Pediatric treatments and the adolescent patient

Assisting with treatments

The medical assistant may be involved in providing treatments for pediatric patients. The following sections examine two types of treatments.

Immunizations

Over the years, immunization has helped dramatically reduce potentially lethal childhood infections. The CDC website shows the 2022 immunization schedule from the CDC for children 0 through 18 years of age. All of the immunization schedules can be found on the CDC’s website at Child and Adolescent Immunization Schedule (Birth-18 Years).

The schedules are updated periodically as new vaccines become available, or research indicates a better method for giving the vaccine. The CDC recommends immunization against infectious diseases for all children, except those for whom a particular vaccination would pose a risk. However, each state develops its own immunization program and methods of enforcement - including which providers may administer vaccines and under what delegation, since there is no single national scope-of-practice rule for vaccine administration. Parents/guardians do have the right to refuse immunizations.

Vaccines contain attenuated (live, weakened) organisms, inactivated (killed) organisms, or their toxins/toxoids - all of which stimulate an active immune response in the body and result in the production of antibodies against the specific pathogen. The injected influenza vaccine and the inactivated poliovirus vaccine (IPV), for example, use killed rather than live organisms. Booster doses are usually equivalent to a single dose of the initial immunization. For some immunizations (e.g., tetanus), boosters are prescribed at designated intervals to ensure the maintenance of immune levels; the cutoff depends on the wound involved - a clean, minor wound needs a booster only if the last dose was 10 or more years ago, while a deep or contaminated (tetanus-prone) wound needs one if the last dose was 5 or more years ago. For example, a patient with a deep, dirt-contaminated wound and a tetanus shot from 6 years ago would need a booster now, even though 6 years wouldn’t trigger one for a clean wound.

Vaccine manufacturers have trade names for each product and have established protocols to ensure potency and stability. All vaccines are tested for safety and effectiveness. Every vaccine package has an insert that fully describes the following:

• The vaccine and its use
• The route of administration
• Adverse reactions
• Signs and symptoms the parent might observe after immunization that would indicate a potential problem

Unfavorable responses include high fever, swelling at the site of the injection, urticaria, breathing difficulties, severe headache, and convulsions. Any of these should be immediately reported to the provider. Vaccine storage should follow the manufacturer’s guidelines (e.g., some vaccines must be refrigerated; others must not be exposed to sunlight).

Some vaccines are grown in birds’ eggs or a medium made of animal organs, or they are weakened with chemicals. Egg allergy is no longer a reason to withhold influenza vaccine, however: the CDC recommends that people with an egg allergy of any severity receive any age-appropriate influenza vaccine with no extra precautions. Yellow fever vaccine, which is not given to people with a severe egg allergy, is an exception. The medical assistant must know the potential allergic problems, common symptoms, and adverse reactions to immunizations and must make sure the parent is informed.

Before a child or adult receives a vaccine, the healthcare provider is required by the National Childhood Vaccine Injury Act (NCVIA) to provide a copy of a Vaccine information statement (VIS) to either the adult patient or the child’s parent or legal guardian. A VIS provides information about the risks and benefits of each vaccine. If providing the parent or guardian with the VIS is the medical assistant’s responsibility, the assistant should do the following:

• Before administering the vaccine, give the parent the most current VIS available for that particular vaccine. Give the parent enough time to review the information, and then answer any questions or refer the parent’s concerns to the provider before administering the vaccine. VIS forms are available online in a number of languages to meet the needs of a diverse patient population.
• Document in the child’s health record the date the VIS was given and the publication date of the VIS (which appears on the bottom of the form).
• To make sure the office has the most current VIS forms, either call the state health department or refer to the CDC’s website at www.cdc.gov/vaccines/hcp/vis/current-vis.html. Forms can be printed directly from the site.
• If an informed consent form is required in your state, it must be signed and attached to the child’s health record or electronically signed in the child’s EHR before immunizations are given.
• Documentation of immunization administration must include the date the vaccine was administered, the manufacturer of the vaccine, the manufacturer’s lot number, the type of vaccine, the exact site of administration if an injection was given, any reported or observed side effects, the name and title of the person who administered the vaccine, and the address of the medical office where the vaccine was administered.
• An immunization record should be given to the parent. If it is in paper form (e.g., a booklet), it should be updated as needed to reflect the child’s current immunization status. Most EHRs allow for the immunization record to be printed after each immunization. Medical assistants should not only document the required details in the patient’s health record, but they should also complete the parent’s immunization record each time the child receives another vaccination or booster. These parent records help schools and day care centers determine the child’s immunization status. Some states are developing computerized immunization record systems.
• It is very important that vaccine vials are handled and stored properly to maintain the compound’s ability to fight disease. The CDC’s recommendations for vaccine management practices can be found on its website at Vaccine Storage and Handling.

