Pediatric board study guide a last minute review

Pediatric Board Study Guide


Osama Naga
Editor

Pediatric Board Study Guide
A Last Minute Review


Editor
Osama Naga
Department of Pediatrics
Paul L Foster School of Medicine,
Texas Tech, University Health Sciences Center
El Paso
Texas
USA

ISBN 978-3-319-10114-9    ISBN 978-3-319-10115-6 (eBook)
DOI 10.1007/978-3-319-10115-6
Springer Cham Heidelberg New York Dordrecht London
Library of Congress Control Number: 2014957480
© Springer International Publishing Switzerland 2015
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To my father, and my mother who supported me in the most critical times in
my life.
To my precious daughter Ayah, whose smiles and laughter constantly provide
me unparalleled joy and happiness.
This book would not have been possible without the support of my very loving
and understanding wife.
I owe my deepest gratitude to all the contributors and experts who make this
great pediatric resource possible and alive.


Foreword

Pediatric Board Study Guide: A Last Minute Review is designed for pediatricians who are
preparing for the pediatric board examination, as an excellent guide for residents taking the
in-service exam during training, or as assistance in preparing for rotations. It is an easy and fast
source of much basic information and many clinical facts.
The book provides the core material needed to pass the General Pediatric Certifying exam.

The first part of the book is the pediatric board study guide explains the content specifications
provided by the American Board of Pediatrics, and includes revisions in treatment protocols
and diagnostic criteria. Figures, radiology images, EKGs, growth curves, tables, and diagrams
make it easy to establish the basic medical knowledge in pediatrics in many different ways;
most of the major chapters were written or reviewed by experts in the field from the top universities in the USA.
The typical and atypical presentation of pediatric conditions characterizes the Guide. An
easy-to-read bulleted format highlights the most pertinent information for conditions commonly encountered by the pediatricians. In the “Last Minute Review” chapter, tables allow
the reader to review in the shortest time possible more than 1000 clinical case scenarios, more
than 70 radiology case scenarios and high-yield facts for the pediatric board examination and
clinical pediatric encounters, making it ideal for review in the days prior to the Board exam.
With smooth transitions from one topic to another, the Guide is easy to read and use, and we
trust it will prove an excellent tool for anyone in the field, whether preparing for the exam, or
brushing up for rotations.




Osama Naga
El Paso, TX

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Contents

General Pediatrics�������������������������������������������������������������������������������������������������������������    1
Osama Naga
Behavioral, Mental Health Issues and Neurodevelopmental Disorders����������������������  29
Mohamad Hamdy Ataalla
Psychological Issues and Problems����������������������������������������������������������������������������������  45

Sitratullah Olawunmi Kukoyi-Maiyegun
The Acutely III Child��������������������������������������������������������������������������������������������������������  57
Osama Naga
Emergency Care����������������������������������������������������������������������������������������������������������������  65
Steven L. Lanski and Osama Naga
Genetics and Dysmorphology������������������������������������������������������������������������������������������  83
Osama Naga, Golder Wilson and Vijay Tonk
Metabolic Disorders����������������������������������������������������������������������������������������������������������  101
Osama Naga
Fetus and Newborn Infants (Neonatology)���������������������������������������������������������������������  119
Osama Naga
Adolescent Medicine and Gynecology�����������������������������������������������������������������������������  149
Marwa Abdou and Osama Naga
Allergic and Immunologic Disorders������������������������������������������������������������������������������  159
Osama Naga
Rheumatologic Disorders�������������������������������������������������������������������������������������������������  177
Osama Naga
Infectious Diseases������������������������������������������������������������������������������������������������������������  193
Osama Naga and M. Nawar Hakim
Gastrointestinal Disorders�����������������������������������������������������������������������������������������������  257
Osama Naga
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Respiratory Disorders������������������������������������������������������������������������������������������������������  291
Karen Hardy and Osama Naga
Cardiovascular Disorders������������������������������������������������������������������������������������������������  313
Joseph Mahgerefteh and Daphne T. Hsu

Blood and Neoplastic Disorders���������������������������������������������������������������������������������������  343
Staci Bryson and Arlynn F. Mulne
Renal Disorders�����������������������������������������������������������������������������������������������������������������  373
Beatrice Goilav and Abhijeet Pal
Urologic Disorders������������������������������������������������������������������������������������������������������������  393
Osama Naga
Endocrine Disorders���������������������������������������������������������������������������������������������������������  403
Kuk-Wha Lee, Amr Morsi and Osama Naga
Pediatric Neurology����������������������������������������������������������������������������������������������������������  435
Ivet Hartonian, Rujuta R. Bhatt and Jason T. Lerner
Eye Disorders��������������������������������������������������������������������������������������������������������������������  457
Violeta Radenovich and Osama Naga
Ear, Nose, and Throat Disorders�������������������������������������������������������������������������������������  469
Josée Paradis and Anna H. Messner
Skin Disorders�������������������������������������������������������������������������������������������������������������������  491
Sitratullah Olawunmi Kukoyi-Maiyegun
Orthopedics Disorders and Sport Injuries���������������������������������������������������������������������  507
Amr Abdelgawad and Marwa Abdou
Research and Statistics�����������������������������������������������������������������������������������������������������  543
Sitratullah Olawunmi Kukoyi-Maiyegun
Radiology Review��������������������������������������������������������������������������������������������������������������  547
Abd Alla Fares, Stephane ALARD, Mohamed Eltomey,
Caroline Ernst and Johan de Mey
The Last Minute Review��������������������������������������������������������������������������������������������������  573
Osama Naga, Kuk-Wha Lee, Jason T. Lerner, Ivet Hartonian,
Rujuta R. Bhatt, Joseph Mahgerefteh, Daphne T. Hsu, Beatrice Goilav,
Sitratullah Olawunmi Kukoyi-Maiyegun, Arlynn F. Mulne Vijay Tonk and
Amr Abdelgawad
Index�����������������������������������������������������������������������������������������������������������������������������������  611

Contents


Contributors

Amr Abdelgawad, MD  Associate Professor of Orthopedic Surgery, Department of Orthopaedic Surgery & Rehabilitation, Texas Tech University Health Sciences Center, El Paso,
TX, USA
Marwa Abdou, MD  Pediatric Resident, Department of Pediatrics, El Paso Children’s Hospital, El Paso, TX, USA
Rujuta R. Bhatt, MD  Child Neurology Resident, Department of Pediatric Neurology, Mattel
Children’s Hospital at UCLA, Los Angeles, CA, USA
Staci Bryson, MD Assistant Professor, Department of Pathology, Texas Tech University
Health Science Center, Paul L. Foster School of Medicine, El Paso Children’s Hospital, El
Paso, TX, USA
Arlynn F. Mulne, MD  Associate Professor, Department of Pediatric Hematology/Oncology,
Texas Tech University Health Science Center, Paul L. Foster School of Medicine, El Paso
Children’s Hospital, El Paso, TX, USA
Abd Alla Fares, MD  Department of Radiology, UZ Brussel, Laarbeeklaan, Brussels, Belgium
Beatrice Goilav, MD  Assistant Professor, Department of Pediatric Nephrology, Children’s
Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
M. Nawar Hakim, MD  Assistant Professor, Department of Pathology and Laboratory Medicine, Texas Tech University Health Science Center, El Paso, TX, USA
Mohamad Hamdy Ataalla, MD  Department of Child and Adolescent Psychiatry, Texas Tech
University Health Sciences Center, El Paso, TX, USA
Karen Hardy, MD  Director of Pediatric Pulmonary and CF Center, Director of Pediatric Pulmonary and CF Center, Pediatric Pulmonary and Cystic Fibrosis Center, Children’s Oakland
and California, Pacific Medical Centers, Oakland, CA, USA
Ivet Hartonian, MD, MS  Pediatric Neurology Consultant, Department of Pediatrics, White
Memorial Pediatric Medical Group, Los Angeles, CA, USA
Daphne T. Hsu, MD  Professor of Pediatrics, Division Chief, and Co-Director, Department
of Pediatric Cardiology, Pediatric Heart Center, Department of Pediatrics, Albert Einstein College of Medicine, Children’s Hospital at Montefiore, Bronx, NY, USA
Sitratullah .O. Maiyegun, MD  Associate Professor, Department of Pediatrics, Paul L. Foster
School of Medicine, Texas Tech University Health Science Center, El Paso, TX, USA

