial coverage for the most likely pathogens. However, of risk factors, who are 12 months or younger during
ceftriaxone use can result in biliary sludging, leading to RSV season. Patients born between 29 weeks’ gestation
reduced elimination of bilirubin and a potential risk of and 32 weeks’ gestation are no longer considered high
kernicterus in neonates. Ceftazidime plus gentamicin risk based solely on their gestational age. To be consid-
lacks coverage for Listeria and group B Streptococcus, ered as candidates for palivizumab prophylaxis, these
which is still necessary empirically even though the infants must have a disease state (e.g., chronic lung
mother received penicillin before delivery. In addition, disease, hemodynamically significant heart disease,
empiric double-coverage of gram-negative organisms airway anomalies, neuromuscular disease, or profound
is not necessary for early neonatal sepsis. immunodeficiency) that puts them at risk for severe
RSV infection. Other potential risk factors (e.g., sib-
2. Answer: C lings younger than 5 years or day care attenders) are no
Given this patient’s age and culture results, the most longer considered when determining the appropriate-
likely infecting organism is E. coli or Klebsiella spp. ness of palivizumab prophylaxis. Patients with complex
(gram-negative rods), for which antimicrobial prophy- heart defects needing surgical repair are at high risk of
laxis is not indicated. The most common pathogens developing severe RSV infections; however, after the
causing meningitis in neonates do not warrant anti- repair is complete, palivizumab is no longer warranted.
microbial prophylaxis. If this patient had been older Patients with a history of chronic lung disease who are
and infected with N. meningitidis or H. influenzae, 24 months or younger and who are receiving, or have
antibiotic prophylaxis with rifampin would have been received in the past 6 months, oxygen or medical man-
indicated for all close contacts, regardless of age or agement for chronic lung disease are also at risk of
immunization status. Rifampin prophylaxis to elim- severe RSV infection.
inate nasal carriage is also indicated for people who
receive index diagnoses of N. meningitidis and treat- 5. Answer: D
ment with an antibiotic other than ceftriaxone. There is no specific treatment of RSV infection.
Intravenous fluids, oxygen, and mechanical ventila-
3. Answer: C tion, if needed, are indicated. Palivizumab is the drug
The most likely causative organisms of sepsis or men- of choice for RSV prophylaxis, but it has no role in
ingitis in this age group are S. pneumoniae and N. treatment. Corticosteroids have not been shown to be
meningitidis. Therefore, a regimen of ceftriaxone plus of benefit and are therefore not indicated. Secondary
vancomycin would provide appropriate empiric cov- bacterial infection with H. influenzae or M. catarrhalis
erage. Depending on the regional incidence of resis- may occur; however, empiric antibiotic therapy is not
tant S. pneumoniae, empiric vancomycin may not be indicated.
necessary. Ampicillin plus gentamicin would not pro-
vide adequate coverage. Cefuroxime does not provide
reliable penetration into the cerebrospinal fluid, so it
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Pediatrics
6. Answer: A 8. Answer: D
Persistence of middle ear fluid after an episode of AOM Vaccines are often deferred for inappropriate reasons,
is common. If these findings are not associated with leading to missed opportunities for immunization.
signs and symptoms of infection, a diagnosis of OME is Previous administration of IVIG can decrease the effi-
made. The AAP practice guideline for the management cacy of live vaccines such as MMR and varicella, but
of OME recommends watchful waiting. A watch-and- it does not affect the efficacy of inactivated products.
wait approach would not be appropriate for this patient The suggested interval between an IVIG dose and the
if she were given a diagnosis of AOM rather than OME administration of live vaccines depends on the immune
because she is younger than 6 months. Spontaneous res- globulin product and indication. Concerns about an
olution of OME occurs within 3 months in 75%–90% of association between MMR vaccine and the develop-
cases after AOM without residual morbidities. Children ment of autism and immunizations overwhelming the
at high risk of speech and learning problems (e.g., cra- immune system have been disproven by scientific eval-
niofacial anomalies, Down syndrome, severe visual uation. The MMR vaccine is grown in chick embryo
impairment) may need earlier, more aggressive inter- tissue; however, an egg allergy is not a contraindication
vention (e.g., tympanostomy tubes). Decongestants and to its administration.
antihistamines do not promote resolution or improve
symptoms. Antibiotics are not effective in treating 9. Answer: A
OME. However, high-dose amoxicillin (80–100 mg/ Immunocompromised patients should not receive live
kg/day) is considered first-line therapy for AOM, so if vaccines; therefore, the MMR and varicella vaccines
this patient’s treatment with the initial course of low- should be deferred in these patients. Mild cold-like
er-dose amoxicillin fails (which is not a recommended symptoms, or administration of antibiotics for mild ill-
regimen) or if she develops new signs of infection, then nesses such as otitis media, are not a contraindication
high-dose amoxicillin will be an appropriate treatment to vaccination, and deferring immunizations for such
choice. Up to 74% of streptococcal strains have been reasons is considered a missed opportunity. Patients
reported to be resistant to azithromycin, which also has with HIV, especially those with asymptomatic disease,
poor activity against H. influenzae, so this would not should be considered candidates for all age-appropriate
be the best antibiotic option if an infection developed. vaccines, including those containing live virus and the
pneumococcal vaccine. Corticosteroid administration
7. Answer: C is an indication for deferral of live vaccines only if the
Four cases of otitis media in 12 months is considered patient is receiving high doses (more than 2 mg/kg/day
recurrent otitis media, for which the watch-and-wait of prednisone equivalent) for more than 14 days.
approach is not recommended. Previously, this patient
would have been a candidate for antibiotic prophylaxis; 10. Answer: B
however, this practice has fallen out of favor because of Rash associated with antiepileptic drugs is a common
the significant risk of antimicrobial resistance compared adverse effect and generally resolves within a few days
with the minor reduction in the occurrence of otitis after discontinuation. There is no reliable method to
media. Tympanostomy tubes are typically reserved for determine whether the rash will remain benign or prog-
patients in whom aggressive antibiotic therapy fails and ress to a more severe skin reaction, so discontinuation
may be effective only in otitis with bulging tympanic of the offending drug is warranted. Carbamazepine
membrane. In addition, the greatest benefit of tympa- has a higher incidence of rash than oxcarbazepine, and
nostomy tubes may be in patients with persistent OMEs cross-reactivity has been noted. Valproic acid is a good
resulting in significant hearing loss. As long as this choice for managing partial seizures and has a low inci-
patient continues to respond to high-dose amoxicillin, dence of rash. However, the principal adverse effects of
this will be considered a first-line regimen. In addition, valproic acid include weight gain and menstrual irreg-
the pneumococcal and influenza vaccines should be ularities, both of which would be undesirable in this
administered according to the recommended schedule overweight teenage girl. In addition, valproic acid is a
because these organisms are common causes of AOM. known teratogen (pregnancy category D) that should
be avoided if other options are available in girls of
1-33
Pediatrics
reproductive age who are unreliable in their use of con- Administering methylphenidate OROS later in the day
traception. Levetiracetam (pregnancy category C) has would probably worsen the insomnia. A better recom-
a low incidence of rash and minimal drug interactions. mendation would be to administer methylphenidate
OROS earlier in the morning, which would allow more
11. Answer: A time in the late afternoon and evening for the serum
Stimulants, especially methylphenidate, are gener- concentration to decrease before bedtime. Changing to
ally considered first-line therapy for treating ADHD. a shorter-acting methylphenidate product (e.g., meth-
Because this patient shows symptoms at school and ylphenidate CD or LA) might improve the insomnia,
at home, the short duration of action (about 3-5 hours) but because of its shorter duration of action, it might
of a twice-daily methylphenidate immediate-release compromise late-afternoon symptom control. In some
regimen will probably not provide adequate symp- cases, insomnia is related to rebound of ADHD symp-
tom relief. Likewise, d-methylphenidate has a short toms when the stimulant wears off, rather than a side
duration of action. In addition, d-methylphenidate is effect of the stimulant. Addition of a short-acting
no more effective and has no fewer adverse effects stimulant late in the day may help in these cases. This
than methylphenidate immediate release. Therefore, does not seem to apply to this patient because his late
d -methylphenidate is generally not considered cost- afternoon ADHD symptoms are reported to be well
effective. Extended-release guanfacine was recently controlled. Counseling about proper sleep hygiene can
FDA label approved for the treatment of ADHD, but also be an effective intervention for the management of
it should be reserved for patients with ADHD and tic insomnia.
disorders or those who have not responded to stimu-
lant agents. Methylphenidate (OROS) with its longer
duration of action (10–12 hours) would provide the best
coverage. Therapy with this drug may be initiated with-
out previous titration using methylphenidate immediate
release.
12. Answer: C
Changing to a methylphenidate transdermal patch
allows flexibility in the duration of drug effect. Wearing
the patch for 9 hours results in about 12 hours of ther-
apeutic effect; however, the patch may be removed
sooner, thus reducing the duration of effect and allow-
ing serum concentrations to decrease before bedtime.
Response rates to atomoxetine are lower than to meth-
ylphenidate (OROS) in children with ADHD. In addi-
tion, the onset of therapeutic effect for atomoxetine is
delayed (typically 2–4 weeks). Atomoxetine does not
have the adverse effect of insomnia. Rather, fatigue
and drowsiness are more common, the tolerability of
which is improved with the initiation of atomoxetine at
low doses with a gradual titration. The dose may also
be administered in the evening to improve tolerabil-
ity. Because this patient responded well to stimulant
therapy with methylphenidate and there are disadvan-
tages to atomoxetine (i.e., lower response rates and
delayed onset), it would be best to manage the adverse
effect of insomnia by altering the stimulant regimen.
1-34
Pediatrics
ANSWERS AND EXPLANATIONS TO SELF-ASSESSMENT QUESTIONS
1. Answer: B should be vaccinated according to chronologic age, and

