MONITORING GROWTH AND VACCINATION FOLLOW-UP IN CHILDREN


​It is not only possible to prevent pediatric diseases with therapeutic medicine. Preventive medicine has been gaining gradually more importance all around the world. Preventive medicine is an ongoing process, ranging from intrauterine life to the end of 18 years of age.

Regular follow-up of pregnancy, genetic counseling, appropriate delivery conditions, neonatal care, screening tests, breast-feeding, starting ingestion of extra foods, vaccination, psychomotor development, growth monitoring, increasing maternal awareness and maternal training are all within the scope of preventive medicine. The main purpose of pediatricians is to make children gain full potential of healthy growth and development and to ensure that they grow to be mature adults. This track to this target is paved with regular monitoring of children at particular intervals. Regular follow-up of children reduces pediatric mortality, prevents diseases and disabilities and ensures that children gain the hereditary growth and development potential, resulting with healthy productive adults.

MONITORING GROWTH

The growth is an ongoing process which starts with intrauterine impregnation and extends to the end of adolescence. Growth potential may vary depending on child's genetic structure, hormonal structure, environmental (nutrition) factors and psychosocial factors. In addition, all body organs (heart, lungs, kidney, etc) should be functioning well. Growth takes place in two phases. The first one is intrauterine growth, and the other is the postnatal growth. Intrauterine growth may vary depending on many maternal and fetal factors, and for postnatal growth, infants and children will have different pace of growth at different age ranges. In postnatal period, growth is divided into three sub-periods, including infancy, childhood and adolescence. The growth rate varies in each period. During infancy, growth is different than that of childhood, and nutrition has a sound effect on growth in this period.

Monitoring growth is one of the most important practices in pediatrics department. Therefore, growth must be assessed irrespective of the reason to seek medical attention. This approach not only ensures detection of current developmental and nutritional status, but it may also enable one to decide whether growth rate is within physiological limits and nutrition is sound. For that reason, extremely careful and accurate measurements must be done. Growth of children should be followed up at regular intervals since any negative condition will have negative impact on the health status of a child. A physiological growth rate is an indicator of healthy status.

Body measurements (anthropometric measurements) are used to monitor the growth at regular intervals. Body weight, height and head circumference are the most commonly used anthropometric measurements. It is not difficult to make these measurements. However, they must be done carefully and accurately. Rather than a single measurement, gradual measurements will be more reliable, which are made at regular intervals. Error rate will be high if measurements are made by different practitioners using different devices. Therefore, child's growth parameters must be measured using appropriate devices by the same person as far as possible, and the child should be controlled by physician at regular intervals. In general, outpatient follow-up should be done at Day 5 and 15 Day following first 24-48 hours after birth, and at monthly intervals within first 6 months, quarterly intervals from 6 months to 24 months, semi-annual intervals from age of 2 years to the age of 3 years and annually afterwards.

Anthropometric Measurements

Body Weight Measurement: it is the most commonly used anthropometric measure. Before measuring body weight, the scale should be well calibrated and it should be placed on a flat surface. Measurements of infants and small children should be made at lying or sitting position on the scale. Baby should be completely undressed before body weight is measured. Ordinary floor Scales may be used for weighing children after the age of 2 years. Average weight is between 3200g and3300 g for a newborn baby. Weight increases two folds at Month 4 in the postnatal period, while it increases three folds at the age of one year. Weight measurement is a sensitive method to monitor growth since body weight changes substantially within a short time. Weight measurement indicates both current and past nutritional status since this parameter is under influence of both short- and long-term nutritional disorder, depending on the age of child.

Height Measurement: Height is measured using wooden measuring tape while baby is at supine position. Height can be measured at standing position after child is two years old. On-feet measurement may give a result, which is 2 cm shorter than measurement at supine position. A newborn baby is approximately 50 cm tall. Height increase will be around 25 cm at the end of the first year, 12 cm in the second year, 9 cm from the second year to the third year and 7 cm between the age of 3 years and 5 years. Afterwards, the increments will be 5 to 6 cm per year until adolescence. Height increase will be adversely influenced by poor nutrition and persistent infections. Therefore, this parameter is an indicator of past healthcare status rather than current status.

