01 Ped

Pediatrics
Pediatrics
Kirsten H. Ohler, Pharm.D., BCPS
University of Illinois Medical Hospital
and Health Sciences System
Chicago, Illinois
ACCP Updates in Therapeutics® 2012: The Pharmacotherapy Preparatory Review and Recertification Course
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Learning Objectives: 3. Which one of the following is the most accu-

rate statement regarding prophylaxis of bacterial
1. Describe the most common pathogens associated meningitis?
with neonatal and pediatric sepsis/meningitis. A. Close contacts of patients with pneumococcal
2. Describe current therapeutic options for the meningitis should receive prophylaxis.
management of neonatal and pediatric sepsis/ B. Close contacts of patients with Haemophilus
meningitis. influenzae meningitis require prophylaxis only
3. Identify the drugs available for preventing and if their immunizations are not up-to-date.
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
5. Identify the recommended pediatric immunization no longer recommended regardless of the
schedule and barriers to routine immunization. causative 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 pa- routine checkup and immunizations. Which one of
tients with attention-deficit/hyperactivity disorder. the following is the best recommendation to make
regarding this patient’s immunization schedule?
A. Only two of the five immunizations due
Self-Assessment Questions
should be given at the same time; schedule
Answers and explanations to these questions
another appointment for the following week
may be found at the end of this chapter.
to administer the rest.
B. Oral polio vaccine should be used to reduce
1. A 15-year-old boy with a history of exercise-
the number of injections required to complete
induced asthma presents with fever, tachypnea,
the schedule.
headache, and myalgia. Which one of the following
C. Vaccines should be based on his corrected
organisms is most likely to be isolated from this
gestational age rather than on his chronologic
patient?
age because he was born prematurely.
A. Respiratory syncytial virus (RSV). D. Influenza vaccine should be administered
B. Streptococcus pneumoniae. with all other scheduled vaccinations.
C. Group B streptococcus.
D. Pseudomonas aeruginosa. 5. A physician asks for your recommendation for
treatment of a 5-year-old child with his first case
2. Which one of the following is the best assessment of acute otitis media. Which one of the following
of the risk of severe RSV infection and subsequent statements is the best advice at this time?
need for prophylaxis in a female infant born at 30
A. A blood culture should be obtained to identify
weeks’ gestation?
the causative organism.
A. This patient should receive prophylaxis if she B. Antibiotics may not be warranted at this time.
is 6 months or younger at the beginning of C. Initiate azithromycin to treat atypical
RSV season. organisms (e.g., mycoplasma).
B. This patient is at risk only if she has chronic D. Administer intramuscular ceftriaxone.
lung disease.
C. All neonates born during RSV season should 6. A 16-year-old girl with asthma, a history of ven-
receive prophylaxis. tricular septal defect, and attention-deficit/hyper-
D. This patient should receive prophylaxis only activity disorder (ADHD) was initially treated with
if she has additional risk factors such as day methylphenidate IR, but her ADHD symptoms
care attendance or school-aged siblings. persisted at home and at school. Her therapy was
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then changed to methylphenidate OROS (Con- admitted during RSV season for stage II repair of
certa). The dose was maximized during the next his heart defect. Which one of the following state-
several weeks; however, her symptoms were still ments is most accurate regarding RSV infection in
not well controlled throughout the day. She and her this patient?
family report adherence to the treatment regimen. A. He is not at significant risk of severe RSV
Which of the following is the best recommendation infection because he was born at 36 weeks
to make regarding the treatment of her ADHD? and is older than 6 months.
A. Switch to clonidine. B. He should not receive palivizumab while in
B. Switch to extended-release mixed the hospital because it has not been shown to
amphetamine salts (i.e., Adderall XR). reduce nosocomial transmission.
C. Switch to methylphenidate transdermal C. The decision to use palivizumab or RSV
system (i.e., Daytrana). intravenous immunoglobulin (IVIG) in this
D. Switch to atomoxetine. patient should be based solely on cost because
there is no clinical difference between the
7. A 7-year-old child with absence seizure is having products.
breakthrough episodes on ethosuximide. Which D. A dose of palivizumab should be
one of the following is the most appropriate alter- administered postoperatively and continued
native therapy? throughout the RSV season because
A. Valproic acid. palivizumab serum concentrations are
B. Phenytoin. reduced after cardiopulmonary bypass.
C. Phenobarbital.
D. Gabapentin.

8. In a retrospective study of the risk of loss of appe-
tite in adolescents taking a specific stimulant agent
for the management of ADHD, 7 of 200 patients
exposed to the stimulant showed appetite loss com-
pared with 1 of 198 controls (unexposed). Which
one of the following choices best reflects the cor-
rect odds ratio of developing loss of appetite for the
cases compared with the controls?
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
one of the following study designs is best to use?
A. Case series.
B. Randomized controlled.
C. Retrospective cohort.
D. Crossover.

10. An 8-month-old, former 36-week gestational-
age infant with hypoplastic left heart disease is
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I. Sepsis/Meningitis
A. Clinical Presentation
1. Signs and symptoms
a. Neonates: Temperature instability, feeding intolerance, lethargy, grunting, flaring, retractions,
apnea, bulging fontanelle, and seizures
b. Children: Fever, loss of appetite, emesis, myalgias, arthralgias, cutaneous manifestations (e.g.,
petechiae, purpura, rash), 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 72 hours 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. Cerebral spinal fluid findings
Table 1. Cerebral Spinal Fluid Findings

Laboratory Value Normal Child Normal Newborn Bacterial Meningitis Viral Meningitis
WBC/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/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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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 one of the following is the best empiric antibiotic
regimen?
A. Vancomycin.
B. Ampicillin plus gentamicin.
C. Ampicillin plus ceftriaxone.
D. Ceftazidime plus gentamicin.
B. Common Pathogens
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 (−) 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 Antibiotic Regimens
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 S. pneumoniae.
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Patient Cases
2. Culture results for the patient in question 1 reveal gram-negative rods in the cerebral spinal fluid. Which one
of the following recommendations regarding antibiotic prophylaxis is best?
A. The patient’s 5-month-old stepsister is at high risk because she is not fully immunized; she 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 32,000 white blood cells with a left shift. Culture results are pending. The patient has no known
drug allergies. Which one of the following antibiotic regimens 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/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. Regimen
Table 4. Regimens for Chemoprophylaxis.a

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 although not routinely recommended.
IM = intramuscularly; PO = orally.
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II. Respiratory syncytial virus (RSV) 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
B. Risk Factors for Severe Disease

1. Premature birth
2. Chronic lung disease/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 RSV season for risk factors associated with the development of severe RSV
infection. Which one of the following is the best recommendation to make regarding the use of palivizumab
for RSV prophylaxis?
A. Palivizumab should not be prescribed for a baby born at 34 weeks’ gestation with a cyanotic
congenital heart defect.
B. Palivizumab should not be prescribed for a 21-day-old baby, born at 31 weeks’ gestation, who is the
only child of nonsmoking parents and who will not attend day care.
C. Palivizumab should not be prescribed for a 5-month-old, former 29-week premature infant with a
history of chronic lung disease who was discharged from the hospital without oxygen or medications.
D. Palivizumab should not 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.
C. Prophylaxis
1. Nonpharmacologic: Avoid crowds during RSV season and conscientiously use good hand-washing
practice.
2. RSV IVIG (RespiGam): No longer marketed in the United States
a. Dosing: 15 mL/kg (750 mg/kg) intravenously once monthly during RSV season
b. Effects on outcomes
i. A 41% reduction in hospitalizations for RSV
ii. Significant increase in cyanotic episodes and death in patients with cyanotic congenital heart
disease
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iii. No reduction in overall mortality

