YOUR CHILD'S IMMUNIZATIONS

Here is some information from Dr. Sears about the immunizations that are administered to your children from birth through adolescence, along with a brief explanation of each illness.

HEPATITIS B

Brand name Engerix-B. This is a viral disease that causes acute and chronic liver damage. It is transmitted by contact with the blood of an infected person (the same way HIV is transmitted). There are only three likely ways an infant or child could contract it:

1. Through blood transfusion (which is very rare since all blood is carefully tested for this)
2. At birth from an infected mother to the baby through blood exposure during the birth process
3. By frequent, close contact with an infected family member

There have also been cases of children acquiring Hepatitis B with no known blood exposure or family member with the disease. This suggests that the disease may be passed by more casual contact, although the risk of this is very small. This is especially true for people of Asian descent, who have a higher rate of Hepatitis B infection with no known risk factors. Please note that Hepatitis B is different from both Hepatitis A (which occurs in outbreaks in restaurants from an infected worker contaminating the food) and Hepatitis C (which is transmitted the same way as Hepatitis B, but may be less likely to cause liver damage). Although the risk of infants and children catching this disease seems to be very small, the American Academy of Pediatrics and Centers for Disease Control recommend immunizing against this disease during infancy for two main reasons:

1. To avoid the small risk of contracting the illness from casual contact or unknown source, and
2. To ensure that our population as a whole is covered against this disease, and this is more easily achieved by immunizing during infancy. This immunization is especially important for teenagers and young adults, when the risk of catching the illness through sexual contact, IV drug use, and tattooing is prevalent.

DTaP

Diphtheria is a serious, and treatable, infection that can cause severe respiratory illness. It is transmitted the same as a cold. It occurs in outbreaks, but is very rare now in the U.S.

Tetanus is a bacterium in nature that can cause serious, but usually treatable, paralysis when allowed to fester in a deep and dirty wound.

Pertussis (cellular) or "whooping cough" is transmitted just like a cold, and causes 1-3 months of severe coughing fits. This is not a rare illness, and outbreaks do periodically occur in the U.S. It is very serious in children under one year of age, and can be fatal or cause brain damage because the severe coughing fits can deprive the brain of oxygen. The disease is treatable with antibiotics to prevent outbreaks from spreading, however, the illness often can remain severe despite antibiotic treatment. An older form of the vaccine, called "whole cell" pertussis, caused some very severe, and sometimes fatal or debilitating, reactions. This form of the vaccine is virtually never used in the U.S. anymore. The new "acellular" form of the vaccine is milder with fewer side effects than the previously used whole cell vaccine. It is very safe, and serious reactions are now very rare. This vaccine is also available as just DT, without the pertussis component, and as just plain Tetanus.

HAEMOPHILUS INFLUENZA B

Hib is a rare bacterium that causes severe blood and bone infections and meningitis in young children. It is transmitted by close contact or like a cold. This bacterium used to be the most common cause of the above serious illnesses, but since the vaccine's introduction in the 1980's, these illnesses occur much less frequently. This vaccine is among the safest and most effective of the vaccines. Unlike Polio, which is rare, Hib bacterial infections mainly occur in children under two.

POLIO

This is a virus that can cause permanent paralysis. Due to vaccination, there have not been any naturally occurring cases of polio in the U.S. since the 1970's, although it is still present in Africa. OPV is the live virus liquid form taken by mouth. This form is no longer routinely used in the U.S. because of its potential to actually cause paralytic disease (8-10 cases of this occurred each year in the U.S.). Virtually all doctors now only use IPV, the new inactivated injectable form that eliminates the risk of vaccine-induced paralysis. Even if your child has already had OPV previously, it is safer to switch to IPV for any further doses.

MMR

Measles is a viral benign illness causing fever, cold symptoms and rash. It occurs in outbreaks. Rarely is it life threatening, and approximately one in every 1000 cases can be fatal or cause brain damage from measles encephalitis. Only several hundred cases occur each year in the U.S.

Mumps is generally a benign illness in children causing swelling of the salivary glands in the cheeks, sore throat and fever. Serious complications and fatality are extremely rare in children, but do occur. It can have more serious consequences in adolescents and adults, such as sterility in men and miscarriages in women, although these complications are rare. Outbreaks do occur in the U.S., but there are less than 1000 cases per year in the U.S.

Rubella is a mild viral illness causing fever and rash. It virtually never causes any serious complications in children. It can, however, cause birth defects if a pregnant women contracts the illness for the first time.