Safe handling and storage of vaccines

The Centers for Disease Control and Prevention (CDC) has devised a list of important rules and steps to ensure safekeeping of a practice’s vaccine supply. This list can be used as a checklist in the office.

1. One person should be in charge of handling and storing vaccines at the facility, with a backup person to ensure proper management.
2. A vaccine inventory log should be maintained, recording the vaccine name, number of doses, date and condition received, manufacturer, lot number, and expiration date.
3. Vaccines should be stored in separate, self-contained units that refrigerate or freeze only. A household-style combination unit can be used to store only refrigerated vaccines; frozen vaccines must be kept in a separate, stand-alone freezer.
4. The vaccine refrigerator and freezer should not be used for food or drinks.
5. Vaccines should be stored in the middle of the refrigerator or freezer, not in the door.
6. New supplies should be placed behind the vials with the closest expiration date; the vials with the nearest expiration date should be used first.
7. A sign should be posted on the refrigerator door identifying which vaccines should be stored in either the refrigerator or the freezer.
8. One thermometer should be kept in the refrigerator and one in the freezer; the refrigerator temperature should be maintained at 36° to 46°F (2° to 8°C) and the freezer temperature at −58° to 5°F (−50° to −15°C) or colder.
9. Containers of water should be kept in the refrigerator and ice packs in the freezer to help maintain cold temperatures.
10. A temperature log should be kept on the refrigerator door; the refrigerator and freezer temperatures should be recorded twice a day: first thing in the morning and at the end of the day.
11. A “Do Not Unplug” sign should be posted next to the refrigerator’s electrical outlet.
12. If the refrigerator or freezer stops working, the following steps should be taken:
    • Immediately place the vaccines in another refrigerator or freezer and mark them so that they can be separated from vaccines that were not affected.
    • Record the temperature of the refrigerator or freezer and contact the vaccine manufacturer or state health department. Follow their instructions on the use, alteration of expiration dates, or disposal of the vaccines.
13. The facility should have a copy of the health department’s general and emergency vaccine management policies.

Nebulizers

Nebulizers are used to administer medication in a form that can be inhaled. A small machine is used to turn liquid medication into a fine mist. This is a useful method for treating certain respiratory conditions such as asthma, croup, or reactive airway disease. Nebulized albuterol is not recommended for routine treatment of bronchiolitis caused by respiratory syncytial virus (RSV) in infants and young children. Often the first dose is administered during the office visit. This serves two purposes. The provider can see if the medication is helpful, and the caregiver can be instructed on how to use the nebulizer. This type of treatment can be done at home.

The nebulizer treatment may be administered via a mask or a mouthpiece. Masks work better for younger patients because it is difficult for them to hold the mouthpiece in place. The medical assistant should provide written, detailed instructions to the caregiver and provide a phone number that the caregiver can call if they have questions.

The adolescent patient

One of the challenges of working in pediatrics is the wide age range of patients and the differing needs of those patients. Adolescent patients have different needs than younger patients. The following sections discuss how the medical assistant can meet the needs of the adolescent patient.

Examination

The adolescent patient may present the greatest challenge to health education and disease management. Adolescence begins with the onset of puberty, a time when the child’s reproductive system matures. This is a period marked by rapid changes in the endocrine and musculoskeletal systems. The adolescent undergoes rapid growth spurts and the development of secondary sexual characteristics.

Health examinations for patients in this age group should include the following:

• Screening for height and weight
• Gathering details about diet and exercise routines
• Screening for sexually transmitted infections (STIs)
• Human papillomavirus (HPV) vaccination status (cervical cancer screening with a Pap test does not begin until age 21, regardless of sexual activity)
• Reviewing the vaccination history and administering boosters as indicated
• Assessing for high-risk behaviors, such as substance abuse, smoking, and sexual behavior

Developing a trusting relationship with the adolescent patient is key to being able to provide the best possible care. Many adolescents are embarrassed by the types of questions and conversations they have during their examination as well as the examination itself. By being professional and empathetic, you can ensure that your patient is getting the care and support they need.