Steven L. Lanski, MD  Medical Director Pediatric Emergency Medicine Department of Pediatric Emergency Medicine, Providence Memorial Hospital, El Paso, TX, USA
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Kuk-Wha Lee, MD, PhD  Associate Professor, Chief, Division of Endocrinology, Department
of Pediatrics, Mattel Children’s Hospital at UCLA, Los Angeles, CA, USA
Jason T. Lerner, MD  Assistant Professor, Department of Pediatric Neurology, Mattel Children’s Hospital at UCLA, Los Angeles, CA, USA
Joseph Mahgerefteh, MD Assistant Professor, Pediatric Heart Center, Department of
Pediatrics, Albert Einstein College of Medicine, Children’s Hospital at Montefiore, Bronx,
NY, USA
Anna H. Messner, MD Professor, Department of Otolaryngology/Head & Neck Surgery,
Stanford University Medical Center and the Lucile Salter Packard Children’s Hospital, Stanford, CA, USA
Amr Morsi, MD  Resident Physician, Department of Pediatrics, Texas Tech University Health
Science Center—Paul L. Foster School of Medicine, El Paso, TX, USA
Osama Naga, MD Clinical Assistant Professor, Department of Pediatrics, Paul L. Foster
School of Medicine, Texas Tech University Health Science Center, El Paso, Avenue, TX, USA
Josée Paradis, MD, MSc, FRCSC  Department of Otolaryngology, Head & Neck surgery,
London Health Science Center, University of Western Ontario, London, Ontario, Canada
Violeta Radenovich, MD, M.P.H Associate Professor of Pediatric Ophthalmology,
Department of Pediatrics, Texas Tech University Health Sciences Center, El Paso, TX, USA
Vijay Tonk, PhD: FACMG  Professor of Pediatrics and Clinical Genetics, Department of
Pediatrics, Texas Tech University Health Sciences Center, Lubbock, TX, USA
Golder Wilson, MD, PhD Professor of Pediatrics and Clinical Genetics, Department of
Pediatrics, Texas Tech University Health Sciences Center, Lubbock, TX, USA

Contributors

General Pediatrics
Osama Naga

Growth
Background
•• Growth is affected by maternal nutrition and uterine size.
•• Genetic growth potential is inherited from parents and
also depends on nutrition throughout childhood.
•• Growth is affected by growth hormone (GH), thyroid
hormone, insulin, and sex hormones, all of which have
varying influence at different stages of growth.
•• Deviation from normal expected patterns of growth often
can be the first indication of an underlying disorder.
•• Carefully documented growth charts serve as powerful
tools for monitoring the overall health and well-being of
patients.
•• Key to diagnosing abnormal growth is the understanding
of normal growth, which can be classified into four primary areas: fetal, postnatal/infant, childhood, and pubertal.
Weight
•• Healthy term infants may lose up to 10 % of birth weight
within the first 10 days after birth.
•• Newborns quickly regain this weight by 2 weeks of age.
•• Infants gain 20–30 g/day for the first 3 postnatal months.
•• Birth weight doubles at 4 months.
•• Birth weight triples by 1 year of age.
Height
•• Height of a newborn increases by 50 % within 1 year.
•• Height of a newborn doubles within 3–4 years.
•• After 2 years the height increases by average 5 cm/year.

O. Naga ()
Pediatric Department, Paul L Foster School of Medicine, Texas Tech
University Health Sciences Center, 4800 Alberta Avenue,
El Paso, TX 79905, USA
e-mail:

Measurements
•• Length or supine height should be measured in infants
and toddlers < 2 years.
•• Standing heights should be used if age > 2 years.
•• Plot gestational age for preterm infants rather than chronological age.
•• Specific growth charts are available for special populations, e.g., Trisomy 21, Turner syndrome, Klinefelter
syndrome, and achondroplasia.
Growth curve reading
•• Shifts across two or more percentile lines may indicate an
abnormality in growth.
•• Shifts on the growth curve toward a child’s genetic potential between 6 and 18 months of age are common.
•• Small infants born to a tall parents begin catch-up growth
around 6 months of age.
•• Weight is affected first in malnourished cases, chronic
disease, and malabsorption, or neglect.
•• Primary linear growth problems often have some congenital, genetic, or endocrine abnormality (see chapter
“Endocrine Disorders”).

Macrocephaly
Definition
•• Head circumference (HC) 2 standard deviations above
the mean
Causes
•• Hydrocephalus

•• Enlargement of subarachnoid space (familial with autosomal dominant inheritance)
•• Achondroplasia (skeletal dysplasia)
•• Sotos syndrome “Cerebral Gigantism”
•• Alexander’s disease
•• Canavan’s disease
•• Gangliosidosis

O. Naga (ed.), Pediatric Board Study Guide, DOI 10.1007/978-3-319-10115-6_1,
© Springer International Publishing Switzerland 2015

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O. Naga

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•• Glutaric aciduria type I
•• Neurofibromatosis type I
Familial macrocephaly
•• It is a benign cause of macrocephaly.
•• It is autosomal dominant and usually seen in the father.
•• Infants are usually born with a large head but within normal range at birth.
•• The head circumference as the infants grow usually
exceeds or is parallel to 98th percentile.
•• Head computed tomography (CT) usually shows enlarged
subarachnoid space.
•• Head CT may show minimal increase in the ventricles,
widening in sulci, and sylvian fissure.
Genetic megalocephaly

•• Similar to familial macrocephaly except the CT is normal
Diagnosis
•• Head ultrasound is the study of choice.
•• Head CT scan.
Management
•• Hydrocephalus and macrocephaly present with enlargement of head circumference; careful attention should
be given specially to the preterm babies who may have
hydrocephalus.
•• Plot the gestational age on growth chart for preterm
babies instead of chronological age.
•• Infants born with microcephaly usually have their head
circumference (HC) catch up faster than length and
weight; abnormal growth pattern may indicate hydrocephalus.

•• Gestational diabetes
•• Maternal hyperphenylalaninemia
•• Hypoxic-ischemic encephalopathy
Diagnosis
•• Maternal phenylalanine level
•• Karyotype of child for suspected congenital abnormality
•• Head imaging (Head ultrasound, Head CT, or Head MRI)
•• Amino acid analysis (plasma and urine)
•• TORCH virus serum titers (mother and child)
•• Urine culture for cytomegalovirus

Plagiocephaly
Background
•• Deformational flattening from lack of changes in head
positions is the most common cause of asymmetric head
shape.

Causes
•• Positional or supine sleeping is the most common cause
of plagiocephaly.
•• Craniosynostosis.
Craniosynostosis
•• If one suture is involved, it is usually isolated, and sagittal
suture involvement is the most common.
•• If more than one suture is involved, it is usually associated with genetic disorders.

Microcephaly

Posterior plagiocephaly (positional) (Table 1)
•• Anterior displacement of the occiput and the frontal
region on the same side (Parallelogram).
•• Ear position is more anterior on the side of flattening in
positional plagiocephaly.