CHICKENPOX

In past years chickenpox was a common childhood illness that was a part of everyday life. Almost everyone got chickenpox, missed a week of school, endured a week of intense itching, and got through it without incident. The problem was that not everyone got through the illness without incident. Approximately 1 in 70,000 cases are fatal, and almost all of these are in previously normal, healthy adults and children. Additionally, missed school days and missed workdays take an economic toll. With the introduction of the chickenpox vaccine, all this has changed. Here are some of the reasons for and against vaccinating your child for this illness:

There are four advantages to getting the vaccine:

1. It is 85% effective in preventing your children from having to go through this very uncomfortable illness
2. The illness tends to be milder in vaccinated children
3. You avoid the extremely rare but life-threatening complications of the illness (approximately 40 normal, healthy children die each year in the U.S. from chickenpox – this is about 1 in 70,000 cases)
4. This vaccine may protect against adult shingles (a form of chickenpox)

There are three disadvantages to the vaccine (and therefore, advantages to getting the illness):

1. Although this is a mild illness for children, it can be very dangerous for adolescents and adults. Since the vaccine may wear off later in life, a booster may be required for adults.
2. Getting this illness as a child provides excellent lifetime immunity
3. Catching chickenpox during pregnancy can be very harmful to the fetus or newborn baby. Getting the illness during childhood virtually insures protection from this.

Perhaps the best of both choices is to get the shot, and then also get the illness. It will be milder, and you'll get better lifelong immunity. As immunization rates increase for chickenpox, the disease will become much less common. Perhaps in 20 years, we won't even need to worry about exposure to this disease anymore. Click on Chickenpox Vaccine for a complete discussion.

PREVNAR

This is a new vaccine released in 2000. It protects against a very common bacteria called pneumococcus, which causes meningitis, blood infections, pneumonia, sinus infections and ear infections. This vaccine has become known as "the ear infection vaccine". This is a misconception. Although it can decrease the number of ear infections, it does so by only about 15%. It does, however, have one very important and exciting effect on ear infections. It can significantly decrease the number of ear infections caused by pneumococcus that are resistant to standard antibiotics. This means that many ear infections will be easier to treat without having to use stronger antibiotics. The main purpose of this vaccine, however, is to prevent the above more serious infections.

HEPATITIS A

This is not a new vaccine. Brand name Havrix. It has been in use for years, but has not been part of the standard recommended vaccine schedule until now. This viral disease is very mild in infants and children. Two-thirds of infants and children who catch this disease won't even show any symptoms at all. The one-third that do have symptoms will have fever, stomach aches, fatigue, nausea, and may turn yellow for only a few days (due to mild and temporary liver damage). It is similar to the stomach flu. Most teen-agers and adults who catch this illness will show similar symptoms, but they will usually be worse and for a longer period of time, sometimes 2 to 3 weeks. It does not cause chronic disease. This disease is transmitted when an infected person's hands are contaminated by their stool while going to the bathroom, and not thoroughly washing their hands. This person can then infect food or other people through touch. This illness usually occurs as outbreaks in restaurants or day-care centers. There are about 20,000 cases reported in the U.S. each year. Although this is a very mild disease in children, it is now recommended to get this vaccine during childhood (as early as age two) in areas of the country where Hepatitis A is prevalent (ask your doctor or public health dept. if your area qualifies). If your do not live in such as area, then the vaccine is not as important. The purpose of this is to eventually decrease or eliminate this disease from our population, so that teenagers and adults won't have to go through several weeks of this troublesome illness.

TUBERCULOSIS TESTING

This is not a vaccine. It does not protect your child from getting TB. TB is a serious respiratory infection that causes severe cough, fevers, chills and night sweats. The reason we test for this is to see if your child has been exposed to someone with this infection. Exposed children can carry this infection inside but not have any symptoms for many years, only to have it flare up and cause infection in the future. TB tests are recommended around age 2 and every 3 years thereafter (some counties with high levels of TB will test yearly). If your child has a positive test (a raised bump 2 – 3 days after the test), he or she should be treated for TB.

STANDARD RECCOMENDED SCHEDULE

1 month – Hep B
2 months – DTaP, Hib, Hep B, Prevnar
4 months – DTaP, Hib, Prevnar
6 months – DTaP, Hib, Prevnar, IPV
9 months – IPV, Hep B
12 months – MMR, Chickenpox
15 months – Hib, Prevnar
18 months – DTaP, IPV
2 years – Hep A
5 years – DTaP, IPV, MMR
11-12 years – Chickenpox and HepB if not yet done
12-15 years – tetanus booster (needed every 7-10 yrs)

Spreading out the shots and decreasing the number of injections. As you can see, there are a lot of shots during the first two years of life, often three or four injections at one visit. This can be overwhelming for parents and quite an ordeal for babies. Here are some tips on how you can spread out the shots and decrease the overall number of injections. Ask your doctor about these options:

1. Use a combination Hib/HepB in one injection. There is only one brand that makes this combination. Ask your doctor.

2. There is a Hib vaccine that only requires 3 total shots, instead of 4. The six-month dose is skipped. This is the brand also used in the combination Hib/HepB above.