iv. Interferes with the response to measles, mumps, and rubella vaccine (MMR) and varicella
vaccine
3. 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
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
c. American Academy of Pediatrics (AAP) recommendations for use:
i. Premature infants born before 32 weeks’ gestation (i.e., 31 weeks, 6 days or earlier) who are 6
months old or younger at the beginning of RSV season
(a) Infants born at less than 28 weeks’ gestation may benefit up to 12 months of age.
(b) Eligible for a maximum of five doses of palivizumab during RSV season
ii. Infants with chronic lung disease who are 2 years or younger and who required medical
management of their chronic lung disease in the previous 6 months – Eligible for a maximum
of five doses of palivizumab during RSV season
iii. Infants born between 32 and 35 weeks’ gestation (i.e., 32 weeks, 0 days through 34 weeks, 6
days) who are 3 months or younger at the beginning of RSV season
(a) With at least one of the following risk factors may benefit: 1) the infant attends childcare
or 2) the infant has one or more siblings younger than 5 years living in the same
household.
(b) Eligible for a maximum of three doses of palivizumab during RSV season
iv. Infants 24 months and younger with hemodynamically significant congenital heart disease
(a) Eligible for a maximum of five doses of palivizumab during RSV season
(b) There is a 58% decrease in palivizumab serum concentration after cardiopulmonary
bypass; therefore, a postoperative dose of palivizumab is recommended as soon as the
patient is medically stable.
v. Infants 12 months and younger with congenital abnormalities of the airway or neuromuscular
disease that compromises the handling of respiratory tract secretions – Eligible for a
maximum of five doses of palivizumab during RSV season
Patient Case
5. An 18-month-old baby with a history of premature birth and chronic lung disease is admitted to the pediat-
ric intensive care unit with respiratory distress requiring intubation; fever; and a 3-day history of cold-like
symptoms. A nasal swab is positive for RSV. Which one of the following is the best intervention?
A. Palivizumab.
B. Corticosteroids.
C. Cefuroxime.
D. Intravenous fluids and supportive care.
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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/hospital, or hospital cost
d. The AAP states that ribavirin “may be considered” in a select group of high-risk patients (e.g.,
complicated congenital heart disease, chronic lung disease/bronchopulmonary dysplasia,
immunocompromised).
3. β2-Agonists/racemic epinephrine
a. Not shown to improve outcome measures
b. Some practitioners may give a trial of these therapies, but they are not considered the standard of
care.
4. Corticosteroids
a. Not shown to improve outcome measures
b. Use is not recommended.
5. Antibiotics: Not indicated unless secondary bacterial infection develops
III. Otitis Media
1. Definitions
a. Acute otitis media: 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
mobility of the tympanic membrane, purulent fluid within 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: Fluid in the middle ear without evidence of local or systemic illness
c. Recurrent acute otitis media: 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 acute otitis media
c. Bottle-feeding (as opposed to breastfeeding)
d. Lower socioeconomic status
e. Smokers in the household
f. Craniofacial abnormalities/cleft palate
B. Common Pathogens
1. Viral
2. S. pneumoniae
3. Nontypeable H. influenzae
4. Moraxella catarrhalis
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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 acute otitis media with bulging tympanic membrane/
perforation.
c. Delayed antibiotic prescribing (i.e., treatment only if otalgia or fever persists for more than 48–72
hours) is an acceptable strategy in children older than 2 years with acute otitis media without
severe systemic symptoms.
i. Antibiotics also may be deferred in otherwise healthy children between age 6 months and 2
years if their symptoms are mild and a diagnosis of otitis media is uncertain.
ii. Caregiver must be reliable to recognize worsening of condition and gain immediate access to
medical care if needed.
iii. Not recommended for infants younger than 6 months
d. Persistence of middle ear fluid is likely after treatment for acute otitis media and does not require
repeated treatment.
e. Antibiotics are not generally warranted for otitis media with effusion 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.
Patient Case
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 full-
ness in the middle ear and a cloudy tympanic membrane with decreased mobility. She is now afebrile and
eating well. Which one of the following is the best recommendation regarding her treatment?
A. No antibiotics are warranted at this time.
B. High-dose (90 mg/kg/day) amoxicillin for 7 days.
C. Decongestant and antihistamine daily until resolution.
D. Azithromycin.
2. Antibiotic regimens
a. Amoxicillin (high dose: 80–90 mg/kg/day): Recommended by AAP as the first-line therapy for
acute otitis media
b. Amoxicillin/clavulanate
c. Cefuroxime
d. Other antibiotic options (e.g., cefdinir, cefpodoxime) may be effective.
e. Duration
i. The most appropriate duration is unclear.
ii. In general, 7–10 days, but a shorter course (5 days) has been used in children older than 2
years
iii. For confirmed cases of acute otitis media not responding to the initial antimicrobial regimen
within 48–72 hours, a change in antibiotic regimen is warranted.
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f. Failure of the previously discussed regimens may warrant the use of intramuscular ceftriaxone for
3 days or tympanocentesis.
i. Intramuscular ceftriaxone may also be considered if adherence is a concern.
ii. Tympanostomy with tube placement may be most beneficial for children with persistent otitis
media with effusions and significant hearing loss (e.g., greater than 25-dB hearing loss in both
ears for more than 12 weeks).
D. Prophylaxis
1. Reserved for patients with recurrent acute otitis media
2. Reduces occurrence by about one episode per year
3. The risk of promoting bacterial resistance may outweigh the slight benefit.
Patient Case
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 one of the following 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 influenza
vaccines.
D. No antibiotic therapy 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
pneumococcal 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
recommended 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 IVIG is being seen by his
pediatrician for a well-child check-up. He is due for the MMR and varicella vaccines. His mother has sev-
eral concerns about administering these immunizations. Which one of the following concerns is the best
reason to defer administration of 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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2. Combination vaccines
a. Main advantage: Reduction in the number of injections required to complete recommended schedule
b. The FDA mandates that the safety and efficacy of combination products not be less than the
individual components.
c. Products
i. The DTaP-Hib (H. influenzae type B [vaccine]) combination
(a) The Hib antibody response is markedly lower after administering the combination product
than when administering it separately for primary immunization.
(b) Only approved for use as the fourth dose
(c) TriHIBit
ii. The DTaP-IPV (inactivated poliovirus [vaccine]) combination
(a) Studies indicate that this combination has no consistent effect on antibody responses.
(b) Indicated only for the fifth dose of DTaP and fourth dose of IPV in the routine series
(c) Kinrix
iii. The DTaP-HepB (hepatitis B) combination – Product is available outside the United States
and provides good safety and antibody concentrations.
iv. The DTaP-HepB-Hib combination – The Hib antibody levels are lower than after separate
administration.
v. The DTaP-HepB-IPV combination
(a) At least as immunogenic as individual components when administered at 2, 4, and 6
months
(b) Not indicated for infants younger than 6 weeks or children older than 7 years
(c) Pediarix
vi. The HepB-Hib combination
(a) Not indicated for infants younger than 6 weeks because of possible decreased immune
response
(b) Comvax
vii. The Hib-DTaP-IPV combination
(a) Approved for use in children aged 6 weeks through 4 years
(b) Pentacel
viii. The HepA-HepB combination
(a) Approved for use in individuals 18 years and older
(b) Twinrix
ix. The MMR vaccine and varicella combination
(a) Research from the Centers for Disease Control and Prevention and manufacturer
indicated a higher incidence of febrile seizures in children aged 12–23 months who
received the combination product compared with those who received the separate MMR
and varicella vaccines.
(b) Since June 2009, the Advisory Committee on Immunization Practices (ACIP) has
expressed a preference for separate MMR and varicella vaccines as the first dose given to
children aged 12–47 months. The combination product may be used for the second dose at
any age and for the first dose in children 48 months or older.
(c) ProQuad
x. Adding HepB to combination products may result in an extra dose being provided (e.g.,
monovalent HepB given at birth and then combination products at 2, 4, and 6 months);
however, the ACIP states that this is a safe practice.
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3. Interchangeability of products
a. The 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 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 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 Hib: These products may be used interchangeably; however, if the regimen is completed using
PedvaxHIB exclusively, only three doses are required; regimens using HibTITER or ActHIB
require 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
gynecologic, 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 contains egg proteins.
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
e. Recent administration of immune globulin: MMR, varicella
i. Delay administration of vaccine product.
ii. Interval between immune globulin dose and administration of vaccine is dependent on
indication for and dose of immune globulin.
f. Encephalopathy within 7 days after administration of a previous dose of DTaP
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 under-immunization
a. Low socioeconomic status
b. Late start of vaccination series
c. Missed opportunities
i. Provider unaware that vaccination is due
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ii. Failure to provide simultaneous vaccines

iii. Inappropriate contraindications (see previous discussion)
d. Concern regarding potential adverse reactions
i. Autism – The association with MMR vaccine has not been proved.
ii. Guillain-Barré syndrome—The association with meningococcal conjugate vaccine has not
been proved.
(a) 15 reported cases in adolescents after receiving meningococcal vaccine
(b) The ACIP continues to recommend routine use of meningococcal vaccine.
iii. Intussusception – An association with rotavirus vaccine led to the market withdrawal of
RotaShield; two currently available products:
(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.
Patient Case
9. All the following patients are seeing their pediatrician today and are due for immunizations on the basis of
the routine schedule. For which one of the following patients would it be best to recommend deferring im-
munizations 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.
C. Considerations in Special Populations

