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WELL BABY VISIT AND IMMUNIZATION SCHEDULE

A current schedule of the necessary routine well baby or child (WC) visit and immunizations given at each visit are detailed below. Please be aware that this is a “fluid” schedule. Immunization recommendations change and certain vaccine are available in several different forms or combinations. The office may use certain “combination” vaccine products that will not be available under the Government vaccine program usually given to Medicaid recipients. Please be aware that we are at the mercy of the State of Florida’s purchasing program for these vaccines and it is very possible that a combination vaccine mentioned below will not be available under the Government vaccine program. In addition when “new” vaccines become available, the schedule or order provided below may change. Please check with us during any of your WC visits for any new changes. Don’t worry you do not need to remember or memorize this schedule, that’s our job. This is to help you understand the recommendations. As always please feel free to ask questions. You will also receive printed information regarding all of these vaccines and well visits.

Please note that insurance companies, Medicaid and even the school system have set timelines that must be honored if you want their reimbursement for or recognition of your child’s immunization. After each WC visit we will give you a specific time recommendation for the next visit. If you need to change a WC appointment that has already been made, please be sure to still pay attention to the previously recommended time frame. For example, for the 6 month and 1 year Immunizations, immunizations will not be recognized by the State of Florida if these vaccines were given at 5 months and 29 days of age or at 364 days of age respectively.

First Visit- This visit is usually done just 1 to 5 days after your new baby’s discharge from the hospital. Dr. Rachesky will tell you, while in the hospital, when to bring your child to the office. If unsure, please call the office. We prefer that you call ahead and schedule this visit. If necessary, due to weekend or holiday schedules, we can provide this visit on the same day that you call, if you call early in the day. At anytime if you have concerns regarding your newborn, please call. We can always see your infant “ahead of schedule.”

Two Week visit- After the first visit, we see you and your infant again in approximately 7-14 days. We refer to this as the 2 week visit. This visit is especially important because we need to ensure that your infant has regained any weight that was lost initially. In addition, this office provides a dilated eye exam, in order to identify early any newborn cataracts which, if found, would require therapy as soon as possible to prevent blindness. If your baby’s NBMST (newborn metabolic screening tests) results have not been received, then we ask that you call the office back again in 1 to 2 weeks to ensure that these important results were received and were normal.

Two Month visit- This visit is typically the first WC visit which involves immunizations.  You will have been provided literature previously containing Immunization information, but you will also receive Vaccine Information Sheets (VIS), vaccine permits as well as other information sheet concerning these vaccines at this and every subsequent WC. Dr. Rachesky as well as the Nurse Practitioner, Cathy Glidden, and Physician’s Assistant, Jennifer Wit, will also discuss the purpose and benefits of each vaccine as well as any contraindications (not able to take them) or potential side effects. We will answer your questions before any vaccines are given. Vaccinations are NOT given without the informed written consent of the child’s parent or legal guardian.

Immunization:1. Pentacel #1- combination of Diphtheria, acellular Pertussis (whooping cough), Tetanus (DaPT) combined with Haemophilus influenza type b (Hib) and injectable killed polio (IPV); if the combination vaccine is not available then your child will receive individual vaccines of DaPT, IPV and Hib

            2. Prevnar 13 #1- (PCV13, Pneumococcal vaccine)

            3. Hepatitis B #2 - (HBV) The first HBV is usually given in the Nursery.

            4. Rotavirus #1 – (Rota) This is the only oral (taken by mouth) vaccine.

Four Month visit- This visit must be 8 weeks or more after the first visit (under special circumstances a 6 week interval may be allowed.) All of the above procedures and recommendations concerning Immunizations and vaccine administration apply just as mentioned above, for this and all subsequent WC visits involving immunizations.

Immunization: 1. Pentacel #2 (or DaPT #2, IPV #2, Hib #2)

            2. PCV 13 #2

            3. Rota #2

(note HBV is not given at this visit unless your baby did NOT receive HBV in the newborn nursery. In that case the HBV #1 is given at age 2 months and the HBV #2 given at 4 months.)

Six Month visit- This visit is a time sensitive visit and needs to be done on or after you baby’s 6 month birthday.

Immunization: 1. Pentacel #3 (or DaPT #3 and Hib #3, IPV #3 can be given now or at 9 months of age)

            2. PCV 13 #3

            3. Rota #3, the final dose in the series

            4. During “flu season” the first of 2 Flu (influenza) vaccines are given. The second dose is given 1 month later as an immunization only. A specific office visit or appointment is not necessary. You will come in for the vaccine only for this second dose.

Nine Month visit- This visit is an important milestone visit. During this visit, in addition to all of our developmental screening questionnaires and tools, we also have you complete an optional “First Words” evaluation which will be scored by FSU’s College of Communication. At this visit we also perform a Hemoglobin test to confirm that your child’s “normal” anemia of infancy has resolved. We will also talk extensively about transitioning in feeding.