Head Circumference: Head circumference is measured at widest part of the head using a non-elastic measuring tape. The measurement line involves forehead and the most protruding part of occipital zone. The head should not be moved during the measurement, and measuring tape should lie beneath ears; measurement should be carefully done if there is swelling on any part of the head. Head circumference of infants is average 34-35 cm. Increment of head circumference is considerable within the first year of the life. When the child is 2 years old, the head circumference is about 90 percent of the head circumference in adulthood.

Growth percentiles (curves) are created using measurement data derived from healthy children in relevant population and such percentiles are used to assess growth precisely and accurately. There are standard growth curves for height, weight and head circumferences. Additionally, different growth curves are used for male, female and both sexes. For Turkish population, age- and sex-matched growth curves are developed by Prof. Dr. Olcay Neyzi et al. for weight, neck, and head circumference measurements. The growth curves involve age on the horizontal axis and actual value on vertical axis. Standard growth curves ranges in 3, 10, 25, 50, 75 and 97 percentiles. Three and 97 percentiles define lower and upper limits of normal, respectively.

The baby is examined and anthropometric measurements are done and later, results are marked on age-matched standard growth curves. A line is drawn from the first to the last mark in order to get growth curve of the child. Child’s growth curve will be in the range of 3 to 97 percentiles under normal conditions and it lies parallel to standard curves. Any deviation (a growth curve below or above normal limits, or sharp decline or increase or horizontal line) is indicative of pathology. Assessment of growth enables us determining poor nutrition (low weight, short height) or overweight children. Regular follow-up of growth enables determination of growth retardation before a severe malnutrition develops or determination of excess weight increase before the child suffers from obesity, resulting with early diagnosis and intervention. In addition, this approach supports balanced and healthy nutrition and trains the care giver. Apart from these advantages, regularly followed up child will be provided with other preventive medicine services.

MONITORING VACCINATION (IMMUNIZATION)

One of the most important preventive medicine services is vaccination in the field of pediatrics. Vaccination has been the most important step in improving human health throughout the history. Vaccination immunizes people against diseases and underlying complications. In addition, spreading of microorganisms, which lead to disease, is prevented, resulting with protection of non-immunized people and public health. Recently, life of three million children is saved per year all over the world thanks to the immunization. In short, immunization with the vaccine is the most important health care victory in the 20th century.

Vaccine implies biological substances which are developed to administer to healthy subjects after virulent factors of microbes, such as virus and bacteria, are deactivated and toxins of some microorganisms are eliminated. Mechanism of action is similar to the natural disease; vaccines and diseases stimulate the immune system, recognize the microbe which invades into the body, and establish a memory and eliminate them before they cause an illness. For the vaccines to demonstrate a protective effect, they should be injected at appropriate dose, at appropriate age range and at regular intervals

Vaccines can be classified in two groups, including live and inactivated ones. Live vaccines are comprised of virus or bacterium with deactivated virulent factors; however, proliferation and immunizing ability is protected (measles, rubella, mumps, OPV, varicella, BCG vaccines etc). Inactivated vaccines are made using whole virus or bacteria (whooping cough, influenza, hepatitis A, polio, etc.) or part of them (such as hepatitis B, influenza, acellular pertussis, diphtheria, tetanus, etc.) Apart from antigens, vaccines include suspension fluids, adjuvant, stabilizing and preserving agents that increase the immunogenicity.

Pediatric Vaccination

BCG (Tuberculosis Vaccine): Tuberculosis is a live vaccine that protects against infection. It is injected in the 2nd month of life. It is the only vaccine which is subcutaneously administered and therefore, a certified healthcare professional is required. BCG vaccine is injected into left shoulder. A slight redness can be seen at the injection site through 6-8 weeks. BCG is injected in the first 6 months without control of PPD, if it is not injected in the first three months and with PPD after 6 months (if it is negative).