1. Preterm infants
a. Immunize on the basis of chronologic age.
b. Do not reduce 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.
1-14
Pediatrics
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.
FIGURE 1: Recommended immunization schedule for persons aged 0 through 6 years—United States, 2012 (for those who fall behind or start late, see the catch-up
schedule.
1 2 4 6 9 12 15 18 19–23 2–3 4–6
Vaccine ▼ Age ► Birth month months months months months months months months months years years
Range of
Hepatitis B1 Hep B HepB HepB recommended
ages for all
children
Rotavirus2 RV RV RV2
Diphtheria, tetanus, pertussis3 DTaP DTaP DTaP see footnote3 DTaP DTaP
Haemophilus influenzae type b4 Hib Hib Hib4 Hib Range of
recommended
Pneumococcal5 PCV PCV PCV PCV PPSV ages for certain
high-risk
Inactivated poliovirus6 IPV IPV IPV IPV groups
Influenza7 Influenza (Yearly)

Measles, mumps, rubella8 MMR see footnote8 MMR
Range of
Varicella9 Varicella see footnote9 Varicella recommended
ages for all
children and
Hepatitis A10 Dose 110 HepA Series certain high-
risk groups
Meningococcal11 MCV4 — see footnote 11
This schedule includes recommendations in effect as of December 23, 2011. 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/pubs/acip-list.htm. 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).
1.
figure 4th PROOF
Hepatitis B (HepB) vaccine. (Minimum age: birth)
1. Recommended immunization schedule for personsvaccine
At birth: PROOF
• Administer monovalent HepB vaccine to all newborns before hospital discharge.
aged[TIV];
0 through
7.
6 years—United
2 years for live, PROOF States,
attenuated influenza vaccine 2012
[LAIV])
• For most healthy children aged 2 years and older, either LAIV or TIV may be
PROOF
Influenza vaccines. (Minimum age: 6 months for trivalent inactivated influenza
(for those whoborn