Definition
•• Head circumference 2 standard deviation below the mean.

Diagnosis
•• Plain film or CT scan if craniosynostosis is suspected

Causes
•• Trisomy 13, 18 (Edward syndrome) and 21 (Down syndrome)
•• Cornelia de Lange
•• Rubinstein–Taybi
•• Smith–Lemli–Opitz
•• Prader–Willi syndrome
•• Teratogen exposure

•• Fetal alcohol syndrome
•• Radiation exposure in utero (< 15 weeks gestation)
•• Fetal hydantoin
•• TORCH: Toxoplasmosis, Other infections, Rubella, Cytomegalovirus, Herpes simplex virus congenital infection
•• Meningitis or encephalitis

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General Pediatrics

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Table 1   Difference between deformational plagiocephaly and unilambdoid synostosis
Deformational plagiocephaly

Plagiocephaly due to unilambdoid
synostosis

Parallelogram shape head
Occipital flattening on one
side
Frontal bossing on the same
side
Anterior displacement of the
ear on the same side
Palpable suture

Trapezoid shape head
Occipital flattening on one side
Frontal bossing on the contralateral
side
Posterior displacement of the ear on
the same side
Absence of suture or palpable fused
lambdoid suture

Treatment
•• Observation; usually resolve in 2–4 months.
•• Keep the wakeful baby in prone position.
•• Helmet may be beneficial in severe cases of posterior plagiocephaly. It requires 22 h/day and gives best result if
used before 6 months.
•• Treatment of synostosis with surgery between 6 and 12
months.

Developmental Milestones
Newborn
•• Able to fixate face on light
•• Visual preference for human face
•• Regarding a face (shortly after birth)
•• Responds to visual threats by blinking and visually fixes
•• Visual acuity is 20/400
•• Moro, stepping, placing, and grasp reflexes are all active
1 month
•• Chin up in prone position
•• Head lifted momentarily to plane of body on ventral suspension
•• Hands fisted near face
•• Watches a person

•• Follows objects momentarily
•• Startles to voice/sound
•• Begins to smile
2 months
•• Chest up in prone position
•• Holds head steady while sitting
•• Hands unfisted 50 %
•• Follows moving object 180°
•• Able to fixate on face and follow it briefly
•• Stares momentarily at spot where object disappeared
•• Listens to voice and coos
•• Smiles on social contact (reciprocal smiling)

3 months
•• Props on forearm in prone position
•• Rolls to side
•• Brings hands together in midline and to mouth (self discovery of hands)
•• Follows object in circle in supine position
•• Regards speaker
•• Chuckles and vocalizes when talked to
4 months
•• Sits with trunk support
•• No head lag when pulled to sit
•• Rolls from front to back
•• Lifts head and chest
•• When held erect pushes with feet
•• Reaches toward object and waves at toy
•• Grasps an object and brings to mouth
•• Plays with rattle
•• Laughs out loudly

•• Excited at sight of food
•• Smiles spontaneously at pleasurable sight/sound
•• May show displeasure if social contact is broken
•• Asymmetric tonic reflex gone
•• Palmar grasp gone
6 months
•• Sits momentarily propped on hands
•• Turns from back to the front
•• Transfers hand-hand
•• Bangs and shakes toys
•• Rakes pellets
•• Removes cloth on face
•• Stranger anxiety (familiar versus unfamiliar people)
•• Stops momentarily to “no”
•• Gestures for “up”
•• Begins to make babbling
•• Listens then vocalizes when adult stops
•• Imitates sounds
•• Smiles/Vocalizes to mirror
7 months
•• Sits without support steadily
•• Puts arms out to side for balance
•• Radial palmar grasp
•• Refuses excess food
•• Explores different aspects of toy and observe cube in
each hand
•• Finds partial hidden objects
•• Looks from object to parents and back when wanting help
•• Looks toward familiar object when named
•• Attends to music

•• Prefers mother


O. Naga

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9 months
•• “Stands” on feet and hands
•• Begins creeping
•• Pulls to stand
•• Bears walks
•• Radial-digital grasps of cube
•• Bangs two cubes together
•• Bites, chews cookie
•• Inspects and rings bell
•• Pulls string to obtain ring
•• Uses sound to get attention
•• Separation anxiety
•• Follows a point “oh look at…”
•• Orients to name well
•• Says “mama” nonspecific
12 months
•• Stands well with arms high, leg splayed
•• Independent steps
•• Scribbles after demonstration
•• Fine pincer grasp of pellet
•• Cooperates with dressing
•• Lifts box lid and finds toy
•• Shows parents object to share interest

•• Says “mama” and “dada”
•• Follows one-step command with gesture
•• Points to get desired object (proto-imperative pointing)
and to share interest
14 months
•• Walks well
•• Stands without pulling
•• Imitates back and forth scribbling
•• Puts round pig in and out of hole
•• Can remove hat and socks
•• Puts spoon in mouth (turn over)
•• Follows one step commands without gesture
•• Functional vocabulary of 4–5 words in addition to
“mama” and “dada”
15 months
•• Stoops to pick up a toy
•• Runs stiff-legged
•• Builds three- to four-cube tower
•• Climbs on furniture
•• Drinks from a cup
•• Releases pellet into bottle
•• Uses spoon with some spilling
•• Turns pages in book
•• Points to one body part
•• Hugs adult in reciprocation
•• Gets object from another room upon demand
•• Uses 3–5 words
•• Mature jargoning with real words

18 months

•• Runs well
•• Creeps downstairs
•• Throws a ball while standing
•• Makes four-cube tower
•• Able to remove loose garments
•• Matches pairs of objects
•• Passes M-CHAT
•• Begins to show shame (when they do wrong)
•• Points to two of three objects when named and three body
parts
•• Understands mine
•• Points to familiar people with name
•• Uses 10–25 words
•• Uses giant words (all gone; stop that)
•• Imitates animal sounds
24 months
•• Walks down stairs holding rail, both feet on each step
•• Kicks ball without demonstration
•• Throws a ball overhead
•• Takes off clothes without button
•• Imitates circle
•• Imitates horizontal line
•• Builds a tower of four cubes
•• Opens door using knob
•• Follows two-step command
•• Points to 5–10 pictures
•• Uses two-word sentence
•• Uses 50 + words
•• 50 % language intelligibility
3 years

•• Balances on one foot for 3 s
•• Goes upstairs alternating feet, no rails
•• Pedals tricycle
•• Copies circle
•• Puts on shoes without laces
•• Draws a two- to three-part person
•• Knows own gender and age
•• Matchs letter/numeral
•• Uses 200 + words
•• Uses three-word sentences
•• 75 % language intelligibility
4 years
•• Balances on one foot for 4–8 s
•• Hops on one foot 2–3 times
•• Copies square
•• Goes to toilet alone
•• Wipes after bowel movement
•• Draws a four- to six-part person
•• Group play
•• Follows three-step commands


General Pediatrics

••
••
••
••
••

5

7 years
•• Ability to repeat five digits
•• Can repeat three digits backward
•• Can draw a person that has 18–22 parts

Tells stories
Speaks clearly in sentences
Says four to five-word sentences
Understands four prepositions
100 % intelligibility

5 years
•• Walks down stairs with rail, alternating feet
•• Skipping
•• Balances one foot for > 8 s
•• Walks backward heel-toe
•• Copies triangle
•• Cuts with scissors
•• Builds stairs from model
•• Draws eight- to ten-part person
•• Names ten color and count to ten
•• Plays board or card games
•• Apologizes for mistakes
•• Knows right and left on self
•• Repeats six- to eight-word sentence
•• Responds to “why” questions
6 years
•• Tandem walk

