Child Health
It is the responsibility of all health care providers to ensure that the children in their catchment area are kept as healthy as possible. Many child health programmes are covered in the care of children in the community. Individual sections in these guidelines also include advice on prevention of various conditions. Other conditions are discussed in detail.
Programmes that help to keep children healthy include:
Adequate nutrition for all children and their parents
Growth monitoring
Ensure proper child care and stimulation to enhance adequate development
Immunization of all children
Screening for disabilities and adequate referral in all cases
Continued support for all children with chronic illnesses
School health programmes
Environmental sanitation and food hygiene
Immunization
The basic principle of immunization is to administer into a healthy person a vaccine that will prevent that person from getting a certain disease. Ideally, all children should complete their primary immunization by the age of 1 year. This may involve community activities to ensure each child has a card and that immunization is up to date. If by any chance the child’s immunization is incomplete, the parent is requested to take the child to an immunization centre at the earliest opportunity.
Immunization may be done with live attenuated vaccines (e.g., rubella, oral polio {OPV},measles, and BCG), inactivated or killed vaccines (e.g., Hib, IPV), or micro-organisms and detoxified toxins (e.g., tetanus). Generally, several vaccines can be given at the same time. This is important since it reduces that number of injections as well as visits to a health facility. BCG, OPV, DPT-HepB-Hib and measles vaccines can be given simultaneously if the child ios of the appropriate age and has not received the immunizations. A critically ill child needing hospital admission must be given the appropriate vaccines upon recovery.
IMMUNIZATION GUIDELINES
All parents are encouraged to take their children for immunization starting soon after birth. Presentation of the child health card at every visit to a health facility helps to detect those children who missed previous vaccinations. In the community, health workers can also check on these cards.
It is necessary that informed consent be obtained before any vaccination, from either the parent or the patient
Vaccine Administration
The following is important for vaccine administration:
The vaccine dose should always be checked against the instructions on the vaccine, but nearly all paediatric doses are 0.5ml.
Site for intramuscular vaccine administration for children under 2 years of age is on the antero-lateral aspect of the thigh, while those aged more than 2 years should be given in the deltoid if big enough. If they are not big enough, use the site as for a child under 2 years of age. All intramuscular vaccine administration must be deep into muscle.
Simultaneous administration of uncombined live vaccines must be given at different sites.
Minimum interval between vaccine doses should be 4 weeks.
Age at Vaccination
Vaccines are given at specific ages, in accordance with the national immunization schedule shown below. The list includes vaccines not currently on the national vaccination schedule, but indicates when such vaccines could be given.
Vaccines given at birth are BCG, OPV, Hepatitis B vaccines.
Vaccines given at 6 weeks, 10 weeks, and 14 weeks include OPV, diphtheria, pertussis, tetanus, Hepatitis B, Haemophilus influenza b
Vaccines given at 9 months include measles and yellow fever.
Other vaccines not on the national vaccination schedule but which can be given between 6 weeks and 12 months include conjugate pneumococcal vaccine and meningococcal vaccine.
Vaccination of the preterm baby follows the chronological age rather than weight, although HepB should be given when the baby weighs at least 2 kg.
Vaccines given between the ages of 12-24 months include measles, mumps and rubella, varicella, and any of the above if missed or booster doses for DPT and Hib.
Vaccines given between 2 and 5 years include DPT-HepB=Hib if never given, varicella, HepA, pneumococcal vaccine, meningococcal and influenza vaccines.
Vaccines given above 6 years (including adults) and comprise tetanus vaccine (with booster every 10 years), pneumococcal, HepB,HepA, influenza (very useful for elderly), and meningococcal vaccines.
Specific Instructions
The following are general instructions with respect to immunization:
A slight fever and/or other minor illness should not prevent you from immunizing a child.
Children should be vaccinated during recovery from a serious illness if they had missed the vaccine.
Mothers/child-caregivers should be informed about possible side effects of each of the given vaccines.
All vaccinations should be recorded on tally sheets and on the Child Health Immunization cards and mothers should be instructed to always bring the cards along with them when taking children to a health facility.
Mothers should be instructed to return the child for the next immunization on the date indicated on the card.
The disposal of used sharp syringes should be handled appropriately to prevent injury and spread of diseases like HIV.