• For infants fall behind
to hepatitis or start
B surface antigenlate, see the mothers,
(HBsAg)–positive catch-up QuickGuide
schedule.)
used. However, LAIV should not be administered to some children, including
administer HepB vaccine and 0.5 mL of hepatitis B immune globulin (HBIG) 1) children with asthma, 2) children 2 through 4 years who had wheezing in
within 12 hours of birth. These infants should be tested for HBsAg and antibody the past 12 months, or 3) children who have any other underlying medical
FIGUREto2. Recommended
HBsAg immunization
(anti-HBs) 1 to 2 schedule
months after completion of at for
leastpersons
3 doses ofaged
the 7 through 18 years
conditions that— United them
predispose States, 2012 (for
to influenza those who
complications. fall
For all behind
other or
start late,
HepBsee theatschedule
series, below
age 9 through and the
18 months catch-up
(generally at theschedule.
next well-child visit). contraindications to use of LAIV, see MMWR 2010;59(No. RR-8), available at
• If mother’s HBsAg status is unknown, within 12 hours of birth administer http://www.cdc.gov/mmwr/pdf/rr/rr5908.pdf.
HepB vaccine for infants
Vaccine Age weighing ≥2,000 7–10
grams, and HepB vaccine plus
years • For children
11–12 years aged 6 months through 8 years:
13–18 years
HBIG for infants weighing <2,000 grams. Determine mother’s HBsAg status — For the 2011–12 season, administer 2 doses (separated by at least
asdiphtheria,
soon as possible and,
1 if she is HBsAg-positive, administer HBIG for 4 weeks) to those who did not receive Range of
Tetanus, pertussis 1 dose (if indicated) 1 dose 1 doseat(ifleast 1 dose of the 2010–11
indicated) recommended
infants weighing ≥2,000 grams (no later than age 1 week). vaccine. Those who received at least 1 dose of the 2010–11 vaccine
2 ages for all
Doses after the birth dose:
Human papillomavirus See footnote 2
3 doses
require 1 dose for the 2011–12Complete season. 3-dose series children
• The second 3
dose should be administered at age 1 to 23 months. Monovalent — For the 2012–13 season, follow dosing guidelines inage
the162012 ACIP
Meningococcal See footnote
HepB vaccine should be used for doses administered before age 6 weeks. Dose 1
influenza vaccine recommendations.
Booster at years
• Administration
4 of a total of 4 doses of HepB vaccine is permissible when a 8.Influenza
Measles, mumps, and rubella (MMR) vaccine. (Minimum age: 12 months)
Influenza combination vaccine containing HepB is administered after the birth dose. (yearly)
• The second dose may be administered before age 4 years, provided at least
• Infants
Pneumococcal who
5 did not receive a birth dose should receive 3 doses of a HepB- See footnotehave
4 weeks 5 elapsed since the first dose. Range of
containing vaccine starting as soon as feasible (Figure 3). • Administer MMR vaccine to infants aged 6 through 11 months who are recomended
• The 6minimum interval between dose 1 and dose 2 is 4 weeks, and between Complete
Hepatitis A 2-doseinternationally.
traveling series These children should be revaccinated with ages for catch-up
2 doses
dose7 2 and 3 is 8 weeks. The final (third or fourth) dose in the HepB vaccine immunization
of MMR vaccine, the first at ages 12 through 15 months and at least 4 weeks
series should be administered no earlier than age 24 weeks and at least 16 Complete
Hepatitis B 3-dose series
after the previous dose, and the second at ages 4 through 6 years.
weeks after the8first dose. 9. Varicella (VAR) vaccine. (Minimum age: 12 months)
2.Inactivated
Rotavirus (RV) vaccines. (Minimum age: 6 weeks for both RV-1 [Rotarix] and Complete
poliovirus 3-dose series
• The second dose may be administered before age 4 years, provided at least
RV-5 [Rota Teq]) 9 3 months have elapsed since the first dose.
2-dose series Range of
Measles, mumps, rubella
• The maximum age for the first dose in the series is 14 weeks, 6 days; and
Complete 2-Dose Series recommended
• For children aged 12 months through 12 years, the recommended minimum
Varicella 8 months, 0 days for the final dose in the series. Vaccination should not be Complete
10 2-dose
interval series doses is 3 months. However, if the second dose was
between ages for certain
initiated for infants aged 15 weeks, 0 days or older. high-risk groups
administered at least 4 weeks after the first dose, it can be accepted as valid.
• If RV-1
This schedule (Rotarix)
includes is administered
recommendations at ages
in effect 2 December
as of and 4 months, a dose
23, 2011. Any at 6 months
dose 10. Hepatitis
not administered A (HepA) vaccine.
at the recommended age should(Minimum age: 12atmonths)
be administered a subsequent visit, when indi-
cated andisfeasible.
not indicated.
The use of a combination vaccine generally is preferred over separate injections of•itsAdminister the secondvaccines.
equivalent component (final) dose 6 to18 providers
Vaccination months after
shouldtheconsult
first. the relevant
3. Diphtheria
Advisory Committee and tetanus toxoids
on Immunization and(ACIP)
Practices acellular pertussis
statement (DTaP)
for detailed vaccine.
recommendations, available online at http://www.cdc.gov/vaccines/pubs/acip-list.htm.
• Unvaccinated children 24 months and older at high risk should Clinicallybesignificant
adverse (Minimum
events thatage: 6 weeks)
follow vaccination should be reported to the Vaccine Adverse Event Reporting System (VAERS) online
vaccinated. See (http://www.vaers.hhs.gov)
MMWR 2006;55(No. RR-7), or byavailable
telephoneat(800-822-7967).
http://www.cdc.gov/
• The fourth dose may be administered as early as age 12 months, provided at mmwr/pdf/rr/rr5507.pdf.
1. Tetanus leastand6 months
diphtheria have elapsed
toxoids andsince the pertussis
acellular third dose.(Tdap) vaccine. (Minimum 5.• Pneumococcal
A 2-dose HepA vaccine
vaccines series is recommended
(pneumococcal for anyone
conjugate vaccine [PCV] agedand 24 months
pneumococ-
figure 2. Recommended immunization schedule for persons aged 7 through 18 years — United States, 2012
4. age: 10 years for Boostrix and 11 years for Adacel)
Haemophilus influenzae type b (Hib) conjugate vaccine. (Minimum age: 6 weeks) and
cal older, previously
polysaccharide unvaccinated,
vaccine [PPSV]). for whom immunity against hepatitis A
• If PRP-OMP (PedvaxHIB or Comvax [HepB-Hib]) is administered at ages 2
• Persons aged 11 through 18 years who have not received Tdap vaccine should receive • virus infection is desired.
A single dose of PCV may be administered to children aged 6 through 18 years who
(for those who fall behind or start late, see the schedule below and the catch-up schedule.)
and followed
a dose 4 months, by atetanus
dose at age
and 6 months
diphtheria is not(Td)
toxoids indicated.
booster doses every 10 years 11. Meningococcal conjugate asplenia,
have anatomic/functional vaccines, quadrivalent
HIV (MCV4).
infection or other (Minimum age: 9
immunocompromising
• Hiberix should only be used for the booster (final) dose in children aged 12
thereafter. months for Menactra
condition, cochlear[MCV4-D],
implant, or2cerebral
years for Menveo
spinal fluid [MCV4-CRM])
leak. See MMWR 2010:59(No.
months through 4 years.
• Tdap vaccine should be substituted for a single dose of Td in the catch-up series for • For children
RR-11), aged
available at9http://www.cdc.gov/mmwr/pdf/rr/rr5911.pdf.
through 23 months 1) with persistent complement
5. children
Pneumococcal vaccines.
aged 7 through (Minimum
10 years. Refer toage:
the6catch-up
weeks for pneumococcal
schedule conjugate
if additional doses • component deficiency; 2) who are residents of or travelers to countries with
Administer PPSV at least 8 weeks after the last dose of PCV to children aged 2 years
vaccine [PCV]; 2 years for pneumococcal polysaccharide vaccine [PPSV])
of tetanus and diphtheria toxoid–containing vaccine are needed. hyperendemic
or older with certainor epidemic disease;
underlying or 3)
medical who are including
conditions, present during outbreaks
a cochlear implant. A
• Administer 1 dose of PCV to all healthy children aged 24 through
• Tdap vaccine can be administered regardless of the interval since the last tetanus and 59 months caused by a vaccineshould
single revaccination serogroup, administerafter
be administered 2 primary
5 years doses of MCV4-D,
to children with anatomic/
who are not completely vaccinated
diphtheria toxoid–containing vaccine. for their age. ideally at ages 9 months and 12 months or
functional asplenia or an immunocompromising condition. at least 8 weeks apart.
• Forpapillomavirus
2. Human children who have (HPV)received
vaccinesan age-appropriate
(HPV4 [Gardasil] andseries
HPV2of 7-valent
[Cervarix]). 6.• Hepatitis
For children agedvaccine.
A (HepA) 24 months and older with 1) persistent complement
PCV (PCV7),
(Minimum a single supplemental dose of 13-valent PCV (PCV13) is
age: 9 years) • component deficiency who have not been previously vaccinated; or 2)
HepA vaccine is recommended for children older than 23 months who live in areas
recommended for:
• Either HPV4 or HPV2 is recommended in a 3-dose series for females aged 11 or 12 anatomic/functional
where vaccination programs asplenia, administer
target 2 primary
older children, whodoses of either MCV4
are at increased risk for at
infec-
— All children aged 14 through 59 months
years. HPV4 is recommended in a 3-dose series for males aged 11 or 12 years. least
tion, 8orweeks
for whom apart.
immunity against hepatitis A virus infection is desired. See MMWR
— Children aged 60 through 71 months with underlying medical conditions.
• The vaccine series can be started beginning at age 9 years. • For children with anatomic/functional asplenia, if MCV4-D (Menactra) is
2006;55(No. RR-7), available at http://www.cdc.gov/mmwr/pdf/rr/rr5507.pdf.
• Administer PPSV at least 8 weeks after last dose of PCV to children aged 2
• Administer the second dose 1 to 2 months after the first dose and the third dose 6 • used, administer at a minimum age of 2 years and at least 4 weeks after
Administer 2 doses at least 6 months apart to unvaccinated persons.
years or older with certain underlying medical conditions, including a cochlear
months after the first dose (at least 24 weeks after the first dose). completion
7. Hepatitis of all PCV
B (HepB) doses.
vaccine.
implant.2010;59:626–32, available at http://www.cdc.gov/mmwr/pdf/wk/mm5920.
• See MMWR See MMWR 2010:59(No. RR-11), available at http://www.cdc.gov/ • • See MMWR 2011;60:72–6, available at http://www.cdc.gov/mmwr/pdf/wk/
Administer the 3-dose series to those not previously vaccinated.
pdf.mmwr/pdf/rr/rr5911.pdf. mm6003. pdf, and Vaccines for Children follow
• For those with incomplete vaccination, Program the resolution
catch-up No. recommendations
6. Inactivated poliovirus
3. Meningococcal vaccine quadrivalent
conjugate vaccines, (IPV). (Minimum age: 6 weeks)
(MCV4). 6/11-1,
(Figure available
3). at http://www. cdc.gov/vaccines/programs/vfc/downloads/
• If 4 or more doses are administered before age 4 years, an additional dose
• Administer MCV4 at age 11 through 12 years with a booster dose at age 16 years. • resolutions/06-11mening-mcv.pdf, and MMWR 2011;60:1391–2, available
A 2-dose series (doses separated by at least 4 months) of adult formulation Recombivax
should be administered at age 4 through 6 years.
• Administer MCV4 at age 13 through 18 years if patient is not previously vaccinated. atHB is licensed for use in children aged 11 through 15 years.
http://www.cdc.gov/mmwr/pdf/wk/mm6040. pdf, for further guidance,
• The final dose in the series should be administered on or after the fourth
• If the first dose is administered at age 13 through 15 years, a booster dose should be including revaccination
8. Inactivated poliovirus vaccineguidelines.
(IPV).
birthday and
administered at least
at age 6 months
16 through afterwith
18 years the previous
a minimum dose.
interval of at least 8 weeks • The final dose in the series should be administered at least 6 months after the previous
after the preceding dose. dose.
This schedule is approved by the Advisory Committee on Immunization Practices (http://www.cdc.gov/vaccines/recs/acip),
• If the first dose is administered at age 16 years or older, a booster dose is not needed.
the American Academy of Pediatrics (http://www.aap.org), and the American • If both OPV and IPV were administered as part of a series, a total of 4 doses should be
Academy of Family Physicians (http://www.aafp.org).
• Administer 2 primary doses at least 8 weeks apart to previously unvaccinated persons
Department of Health and Human Services • Centers for administered, regardless of the child’s current age.
Disease Control and Prevention
ACCP Updates
with persistent in Therapeutics®
complement component deficiency or 2012: The Pharmacotherapy
anatomic/functional asplenia, Preparatory Review and Recertification Course
• IPV is not routinely recommended for U.S. residents aged18 years or older.
and 1 dose every 5 years thereafter. 9. Measles, mumps, and rubella (MMR) vaccine.
• Adolescents aged 11 through 18 years with human immunodeficiency virus (HIV) • The minimum interval between the 2 doses of MMR vaccine is 4 weeks.
infection should receive a 2-dose primary series of MCV4, at least 8 weeks apart. 1-15 10. Varicella (VAR) vaccine.
• See MMWR 2011;60:72–76, available at http://www.cdc.gov/mmwr/pdf/wk/mm6003. • For persons without evidence of immunity (see MMWR 2007;56[No. RR-4], available
pdf, and Vaccines for Children Program resolution No. 6/11-1, available at http://www. at http://www.cdc.gov/mmwr/pdf/rr/rr5604.pdf ), administer 2 doses if not previously
cdc.gov/vaccines/programs/vfc/downloads/resolutions/06-11mening-mcv.pdf, for vaccinated or the second dose if only 1 dose has been administered.
further guidelines. • For persons aged 7 through 12 years, the recommended minimum interval between
4. Influenza vaccines (trivalent inactivated influenza vaccine [TIV] and live, attenu- doses is 3 months. However, if the second dose was administered at least 4 weeks after
Pediatrics
V. Pediatric Seizure Disorders
A. Treatment Options Based on Seizure Type
Table 5. Treatment Options Based on Seizure Type

