Growing Healthy One Visit At A Time - PowerPoint Presentation

Growing Healthy One Visit At A Time Alexandra Iacob, MD

About Me Born in Romania Med School: Univ of Texas Health Science Center – HoustonPediatric Residency: Loma Linda UniversityCurrent practiceOutpatient in San BernardinoInpatient in Loma Linda, Riverside, and Downtown LASan Bernardino County Medical SocietyCalifornia Medical AssociationAmerican Medical Association

Thank YOU!

PollEverywhere Smartphones Actively participate during this session AnonymousAudience representation

Agenda 9:00-9:50 First Month: Establishing a Medical Home10:00-10:50 Two, Four, and Six Month Visits: Vaccines and Milestones11:00-11:50 Nine – Eighteen Month Visits: Vaccines, Milestones and Screening

First Month Timeline Birth 1 month 2 month

First Month Timeline Birth at Hospital Hepatitis B vaccine Newborn ScreenHearing ScreenCardiac ScreenRed Reflex ScreenLactation Consult24 Hour Bilirubin Level Birth 1 month 2 month

First Month Timeline 3-5 Days Visit Postpartum Depression Screen Birth 1 month 2 month

First Month Timeline 3-5 Days Visit Postpartum Depression Screen Bilirubin CheckMilk ProductionWeight LossVit D SupplementationHip Dysplasia ScreenFever DangerSleep Safety Birth 1 month 2 month

First Month Timeline 2 Weeks Visit Post Partum Depression Home Dynamics Birth 1 month 2 month

First Month Timeline 2 Weeks Visit Post Partum Depression Home DynamicsWeight RegainedCord StumpHip DysplasiaFever DangerSleep Safety Birth 1 month 2 month

First Month Timeline 1 Month V isit (optional)DepressionAdjustment/Coping SkillsFamily SupportCommunity Support Birth 1 month 2 month

First Month Timeline 2 Month Visit Next section! Birth 1 month 2 month

Questions?

BREAK

Two, Four, Six Month Visits Vaccines Milestones

Vaccines – Schedules

Vaccines – Hep B Birth, 1-2 months, 6 monthsPrevents hepatitis, liver cancer, liver failure, deathCommon side effects:SorenessMild feverSerious side effects:Allergic reactionContraindication: Allergic reaction to previous dose https://www.cdc.gov/vaccines/vpd/hepb/public/photos.html

Vaccines – Rotavirus 2 months, 4 months, (6 months) Prevents severe watery diarrhea, vomiting, fever, dehydration, death Common side effect:Mild diarrhea and vomitingSerious side effect:IntussusceptionAllergic reactionContraindication: Immunological deficitAllergic reaction to previous dose Intussusception http://www.immunize.org/images/rotavirus/thumbs/rotavirus-1-lg.jpg

Vaccines – DTaP 2 months, 4 months, 6 months, 15-18 months, 4 years Diphteria (Throat infection), Tetanus (Lockjaw), Pertussis (Whooping Cough)Minor side effects:Fever, fussy, tiredRedness, sorenessSerious side effects:SeizureHigh feverAllergic reaction Contraindication Allergic reaction to previous dose Brain or nervous system disease after previous dose https://blogs.cdc.gov/publichealthmatters/files/2012/06/Coughing-child_Banner.jpg

Vaccines – Hib 2 months, 4 months, 6 months, 12-15 months Prevents meningitis, pneumonia, epiglottitis, death Minor side effects:FeverWarmth, Redness, SwellingSevere side effects:Allergic reactionContraindication:Allergic reaction to previous dose

Vaccines – IPV 2 months, 4 months, 6 months, 4 years Prevents Polio disease Minor side effect: sorenessSerious side effect:Allergic reactionContraindication: Allergic reaction to previous dose https://www.cdc.gov/features/poliofacts/

Vaccines – PCV13 2 months, 4 months, 6 months, 12-15 months Prevents pneumonia, bacteremia, meningitis Minor side effectsDrowsyMild fever, redness, swellingSerious side effect:Allergic reactionContraindicationAllergic reaction to previous dose https://carrington.edu/wp-content/uploads/2015/02/Pneumococcal-Disease-770x392.png

Vaccines – Free Resources

Milestones Social Verbal Motor

Milestones 2 Months Social Begins to smile at people Verbal Coos Motor Can lift head off table Can push off in tummy time

Milestones 2 Months 4 Months Social Begins to smile at people Smiles spontaneously Mimics expressions Verbal Coos Cries in different ways Begins to babble Motor Can lift head off table Can push off in tummy time Rolls from tummy to back

Milestones 2 Months 4 Months 6 Months Social Begins to smile at people Smiles spontaneously Mimics expressions Observes self in mirror Likes to play with others Verbal Coos Cries in different ways Begins to babble Babbles with different consonants and vowels Motor Can lift head off tableCan push off in tummy timeRolls from tummy to backRolls over in both directionsAble to sit without support

Questions?

