A 4-month-old boy is brought to the office for a well-child visit. The boy is rolling over and cooing. He reaches for toys and mouths them frequently. He is breastfed exclusively and takes a multivitamin with iron. Last week, the patient was diagnosed with acute otitis media and croup, which were treated with a 10-day course of amoxicillin and a single dose of dexamethasone. He is currently on day 6 of antibiotics and is no longer irritable or coughing. His last fever was 4 days ago. The patient lives at home with his parents and sister age 3. His sister has a seizure disorder of unclear etiology that is well controlled on antiepileptic medication. Temperature is 36.7 C (98.1 F). Physical examination is normal for his age. The infant is scheduled to receive several immunizations today as part of the recommended schedule. The parents express concern about their son receiving the diphtheria-tetanus-acellular pertussis vaccination. The father says, "After he got his shots the first time, he had a fever of 103 and was so fussy that we had to take him to the urgent care clinic to make sure he was okay. I'm not sure I can go through that again." Based on this child's history, which of the following is the most appropriate step regarding DTaP administration in this patient?

Question

A 4-month-old boy is brought to the office for a well-child visit.  The boy is rolling over and cooing.  He reaches for toys and mouths them frequently.  He is breastfed exclusively and takes a multivitamin with iron.  Last week, the patient was diagnosed with acute otitis media and croup, which were treated with a 10-day course of amoxicillin and a single dose of dexamethasone.  He is currently on day 6 of antibiotics and is no longer irritable or coughing.  His last fever was 4 days ago.  The patient lives at home with his parents and sister age 3.  His sister has a seizure disorder of unclear etiology that is well controlled on antiepileptic medication.  Temperature is 36.7 C (98.1 F).  Physical examination is normal for his age.  The infant is scheduled to receive several immunizations today as part of the recommended schedule.  The parents express concern about their son receiving the diphtheria-tetanus-acellular pertussis vaccination.  The father says, "After he got his shots the first time, he had a fever of 103 and was so fussy that we had to take him to the urgent care clinic to make sure he was okay.  I'm not sure I can go through that again."  Based on this child's history, which of the following is the most appropriate step regarding DTaP administration in this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bddd_e946_8f63_495d01165a1c_MD0005_00 Diphtheria-tetanus-acellular pertussis (DTaP) immunization virtually eliminated diphtheria and tetanus in the United States and markedly reduced the incidence and severity of pertussis. DTaP is composed of conjugated acellular pertussis antigen (pertactin) as well as diphtheria and tetanus toxoid. The DTaP vaccine has an excellent safety profile. Either of 2 serious complications is an absolute contraindication to future DTaP immunization: anaphylaxis immediately after the vaccination or encephalopathy within 7 days. The latter reaction is due to the pertussis components, and children who can no longer receive pertussis immunization can still receive tetanus and diphtheria toxoid (Td) vaccines. Relative contraindications (eg, situations in which immunizations are normally given but might be deferred if risks are perceived to outweigh benefits) include extremely high fever (>40.6 C [105 F]) or seizures following previous DTaP vaccination or ongoing evaluation for a neurologic condition. Since this child has no absolute or relative contraindications, he should receive DTaP as scheduled. (Choice A) Fever <40.6 C (105 F) and local site reactions (eg, erythema, swelling) are common following DTaP administration and are not contraindications to future doses. (Choice B) A family history of encephalopathy, seizures, or other central nervous system disorders is not a contraindication to immunization for this child, whose development is normal and who has had no seizures. (Choice D) Immunosuppression of any kind is not a contraindication to DTaP immunization. The immune dysfunction following a single dose of dexamethasone is mild and short-lived. (Choice E) Minor illnesses such as acute otitis media and croup are not contraindications to the DTaP immunization. There is no benefit to waiting until antibiotic therapy has been completed. Educational objective: Anaphylaxis or encephalopathy following diphtheria-tetanus-acellular pertussis vaccine is an absolute contraindication to receiving additional doses. Minor illnesses, local site reactions, and immunosuppression are not contraindications. References: Update on child and adolescent immunizations: selected review of US recommendations and literature. (http://www.ncbi.nlm.nih.gov/pubmed/22572761)

A 4-Month-Old Boy Is Brought to the Office for a Well-Child