Immunization: 1. HBV #3 if not completed previously

            2. If Pentacel NOT used then give IPV #3 if not already done

            3. Flu vaccine if during flu season and not completed previously

One Year visit- This visit is also time sensitive. Your infant needs to be 1 year of age or older. During this visit we wish to ensure that you have been able to transition your baby off of the bottle and onto the cup. At the next 3 visits 1 year, 15 months and 18 months, there is some variability or additional options regarding timing of vaccinations. As a general rule the following schedule is followed.

Immunization: 1. Hepatitis A #1 (HAV)

            2. PCV 13 #4, final dose in the series

            3. If Pentacel NOT used then give DaPT #4 – For this vaccine, there must be 6 months or at least 24 weeks after the #3 dose. If it has been less than 24 weeks then other options of vaccines may be used.

            4. Flu vaccine if during flu season and not completed previously

Fifteen Month visit- This visit is not time sensitive and can occur a little before or after the 15 month birthday.

Immunization: 1. Pentacel #4 – For this vaccine, there must be 6 months or at least 24 weeks after the #3 dose. If it has been less than 24 weeks then other options of vaccines may be used. If Pentacel is used this will be the final dose of Hib #4 (included in Pentacel.)

2. Measles, Mumps and Rubella #1 (MMR)

            3. Chicken Pox (Varicella) #1 (VZV). Both MMR and VZV are live attenuated (weakened) vaccines. They are safe for infants with normal immune systems (not on chemotherapy or daily systemic steroids and not HIV positive.) As with any “live” vaccine, these vaccines must be given on the same day or they must be given at least 1 month apart. We will be happy to explain both of these vaccines in great detail to you at your visit. You may even request copies of our VIS or permit information before the visit, if you would prefer

            3. If Pentacel NOT used then give Hib #4, the final dose in the series

            4. Ensure that Pentacel #4 or DaPT #4 has been completed

            5. Flu vaccine if during flu season and not completed previously

Eighteen Month visit- This visit may occur a little before or after the 18 month birthday. It is often timed to be 6 months after the date the HAV #1 vaccine was given. This is a very important developmental check up visit.

Immunization: 1. HAV #2 final dose in the series. It must be at least 6 months (24 weeks) since HAV #1 was given.

            2. Flu vaccine if during flu season and not completed previously

By this visit your child should have received at least 4 each of Pentacel and PCV 13. If Pentacel was not used your child should have 4 each of DaPT and Hib and at least 3 IPV. All infants should have also completed 3 each of HBV and Rotavirus, 2 each of HAV and Flu, and 1 each of MMR and VZV.

Note the Menactra vaccine for meningococcemia and meningitis is presently given starting at age 11 yrs. In 2011, the FDA did approve the vaccine for use in infants but the AAP (American Academy of Pediatrics) and the ACIP (American Council on Immunization Practices) did not yet offer their endorsement of this vaccine for infants as of yet. It is possible that this will be added to the well baby immunization schedule in the near future. We do recommend this vaccine and as always are happy to provide additional information to you regarding this is you so desire.

YEARLY WELL CHILD AND IMMUNIZATION SCHEDULE

Many families question the need for a Well Child exam if immunizations are not required. Immunizations are only one small aspect of maintaining your child’s overall good health. There are many changes (physical, emotional, developmental) occurring to your child during their toddler and school age years. Many diseases can be recognized early during “well child” visits. In addition developmental concerns can be recognized early, treated and often resolved during the course of these very important well child exams. Further “adult” medical problems may often be avoided if lifestyle or other problems are recognized and corrected during childhood.

With all of our toddler visits, we will access your child’s developmental status and provide for you guidelines on what to expect next and how to teach your child important new skills unique to each age.

For all yearly well checks, we will perform a weight, height and Blood Pressure check on your child. We will “plot” their growth on the “Growth Charts” and inform you of their growth percentiles. We will also calculate and plot their Body Mass Index (BMI.)

Visits are recommended yearly.

Significant visits for immunizations or testing are listed below.

If your child is attending Daycare or needs a “school” physical form completed please inform the nurse or MA at the start of your visit so that the form can be completed before the end of your visit.

Two Year visit- This visit can occur at any time after your child’s second birthday. If your child was born during the winter months, has completed all of their infant immunizations AND is developing well with a vocabulary of over 20- 30 words, then we may “delay” this visit until the spring, summer or possibly early fall months. Typically these times of year are less hectic at the office with fewer “ill” patients in the office. In addition spring and summer visits usually correlate better with Physical Examinations required for school or sports participation. After the 2 year visit subsequent well visits occur yearly thereafter. If not completed already, guidance for toilet training will be provided.

Four to Five year visit or the Pre-Kindergarten visit- When your child enters either Public 4K or Private 5K, they will need to have a complete preK physical exam, immunizations and laboratory studies preformed. We still recommend both a 4 year and 5 year visit. Typically, due to cooperation issues in 4 year olds, we only do the recommended hearing and vision assessment and laboratory studies at the 5 year visit. But any child in the Public School system must have their “Kindergarten” immunizations completed if they are 4 years of age or older.