•• Builds stairs from memory
•• Can draw a diamond shape
•• Writes first and last name
•• Combs hair
•• Looks both ways at street
•• Draws 12- to 14-part person
•• Have best friend of same sex
•• Asks what unfamiliar word means
•• Repeats eight- to ten-word sentences
•• Knows days of the week
•• 10,000 word vocabulary

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Key Points to Developmental Milestones
Reflexes
•• Moro is absent around 3–4 months of age
•• Palmar grasp absent around 2–3 months of age
•• Parachute starts around 6–9 months of age
Following objects
•• 1 month: follows to midline
•• 2 months: follows past midline
•• 3 months: follows 180°
•• 4 months: circular tracking 360°
Speech intelligibility
•• 50 % intelligible at 2 years
•• 75 % intelligible at 3 years
•• 100 % intelligible at 4 years

Language: receptive
•• Newborn
–– Alerts to sound
•• 4 months
–– Orients head to direction of a voice
•• 8 months
–– Responds to come here
•• 9 months
–– Enjoys gesture game
•• 10 months
–– Enjoys Peek-a-boo
•• 12 months

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ϱLJĞĂƌƐ

ϯLJĞĂƌƐ

ϲLJĞĂƌƐ


O. Naga

6

–– Follows one-step command with a gesture
•• 15 months
–– Follows one-step command without a gesture
Language: expressive
•• Coos
–– 2 months (2–4 months)
•• Laughs out loud
–– 4 months
•• Babbles
–– 6 months
•• Mama or dada nonspecific
–– 9 months
•• Mama and dada specific
–– 12 months
•• Vocabulary of 10–25 words
–– 18 months
•• Two-word sentences
–– 2 years (18–24 months)
•• Three-word sentences
–– 3 years (2–3 years)
•• Four-word sentences
–– 4 years (3–4 years)
Drawing
•• Scribbles
–– 15 months
•• Circle
–– 3 years
•• Cross
–– 4 years
•• Square

–– 4.5 years
•• Triangle
–– 5 years
•• Diamond
–– 6 years
Social skills
•• Reciprocal smiling
–– 2 months
•• Follows person who is moving across the room
–– 3 months
•• Smiles spontaneously at pleasurable sight/sound
–– 4 months
•• Recognizes caregiver socially
–– 5 months

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ϮϰŵŽŶƚŚƐ

•• Stranger anxiety
–– 6 months
•• Separation anxiety and follows point “oh look at”
–– 9 months
•• Waves bye-bye back
–– 10 months
•• Shows objects to parents to share interests
–– 12 months
•• Parallel play

–– 2 years
•• Reduction in separation anxiety
–– 28 months
•• Cooperative play
–– 3–4 years
•• Ties shoelaces
–– 5 years
•• Distinguishes fantasy from reality
–– 6 years
Blocks
•• Passes cubes
–– More than 6 months
•• Bangs cubes
–– 9 months
•• Block in a cup
–– 12 months
•• Tower three blocks
–– 15 months
•• Tower four blocks
–– 18 months
•• Tower six blocks
–– 24 months
•• Bridge from blocks
–– 3 years
•• Gate from blocks
–– 4 years
•• Steps from blocks
–– 5 years
Catching objects
•• Rakes

–– 5–6 months
•• Radial-palmar grasp
–– 7–8 months
•• Inferior pincer
–– 10 months

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ϱLJĞĂƌƐ;ƐƚĞƉƐͿ


General Pediatrics

•• Fine pincer
–– 12 months
Walking and running
•• Independent steps
–– 12 months
•• Walks well
–– 14 months
•• Runs stiff-legged
–– 15 months
•• Walks backwards
–– 16 months
•• Runs well
–– 18 months
•• Kicks ball without demonstration
–– 2 years

•• Skips and walks backward heel-toe
–– 5 years
Climbing stairs
•• Creeps up stairs
–– 15 months
•• Creeps down stairs
–– 18 months
•• Walks down stairs holding rail, both feet on each step
–– 2 years
•• Goes up stairs alternating feet, no rail
–– 3 years
•• Walks down stairs with rail alternating feet
–– 5 years
Red flags at 2 months of age
•• Does not respond to loud sounds
•• Does not watch things as they move
•• Does not smile at people
•• Does not bring hands to mouth
•• Cannot hold head up when pushing up when on tummy
Red flags at 4 months of age
•• Does not watch things as they move
•• Does not smile at people
•• Cannot hold head steady
•• Does not coo or make sounds
•• Does not bring things to mouth
•• Does not push down with legs when feet are placed on a
hard surface
•• Has trouble moving one or both eyes in all directions
Red flags at 6 months of age
•• Does not try to get things that are in reach

•• Shows no affection for caregivers
•• Does not respond to sounds around them
•• Has difficulty getting things to mouth
•• Does not make vowel sounds (“ah,” “eh,” “oh”)
•• Does not roll over in either direction

7

•• Does not laugh or make squealing sounds
•• Seems very stiff, with tight muscles
•• Seems very floppy, like a rag doll
Red flags at 9 months of age
•• Does not bear weight on legs with support
•• Does not sit with help
•• Does not babble (“mama,” “baba,” “dada”).
•• Does not play any games involving back-and-forth play
•• Does not respond to own name
•• Does not seem to recognize familiar people
•• Does not look where you point
•• Does not transfer toys from one hand to the other
Red flags at 1 year of age
•• Does not crawl
•• Cannot stand when supported
•• Does not search for things that they see you hide
•• Does not say single words like “mama” or “dada”
•• Does not learn gestures like waving or shaking head
•• Does not point to things
•• Lose skills they once had
Red flags at 18 months of age
•• Does not point to show things to others

•• Cannot walk
•• Does not know what familiar things are for
•• Does not copy others
•• Does not gain new words
•• Does not have at least six words
•• Does not notice or mind when a caregiver leaves or
returns
•• Loses skills they once had
Red flags at 2 years of age
•• Does not use two-word phrases (e.g., “drink milk”)
•• Does not know what to do with common things, like a
brush, phone, fork, spoon
•• Does not copy actions and words
•• Does not follow simple instructions
•• Does not walk steadily
•• Loses skills they once had
Red flags at 3 years of age
•• Falls down a lot or have trouble with stairs
•• Drools or have very unclear speech
•• Cannot work simple toys (such as peg boards, simple
puzzles, turning handle)
•• Does not speak in sentences
•• Does not understand simple instructions
•• Does not play, pretend, or make-believe
•• Does not want to play with other children or with toys
•• Does not make eye contact
•• Loses skills they once had


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8

Red flags at 4 years of age
•• Cannot jump in place
•• Has trouble scribbling
•• Shows no interest in interactive games or make-believe
•• Ignores other children or do not respond to people outside
the family
•• Resist dressing, sleeping, and using the toilet
•• Cannot retell a favorite story
•• Does not follow three-part commands
•• Does not understand “same” and “different”
•• Does not use “me” and “you” correctly
•• Speaks unclearly
•• Loses skills they once had

Cause of language developmental delay
•• Hearing impairment
•• Intellectual disability
•• Autism
•• Specific language disorders
•• Dysarthria
•• Dyspraxia
•• Maturation delay
•• Neglect

Red flags at 5 years of age
•• Does not show a wide range of emotions
•• Shows extreme behavior (unusually fearful, aggressive,

shy, or sad)
•• Unusually withdrawn and not active
•• Is easily distracted, has trouble focusing on one activity
for more than 5 min
•• Does not respond to people, or responds only superficially
•• Cannot tell what is real and what is make-believe
•• Does not play a variety of games and activities
•• Cannot give first and last name
•• Does not use plurals or past tense properly
•• Does not talk about daily activities or experiences
•• Does not draw pictures
•• Cannot brush teeth, wash and dry hands, or get undressed
without help
•• Loses skills they once had

