Practice Guidelines
ACIP Releases 2008 Child and Adolescent Immunization Schedules
Guideline source: Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices
Literature search described? No
Evidence rating system used? No
Published source: Morbidity and Mortality Weekly Report [in press]
The 2008 recommended immunization schedules for children and adolescents are unveiled in this issue of American Family Physician. There are no significant additions to this year's schedule. Rather, formatting has been simplified and footnotes have been updated for hepatitis B, pneumococcal, meningococcal, and influenza vaccines. Two changes are of note: the expanded age ranges for quadrivalent meningococcal conjugate vaccine (MCV4; Menactra) and for live, attenuated influenza vaccine (LAIV; Flumist).
MCV4 replaces the meningococcal polysaccharide vaccine (Menomune) as the preferred vaccine for children two to 10 years of age with terminal complement deficiencies, anatomic or functional asplenia, or certain other high-risk conditions. In addition, MCV4 is recommended for any previously unimmunized adolescent 11 to 18 years of age.1 Because adolescents present less often to their physicians for well care, any visit should be considered an opportunity to provide MCV4, the quadrivalent human papillomavirus vaccine (Gardasil), and tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap; Adacel), as well as a second dose of varicella vaccine.
The approval of LAIV by the Advisory Committee on Immunization Practices (ACIP), as well as the vaccine's recommendation by the U.S. Food and Drug Administration and coverage by the Vaccines for Children Program, can only help to improve influenza immunization rates for young children in the United States. Based on the 2005 National Immunization Survey, only 20.6 percent of children six to 23 months of age were fully immunized for influenza.2 Estimated rates for full immunization in older children (24 to 59 months) ranged from 3.0 to 26.9 percent.3
During the 2006-07 influenza season, 73 children died of the disease.4 However, the morbidity and mortality associated with influenza can be significantly reduced in children. The number needed to vaccinate (NNV) to prevent one hospitalization for younger children (six to 23 months) is 1,031 to 3,050.5 For children 24 to 59 months of age, the NNV is estimated at 4,255 to 6,897.5 Furthermore, one outpatient visit is prevented for every 12 to 42 children immunized, regardless of age.5
In a rare head-to-head, double-blind, randomized controlled vaccine trial involving children six to 59 months of age, LAIV significantly outperformed trivalent inactivated vaccine (TIV).6 Two findings from this study were notable. First, only 491 culture-confirmed cases of influenza were identified in the 7,852 vaccine recipients (infection rate = 6.3 percent), regardless of type. Second, LAIV recipients had a 55 percent decrease in influenza infection compared with TIV recipients (P < .001).
LAIV is a nasal spray vaccine and is refrigerator stable. The following conditions are contraindications or precautions for the use of LAIV in young children:
• concomitant aspirin therapy
• history of recurrent wheezing
• altered immunocompetence
• medical conditions predisposing the patient to influenza complications.7
The widespread use of vaccines has profoundly altered children's health. A recent review underscores the declines in the prevalence of vaccine-preventable diseases (more than 92 percent) and deaths (more than 99 percent) in the United States.8 However, compared with the prevaccine prevalence of most vaccine-preventable diseases and their associated mortality rates, contemporary influenza remains an outlier, with extremely high prevalence and moderate mortality. New vaccines and new approaches can help address influenza's challenge, but they require coupling with the efforts of the medical community and within the medical home9 to ensure the health and safety of children.
editor's note: The authors serve as liaisons to ACIP for the AAFP, and Dr. Temte is a member of the Harmonized Schedule Working Group.
Address correspondence to Jonathan L. Temte, MD, PhD, at: jon.temte@fammed.wisc.edu. Reprints are not available from the authors.
Author disclosure: Nothing to disclose.
References
1. Centers for Disease Control and Prevention. Revised recommendations of the Advisory Committee on Immunization Practices to vaccinate all persons aged 11-18 years with meningococcal conjugate vaccine. MMWR Morb Mortal Wkly Rep. 2007;56(31):794-795.