The pathogens most likely to cause pediatric sepsis or doses should not be reduced. As of 2008, influenza vac-
meningitis are S. pneumoniae, N. meningitidis, and H. cine is recommended for all children 6 months to 18
influenzae. P. aeruginosa is more commonly associated years of age during influenza season.
with nosocomial sepsis. Adolescents who develop an
RSV infection typically present with mild upper respi- 5. Answer: B
ratory tract symptoms, whereas this patient’s presenta- Otitis media is most commonly caused by S. pneumo-
tion suggests meningitis. niae, H. influenzae, M. catarrhalis, and viruses. Blood
culture results do not predict causative organisms of oti-
2. Answer: B tis media. If the patient is older than 2 years and does not
Before the 2014 publication of the AAP’s updated have severe symptoms (i.e., moderate to severe otalgia
guidelines, infants who were born before 31 weeks’, 6 or temperature of 39°C or greater), delaying the deci-
days’ gestation who were 6 months or younger at the sion to prescribe antibiotics is an acceptable strategy.
beginning of RSV season were considered at high risk If otalgia or fever persists for more than 48–72 hours,
of severe infection; therefore, routine palivizumab then antibiotic therapy is acceptable, but if these symp-
prophylaxis was recommended based solely on their toms resolve spontaneously within this time, antibiotics
prematurity. The 2014 guidelines changed the prematu- are not necessary. If antibiotics are warranted and the
rity-based criteria for routine palivizumab prophylaxis patient does not have an allergy, high-dose amoxicil-
to include only infants born before 29 weeks’ gestation lin is the treatment of choice rather than azithromycin.
who are younger than 12 months at the beginning of Broad-spectrum antibiotics such as ceftriaxone should
RSV season. According to the new guidelines, infants be reserved for resistant cases.
born between 29 and 32 weeks’ gestation must have
chronic lung disease, hemodynamically significant con- 6. Answer: D
genital heart disease, airway anomalies, neuromuscular In general, patients who do not respond to one stimulant
disease, or profound immunocompromise to be con- agent should be treated with a different stimulant before
sidered candidates for palivizumab prophylaxis. Risk they are considered not to have responded to this class
factors such as day care attendance and school-aged of drug therapy. However, switching from a methylphe-
siblings are no longer considered when determining nidate-containing stimulant to extended-release mixed
whether prophylaxis is warranted. Routine prophylaxis amphetamine salts (a different stimulant) should be
for otherwise healthy, full-term neonates is not recom- avoided in this patient because amphetamine-contain-
mended because evidence of benefit is lacking. ing products have been associated with SCD in chil-
dren with structural heart defects. The methylphenidate
3. Answer: C transdermal system has a duration of action and effi-
Prophylaxis with rifampin is recommended for close cacy similar to those of methylphenidate OROS; there-
contacts of patients with N. meningitidis or H. influ- fore, it is unlikely to benefit this patient because her
enzae, regardless of their immunization status. therapy with methylphenidate immediate release and
Postexposure prophylaxis against pneumococcal men- methylphenidate OROS has already failed. If adherence
ingitis is not recommended. or difficulty swallowing pills were a suspected cause
of treatment failure in this patient, a patch might be a
4. Answer: D reasonable alternative. Clonidine may be added as an
All scheduled immunizations should be given during adjunctive therapy for patients whose treatment with a
the same visit. Delaying some vaccines until a later date single stimulant agent fails; however, it should not be
is considered a missed opportunity. Oral polio vaccine used as the sole agent for treating ADHD. Atomoxetine,
is no longer recommended as part of the routine sched- a nonstimulant, would be a reasonable alternative to
ule because of the risk of vaccine-associated poliomy- the stimulant class of agents in this patient because
elitis, which accounts for most newly diagnosed cases some patients respond better to one class of agent than
in the United States since 1979. Premature neonates another.
1-35
Pediatrics
7. Answer: A In addition, cardiopulmonary bypass reduces palivi-