DBaT (Diphtheria Tetanus Pertussis): Diphtheria-tetanus-pertussis vaccine is also referred as combination vaccine. It is an inactivated vaccine. Together with inactivated polio and hemophilus influenza vaccines, it is injected in combination of 5 vaccines. It is administered at 2nd, 4th, 6th and 18th months of life. Booster dose is administered in the form of combination of 4 vaccines (DBT-IPV) in the first grade of the primary school, and tetanus and diphtheria (Td) in Grade 8. It is intramuscularly injected. Pain and swelling at injection site and fever may develop secondary to vaccination and such complaints occur in the first day and they may last 1 to 2 days.

Polio Vaccine: Poliomyelitis is an infection caused by the polio virus. It is an important cause of disability at an early age. It has two types, including live (OPV) and inactivated (IPV) vaccines. Inactivated vaccine is intramuscularly injected together with combination vaccine in the 2nd, 4th, 6th and 18th months of age. Booster dose is injected at the age of 6 years. The live vaccine is orally administered when the child is 6 and 18 months old. Polio is the disease that should be eradicated all around the world. In our country, the last case of polio was in 1998.

Hepatitis B Vaccine: Hepatitis B vaccine is administered to all newborns immediately after birth or before baby is discharged. Doses are repeated when the child is 1 and 6 months old. It is intramuscularly injected. Hepatitis B vaccine is an inactivated vaccine. In our country, the incidence of being carrier is 10 percent. Hepatitis B infection may lead to cirrhosis and liver failure in the future. Vaccination is very important at neonatal period in order to prevent being hepatitis B carrier. Therefore, if the mother is a hepatitis B carrier, the baby should be administered Hepatitis B immunoglobulin protective antibody together with the vaccine within first 12 hours in postnatal period. Side effects include pain at injection site, fever, headache, and fatigue.

Measles, Rubella, Mumps Vaccine: MMR vaccine is injected when baby is 12 months old. It is subcutaneously administered. Second dose is administered between ages of 4-6 years. MMR vaccine leads to fever 5-7 days after vaccination. Body temperature may rise to 39 Degrees Celsius in 5-10 % of all children. It may last 1 to 2 days. Rashes can be seen in 7 to 10 days in some children.

H. Influenza Type B: this vaccine is developed against Hemophilus influenza type B, which leads to pneumonia, meningitis, otitis media and laryngitis, for children <5 years old. It is intramuscularly administered; this is an inactivated vaccine. Usually, it is administered in combination of vaccine. It is injected when the child is 2, 4, 6 and 18 months old. The vaccine may not be administered after baby is >5 years old. Fever, irritability, injection site pain, redness may be faced after vaccination.

Pneumococcus Vaccine: Pneumococcus has many species which may lead to infections such as pneumonia, meningitis and otitis media. The vaccine is developed against the most common 13 species and it is administered when the child is 2, 4 and 6 months old. Booster dose is injected at age of 12 months. It is an inactivated vaccine. The vaccine may not be administered after baby is >5 years old.

Chickenpox Vaccine: it is a live vaccine against varicella infection. It is administered when the baby is ≥1 year old. It is administered via intramuscular route. Mild fever, rash can be seen 9-10 days after vaccination.

Hepatitis A (HAV): it protects against hepatitis A infections. It is injected in two doses at six-month interval when the baby is 18 and 24 months old. It is intramuscularly administered. Pain and swelling may occur at injection site at rate of 20%, and the frequency of headache is 10 percent.

Influenza Virus Vaccine: The flu vaccine is recommended for children who are under risk and are aged >6 months. It is repeated annually. It is an inactivated vaccine.

Risk groups: Chronic lung problems such as asthma, cystic fibrosis, heart disease leading to hemodynamically significant problems, conditions leading to suppression of immune system, HIV infection, sickle-cell anemia, conditions requiring long-term use of aspirin such as rheumatoid arthritis and Kawasaki, renal failure and chronic metabolic diseases such as diabetes mellitus.