Immunizations: See well infant section for additional details

            1.DaPT #5 (note if your child is over 4 years of age and has not completed a 4th DaPT previously, then this “4th DaPT” will be the final DaPT  and a 5th DaPT will not be needed.)

            2.IPV #4 (note if your child is over 4 years of age and has not completed a 3rd IPV previously, then this 3rd “IPV” will be the final IPV  and a 4th IPV will not be needed.)

            3.MMR #2

            4.VZV #2

Screening evaluations: As always, for all yearly well checks, we will perform a weight, height and Blood Pressure check on your child. We will “plot” their growth on the “Growth Charts” and inform you of their growth percentiles. We will also calculate and plot their Body Mass Index (BMI.)

            1.Vision screening

            2.Hearing screening

            3.Developmental screening and school readiness

            4.Hemoglobin to check for anemia

            5.Urinanalysis


Yearly School Age Visits- While immunizations, expect for yearly Flu vaccine, are usually not indicated again until the 6th grade, pre 7th grade visit, these yearly well visits are very important. We must closely monitor your child’s yearly growth rate as well as their growth percentile curves and BMI status. Many medical causes of delayed or abnormal growth can be corrected if identified early, before puberty has arrived. In addition, monitoring your child during the transitions of puberty is also necessary. In addition, we will provide for you information relevant to your child’s age with each of these visits.

Eleven to Twelve Year old visit – 6th grade or pre-7th grade visit- Before your child will be allowed into 7th grade they must have received a Tdap vaccine. Please remember to schedule your child for this visit sometime during or just after their 6th grade school year. This visit is also important as it may be the last visit when growth delays due to hormonal defects could be treated in the critical pre-puberty period.

Immunization: 1. Tdap (Tetanus with diphtheria and acellular pertussis or whooping cough.) This should be used instead of a regular Tetanus or dT shot. If for some reason your child requires a “tetanus shot” after the age of 9-10, for an injury, be sure to request a Tdap at that time and not a regular dT shot.

            2. Menactra #1 (meningococcal vaccine)

            3. optional if not already completed VZV #2

            4. yearly Flu vaccine as nasal Flumist or injectable Flu vaccine as indicated

            5. Optional Human Papilloma Virus vaccine (HPV) but we usually start this at age 12 -13 unless there is concern for early exposure to HPV.

Screening studies: 1. Urinanalysis

                   2. Hemoglobin in females

Adolescent visits – All of the above mention reasons for well visits still apply. In addition college applications often have specific and unique recommendations specific to each college. If your child is applying to college, please assess and bring in the physical examination form so we can be sure that additional laboratory studies, such a Tuberculosis testing or immunization titers can be ordered and the results received BEFORE the application deadline. Please try to plan ahead for this. Certain tests can take weeks for the results to arrive.

Immunization: 1. HPV #1. This vaccine is voluntary but highly recommended for all adolescents both male and female. It is a 3 immunization series with unique timing of vaccines.

                a.HPV #2 is given 2 months AFTER HPV #1

                b.HPV #3 is given 4 months AFTER HPV #2 (not just 6 months after HPV #1)

            2. Menactra #2 given 5 years after Menactra #1

            3. Yearly Flumist or Flu shot if indicated

Sports participation or Summer Camp Physical Examinations- These visits are usually done at the same time as your adolescent or well child exams. Please inform us ahead of time or at least at the time of your child’s well exam if one of these forms is required. Please bring in the specific form (we may possibly have a form but this is not always the case) required by the school or organization. It is imperative that the parent and/or child complete all of the health questions that are asked on the form. These questions are important as possible screening tools for risks from physical exertion. No sports physical examination can rule out all potential problems that can occur as a result of sports. This is especially true for some possibly fatal cardiac disorders such as arrhythmias or hypertrophic cardiomyopathy. Often, but not always, children will have had some warning signs or symptoms previously during physical activity. These important symptoms may indicate the need for a complete cardiac work-up on your child. Many questions are also asked of you and your child by the Nurse/MA working your child up as well as by the Dr/ARNP/PA examining your child.  Your visit will go more quickly if the nurse is aware of the need for these questions initially so that the appropriate questions can be asked and forms can be completed before the Doctor or Nurse Practitioner or Physician’s Assistant examines your child.

Please ask for our Sports Participation and Heat Stroke Prevention Handouts during this visit or at any other time if you desire the information.

Please be advised that the Immunization Schedule is a "fluid" document. It may change as a result of vaccine availability due to manufacturer shortages or be updated as new vaccines or recommendations emerge. Please always check with Dr. Rachesky or Nurse Glidden during your appointment for the most up to date information. No vaccines will be administered to your child without your informed consent. You will be informed both in writing with the Vaccine Information Sheets (VIS) and permits as well as by discussion with your child's Doctor or Nurse.

Copyrighted 2011 by Dr. Rachesky. All rights are reserved