Valproic acid is considered a first-line therapy for treat- zumab serum concentrations; therefore, patients under-
ing absence seizures. If the patient is having break- going congenital heart defect repair during RSV season
through seizures on ethosuximide—also a first-line should receive a postoperative dose of palivizumab as
therapy—and the dose has been maximized, it is rea- soon as they are medically stable, regardless of when
sonable to switch to valproic acid. Phenytoin, pheno- their next scheduled dose is due.
barbital, and gabapentin have not been shown effective
in treating absence seizures.
8. Answer: C
Adverse Event
(loss of appetite)
Yes No
Exposure (stimulant)
Yes 7 (a) 193 (b)
No 1 (c) 197 (d)
Odds ratio = (a/c)/(b/d)
= (7/1)/(193/197)
= 7.15
9. Answer: C
A case series does not reliably establish a causal rela-
tionship but rather suggests a potential hypothesis to be
further studied. Given the current knowledge about the
potential risk of kernicterus related to ceftriaxone use,
obtaining investigational review board approval for a
randomized controlled or a crossover trial design would
be difficult, given ethical considerations, although this
study design is the gold standard for establishing a
causal relationship. Therefore, a retrospective cohort
would be best to investigate a causal relationship in this
instance.
10. Answer: D
Patients with congenital heart defects, particularly those
with hemodynamically significant lesions, are at high
risk of severe RSV infection regardless of their gesta-
tional age. These patients are considered to be at high
risk if they are younger than 12 months at the beginning
of RSV season and have not undergone definitive sur-
gical repair of their heart defect. It is not recommended
that palivizumab be initiated as routine prophylaxis in
hospitalized patients because it does not reduce the inci-
dence of nosocomial-acquired RSV infection. However,
patients currently receiving a course of palivizumab
(one dose per month for 5 months) at the time of hospi-
tal admission should have that intervention continued.
1-36