BREAK

9 – 18 Months Vaccines Screening Milestones

Vaccines - MMR 1 year, 4 year Prevents Measles (encephalitis, pneumonia, death), Mumps (meningitis, encephalitis, testes inflammation, deafness) and Rubella (rash, arthritis) Minor side effectsSoreness, redness, feverFebrile seizure (~3 per 10,000)Major side effectsAllergic reactionContraindicationsAllergic reaction to prev dose Weak immune system

Vaccines - Varicella 1 year, 4 year Prevents Chickenpox (rash, shingles, pneumonia, encephalitis)Minor side effectsSoreness, rednessFeverMajor side effectsAllergic reactionContraindications Allergic reaction to prev dose Weak immune system

Vaccines – MMR/Varicella Option to do MMR and Varicella vs MMR/V at 1 year and 4 years Klein NP, Fireman B, Yih WK, Lewis E, Kulldorff M. Measles-mumps-rubella-varicella combination vaccine and the risk of febrile seizures . Pediatrics . 2010 Jul;126(1):e1-8.   Klein NP, Lewis E, Baxter R, et al. Measles-containing vaccines and febrile seizures in children age 4 to 6 years . Pediatrics . 2012 May;129(5):809 -814.   Rowhani-Rahbar A, Fireman B, Lewis E, Nordin J, Naleway A, et al. Effect of age on the risk of Fever and seizures following immunization with measles-containing vaccines in children . JAMA Pediatr . 2013 Dec;167(12):1111-7.

Vaccines – MMR/Varicella Option to do MMR and Varicella vs MMR/V at 1 year and 4 years If separate, ~4 per 10,000 have febrile seizure If combined, ~8 per 10,000 have febrile seizuresKlein NP, Fireman B, Yih WK, Lewis E, Kulldorff M. Measles-mumps-rubella-varicella combination vaccine and the risk of febrile seizures . Pediatrics . 2010 Jul;126(1):e1-8.   Klein NP, Lewis E, Baxter R, et al. Measles-containing vaccines and febrile seizures in children age 4 to 6 years . Pediatrics . 2012 May;129(5):809 -814.   Rowhani-Rahbar A, Fireman B, Lewis E, Nordin J, Naleway A, et al. Effect of age on the risk of Fever and seizures following immunization with measles-containing vaccines in children . JAMA Pediatr . 2013 Dec;167(12):1111-7.

Elephant in the Room - Autism Undisclosed Conflict of Interest Manipulation of Data Invasive and unnecessary tests without proper consents and approval 1988 – article published 2002 – article gains momentum 2004-2009 – investigation 2010 – paper retracted

So is there a link?

In 2012, the Cochrane Library published a review of dozens of scientific studies involving about 14,700,000 children, which found no credible evidence of an involvement of MMR with either autism or Crohn's disease. The authors stated "the design and reporting of safety outcomes in MMR vaccine studies, both pre- and post-marketing, are largely inadequate".A June 2014 meta-analysis involving more than 1.25 million children found "vaccinations are not associated with the development of autism or autism spectrum disorder. Furthermore, the components of the vaccines (thimerosal or mercury) or multiple vaccines (MMR) are not associated with the development of autism or autism spectrum disorder."