Seizure Type Drugs of Choice Alternatives
Partial VPA, CBZ, PHT PB, gabapentin, lamotrigine, tiagabine, topiramate,
oxcarbazepine, zonisamide, levetiracetam
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 6. Comparison of Available Antiepileptic Drugs

Drug Adverse Effects Pharmacokinetic Considerations Other Comments
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
Carbamazepine Rash Autoinduction Significant drug interactions
Hyponatremia ↓ Effectiveness of OCs
↓ Bone density
Teratogenic
Valproic acid Weight gain CYP induction > in children Significant drug interactions
Menstrual irregularities Most cases of hepatotoxicity
Polycystic ovarian syndrome in children < 2 years
Hyperandrogenism
Hepatotoxicity
Teratogenic
Thrombocytopenia
Gabapentin Somnolence ↑ Clearance in children < 6 years Minimal drug interactions
Weight gain Dose adjustment required in renal Minimal cognitive effects
insufficiency May worsen Lennox-Gastaut
Nonlinear pharmacokinetics
1-16
Pediatrics
Table 6. Comparison of Available Antiepileptic Drugs (continued)

Drug Adverse Effects Pharmacokinetic Considerations Other Comments
Felbamate Anorexia, nausea, weight Clearance ~50:50 renal/hepatic Significant drug interactions
loss Aplastic anemia: Adults >
Insomnia, somnolence children
Aplastic anemia
Hepatic failure
Lamotrigine Rash Autoinduction Rash: children > adults
Stevens-Johnson syndrome Minimal cognitive effects
Topiramate Cognitive dysfunction ↑ Clearance in children Weight loss more common in
Weight loss Dose adjustment required in renal obese patients
Glaucoma insufficiency Children at higher risk of
Oligohidrosis oligohidrosis than adults
Tiagabine Dizziness Clearance 50% ↑in children Minimal cognitive effects
Nonconvulsive status
epilepticus (case reports)
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 < 6 in adults than children
years old Minimal cognitive effects
Induces CYP3A4
Inhibits CYP2C19
Zonisamide Weight loss Linear pharmacokinetics Better tolerated by children
Rash Primarily renal excretion than adults
Oligohidrosis No effect on CYP system
Somnolence
Agitation
Hallucinations
Vigabatrin Vision loss Available only through
Weight gain restricted distribution
program
CBZ = carbamazepine; CYP = cytochrome P450; OCs = oral contraceptives; PHT = phenytoin.
Patient Case
10. A 14-year-old moderately obese girl comes to the clinic with an erythematous pruritic rash. She was initi-
ated on oxcarbazepine about 3 weeks ago for management of partial seizures. Her medical history is sig-
nificant only for seizures. She has recently become sexually active and admits to inconsistent contraceptive
use. Which one of the following interventions is best for her?
A. Change to carbamazepine.
B. Change to levetiracetam.
C. Change to valproic acid.
D. No change in therapy is necessary.
1-17
Pediatrics
VI. Attention-deficit/hyperactivity disorder
1. Diagnostic and Statistical Manual for Mental Disorders (DSM-IV-TR) 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 easily distracted
(i) Often 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 “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. Another mental disorder does not better describe the symptoms.
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 by almost 11-fold.
b. Anxiety disorder – May exist in about 25% of children with ADHD
c. Tics
i. A total of 21%–90% of children with Tourette syndrome may also have ADHD.
ii. May not be exacerbated by stimulant agents, as once thought
B. Classification: Based on DSM-IV-TR 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.
1-18
Pediatrics
Patient Case
11. A 9-year-old boy has a new diagnosis of ADHD. At school, he is disruptive, talks when the teacher is talk-
ing, and runs around the classroom. His parents report extreme difficulty in getting him to do his homework
after school. Which one of the following is best for his initial drug therapy?
a. Methylphenidate (OROS) (Concerta) given once daily.
b. Methylphenidate immediate release (Ritalin) given 2 times/day with doses administered 4 hours apart.
c. Guanfacine given at bedtime.
d. d-Methylphenidate (Focalin) given 2 times/day with doses administered 4 hours apart.
C. Treatment Options: Combination of pharmacotherapy and behavioral therapy is more beneficial compared
with either intervention alone.
1. 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.
a. Methylphenidate-containing products: “Ramp effect” = behavioral effects are proportional to the
rate of methylphenidate absorption into the central nervous system
i. Methylphenidate immediate release (Ritalin)
(a) A 50:50 racemic mixture of l-threo and d-threo isomers of methylphenidate
(b) The short duration of action requires two or three doses daily.
ii. Dexmethylphenidate (Focalin)
(a) Contains only d-threo isomer, thought to be the pharmacologically active enantiomer of
methylphenidate
(b) l-Threo isomer has not been shown to hinder the effectiveness or increase the adverse
effects of methylphenidate.
(c) Recommended doses are half those of racemic methylphenidate immediate release.
(d) Short duration of effect requires two or three doses daily.
(e) Offers no proven pharmacoeconomic benefit over other methylphenidate immediate-
release products (i.e., Ritalin and generics)
iii. Methylphenidate sustained/extended release (Metadate ER, Ritalin SR)
(a) Duration of action may be up to 8 hours, but typically requires two doses daily for
afternoon symptom control
(b) May be used in place of methylphenidate immediate-release twice-daily dosing regimen
after dose titration has occurred with the immediate-release product
iv. Methylphenidate (OROS) (Concerta)
(a) Indicated for the treatment of ADHD in children 6 years and older
(b) Tablet contains osmotic agents and a rate-controlling membrane with a laser-drilled hole
for drug release.
(c) Outer capsule contains about 22% of the drug, allowing immediate release, and tablet
core contains remainder of drug, which is released over 10 hours, minimizing peak to
trough fluctuations.
(d) Must be swallowed whole; do NOT chew, crush, or divide
(e) Duration of behavioral effects is 10–12 hours.
(f) Once-daily dosing, with or without food
v. Dexmethylphenidate ER (Focalin XR)
(a) Uses spheroidal oral drug absorption system polymer-coated beads
1-19
Pediatrics
(b) Bimodal drug release results in peak serum concentrations at 1.5 and 6.5 hours after
dose administration.
(c) Faster onset than methylphenidate (OROS), but shorter duration of action; therefore,
afternoon symptom control is not as good as with methylphenidate (OROS)
vi. Methylphenidate modified release (Metadate CD)
(b) Capsule contains 30% immediate-release beads and 70% extended-release beads
(slowly released about 4 hours after ingestion).
(c) Duration of behavioral effects is 6–8 hours; therefore, efficacy may be diminished in the
afterschool/late afternoon hours; may require addition of methylphenidate immediate
release for later-day coverage
(d) Once-daily dosing; capsule may be opened and sprinkled on applesauce
vii. Methylphenidate extended release (Ritalin LA)
(b) Uses spheroidal oral drug absorption system polymer-coated beads
(c) Contains 50% immediate-release and 50% extended-release beads designed to mimic
the action of 2 times/day methylphenidate immediate release
(d) Efficacy may wane later in the day, requiring the addition of methylphenidate
immediate release for coverage of late-day symptoms.
(e) Once-daily dosing; capsule contents may be sprinkled on applesauce
viii. Methylphenidate transdermal system (Daytrana)
(b) Apply to hip 2 hours before effect is needed; recommended to remove 9 hours after
application but may be worn up to 16 hours
(c) Duration of effect is about 3 hours after patch removal.
(d) Dose may be titrated weekly to desired effect.
(e) May be worn while swimming or exercising
ix. Adverse effects and precautions
(a) Headache, stomachache, loss of appetite, and insomnia
(b) Use with caution in patients with glaucoma, tics, psychosis, and concomitant
monoamine oxidase inhibitors.
(c) Insomnia, anorexia, and tics occur more often with transdermal patch, also mild skin
reactions
b. Amphetamine-containing products
i. Mixed amphetamine salts immediate release (Adderall)
ii. Mixed amphetamine salts extended release (Adderall XR)
(b) Capsule contains 50% immediate-release and 50% extended-release beads (released 4
hours after ingestion).
(c) Duration of efficacy is 10–12 hours.
(d) Once-daily dosing; contents may be sprinkled on applesauce
iii. Lisdexamfetamine dimesylate (Vyvanse)
(a) Prodrug with d-amphetamine covalently bound to l-lysine
(b) Designed for less abuse potential than amphetamine
(c) Duration of action is about 10 hours.
(d) No clinical evidence of superiority over other amphetamine-containing agents
iv. Adverse effects and precautions
(a) Loss of appetite, insomnia, abdominal pain, and nervousness
1-20
Pediatrics
(b) May exacerbate preexisting hypertension and tic disorders