Hepatitis B Vaccine

Language Development
Background
•• It is critical for pediatrician to know language development and possible causes of language delay (Table 2)

Table 2   Cognitive red flags
Age

Red flags

2 months
4 months
6 months
9 months

24 months

Lack of fixation
Lack of visual tracking
Failure to turn to sound or voice
Lack of babbling consonant sounds
Failure to use single words, cannot follow simple
direction, pointing instead of speaking
Failure to speak in three word sentence
Cannot tell story

3 years
4 years

Immunizations

Hepatitis B vaccine (HepB) at birth
•• Administer to all newborn before hospital discharge.
•• If mother is hepatitis B surface antigen positive (HBsAg)positive, administer HepB and 0.5 mL of hepatitis B
immunoglobulin (HBIG) within 12 h of birth.
•• If mother’s HBsAg status is unknown, administer HepB
within 12 h of birth and determine mother’s HBsAg status as soon as possible and if HBsAg-positive, administer
HBIG (not later than 1 week).
•• Infant born to HBsAg-positive mother should be tested
for HBsAg and antibodies to HBsAg 1 to 2 months after
completing the three doses of HepB series (on the next
well-visit).
Doses following birth dose (Table 3)
•• Administer the second dose 1-2 months after the first
dose (minimum interval of 4 weeks).

•• Administration of 4 doses of HepB is permissible if combination is used after birth dose.
•• The final third or fourth dose in HepB series should not
be administered before 6 months of age.
Table 3   Immunization schedule
Age
Birth
2 months
4 months
6 months

Vaccine

HepB
HepB, DTaP, Hib, IPV, PCV, RV
DTaP, Hib, IPV, PCV, RV
HepB, DTaP, Hiba, IPV, PCV, RVb,
Influenzac
12 months
Hib, PCV, Varicella, MMR, HepA
15–18 months
DTaP
18 months
HepA
4–6 years
DTap, IPV, MMR, Varicella
11–12 years
Tdap, MCV4, HPV
High risk
PPSV 2–18 years
MCV4 2–10 years

a Hib dose at 6 months is not required if using PedvaxHib or COMVAX
b Dose at 6 months is not required if using Rotarix,
c
Influenza every year beginning at 6 months


General Pediatrics

Catch-up vaccination
•• Unvaccinated person should complete a three-dose series.

Rotavirus Vaccine
Minimum age is 6 weeks
•• If Rotarix is used administer a 2-dose series at 2 and 4
months of age.
•• If RotaTeq is used, administer a 3-dose series at age 2, 4,
and 6 months.
Catch-up vaccination
•• The maximum age for the first dose in the series is 14
weeks, 6 days; vaccination should not be initiated in
infants of age 15 weeks, 0 days or older.
•• The maximum age for the final dose is 8 months, 0 days.

DTaP/Tdap Vaccine
DTaP
•• Composition: Diphtheria toxoid, tetanus toxoid, and acellular pertussis
•• Administration
–– DTaP given to children of more than 6 weeks and less
than 7 years of age.
–– Five-dose series DTaP vaccine at age 2, 4, 6, 15

through 18 months, and 4 through 6 years.
•• The fourth dose may be administered as early as 12
months, provided at least 6 months from the third dose.
•• Catch-up vaccination
–– The fifth dose of DTaP vaccine is not necessary if the
fourth dose was administered at age 4 years or older.
Tdap
•• Composition
–– Similar to DTaP but contain smaller amount of pertussis antigen
•• Administration
–– Administer one dose of Tdap vaccine to all adolescents
aged 11 through 12 years. Administer one dose of
Tdap to pregnant adolescents during each pregnancy
(preferred during 27 through 36 weeks gestation)
regardless of time since prior Td or Tdap vaccination.
•• Catch-up vaccination (Fig. 2)
–– Person aged 7 years and older who are not fully immunized with DTaP vaccine should receive Tdap vaccine
as one dose in the catch-up series; if additional doses
needed, use Td.
–– For those children between 7 and 10 years who receive
a dose of Tdap as part of catch-up series, an adolescent
Tdap vaccine dose at age 11 through 12 years should

9

NOT be administered. Td should be administered
instead 10 years after Tdap dose.
Absolute contraindication
•• History of encephalopathy within 7 days of dosing
Relative contraindication

•• History of fever > 40.5 °C (105 °F) within 48 h after prior
dose
•• Seizure within 3 days
•• Shock like condition within 2 days
•• Persistent crying for more than 3 h within 2 days
Vaccination may be administered under these conditions
•• Fever of < 105 °F (< 40.5 °C), fussiness, or mild drowsiness after a previous dose of DTaP
•• Family history of seizures
•• Family history of sudden infant death syndrome
•• Family history of an adverse event after DTaP administration
•• Stable neurologic conditions (e.g., cerebral palsy, wellcontrolled seizures, or developmental delay)

Haemophilus Influenzae Type b Conjugate
Vaccine (Hib)
Background
•• Hib vaccine prevent invasive bacterial infections usually
caused by H. influenzae type b.
•• Before the advent of an effective type b conjugate vaccine in 1988, H. influenzae type b was a major cause of
•• serious disease among children in all countries,
e.g.,
meningitis, epiglottitis.
Routine vaccination of HIB (Fig. 1)
•• Administer a 2- or 3-dose Hib vaccine primary series and
a booster dose (dose 3 or 4 depending on vaccine used in
primary series) at age 12 through 15 months to complete
a full Hib vaccine series.
•• The primary series with ActHIB, MenHibrix, or Pentacel
consists of 3 doses and should be administered at 2, 4,
and 6 months of age.
•• The primary series with PedvaxHib or COMVAX consists of 2 doses and should be administered at 2 and 4

months of age; a dose at age 6 months is not indicated.
•• One booster dose (dose 3 or 4 depending on vaccine used
in primary series) of any Hib vaccine should be administered at age 12 through 15 months.
•• An exception is Hiberix vaccine. Hiberix should only
be used for the booster (final) dose in children aged 12
months through 4 years who have received at least one
prior dose of Hib-containing vaccine.


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10

(FOR THOSE WHO FALL BEHIND OR START LATE, SEE THE CATCH-UP SCHEDULE [FIGURE 2]).
These recommendations must be read with the footnotes that follow. For those who fall behind or start late, provide catch-up vaccination at the earliest opportunity as indicated by the green bars in Figure 1.
To determine minimum intervals between doses, see the catch-up schedule (Figure 2). School entry and adolescent vaccine age groups are in bold.
Vaccine

Birth

Hepatitis B1 (HepB)

1st dose

1 mo

2 mos

4 mos

6 mos

2nd dose

9 mos

12 mos

15 mos

19–23
mos

2-3 yrs

4-6 yrs

1st dose

2nd dose

See
footnote 2

Diphtheria, tetanus, & acellular pertussis3 (DTaP: <7 yrs)

1st dose

2nd dose

3rd dose

1st dose

2nd dose

See
footnote 5

3 or 4 dose,
See footnote 5

1st dose

2nd dose

3rd dose

4th dose

1st dose

2nd dose

b5 (Hib)

Pneumococcal conjugate6
(PCV13)

11-12 yrs

13–15
yrs

16–18
yrs

5th dose

4th dose

Tetanus, diphtheria, & acellular pertussis4 (Tdap: >7 yrs)
type

7-10 yrs

3rd dose

Rotavirus (RV) RV1 (2-dose
series); RV5 (3-dose series)
2

18 mos

(Tdap)
rd

th

Pneumococcal polysaccharide6 (PPSV23)