First dose is injected when the baby is eight years old, and two doses are injected in one-month interval and one dose is repeated when the baby is 9 years old. Half dose (0.25 ml) is administered when baby is 6 months old and 36 months old. Full dose (0.5 ml) is administered when baby is >3 months old.

Rota virus vaccine: it is protective against rotavirus which leads to acute diarrhea. It is injected within age of first 5 years. Rotavirus infection is associated with fever, vomiting, diarrhea, and loss of water. Vomiting may last two days, while diarrhea may last 5-8 days. Rota vaccine is a live vaccine which is administered via oral route. Depending on the type of vaccine, it is given in two doses when baby is 2 and 4 months old or in three doses when the baby is 2, 4 and 6 months old. Side effects of the vaccine include very mild diarrhea and fever.

Human Papilloma Virus Vaccine (HPV): It is protective against cervical cancer, which is seen in female subjects. It is injected in three doses to female subjects at age range of 11 and 15 years. It is administered at Month 0, 2 and 6. This is an inactivated vaccine. Possible side effects include fever, pain at injection site, redness, swelling and itching.

Meningitis vaccine: on the contrary to other meningitis vaccines, it provides protection against meningococcemia, which is caused by a microorganism called Neisseria menengitidis. Meningococcemia outbreaks in certain periods, and it is a severe condition resulting with death at rate of 50 percent within 24 hours. Two doses are injected in three-month intervals below the age of 2 years, and a single dose is repeated after baby is two years old. The most common side effects are fever, irritability, crying, swelling at injection site and redness.

Conditions hindering vaccination are very rare. These are called as “contraindications of vaccination”. Vaccine cannot be administered if there is clear contraindication. Dose of vaccine should not be administered if anaphylactic reaction (severe allergy) develops against the active substance or any ingredient, or if any infectious or non-infectious severe disease is the case. Moreover, live vaccines cannot be administered during pregnancy and when there is immune suppression, while DPT vaccine is contraindicated in patients with encephalopathy. In addition, vaccination program should be strictly followed in order not to violate vaccination schedule. Mild febrile diseases, antibiotics, chronic heart, lung, kidney and liver disease, neurological disorders, prematurity, neonatal jaundice, history of seizure, pre- and postoperative period and malnutrition do not contraindicate vaccination.

Vaccine procedures and creation of vaccine schedules are dynamic events, and therefore, the organizations and institutions, which play the leader role in protection of pediatric health, should issue vaccine schedule recommendations and develop such schedules in line with the country's resources and requirements. Accordingly, each country should issue its own vaccine schedule in accordance with epidemiological, economic and social data (Table Vaccination schedule for Year 2013)

There is no necessity to administer vaccines, which are not included in routine vaccination program of Ministry of Health (flu, rota, meningococcal, HPV vaccines). However, such vaccines should be administered after parents are appropriately informed.

In conclusion, it is the right of every child to be vaccinated for a disease with available vaccine; this right should not be restrained and everyone must be informed about all vaccination and immunization with respect to diseases with available vaccines.


Table –Vaccine Schedule for Year 2013


Vaccines

At Birth

End of Month 1

End of Month 2

End of Month 4

End of Month 6

End of Month 12

End of Month 18

End of Month 24

Grade 1

Grade 8

Hepatitis B

I

II

III

BCG (tuberculosis)

I

DaBT-IPA-Hib

I

II

III

Rapel

CPA

I

II

III

Rapel

KKK

I

Rapel

DaBT-IPA

Rapel

OPA

I

II

Td

Rapel

Hepatitis A

I

II

Varicella

I

DaBT-IPA-Hb: Diphtheria, Acellular Pertussis, Tetanus, Inactivated Polio, Hemaphilus influenza type B vaccine (combination of 5 vaccines)

KPA: Conjugated pneumococcus vaccine

MRM: Measles, Rubeola, Mumps

DaBT-IPA: Diphtheria, Acellular Pertussis, Tetanus, Inactivated Polio

OPA: Oral polio vaccine

Td: Adult type Diphteria-Tetanus vaccine

Rapel: Pekiştirme dozu


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