To ensure appropriate cold storage of the vaccines, follow the recommended cold-chain instructions for each of the vaccines carefully. All the vaccines and diluents must be kept cold. DPT, HB, nad TT vaccines are damaged if kept below 0 degrees celsius and therefore should never be frozen. Always check the Vaccine Vial Monitor (VVM). The cold chain should be maintained because vaccines are easily destroyed by heat and rendered ineffective.
Hands should be washed before and after handling vaccines.
Contra indications
A definite severe reaction to a preceding vaccine dose is a contra-indication to further doses of the same vaccine
IMMUNIZATION IN SPECIAL SITUATIONS
Immunization in immunocompromised Host
HIV/AIDS infection:
HIV exposed and asymptomatic children infected with HIV should receive all standard Kenya Expanded Programme on Immunization (KEPI) vaccines.
BCG vaccination should not be repeated if there is no reaction and live vaccines are avoided for children in stages in clinical stage 3 or 4 of the disease and immunological stage 3.
Oncology patients:
Live vaccines are best given during remission
Corticosteroid therapy (high dose):
Live vaccines can be given after cessation of therapy. If they cannot discontinue, do not give.
Pregnancy:
Generally live vaccines are contraindicated during pregnancy unless the risk of disease outweighs the risk of vaccines, e.g., yellow fever epidemic.
Side Effects and Adverse Reactions to Vaccinations
The side effects ranges from mild to severe for various vaccines
BCG vaccine: These include injection abscess, regional or widespread lymphadenitis, osteomyelitis, and disseminated BCG infection. These should be treated with anti-tuberculosis drugs.
Oral polio vaccine: Adverse reactions rarely occur
Measles vaccine: Adverse reactions include fever, mild rash, and rarely convulsions and encephalitis
DPT (diphtheria, pertussis, tetanus): Most adverse reactions are attributed to the pertussis component. Minor reactions include pain at the injection site and fever. Major reactions are persistent crying, high pitched cry, excessive somnolence, convulsions, encephalopathy, and coma.
Recombinant DNA Hepatitis B vaccines: Side effects include pain, fever,and swelling at the site of injection.
IMMUNIZATION SCHEDULE FOR PREGNANT MOTHERS WITH TETANUS TOXOID (TT2+)
1st dose with first pregnancy or subsequent pregnancy
2nd dose-4 weeks after first dose
3rd dose-6 months after 2nd dose
4th dose-at least 1 year after the third dose
5th dose-at least 1 year after the fourth dose
A total of 5 doses is recommended during a woman’s reproductive age. The 3rd, 4th, and 5th doses can be given in subsequent pregnancies if not given as suggested above. Immunizing a pregnant mother ensures protection of here newborn baby against tetanus.
VITAMIN A SUPPLEMENTS
Strictly speaking, vitamin A is not a vaccine but is an important immune booster. It is currently recommended to be given to all under-5 children
Vitamin A supplementation schedule
Dosage (in IU) When to give
<6 months-50,000 A dose can be given to a non-breastfeeding baby in the first 6
6-12 months-100,000 months. Otherwise first dose is at 6 months then every 6
>12 months-200,000 months (twice per year) up to the age of 60 months. All
Mothers are given 200,000IU immediately after birth or within
First month of delivery.
IMMUNE GLOBULINS (PASSIVE IMMUNIZATIONS)
These may be nonspecific or specific and are given either IM or IV.
Non specific immunoglobulins: Can be used as replacement in individuals with antibody deficiency disorders.
Specific immunoglobulins: Prepared from donors known to have high antibodies to specific antigens or specific sources. Very useful in post exposure prophylaxis (PEP). Examples include rabies, varicella, and RhO(D) immune globulin (anti D).
RABIES
Any mammalian animal may carry rabies. Saliva from a rabid animal contains a large number of the rabies virus, which is inoculated through a bite or any laceration or break in the skin.
Management
Emergency care for a suspected rabid bite includes the following
Thorough irrigation of bite with copious amounts of saline solution.
Cleansing the bite with a soap solution.
Debridement of the bite area.
Administration of antibiotic.
Delayed suture or skin grafting
Infiltrate the wound with rabies immunoglobulin
Indications for rabies are like the following:
Bites from wild animals
Bites from UNPROVOKED domestic animal
Bites from a sick looking domestic animal, whether immunized or not
Laboratory findings of Negri bodies in the brain of the involved animal
Persons at high risk of exposure.
NB: Always refer as soon as possible to a centre that can vaccinate.