Practice Guideline Briefs

Am Fam Physician. 2004 Sep 1;70(5):985.

Update on Pneumococcal Conjugate Vaccine Shortage

The Centers for Disease Control and Prevention (CDC) has recommended that physicians increase the number of doses of pneumococcal conjugate vaccine (PCV7, Prevnar) administered to healthy children from two to three. Production problems earlier this year caused shortages of the vaccine and prompted the CDC to reduce the recommended four doses to two in order to most effectively use the limited available doses.

The CDC, the Advisory Committee on Immunization Practices, the American Academy of Family Physicians, and the American Academy of Pediatrics also recommended that providers continue to administer the full four-dose series of the vaccine to children up to 15 months of age with health conditions such as sickle cell anemia or immune system disorders, who are at increased risk of severe disease. The groups said providers should defer the fourth dose of the vaccine for healthy children until production and supply data convincingly demonstrate supplies of the vaccine are adequate for routine administration of the four-dose series.

The vaccine is normally recommended for young children in a four-dose schedule: one dose each at two, four, and six months of age, and one dose between 12 and 15 months of age. This recommendation reinstates the third dose usually administered at six months for healthy children. PCV7 is not routinely recommended for children older than two years.

The CDC also issued a recommended catch-up schedule for children who missed the third dose. The highest priority for catch-up vaccination is children at high risk for invasive pneumococcal disease. Second priority is vaccination of healthy children younger than 24 months who have not received any doses of pneumococcal conjugate vaccine. The third priority is vaccination of healthy children younger than 12 months of age who have not yet received three doses.

Because of the frequency of physician visits for children during their first 18 months, catch-up vaccination might occur at regularly scheduled visits for most children who receive vaccines from their primary care physician. Physicians who administer vaccinations but do not see children routinely for other reasons should consider a notification process to contact parents of under-vaccinated children.

The catch-up schedule and additional information about the recommendations and PCV7 is available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5326a7.htm.

Neuroimaging Tests for Cerebral Palsy

The Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society have released a new guideline on neuroimaging tests for cerebral palsy and related disorders. “Practice Parameter: Diagnostic Assessment of the Child with Cerebral Palsy” appears in the March 2004 issue of Neurology and is available online at http://www.neurology.org/content/62/6.toc.

According to the guideline, available evidence now supports the use of magnetic resonance imaging (MRI) rather than computerized tomography when cerebral palsy is suspected, although this is not yet routine. Metabolic and genetic studies need not be done routinely unless the cause of the brain’s abnormality is not evident on the MRI scan or by clinical history and examination.

Because the incidence of cerebral infarction is high in children with hemiplegic cerebral palsy, diagnostic testing for coagulation disorders should be considered. However, there is insufficient evidence at present to be precise as to what studies should be ordered. Electroencephalography is not recommended unless there are characteristics suggestive of epilepsy or a specific epileptic syndrome.

Evidence also suggests that children who are diagnosed with cerebral palsy should be routinely examined for other related disorders, such as mental retardation, vision and hearing impairments, speech and language disorders, and chewing and swallowing disorders.

An early diagnosis helps the child’s parent or caregiver and the child’s physician understand the cause of the disorder, as well as make informed decisions on a treatment plan. Most children with cerebral palsy are diagnosed by the time they are two years of age and their condition improves as they get older.


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