Inactivated poliovirus7 (IPV)
(<18 yrs)
8 (IIV; LAIV) 2 doses
for some: See footnote 8

3rd dose

4th dose

Annual vaccination (IIV only)

Annual vaccination (IIV or LAIV)

Measles, mumps, rubella9
(MMR)

1st dose

2nd dose

Varicella1 0 (VAR)

1st dose

2nd dose

Hepatitis A11 (HepA)

2-dose series, See footnote 11

Human papillomavirus1 2
(HPV2: females only; HPV4:
males and females)

(3-dose
series)

Meningococcal1 3 (Hib-MenCY > 6 weeks; MenACWY-D
>9 mos; MenACWY-CRM
≥ 2 mos)
Range of
recommended ages for
all children

1st dose

See footnote 13

Range of recommended
ages for catch-up
immunization

Range of recommended
ages for certain high-risk
groups

Range of recommended ages
during which catch-up is
encouraged and for certain
high-risk groups

Booster

Not routinely
recommended

This schedule includes recommendations in effect as of January 1, 2014. Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and feasible. The use of a combination
vaccine generally is preferred over separate injections of its equivalent component vaccines. Vaccination providers should consult the relevant Advisory Committee on Immunization Practices (ACIP) statement for detailed
recommendations, available online at Clinically significant adverse events that follow vaccination should be reported to the Vaccine Adverse Event Reporting System
(VAERS) online () or by telephone (800-822-7967).Suspected cases of vaccine-preventable diseases should be reported to the state or local health department. Additional information, including
precautions and contraindications for vaccination, is available from CDC online ( or by telephone (800-CDC-INFO [800-232-4636]).
This schedule is approved by the Advisory Committee on Immunization Practices (http//www.cdc.gov/vaccines/acip), the American Academy of Pediatrics (), the American Academy of Family Physicians
(), and the American College of Obstetricians and Gynecologists ().

NOTE: The above recommendations must be read along with the footnotes of this schedule.

Fig. 1   Recommended immunization schedule for persons aged 0 through 18 years—USA, 2014


General Pediatrics

11

Footnotes — Recommended immunization schedule for persons aged 0 through 18 years—United States, 2014

For further guidance on the use of the vaccines mentioned below, see: />For vaccine recommendations for persons 19 years of age and older, see the adult immunization schedule.

Additional information
• For contraindications and precautions to use of a vaccine and for additional information regarding that vaccine, vaccination providers should consult the relevant ACIP statement available online
at />• For purposes of calculating intervals between doses, 4 weeks = 28 days. Intervals of 4 months or greater are determined by calendar months.

• Vaccine doses administered 4 days or less before the minimum interval are considered valid. Doses of any vaccine administered ≥5 days earlier than the minimum interval or minimum age
should not be counted as valid doses and should be repeated as age-appropriate. The repeat dose should be spaced after the invalid dose by the recommended minimum interval. For further
details, see MMWR, General Recommendations on Immunization and Reports / Vol. 60 / No. 2; Table 1. Recommended and minimum ages and intervals between vaccine doses available online at
/>• Information on travel vaccine requirements and recommendations is available at />•
,” in General Recommendations
on Immunization (ACIP), available at and American Academy of Pediatrics. Immunization in Special Clinical Circumstances, in Pickering LK, Baker CJ,
Kimberlin DW, Long SS eds. Red Book: 2012 report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics.
1.

2.

Hepatitis B (HepB) vaccine. (Minimum age: birth)
Routine vaccination:
At birth:
• Administer monovalent HepB vaccine to all newborns before hospital discharge.
• For infants born to hepatitis B surface antigen (HBsAg)-positive mothers, administer HepB vaccine and
0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth. These infants should be tested
for HBsAg and antibody to HBsAg (anti-HBs) 1 to 2 months after completion of the HepB series, at age
9 through 18 months (preferably at the next well-child visit).
• If mother’s HBsAg status is unknown, within 12 hours of birth administer HepB vaccine regardless of
birth weight. For infants weighing less than 2,000 grams, administer HBIG in addition to HepB vaccine
within 12 hours of birth. Determine mother’s HBsAg status as soon as possible and, if mother is HBsAgpositive, also administer HBIG for infants weighing 2,000 grams or more as soon as possible, but no
later than age 7 days.
Doses following the birth dose:
• The second dose should be administered at age 1 or 2 months. Monovalent HepB vaccine should be
used for doses administered before age 6 weeks.
• Infants who did not receive a birth dose should receive 3 doses of a HepB-containing vaccine on a
schedule of 0, 1 to 2 months, and 6 months starting as soon as feasible. See Figure 2.
•
administer the third dose at least 8 weeks after the second dose AND at least 16 weeks after the

age 24 weeks.
• Administration of a total of 4 doses of HepB vaccine is permitted when a combination vaccine
containing HepB is administered after the birth dose.
Catch-up vaccination:
• Unvaccinated persons should complete a 3-dose series.
• A 2-dose series (doses separated by at least 4 months) of adult formulation Recombivax HB is licensed
for use in children aged 11 through 15 years.
• For other catch-up guidance, see Figure 2.
Rotavirus (RV) vaccines. (Minimum age: 6 weeks for both RV1 [Rotarix] and RV5 [RotaTeq])
Routine vaccination:
Administer a series of RV vaccine to all infants as follows:
1. If Rotarix is used, administer a 2-dose series at 2 and 4 months of age.
2. If RotaTeq is used, administer a 3-dose series at ages 2, 4, and 6 months.
3. If any dose in the series was RotaTeq or vaccine product is unknown for any dose in the series, a total
of 3 doses of RV vaccine should be administered.
Catch-up vaccination:
•
initiated for infants aged 15 weeks, 0 days or older.
•
• For other catch-up guidance, see Figure 2.

3.

4.

5.

Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine. (Minimum age: 6 weeks.
Exception: DTaP-IPV [Kinrix]: 4 years)
Routine vaccination:

• Administer a 5-dose series of DTaP vaccine at ages 2, 4, 6, 15 through 18 months, and 4 through 6 years.
The fourth dose may be administered as early as age 12 months, provided at least 6 months have
elapsed since the third dose.
Catch-up vaccination:
•
• For other catch-up guidance, see Figure 2.
Tetanus and diphtheria toxoids and acellular pertussis (Tdap) vaccine. (Minimum age: 10 years for
Boostrix, 11 years for Adacel)
Routine vaccination:
• Administer 1 dose of Tdap vaccine to all adolescents aged 11 through 12 years.
• Tdap may be administered regardless of the interval since the last tetanus and diphtheria toxoid-containing vaccine.
• Administer 1 dose of Tdap vaccine to pregnant adolescents during each pregnancy (preferred during
27 through 36 weeks gestation) regardless of time since prior Td or Tdap vaccination.
Catch-up vaccination:
• Persons aged 7 years and older who are not fully immunized with DTaP vaccine should receive Tdap
vaccine. For children 7 through 10 years who receive a dose of Tdap as part of the catch-up series, an
adolescent Tdap vaccine dose at age 11 through 12 years should NOT be administered. Td should be
administered instead 10 years after the Tdap dose.
• Persons aged 11 through 18 years who have not received Tdap vaccine should receive a dose followed
by tetanus and diphtheria toxoids (Td) booster doses every 10 years thereafter.
• Inadvertent doses of DTaP vaccine:
- If administered inadvertently to a child aged 7 through 10 years may count as part of the catch-up
series. This dose may count as the adolescent Tdap dose, or the child can later receive a Tdap
booster dose at age 11 through 12 years.
- If administered inadvertently to an adolescent aged 11 through 18 years, the dose should be
counted as the adolescent Tdap booster.
• For other catch-up guidance, see Figure 2.
type b (Hib) conjugate vaccine. (Minimum age: 6 weeks for PRP-T [ACTHIB,
DTaP-IPV/Hib (Pentacel) and Hib-MenCY (MenHibrix)], PRP-OMP [PedvaxHIB or COMVAX], 12 months
for PRP-T [Hiberix])