3. There is one brand of DtaP/Hib that can be combined for the 4th dose at 18 months, but not the earlier doses.

4. During the first two years, most of these shots don't have to be given at the exact above ages. They can be given over a wide range of months. Here are the options for altering the schedule during the first two years:

• Spread it out. Each shot should be given at least 6 to 8 weeks apart, except for HepB. (The first two doses can be one month apart – or longer).
• HepB. These three shots can be spread out at any time during the first two years. You don't have to start at one month. It can be safely delayed if you wish. The second and third doses must be 4 to 6 months apart.
• IPV (polio). These three shots can be given at any time, starting as young as 2 months of age, with the 3rd shot usually between 15 and 24 months.
• DtaP. These 4 shots can be given at any time, with the 4th shot usually between 18 and 24 months.
• Prevnar. These 4 shots can be given at a variety of times. Additionally, if you wait until your baby is over age one, he will only need one or two shots, instead of four (however, he goes without protection during the first year).
• Hib. Can be given at a variety of ages.
• MMR and Chickenpox. These can be given any time after the first birthday, and don't have to be given together.
• HepA. This does not have to be given at age two. You can delay this one for years.

5. To avoid getting more than two shots at a time, ask your doctor if you can come in for some "shot only" visits in between your regular check ups. This can avoid giving your child as many as four injections at once. One drawback is that you are coming in for a greater number of painful episodes.

6. If the number of shots during these first two years is simply overwhelming to you, the talk with your doctor about spreading them out over several years. The shots that you can safely delay (illnesses that your child has little or no risk of catching as an infant, or are not serious for infants) include Polio, Hep B, and Hep A. A note on Polio: it is not safe to delay this shot if you plan to live in or travel frequently to Africa and some other third world continents. You may also consider delaying the Chickenpox vaccine until your child is done with the rest of the infant immunizations (although delaying this does put your infant at risk of catching the illness). If you give the M-M-R components separately, start with the measles first after age one, then mumps at least one year later, then eventually rubella.

Vaccine side effects. The most common reactions are fever and fussiness for 2 – 3 days. Redness, swelling, and pain at the site of injection are also common. You can treat this with ice. These reactions are most likely to occur after DTaP. Sometimes a small harmless nodule may be felt at the injection site that will disappear after several weeks. MMR has two additional reactions that occasionally occur: mild pain or stiffness in the joints that lasts 2 – 4 days, and around 5% of children receiving the MMR vaccine develop a rash, fever, and swelling of the glands in the cheeks or neck 1 – 2 weeks after the injection. The Chickenpox shot may cause flu-like symptoms within a month of the shot.

Please notify your doctor at the next visit if your child had an unusually severe reaction such as fevers higher than 103, high-pitched and prolonged crying or any other unexpected reaction. This may be an indication not to continue with that particular vaccine.

Ranking potential reactivity of vaccines. Here are the vaccines listed in order of least potential for side effects to most potential for side effects:

• HIB Least reactive – little or no side effects
• Polio
• Tetanus by itself
• Hep B
• Hep A
• Chickenpox
• MMRDTaP Most reactive – more chance of side effects such as fever and irritability.
• Prevnar – not yet known.

MMR & AUTISM

There has been some recent press over a concern of some medical researchers that the MMR vaccine may be a contributing link to autism. There has been no conclusive medical evidence to date that supports this concern, and the potential severity of these three illnesses makes vaccinating against them very important. Some parents who have a child with autism, or know someone who has a child with autism, and have a concern about it's relation to the MMR vaccine, can give their child each of the three components of this shot separately, one year apart. However, this is two extra injections.

Administering Acetaminophen every 4 hours (only if needed) for 1 – 3 days can alleviate some of the fever and fussiness associated with the vaccines. Click on Acetaminophen for dosing. Here is a suggested dosing schedule based on your child's weight. Tylenol infant concentrated drops are 80mg/0.8 ml dropper-full. Tylenol children's liquid is 160mg/5 ml.

10 lbs – 60 mg
12 lbs – 80 mg
15 lbs – 100 mg
18 lbs – 120 mg
23 lbs – 160 mg
28 lbs – 200 mg
35 lbs – 240 mg
52 lbs–360 mg

MINIMIZING THE PAIN OF SHOTS

• Engage the child in funny antics before and after.
• Rub the injection site before and after giving the shot.
• Apply an ice pack to the area if it gets sore.
• Apply prescription EMLA cream (a topical anesthetic) one hour before the anticipated injection time. Follow instructions on the package.
• Nurse or comfort your infant immediately after the shot.
• Promise your scared child a treat after the shot.