Pediatrics

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Pediatrics

Kirsten H. Ohler, Pharm.D., BCPS, BCPPS

Learning Objectives 3. Which is the most accurate statement about pro-

8. In a retrospective study of the risk of appetite loss

9. An investigator wants to establish a causal relation-

BPS Pharmacotherapy Specialty Examination Content Outline

I. SEPSIS AND MENINGITIS

Table 1. Cerebrospinal Fluid Findings

B. Common Pathogens for Sepsis and Meningitis (Table 2)

Table 2. Common Pathogens

C. Potential Empiric Antibiotic Regimens for Sepsis and Meningitis (Table 3)

Table 3. Potential Antibiotic Regimens

E. Chemoprophylaxis of Bacterial Meningitis

Table 4. Regimens for Chemoprophylaxisa

II. RESPIRATORY SYNCYTIAL VIRUS INFECTION

B. Risk Factors for Severe Disease

Table 5. AAP Guidelines for Palivizumab Use

AAP = American Academy of Pediatrics; RSV = respiratory syncytial virus.

III. OTITIS MEDIA

2. Suggested treatment algorithm (Figure 1)

NO Otorrhea or severe symptoms?

Reevaluate at 48–72 hours

• Start antibiotic if prescribing was delayed

• Continue current treatment strategy • Consider changing antibiotic regimen

Figure 1. AOM suggested treatment algorithm.

B. Barriers to Routine Immunization

e. Recent administration of immune globulin: MMR, varicella

C. Considerations in Special Populations

Hepatitis B1 (HepB) 1st dose 2nd dose 3rd dose

Rotavirus2 (RV) RV1 (2-dose See

Varicella9 (VAR) 1st dose 2nd dose

Hepatitis A1 0 (HepA) 2-dose series, See footnote 10

pertussis1 2 (Tdap: >7 yrs)

disease and other hemoglobinopathies; anatomic or functional asplenia; congenital or acquired

V. PEDIATRIC SEIZURE DISORDERS

A. Treatment Options Based on Seizure Type (Table 6)

Table 6. Treatment Options Based on Seizure Type

B. Comparison of Available Antiepileptic Drugs (Table 7)

Table 7. Comparison of Available Antiepileptic Drugs

Table 7. Comparison of Available Antiepileptic Drugs (continued)

VI. ATTENTION-DEFICIT/HYPERACTIVITY DISORDER

B. Classification: Based on DSM-V Criteria (see pages 1–17)

Table 8. Stimulant Agents for the Treatment of ADHD

Table 8. Stimulant Agents for the Treatment of ADHD (continued)

Table 9. Nonstimulant Agents for the Treatment of ADHD

ANSWERS AND EXPLANATIONS TO PATIENT CASES

1. Answer: B would not be appropriate empiric coverage because

ANSWERS AND EXPLANATIONS TO SELF-ASSESSMENT QUESTIONS

1. Answer: B should be vaccinated according to chronologic age, and

7. Answer: A In addition, cardiopulmonary bypass reduces palivi-

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Learning Objectives 3. Which is the most accurate statement about pro-

8. In a retrospective study of the risk of appetite loss

9. An investigator wants to establish a causal relation-