(c) Recent labeling change warns of potential association with sudden cardiac
death (SCD); therefore, not recommended for patients with known structural heart defects
c. Potential association with SCD
i. No established evidence of causative relationship between stimulants and SCD
ii. The frequency of SCD is no higher in children taking stimulants than in the general pediatric
population.
iii. The AAP recommends targeted cardiac history and careful physical examination before
initiating stimulant therapy.
(a) Routine electrocardiography is not recommended unless history and physical
examination suggest cardiac disease.
(b) For otherwise healthy children, stimulant therapy should not be withheld because of the
inability to obtain an electrocardiogram or assessment by a pediatric cardiologist.
2. Nonstimulant medications
a. Atomoxetine (Strattera)
i. Potent inhibitor of norepinephrine reuptake
ii. Once- or twice-daily dosing
iii. May be considered first-line therapy for children with an active substance abuse problem,
comorbid anxiety, or tics
iv. Adverse effects: Dyspepsia, decreased appetite, weight loss, and fatigue
(a) Recent labeling change warns of potential for severe liver injury, although routine
monitoring of hepatic function is not required.
(b) Recent addition of black box warning regarding increased risk of suicidal ideation in
children and adolescents
(c) Does not exacerbate tics
v. Metabolized through cytochrome P450 2D6 (CYP2D6)
b. Antidepressants: Non-FDA label approved for treatment of ADHD
i. Noradrenergic antidepressant (e.g., Bupropion [Wellbutrin])
(a) May use immediate- or extended-release product given in two or three doses
(b) Contraindicated for children with active seizure disorder
ii. Tricyclic antidepressants (e.g., imipramine, Nortriptyline)
(a) Baseline electrocardiogram is recommended before therapy initiation and after each
dose increase.
(b) Desipramine should be used with extreme caution because of reports of sudden death.
c. α-Adrenergic receptor agonists
i. Clonidine
(a) Clonidine extended release (KAPVAY) – The FDA approved its use for treatment of
ADHD in 6- to 17-year-old children in 2010.
(b) Shown to lessen the severity of tics, especially when used in combination with
methylphenidate
(c) May be more effective for hyperactivity than for inattention symptoms
(d) The primary adverse effect is sedation.
ii. Guanfacine
(a) Guanfacine extended release (Intuniv) – The FDA approved its use for treatment of
ADHD in 6- to 17-year-old children in 2009.
(b) Shown to improve comorbid tic disorder
(c) Less sedating with a longer duration of action than clonidine
(d) Abrupt discontinuation of extended-release product may cause rebound hypertension.
1-21
Pediatrics
Patient Case
12. The patient in question 11 has been doing well in school since initiation of methylphenidate (OROS) (Con-
certa) 6 months ago. His late afternoon symptoms are well controlled; however, he has had insomnia since
the initiation of drug therapy. Which one of the following is the best modification to make 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.
1-22
Pediatrics
References
Sepsis/Meningitis the Committee on Infectious Diseases, 28th ed. Elk

1. Feigin RD, McCracken GH, Klein JO. Diagnosis Grove Village, IL: American Academy of Pediat-
and management of meningitis. Pediatr Infect Dis rics, 2009:740–2.
J 1992;11:785–814. 2. Hendley JO. Clinical practice. Otitis media. N Engl
2. American Academy of Pediatrics. Meningococcal J Med 2002;347:1169–74.
infections. In: Pickering LK, ed. 2009 Red Book: 3. American Academy of Pediatrics Subcommittee
Report of the Committee on Infectious Diseases, on Management of Acute Otitis Media. Diagnosis
28th ed. Elk Grove Village, IL: American Acad- and management of acute otitis media. Pediatrics
emy of Pediatrics, 2009:455–63. 2004;113:1451–65.
3. Wubbel L, McCracken GH. Management of bacte-
rial meningitis: 1998. Pediatr Rev 1998;19:78–84. Immunizations
4. Brierly J, Carcillo JA, Choong K, et al. Clinical 1. American Academy of Pediatrics. Active and pas-
practice parameters for hemodynamic support of sive immunization. In: Pickering LK, ed. 2009 Red
pediatric and neonatal septic shock: 2007 update Book: Report of the Committee on Infectious Dis-
from the American College of Critical Care Medi- eases, 28th ed. Elk Grove Village, IL: American
cine. Crit Care Med 2009;37:666–88. Academy of Pediatrics, 2009:1–104.
2. Santoli JM, Szilagyi PG, Rodewald LE. Barriers
Respiratory Syncytial Virus (RSV) Infection to immunization and missed opportunities. Pediatr
1. American Academy of Pediatrics Committee on Ann 1998;27:366–74.
Infectious Diseases and Committee on Fetus and 3. Feldman S. Interchangeability of vaccines. Pediatr
Newborn. Policy statement – modified recommen- Infect Dis J 2001;20:S23–S29.
dations for use of palivizumab for prevention of
respiratory syncytial virus infections. Pediatrics
Pediatric Seizure Disorders
2009;124:1694–701.
1. Asconape JJ. Some common issues in the use of
2. American Academy of Pediatrics. Respiratory syn-
antiepileptic drugs. Semin Neurol 2002;22:27–39.
cytial virus. In: Pickering LK, ed. 2009 Red Book:
Report of the Committee on Infectious Diseases, 2. Anderson GD. Children versus adults: pharmaco-
28th ed. Elk Grove Village, IL: American Acad- kinetic and adverse-effect differences. Epilepsia
emy of Pediatrics, 2009:560–9. 2002;43(Suppl 3):53–9.
3. Khoshoo V, Ross G, Edell D. Effect of interven- 3. Sarco DP, Bourgeois BFD. The safety and toler-
tions during acute respiratory syncytial virus bron- ability of newer antiepileptic drugs in children and
chiolitis on subsequent long-term respiratory mor- adolescents. CNS Drugs 2010;24:399–430.
bidity. Pediatr Infect Dis J 2002;21:468–72. 4. Sheth R, Gidel B. Optimizing epilepsy manage-
4. Patel H, Platt RW, Pekeles GS, Ducharme FM. A ment in teenagers. J Child Neurol 2006;21:273–9.
randomized, controlled trial of the effectiveness of
nebulized therapy with epinephrine compared with Attention-Deficit/Hyperactivity Disorder
albuterol and saline in infants hospitalized for acute
1. American Psychiatric Association. Attention-defi-
viral bronchiolitis. J Pediatr 2002;141:818–24.
cit hyperactivity disorder. In: Diagnostic and Sta-
tistical Manual of Mental Disorders, 4th ed. Text
Otitis Media Rev. Washington, DC: American Psychiatric As-
1. American Academy of Pediatrics. Principles of ap- sociation, 2000:85–7.
propriate use for upper respiratory tract infections. 2. Kaplan G, Newcorn JH. Pharmacotherapy for
In: Pickering LK, ed. 2009 Red Book: Report of child and adolescent attention-deficit hyperactivity
1-23
Pediatrics
disorder. Pediatr Clin N Am 2011;58:99–120.