Routine vaccination:
• Administer a 2- or 3-dose Hib vaccine primary series and a booster dose (dose 3 or 4 depending on
vaccine used in primary series) at age 12 through 15 months to complete a full Hib vaccine series.
• The primary series with ActHIB, MenHibrix, or Pentacel consists of 3 doses and should be administered
at 2, 4, and 6 months of age. The primary series with PedvaxHib or COMVAX consists of 2 doses and
should be administered at 2 and 4 months of age; a dose at age 6 months is not indicated.
• One booster dose (dose 3 or 4 depending on vaccine used in primary series) of any Hib vaccine should
be administered at age 12 through 15 months. An exception is Hiberix vaccine. Hiberix should only
least 1 prior dose of Hib-containing vaccine.

Fig. 1  (continued)


O. Naga

12
For further guidance on the use of the vaccines mentioned below, see: />5.

type b (Hib) conjugate vaccine (cont’d)
• For recommendations on the use of MenHibrix in patients at increased risk for meningococcal disease,
please refer to the meningococcal vaccine footnotes and also to MMWR March 22, 2013; 62(RR02);1-22,
available at />Catch-up vaccination:
•
weeks after dose 1, regardless of Hib vaccine used in the primary series.
•
•

6.

HIV infection; chronic renal failure; nephrotic syndrome; diseases associated with treatment with

immunosuppressive drugs or radiation therapy, including malignant neoplasms, leukemias, lymphomas, and
Hodgkin disease; generalized malignancy; solid organ transplantation; or multiple myeloma:
1. If neither PCV13 nor PPSV23 has been received previously, administer 1 dose of PCV13 now and 1
dose of PPSV23 at least 8 weeks later.
2. If PCV13 has been received previously but PPSV23 has not, administer 1 dose of PPSV23 at least 8
weeks after the most recent dose of PCV13.
3. If PPSV23 has been received but PCV13 has not, administer 1 dose of PCV13 at least 8 weeks after the
most recent dose of PPSV23.
• For children aged 6 through 18 years with chronic heart disease (particularly cyanotic congenital heart
disease and cardiac failure), chronic lung disease (including asthma if treated with high-dose oral
corticosteroid therapy), diabetes mellitus, alcoholism, or chronic liver disease, who have not received
PPSV23, administer 1 dose of PPSV23. If PCV13 has been received previously, then PPSV23 should be
administered at least 8 weeks after any prior PCV13 dose.
•
with sickle cell disease or other hemoglobinopathies; anatomic or functional asplenia; congenital

weeks after the second dose.

•
• For unvaccinated children aged 15 months or older, administer only 1 dose.
• For other catch-up guidance, see Figure 2. For catch-up guidance related to MenHibrix, please see the
meningococcal vaccine footnotes and also MMWR March 22, 2013; 62(RR02);1-22, available at
/>Vaccination of persons with high-risk conditions:
• Children aged 12 through 59 months who are at increased risk for Hib disease, including
chemotherapy recipients and those with anatomic or functional asplenia (including sickle cell disease),
months of age, should receive 2 additional doses of Hib vaccine 8 weeks apart; children who received
2 or more doses of Hib vaccine before 12 months of age should receive 1 additional dose.
• For patients younger than 5 years of age undergoing chemotherapy or radiation treatment who
received a Hib vaccine dose(s) within 14 days of starting therapy or during therapy, repeat the dose(s)
at least 3 months following therapy completion.

• Recipients of hematopoietic stem cell transplant (HSCT) should be revaccinated with a 3-dose regimen
of Hib vaccine starting 6 to 12 months after successful transplant, regardless of vaccination history;
doses should be administered at least 4 weeks apart.
• A single dose of any Hib-containing vaccine should be administered to unimmunized* children and
adolescents 15 months of age and older undergoing an elective splenectomy; if possible, vaccine
should be administered at least 14 days before procedure.
• Hib vaccine is not routinely recommended for patients 5 years or older. However, 1 dose of Hib vaccine
should be administered to unimmunized* persons aged 5 years or older who have anatomic or
functional asplenia (including sickle cell disease) and unvaccinated persons 5 through 18 years of age

6.

* Patients who have not received a primary series and booster dose or at least 1 dose of Hib vaccine
after 14 months of age are considered unimmunized.
Pneumococcal vaccines. (Minimum age: 6 weeks for PCV13, 2 years for PPSV23)
Routine vaccination with PCV13:
• Administer a 4-dose series of PCV13 vaccine at ages 2, 4, and 6 months and at age 12 through 15 months.
• For children aged 14 through 59 months who have received an age-appropriate series of 7-valent PCV
(PCV7), administer a single supplemental dose of 13-valent PCV (PCV13).
Catch-up vaccination with PCV13:
• Administer 1 dose of PCV13 to all healthy children aged 24 through 59 months who are not
completely vaccinated for their age.
• For other catch-up guidance, see Figure 2.
Vaccination of persons with high-risk conditions with PCV13 and PPSV23:
• All recommended PCV13 doses should be administered prior to PPSV23 vaccination if possible.
• For children 2 through 5 years of age with any of the following conditions: chronic heart disease
(particularly cyanotic congenital heart disease and cardiac failure); chronic lung disease (including
leak; cochlear implant; sickle cell disease and other hemoglobinopathies; anatomic or functional
asplenia; HIV infection; chronic renal failure; nephrotic syndrome; diseases associated with treatment
with immunosuppressive drugs or radiation therapy, including malignant neoplasms, leukemias,

1. Administer 1 dose of PCV13 if 3 doses of PCV (PCV7 and/or PCV13) were received previously.
2. Administer 2 doses of PCV13 at least 8 weeks apart if fewer than 3 doses of PCV (PCV7 and/or PCV13)
were received previously.

Fig. 1  (continued)

Pneumococcal vaccines (cont’d)
3. Administer 1 supplemental dose of PCV13 if 4 doses of PCV7 or other age-appropriate complete PCV7
series was received previously.
4. The minimum interval between doses of PCV (PCV7 or PCV13) is 8 weeks.
5. For children with no history of PPSV23 vaccination, administer PPSV23 at least 8 weeks after the most
recent dose of PCV13.
•

7.

8.

associated with treatment with immunosuppressive drugs or radiation therapy, including malignant
neoplasms, leukemias, lymphomas, and Hodgkin disease; generalized malignancy; solid organ
transplantation; or multiple myeloma.
Inactivated poliovirus vaccine (IPV). (Minimum age: 6 weeks)
Routine vaccination:
•
dose in the series should be administered on or after the fourth birthday and at least 6 months after
the previous dose.
Catch-up vaccination:
•
for imminent exposure to circulating poliovirus (i.e., travel to a polio-endemic region or during an outbreak).
• If 4 or more doses are administered before age 4 years, an additional dose should be administered at

age 4 through 6 years and at least 6 months after the previous dose.
• A fourth dose is not necessary if the third dose was administered at age 4 years or older and at least 6
months after the previous dose.
• If both OPV and IPV were administered as part of a series, a total of 4 doses should be administered, regardless
of the child’s current age. IPV is not routinely recommended for U.S. residents aged 18 years or older.
• For other catch-up guidance, see Figure 2.
Routine vaccination:
•
nonpregnant persons aged 2 through 49 years, either LAIV or IIV may be used. However, LAIV should
NOT be administered to some persons, including 1) those with asthma, 2) children 2 through 4 years who
had wheezing in the past 12 months, or 3) those who have any other underlying medical conditions that
MMWR
2013; 62 (No. RR-7):1-43, available at KWWSZZZFGFJRYPPZUSGIUUUUSGI.
For children aged 6 months through 8 years:
• For the 2013–14 season, administer 2 doses (separated by at least 4 weeks) to children who are
vaccinated previously will also need 2 doses. For additional guidance, follow dosing guidelines in the
MMWR 2013; 62 (No. RR-7):1-43, available at
/>
•
recommendations.
For persons aged 9 years and older:
• Administer 1 dose.