2. Centers for Disease Control and Prevention. Influenza vaccination coverage among children aged 6-23 months-United States, 2005-06 influenza season. MMWR Morb Mortal Wkly Rep. 2007;56(37):959-963.
3. Centers for Disease Control and Prevention. Influenza vaccination coverage among children aged 6-59 months-six immunization information system sentinel sites, United States, 2006-07 influenza season. MMWR Morb Mortal Wkly Rep. 2007;56(37):963-965.
4. Centers for Disease Control and Prevention. FluView: 2007-2008 influenza season week 47, ending November 24, 2007. http://www.cdc.gov/flu/weekly/index.htm. Accessed December 7, 2007.
5. Lewis EN, Griffin MR, Szilagyi PG, Zhu Y, Edwards KM, Poehling KA. Childhood influenza: number needed to vaccinate to prevent 1 hospitalization or outpatient visit. Pediatrics. 2007;120(3):467-472.
6. Belshe RB, Edwards KM, Vesikari T, et al., for the CAIV-T Comparative Efficacy Study Group. Live attenuated versus inactivated influenza vaccine in infants and young children [published correction appears in N Engl J Med. 2007;356(12):1283]. N Engl J Med. 2007;356(7):685-696.
7. Centers for Disease Control and Prevention. Resolution no. 10/07-1. Advisory Committee on Immunization Practices Vaccines for Children Program: influenza. Vaccines to treat influenza. http://www.cdc.gov/vaccines/programs/vfc/downloads/resolutions/1007influenza.pdf. Accessed December 7, 2007.
8. Roush SW, Murphy TV, for the Vaccine-Preventable Disease Table Working Group. Historical comparisons of morbidity and mortality for vaccine-preventable diseases in the United States. JAMA. 2007;298:2155-2163.
9. Temte JL, Campos-Outcalt D. Strengthening adult and adolescent immunization: a policy without a home. Clin Infect Dis. 2007;45(10):1402-1403.
Practice Guideline Briefs
AAP Recommendations on Munchausen by Proxy
Guideline source: American Academy of Pediatrics
Literature search described? No
Evidence rating system used? No
Published source: Pediatrics, May 2007
Available at: http://pediatrics.aappublications.org/cgi/content/full/119/5/1026
Munchausen syndrome by proxy is a form of child abuse involving both physical abuse and medical neglect. It occurs in the medical setting when a parent or caregiver causes injury to a child by seeking or administering unnecessary and possibly harmful medical treatment for the child. Although Munchausen syndrome by proxy is a rare circumstance, physicians need to consider it when treating a child with seemingly inexplicable findings or failed treatments. For a child whose illness is fabricated by a caregiver, the prognosis may be poor if the abused child is left in the home. The American Academy of Pediatrics (AAP) has identified factors that may help physicians recognize this form of child abuse and has provided recommendations on when to report a case to their state child protective services agency.
Continuing unnecessary medical care may become abusive to the child if the parent or caregiver is consistently misrepresenting or making up symptoms, manipulating laboratory tests, or intentionally inflicting harm on the child to create symptoms. The AAP advises physicians to consider three questions that may help diagnose this condition: (1) Are the history, signs, and symptoms of disease credible?; (2) Is the child receiving unnecessary and harmful or potentially harmful medical care?; and (3) If so, who is instigating the evaluations and treatment? In determining whether signs and symptoms have been fabricated, physicians need to gather relevant information from everyone involved and report concerns to other health care professionals and social service workers. A thorough evaluation of medical charts and clear communication among medical professionals are important in making a proper diagnosis.
The state child protective services agency should be informed if the parent or caregiver is harming the child and will not cooperate with the child's physician in limiting the amount of medical care to an appropriate level. Medical child abuse should be reported in the same way as physical and sexual child abuse if the parent or caregiver continues to harm the child. Care of the abused child may include a multidisciplinary approach that involves primary care physicians, medical subspecialty consultants, dietitians, physical therapists, and social service workers. Treatment considerations include ensuring the child's future safety and allowing treatment to occur in the least restrictive setting possible.
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