Vaccines – Hepatitis A 12 months, 18 months Prevents serious liver diseaseMinor side effectsLow grade feverSoreness, rednessMajor side effectsAllergic reactionContraindications Allergic reaction to prev dose

Vaccines – Influenza >6 months, yearly Prevents Flu (upper respiratory infection, pneumonia, meningitis)Minor side effectsSoreness, rednessFever, aches, coughMajor side effectsGuillan – Barre Syndrome (1 in a million) Contraindications Allergic reaction to prev dose GBS https:// gis.cdc.gov/GRASP/Fluview/PedFluDeath.html

Screening Anemia: 12 months – hemoglobin Lead: 12 months, 24 months – lead levelASQ-3 (Ages and Stages Questionnaire): 1 month – 5 years

Screening Anemia: 12 months – hemoglobin Lead: 12 months, 24 months – lead levelASQ-3 (Ages and Stages Questionnaire): 1 month – 5 yearsMCHAT (Modified Checklist for Autism in Toddlers): 18 mo , 24 mo

Milestones Social Verbal Motor

Milestones 9 Months Social Stranger anxiety Peek-a-boo Verbal Mama, Dada nonspecific Motor Pincer grasp Pulls to stand Crawls

Milestones 9 Months 12 Months Social Stranger anxiety Peek-a-boo Stranger anxiety Cries when parents leave Hands book to read Verbal Mama, Dada nonspecific Mama, Dada One other word Motor Pincer grasp Pulls to standCrawlsHelps with dressing Bangs things Pokes with finger

Milestones 9 Months 12 Months 15 Months Social Stranger anxiety Peek-a-boo Stranger anxiety Cries when parents leave Hands book to read Shows empathy Returns hugs Verbal Mama, Dada nonspecific Mama, DadaOne other wordUses 3-5 wordsMotorPincer graspPulls to stand Crawls Helps with dressing Bangs things Pokes with finger Climbs on furniture Stoops to pick up toys Runs stiff-legged

Milestones 9 Months 12 Months 15 Months 18 Months Social Stranger anxiety Peek-a-boo Stranger anxiety Cries when parents leave Hands book to read Shows empathy Returns hugs Temper tantrums Pretend playShares worldVerbalMama, Dada nonspecificMama, DadaOne other wordUses 3-5 words Uses 10-25 words “No” Motor Pincer grasp Pulls to stand Crawls Helps with dressing Bangs things Pokes with fingerClimbs on furnitureStoops to pick up toysRuns stiff-leggedWalks aloneMaybe up the stairsHelps undress self

Resources http:// tommysinfantcataract.blogspot.com/2011/04/red-reflex.html http://www.diversifiedhearing.com/2017/02/children-and-hearing-loss/https://globalgenes.org/raredaily/rhode-island-adds-immune-deficiency-newborn-screening-test/http://diseasespictures.com/wp-content/uploads/2017/04/Neonatal-jaundice.jpg https:// 78.media.tumblr.com/29e0e4668e8fc6ff0ef4a411305ed1ec/tumblr_n3yyedTls91rq470wo1_500.jpg https:// www.todaysparent.com/wp-content/uploads/2017/04/recognizing-the-signs-of-postpartum-depression.jpg https:// www.bellybelly.com.au/bllyblly/wp-content/uploads/2015/05/newborn-weight-loss.jpg https:// med.ucf.edu/media/2012/10/baby-and-hip-dysplasia.jpg http://4.bp.blogspot.com/- 3whD8hWH1JE/Ta7uY4lI47I/AAAAAAAAFaM/Kbdg-fKQMMc/s1600/cord2.jpg https:// 0f14676b303fd91881eb-98dd17e178263eba3c55ca6434a72b9d.ssl.cf5.rackcdn.com/oncology/mobile-app-center/uploads/7241/7241_2.jpeg http:// library.uchc.edu/departm/cec/images/hh/cdc004.pnghttp://www.imedicalapps.com/wp-content/uploads/2014/12/Screenshot-2014-12-30-09.36.37.pnghttp://a3.mzstatic.com/us/r30/Purple1/v4/6b/e6/25/6be62578-66ac-0e2e-a1cc-bbe949920132/screen322x572.jpeghttp://www.parent.com/wp-content/uploads/2015/08/Stocksy_txpa5444ddbF4Y000_Medium_605050.jpg https:// cdn-images-1.medium.com/max/1600/1*pPULoorfNGndlpZ2lH4Kbw.png

Resources National Vital Statistics Reports Vol 65, Number 4. CDC American Academy of Pediatrics Bright FuturesCDCTaylor LE, Swerdfeger AL, Eslick GD. Vaccines are not associated with autism: an evidence-based meta-analysis of case-control and cohort studies. Vaccine. 2014;32(29):3623-9.Demicheli V, Rivetti A, Debalini MG, Di pietrantonj C. Vaccines for measles, mumps and rubella in children. Cochrane Database Syst Rev. 2012;(2):CD004407.

Questions?

Thank You! sandra.iacob@gmail.com