3. American Academy of Child and Adolescent Psy-
chiatry Work Group. Practice parameter for the as-
sessment and treatment of children and adolescents
with attention-deficit/hyperactivity disorder. J Am
Acad Child Adolesc Psychiatry 2007;46:894–921.
4. Perrin JM, Friedman RA, Knilans TK, the Black
Box Working Group. Cardiovascular monitoring
and stimulant drugs for attention-deficit/hyperactiv-
ity disorder. Pediatrics 2008;122:451–3.
1-24
Pediatrics
Answers and Explanations to Patient Cases
1. Answer: B would not be appropriate empiric coverage because this

Group B streptococcus, E. coli, Klebsiella spp., and patient’s presentation suggests he has meningitis. Ri-
Listeria are the most likely pathogens of neonatal sep- fampin would be the drug of choice for the prophylaxis
sis/meningitis. Ampicillin plus gentamicin administered of close contacts if this patient receives a diagnosis of
in meningitic doses would provide reasonable empiric meningococcal meningitis; however, it is inadequate
coverage. Although coagulase-negative Staphylococ- for treatment.
cus is the most likely cause of nosocomial neonatal
sepsis, this patient’s early presentation makes a hospi- 4. Answer: D
tal-acquired pathogen extremely unlikely. Therefore, Palivizumab is the drug of choice for prophylaxis
vancomycin is unnecessary. Ampicillin plus ceftri- against RSV infection in high-risk patient populations,
axone would provide adequate empiric antimicrobial including those born before 31 weeks’, 6 days’ gesta-
coverage for the most likely pathogens. However, cef- tion, regardless of risk factors, who are 6 months or
triaxone use can result in biliary sludging, leading to younger during RSV season. Patients born between 32
reduced elimination of bilirubin and a potential risk of weeks, 0 days and 34 weeks’, 6 days’ gestation are not
kernicterus in neonates. Ceftazidime plus gentamicin considered high risk unless they have at least one of two
lacks coverage for Listeria and group B streptococcus, risk factors (i.e., siblings younger than 5 years or day
which is still necessary empirically despite the mother’s care attenders). Patients with complex cyanotic heart
receiving penicillin before delivery. In addition, empiric defects are at high risk of developing severe RSV infec-
double-coverage of gram-negative organisms is not tions. Palivizumab has been shown to be safe and ef-
necessary for early neonatal sepsis. fective in this population. However, RSV IVIG should
not be administered to these patients because studies
2. Answer: C have shown a higher incidence of mortality after re-
Given this patient’s age and culture results, the most ceiving RSV IVIG in patients with complex cyanotic
likely infecting organism is E. coli or Klebsiella spp. heart defects compared with other high-risk groups.
(gram-negative rods), for which antimicrobial prophy- Patients with a history of chronic lung disease who are
laxis is not indicated. The most common pathogens 24 months or younger and who are receiving, or have
causing meningitis in neonates do not warrant antimi- received in the past 6 months, oxygen or medical man-
crobial prophylaxis. If this patient had been older and agement for chronic lung disease are also at risk of se-
infected with N. meningitidis or H. influenzae, antibi- vere RSV infection.
otic prophylaxis with rifampin would have been indi-
cated for all close contacts regardless of age or immuni- 5. Answer: D
zation status. Rifampin prophylaxis to eliminate nasal There is no specific treatment of RSV infection. Intra-
carriage is also indicated for people who receive index venous fluids, oxygen, and mechanical ventilation, if
diagnoses of N. meningitidis and receive treatment with needed, are indicated. Palivizumab is the drug of choice
an antibiotic other than ceftriaxone. for RSV prophylaxis but has no role in treatment. Corti-
costeroids have not been shown to be of benefit and are
3. Answer: C therefore not indicated. Secondary bacterial infection
The most likely causative organisms of sepsis/men- with H. influenzae or M. catarrhalis may occur; how-
ingitis in this age group are S. pneumoniae and N. ever, empiric antibiotic therapy is not indicated.
meningitidis. Therefore, a regimen of ceftriaxone plus
vancomycin would provide appropriate empiric cover- 6. Answer: A
age. Depending on the regional incidence of resistant Persistence of middle ear fluid after an episode of acute
S. pneumoniae, empiric vancomycin may not be nec- otitis media is common. If these findings are not associ-
essary. Ampicillin plus gentamicin would not provide ated with signs and symptoms of infection, a diagnosis
adequate coverage. Cefuroxime does not provide re- of otitis media with effusion (OME) is made. The AAP
liable penetration into the cerebral spinal fluid, so it practice guideline for the management of OME recom-
1-25
Pediatrics
mends “watchful waiting.” A watch-and-wait approach cacy of live vaccines such as MMR and varicella, but
would not be appropriate for this patient if she were giv- it has no effect on the efficacy of inactivated products.
en a diagnosis of AOM rather than OME because she is The suggested interval between an IVIG dose and the
younger than 6 months. Spontaneous resolution of OME administration of live vaccines depends on the immune
occurs within 3 months in 75%–90% of cases after AOM globulin product and indication. Concerns regarding an
without residual morbidities. Children at high risk of association between MMR vaccine and the development
speech and learning problems (e.g., craniofacial anoma- of autism and immunizations overwhelming the immune
lies, Down syndrome, severe visual impairment) may system have been disproved by scientific evaluation. The
require earlier, more aggressive intervention (ex. tym- MMR vaccine is grown in chick embryo tissue; however,
panostomy tubes). Decongestants and antihistamines an egg allergy is not a contraindication to its administra-
have not been shown to promote resolution or improve tion.
symptoms. Antibiotics are not effective in treating OME.
However, high-dose amoxicillin (80–100 mg/kg/day) is 9. Answer: A
considered first-line therapy for acute otitis media, so if Immunocompromised patients should not receive live
this patient’s treatment with the initial course of lower- vaccines; therefore, the MMR and varicella vaccines
dose amoxicillin failed (which is not a recommended should be deferred in these patients. Mild cold-like
regimen) or if she develops new signs of infection, then symptoms, or administration of antibiotics for mild ill-
high-dose amoxicillin will be an appropriate treatment nesses such as otitis media, are not a contraindication
choice. Up to 74% of streptococcal strains have been to vaccination, and deferring immunizations for such
reported to be resistant to azithromycin, which also has reasons is considered a “missed opportunity.” Patients
poor activity against H. influenzae, so this would not be with HIV, especially those with asymptomatic disease,
the best antibiotic option if an infection develops. should be considered candidates for all age-appropriate
vaccines, including those containing live virus and the
7. Answer: C pneumococcal vaccine. Corticosteroid administration
Four cases of otitis media in 12 months are considered is an indication for deferral of live vaccines only if the
recurrent otitis media, for which the watch-and-wait patient is receiving high doses (more than 2 mg/kg/day
approach is not recommended. Previously, this patient of prednisone equivalent) for more than 14 days.
would have been a candidate for antibiotic prophylaxis;
however, this practice has fallen out of favor because 10. Answer: B
of the significant risk of antimicrobial resistance com- Rash associated with antiepileptic drugs is a common
pared with the minor reduction in the occurrence of oti- adverse effect and generally resolves within a few days
tis media. Tympanostomy tubes are typically reserved after discontinuing the drug. There is no reliable meth-
for patients for whom aggressive antibiotic therapy od to determine whether the rash will remain benign or
fails and may be effective only in otitis with bulging progress to a more severe skin reaction, so discontinua-
tympanic membrane. In addition, the greatest benefit of tion of the offending drug is warranted. Carbamazepine
tympanostomy tubes may be in patients with persistent has a higher incidence of rash than oxcarbazepine, and
otitis media with effusions resulting in significant hear- cross-reactivity has been noted. Valproic acid is a good
ing loss. As long as this patient continues to respond to choice for managing partial seizures and has a low in-
high-dose amoxicillin, this will be considered a first- cidence of rash. However, the principal adverse effects
line regimen. In addition, the pneumococcal and influ- of valproic acid include weight gain and menstrual ir-
enza vaccines should be administered according to the regularities, both of which would be undesirable in this
recommended schedule because these organisms are overweight teenage girl. In addition, valproic acid is a
common causes of acute otitis media. known teratogen (pregnancy category D) that should
be avoided if other options are available in females of
8. Answer: D reproductive age who are unreliable in their use of con-
Vaccines are often deferred for inappropriate reasons, traception. Levetiracetam (pregnancy category C) has
leading to “missed opportunities” for immunization. a low incidence of rash and minimal drug interactions.
Previous administration of IVIG can decrease the effi-
1-26
Pediatrics
11. Answer: A acting methylphenidate product (e.g., methylphenidate