General Pediatrics

13

For further guidance on the use of the vaccines mentioned below, see: />9.

Measles, mumps, and rubella (MMR) vaccine. (Minimum age: 12 months for routine vaccination)
Routine vaccination:
• Administer a 2-dose series of MMR vaccine at ages12 through 15 months and 4 through 6 years. The second
• Administer 1 dose of MMR vaccine to infants aged 6 through 11 months before departure from the
United States for international travel. These children should be revaccinated with 2 doses of MMR
risk is high), and the second dose at least 4 weeks later.
• Administer 2 doses of MMR vaccine to children aged 12 months and older before departure from the

10.

and the second dose at least 4 weeks later.
Catch-up vaccination:
• Ensure that all school-aged children and adolescents have had 2 doses of MMR vaccine; the minimum
interval between the 2 doses is 4 weeks.
Varicella (VAR) vaccine. (Minimum age: 12 months)
Routine vaccination:
• Administer a 2-dose series of VAR vaccine at ages 12 through 15 months and 4 through 6 years. The
second dose may be administered before age 4 years, provided at least 3 months have elapsed since
accepted as valid.
Catch-up vaccination:
• Ensure that all persons aged 7 through 18 years without evidence of immunity (see MMWR 2007; 56
[No. RR-4], available at have 2 doses of varicella vaccine.
For children aged 7 through 12 years, the recommended minimum interval between doses is 3 months

11.

for persons aged 13 years and older, the minimum interval between doses is 4 weeks.
Hepatitis A (HepA) vaccine. (Minimum age: 12 months)
Routine vaccination:
• Initiate the 2-dose HepA vaccine series at 12 through 23 months; separate the 2 doses by 6 to 18 months.

• Children who have received 1 dose of HepA vaccine before age 24 months should receive a second dose
• For any person aged 2 years and older who has not already received the HepA vaccine series, 2 doses of
HepA vaccine separated by 6 to 18 months may be administered if immunity against hepatitis A virus
infection is desired.
Catch-up vaccination:
• The minimum interval between the two doses is 6 months.
Special populations:
• Administer 2 doses of HepA vaccine at least 6 months apart to previously unvaccinated persons who
live in areas where vaccination programs target older children, or who are at increased risk for infection.
This includes persons traveling to or working in countries that have high or intermediate endemicity of
infection; men having sex with men; users of injection and non-injection illicit drugs; persons who work
with HAV-infected primates or with HAV in a research laboratory; persons with clotting-factor disorders;
persons with chronic liver disease; and persons who anticipate close, personal contact (e.g., household

12.

soon as the adoption is planned, ideally 2 or more weeks before the arrival of the adoptee.
Human papillomavirus (HPV) vaccines. (Minimum age: 9 years for HPV2 [Cervarix] and HPV4
[Gardisil])
Routine vaccination:
• Administer a 3-dose series of HPV vaccine on a schedule of 0, 1-2, and 6 months to all adolescents aged 11
through 12 years. Either HPV4 or HPV2 may be used for females, and only HPV4 may be used for males.
• The vaccine series may be started at age 9 years.
•
interval of 12 weeks).
Catch-up vaccination:
• Administer the vaccine series to females (either HPV2 or HPV4) and males (HPV4) at age 13 through 18
years if not previously vaccinated.
• Use recommended routine dosing intervals (see above) for vaccine series catch-up.

Fig. 1  (continued)

13.

Meningococcal conjugate vaccines. (Minimum age: 6 weeks for Hib-MenCY [MenHibrix], 9 months for
MenACWY-D [Menactra], 2 months for MenACWY-CRM [Menveo])
Routine vaccination:
• Administer a single dose of Menactra or Menveo vaccine at age 11 through 12 years, with a booster
dose at age 16 years.
•
receive a 2-dose primary series of Menactra or Menveo with at least 8 weeks between doses.
• For children aged 2 months through 18 years with high-risk conditions, see below.
Catch-up vaccination:
• Administer Menactra or Menveo vaccine at age 13 through 18 years if not previously vaccinated.
•
age 16 through 18 years with a minimum interval of at least 8 weeks between doses.
•
• For other catch-up guidance, see Figure 2.
Vaccination of persons with high-risk conditions and other persons at increased risk of disease:
• Children with anatomic or functional asplenia (including sickle cell disease):
1. For children younger than 19 months of age, administer a 4-dose infant series of MenHibrix or Menveo
at 2, 4, 6, and 12 through 15 months of age.
2. For children aged 19 through 23 months who have not completed a series of MenHibrix or Menveo,
administer 2 primary doses of Menveo at least 3 months apart.
3. For children aged 24 months and older who have not received a complete series of MenHibrix or
Menveo or Menactra, administer 2 primary doses of either Menactra or Menveo at least 2 months apart.
If Menactra is administered to a child with asplenia (including sickle cell disease), do not administer
Menactra until 2 years of age and at least 4 weeks after the completion of all PCV13 doses.
•
1. For children younger than 19 months of age, administer a 4-dose infant series of either MenHibrix or

Menveo at 2, 4, 6, and 12 through 15 months of age.
2. For children 7 through 23 months who have not initiated vaccination, two options exist depending
on age and vaccine brand:
a. For children who initiate vaccination with Menveo at 7 months through 23 months of age, a 2-dose
series should be administered with the second dose after 12 months of age and at least 3 months
b. For children who initiate vaccination with Menactra at 9 months through 23 months of age, a 2-dose
series of Menactra should be administered at least 3 months apart.
c. For children aged 24 months and older who have not received a complete series of MenHibrix,
Menveo, or Menactra, administer 2 primary doses of either Menactra or Menveo at least 2 months
apart.
• For children who travel to or reside in countries in which meningococcal disease is hyperendemic
or epidemic, including countries in the African meningitis belt or the Hajj, administer an ageappropriate formulation and series of Menactra or Menveo for protection against serogroups A and
meningitis belt or the Hajj because it does not contain serogroups A or W.
• For children at risk during a community outbreak attributable to a vaccine serogroup, administer or
complete an age- and formulation-appropriate series of MenHibrix, Menactra, or Menveo.
• For booster doses among persons with high-risk conditions, refer to MMWR 2013; 62(RR02);1-22,
available at />Catch-up recommendations for persons with high-risk conditions:
1. If MenHibrix is administered to achieve protection against meningococcal disease, a complete ageappropriate series of MenHibrix should be administered.
2.
least 8 weeks apart to ensure protection against serogroups C and Y meningococcal disease.
3. For children who initiate vaccination with Menveo at 7 months through 9 months of age, a 2-dose
series should be administered with the second dose after 12 months of age and at least 3 months
4. For other catch-up recommendations for these persons, refer to MMWR 2013; 62(RR02);1-22, available
at />For complete information on use of meningococcal vaccines, including guidance related to
vaccination of persons at increased risk of infection, see MMWR March 22, 2013; 62(RR02);1-22,
available at />

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