week 8 disc 1 reply to Maria S
A healthy 2-month-old child was brought to your clinic by her parents. The child is a full-term infant with no concerns. Her exam is normal, and she received her Hep B #1 in the nursery.
Q1. What vaccines does she get? What combinations are available at your clinic?
CDC recommends that an infant receive the 2nd dose of the three Hepatitis B vaccine series. The 2 month old infant should also get the 1st dose of the series of 5 of the DTaP which protects against diphtheria, tetanus and whooping cough or pertussis (CDC, 2023). Other vaccines that are scheduled and recommended by the CDC (2023) during the 2nd month include the first doses of the following: Haemophilus influenza type B (HiB), pneumococcal conjugate vaccine (PCV13), inactivated polio vaccine (IPV), and rotavirus vaccine (RV5 or RV1).
There are several types of combination vaccines available. Some examples are Pediarix, which combines DTaP, Hep B and IPV; Pentacel, which combines DTaP, IPV and Hib; and Vaxelis, which contains DTaP, IPV, Hib and Hep B (CDC, 2019).
- Q2. The child returns at 12 months after completing her primary series of vaccines at 2, 4, and 6 months of age. Her vaccines are right on schedule, her parents have no concerns, she is developing normally, and her exam is normal. What vaccines can she get today?
At 12 months, the child can receive the first dose of Varicella to protect her from the highly contagious chickenpox that causes itchy, vesicular rash (CDC, 2023). The first dose of MMR, which protects against measles, mumps and rubella or German measles is also given at 12 months. In countries where measles is common, first dose can be given at 9 months, but the usual schedule is 12-15 months, and often combined with vaccine for mumps and rubella (WHO, 2023). There is also the MMRV vaccine that combines measles, mumps, rubella and varicella. Using MMRV results in one less injection, compared to giving MMR and varicella vaccine separately, but the risk for fever and febrile seizures is higher with the MMRV’s first dose (CDC, 2021). Live, attenuated influenza vaccine may also be administered at 12 months if it is necessary, and can be administered with MMR and varicella at the same visit with no interference in the immune response to the vaccines (CDC, 2023). At 12 months, the CDC recommends to give the 3rd dose or booster dose (4th dose) of Haemophilus influenzae type b vaccine and the 4th dose of the pneumococcal conjugate (PCV 13). The first dose of a series of 2 doses of Hepatitis A vaccine can be given at 12 months. Studies have shown that administering more than one vaccine on the same visit, at different sites, and not combined in the same syringe is safe and will increase the probability that the child will be fully vaccinated by the appropriate age (CDC, 2023)
Q3. Which groups of patients are at higher risk for pneumococcal disease, and need PPSV23 early starting at 2-years old?
PSV23 or the pneumococcoal polysaccharide vaccine protects against 23 types of bacteria that cause pneumococcal disease, and is recommended for all adults 65 years and older and for 2 years old and older with certain high risk medical conditions that puts him or her at increased risk for pneumococcal disease (CDC, 2019). The list of high risk conditions include cerebrospinal fluid leak, cochlear implants, HIV infection or immunodeficiencies, asplenia, sickle cell disease, neoplasms, previous repetitive episodes of invasive pneumococcal disease (IPD), trisomy 21, and solid organ transplants (Lagousi et al, 2021). The American Academy of Pediatrics (2023) recommends 4 doses of PCV 13 and a PPV23 dose at 2 years old for children considered to be high risk, or as soon as a diagnosis for chronic illness is made. Studies have shown that PPV23 effectivity is greater among children older than 2 years of age and young adults, compared to its effectivity in protecting elderly adults (Lagousi et al, 2021).
A 25-year-old woman comes to your office asking for oral contraceptive refills. She stated that she was feeling depressed and heard about St. John’s wort used in depression which she started taking a week ago.
Q4. How might concomitant administration of St. John’s wort affect the efficacy of drugs this patient is taking such as the oral contraceptives? Discuss another example of a possible drug interaction that might occur with St. John’s wort?
St. John’s Wort , an herbal supplement that is used for mild to moderate depression, contains two compounds, hyperforin and hypericin, that decrease the reuptake of serotonin, norepinephrine and dopamine (Rosenthal and Burchum, 2021). St. John’s wort is an inducer of 3A4 isoenzymes of cytochrome P450, thus, it can increase the rate of metabolism of many drugs, leading to a lowered efficacy (Rosenthal and Burchum, 2021). Oral hormonal contraceptives usually contain a combination of thinyl estradiol and progestin, which are substrates of CYP3A4, thus using St. John’s Wort with oral contraceptives can possibly lead to unintended pregnancy or breakthrough bleeding (Berry-Bibee et al, 2016).
- St. John’s wort has several drug to drug interactions that can be serious and life threatening. Certain medications that are substrates of P-glycoproteins in metabolism can have decreased efficacy and produce adverse effects when combined with St. John’s wort (Peterson and Nguyen, 2023). St. John’s Wort increases P-glycoprotein synthesis, leading to faster elimination of drugs such as digoxin, and calcium channel blockers, decreasing their therapeutic effects which can be serious (Rosenthal and Burchum, 2021).
The 25-year-old woman stated that her 4-year-old child has been coughing and sounds congested. She wants to know if echinacea might help her child.
Q5. What is echinacea used for and how is it taken?
Echinacea, an herbal supplement, when taken orally can improve immunity, suppress inflammation and treat viral infections such as the common cold (Rosenthal and Burchum, 2021). Using echinacea may help with the symptoms of acute respiratory infections, when administered early in the course of the disease, by decreasing the duration and severity of the infection (Aucoin et al, 2020). Studies done in the past, according to Aucoin et al (2020) have shown that echinacea can enhance immunity through macrophage activation and its effects on cytokine expression. Echinacea is available in several forms such as gummies, chewables, capsules, lozenges, syrup, powder, tea and liquid extract (Whelan, 2019).
Q6. Is it safe for this mother to give her child echinacea?
In a randomized, controlled clinical trial done in the United Kingdom, the use of echinacea tablets in children 4 – 12 years of age resulted in prevention of cold days and respiratory tract infections including RSV and influenza (Ogal et al, 2021). However, caution should be used with homeopathic and herbal remedies due to several reasons: these are not regulated by the Food and Drug Administration, properties of various echinacea products may be significantly different from one another, more research is needed to confirm the beneficial effects of echinacea in children with cough and colds (Whelan, 2019). Because of these, for the benefit of safety, the mother should not give her child echinacea.
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