Stimulants, especially methylphenidate, are generally CD or LA) may improve the insomnia, but because of
considered first-line therapy for treating ADHD. Be- its shorter duration of action may compromise late-af-
cause this patient exhibits symptoms at school and at ternoon symptom control.
home, the short duration of action (about 6–8 hours) of
a twice-daily methylphenidate immediate-release regi-
men will not likely provide adequate symptom relief.
Likewise, d-methylphenidate has a short duration of
effect. In addition, d-methylphenidate is no more effec-
tive and has no fewer adverse effects than methylpheni-
date immediate release. Therefore, d-methylphenidate
is generally not considered cost-beneficial. Extended-
release guanfacine was recently FDA label approved
for the treatment of ADHD, but it should be reserved
for patients with ADHD and tic disorders or those who
have not responded to stimulant agents. Methylpheni-
date (OROS) with its longer duration of action (10–12
hours) would provide the best coverage. Therapy with
this drug may be initiated without previous titration us-
ing methylphenidate immediate release.
12. Answer: C
Changing to a methylphenidate transdermal patch al-
lows flexibility in the duration of drug effect. Wear-
ing the patch for 9 hours results in about 12 hours of
therapeutic 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 tolerability.
Because this patient responded well to stimulant ther-
apy with methylphenidate and there are disadvantages
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. Admin-
istering methylphenidate OROS later in the day would
likely worsen the insomnia. A better recommendation
would be to administer the methylphenidate OROS ear-
lier in the morning, which would allow more time in
the late afternoon and evening for the serum concentra-
tion to decrease before bedtime. Changing to a shorter-
1-27
Pediatrics
Answers and Explanations to Self-Assessment Questions
1. Answer: B gia or temperature of 39°C or greater), delaying the de-

The pathogens most likely causing pediatric sepsis/men- cision to prescribe antibiotics is an acceptable strategy.
ingitis are Streptococcus pneumoniae, Neisseria men- If otalgia or fever persists for more than 48–72 hours,
ingitidis, and Haemophilus influenzae. P. aeruginosa then antibiotic therapy is acceptable, but if these symp-
is more commonly associated with nosocomial sepsis. toms resolve spontaneously within this time, antibiotics
Adolescents who develop an RSV infection typically are not necessary. If antibiotics are warranted and the
present with relatively mild upper respiratory tract patient does not have an allergy, high-dose amoxicil-
symptoms, whereas this patient’s presentation suggests lin is the treatment of choice rather than azithromycin.
meningitis. Broad-spectrum antibiotics such as ceftriaxone should
be reserved for resistant cases.
2. Answer: A
Infants born before 31 weeks’, 6 days’ gestation who are 6. Answer: D
6 months or younger at the beginning of RSV season In general, patients who do not respond to one stimu-
are at high risk of severe infection regardless of other lant agent should be treated with a different stimulant
risk factors. Risk factors are considered when deter- before they are considered not to have responded to this
mining whether prophylaxis is warranted for infants class of drug therapy. However, extended-release mixed
born between 32 weeks, 0 days and 34 weeks’, 6 days’ amphetamine salts should be avoided in this patient be-
gestation. Routine prophylaxis for otherwise healthy, cause it has been associated with SCD in children with
full-term neonates is not recommended. structural heart defects. The methylphenidate transder-
mal system has a similar duration of action and efficacy
3. Answer: C as methylphenidate OROS; therefore, it is unlikely to
Prophylaxis with rifampin is recommended for close benefit this patient because her therapy with methyl-
contacts of patients with N. meningitidis or H. influenzae phenidate IR and methylphenidate OROS has already
regardless of their immunization status. Postexposure failed. If adherence or difficulty swallowing pills were
prophylaxis against pneumococcal meningitis is not a suspected cause of treatment failure in this patient, a
recommended. patch might be a reasonable alternative. Clonidine may
be added as an adjunctive therapy for patients whose
4. Answer: D treatment with a single stimulant agent fails; however, it
All scheduled immunizations should be given during should not be used as the sole agent for treating ADHD.
the same visit. Delaying some vaccines until a later date
is considered a “missed opportunity.” Oral polio vac- 7. Answer: A
cine is no longer recommended as part of the routine Valproic acid is considered a first-line therapy for treat-
schedule because of the risk of vaccine-associated po- ing absence seizures. If the patient is having break-
liomyelitis, which accounts for most newly diagnosed through seizures on ethosuximide—also a first-line
cases in the United States since 1979. Premature neo- therapy—and the dose has been maximized, it is rea-
nates should be vaccinated on the basis of chronologic sonable to switch to valproic acid. Phenytoin, pheno-
age, and doses should not be reduced. As of 2008, in- barbital, and gabapentin have not been shown effective
fluenza vaccine is recommended for all children aged 6 in treating absence seizures.
months to 18 years during influenza season.
5. Answer: B
Otitis media is most commonly caused by S. pneumoni-
ae, H. influenzae, M. catarrhalis, and viruses. Blood
culture results do not predict causative organisms of
otitis media. If the patient is older than 2 years and does
not have severe symptoms (i.e., moderate to severe otal-
1-28
Pediatrics
8. Answer: C
Odds ratio = (a/c)/(b/d)
= (7/1)/(193/197)
= 7.15
Adverse Event
(loss of appetite)
Yes No
Exposure (stimulant)
Yes 7 (a) 193 (b)
No 1 (c) 197 (d)
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 regarding
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, al-
though this study design is the gold standard for estab-
lishing a casual 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, cyanotic lesions, are
at high risk of severe RSV infection. Study patients
with congenital heart disease who receive RSV IVIG
have a higher mortality rate than other patient groups.
Conversely, palivizumab has been shown to be safe
and effective in this patient population. It is not rec-
ommended that palivizumab be initiated as routine
prophylaxis in hospitalized patients because it does not
reduce the incidence of nosocomial-acquired RSV in-
fection. However, patients currently receiving a course
of palivizumab (one dose per month for 5 months) at the
time of hospital admission should have that interven-
tion continued. In addition, cardiopulmonary bypass
reduces palivizumab serum concentrations; therefore,
patients undergoing congenital heart defect repair dur-
ing RSV season should receive a postoperative dose of
palivizumab as soon as they are medically stable, re-
gardless of when their next scheduled dose is due.
1-29
Pediatrics
1-30

01 Ped

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Pediatrics

Learning Objectives: 3. Which one of the following is the most accu-

9. An investigator wants to establish a causal relation-

Table 1. Cerebral Spinal Fluid Findings

Table 2. Common Pathogens

C. Potential Antibiotic Regimens

Table 3. Potential Antibiotic Regimens

E. Chemoprophylaxis of Bacterial Meningitis

Table 4. Regimens for Chemoprophylaxis.a

II. Respiratory syncytial virus (RSV) Infection

B. Risk Factors for Severe Disease

iii. No reduction in overall mortality

III. Otitis Media

B. Barriers to Routine Immunization

ii. Failure to provide simultaneous vaccines

C. Considerations in Special Populations

4. Patients with HIV infection

Influenza7 Influenza (Yearly)

(for those whoborn

V. Pediatric Seizure Disorders

A. Treatment Options Based on Seizure Type

Table 5. Treatment Options Based on Seizure Type

B. Comparison of Available Antiepileptic Drugs

Table 6. Comparison of Available Antiepileptic Drugs

Table 6. Comparison of Available Antiepileptic Drugs (continued)

VI. Attention-deficit/hyperactivity disorder

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

(b) May exacerbate preexisting hypertension and tic disorders

Sepsis/Meningitis the Committee on Infectious Diseases, 28th ed. Elk

disorder. Pediatr Clin N Am 2011;58:99–120.

Answers and Explanations to Patient Cases

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

11. Answer: A acting methylphenidate product (e.g., methylphenidate

Answers and Explanations to Self-Assessment Questions

1. Answer: B gia or temperature of 39°C or greater), delaying the de-

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