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Recommended Immunizat Children and Adolescents Aged 18 Years o This schedule was updated for Caring for Our Children online version in 2018. • Consult relevant ACIP statements for detailed recommendations The tab To check for the latest edition, go to http://www.cdc.gov/vaccines/schedules. (www.cdc.gov/vaccines/hcp/acip-recs/index.html). ed for c identifi • When a vaccine is not administered at the recommended age, administer at a subsequent visit. Diphth • Use combination vaccines instead of separate injections when Diphth appropriate. Haemo • Report clinically signi cant adverse events to the Vaccine Adverse Hepat Event Reporting System (VAERS) online (www.vaers.hhs.gov) or by Hepat telephone (800-822-7967). Huma • Report suspected cases of reportable vaccine-preventable diseases Influen to your state or local health department. Measle Menin • For information about precautions and contraindications, see www. cdc.gov/vaccines/hcp/acip-recs/general-recs/contraindications.html. Menin Approved by the Pneum Advisory Committee on Immunization Practices Pneum Poliov (www.cdc.gov/vaccines/acip) Rotavi American Academy of Pediatrics Tetanu (www.aap.org) Tetanu Varice American Academy of Family Physicians (www.aafp.org) American College of Obstetricians and Gynecologists DTaP, h (www.acog.org) DTaP, i type B This schedule includes recommendations in e ect as of January 1, 2018. DTaP a Measle U.S. Department of Health and Human Services Centers for Disease Control and Prevention

G tion Schedule for 468 or Younger, UNITED STATES, 2018 Appendix G: Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger ble below shows vaccine acronyms, and brand names for vaccines routinely recommend- children and adolescents. The use of trade names in this immunization schedule is for APPENDIX G: RECOMMENDED IMMUNIZATION SCHEDULE FOR CHILDREN fication purposes only and does not imply endorsement by the ACIP or CDC. AND ADOLESCENTS AGED 18 YEARS OR YOUNGER Vaccine type Abbreviation Brand(s) heria, tetanus, and acellular pertussis vaccine DTaP Daptacel Infanrix heria, tetanus vaccine DT No Trade Name ophilus influenzae type B vaccine Hib (PRP-T ) ActHIB Hib (PRP-OMP) Hiberix PedvaxHIB titis A vaccine HepA Havrix Vaqta titis B vaccine HepB Engerix-B Recombivax HB an papillomavirus vaccine HPV Gardasil 9 nza vaccine (inactivated) IIV Multiple es, mumps, and rubella vaccine MMR M-M-R II ngococcal serogroups A, C, W, Y vaccine MenACWY-D Menactra MenACWY-CRM Menveo ngococcal serogroup B vaccine MenB-4C Bexsero MenB-FHbp Trumenba mococcal 13-valent conjugate vaccine PCV13 Prevnar 13 mococcal 23-valent polysaccharide vaccine PPSV23 Pneumovax virus vaccine (inactivated) IPV IPOL irus vaccines RV1 Rotarix RV5 RotaTeq us, diphtheria, and acellular pertussis vaccine Tdap Adacel Boostrix us and diphtheria vaccine Td Tenivac No Trade Name ella vaccine VAR Varivax Combination Vaccines hepatitis B and inactivated poliovirus vaccine DTaP-HepB-IPV Pediarix inactivated poliovirus and Haemophilus influenzae DTaP-IPV/Hib Pentacel B vaccine and inactivated poliovirus vaccine DTaP-IPV Kinrix Quadracel es, mumps, rubella, and varicella vaccines MMRV ProQuad Appendix G

Caring for Our Children: National Health and Figure 1. Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Young (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, To determine minimum intervals between doses, see the catch-up schedule (Figure 2). School entry and ado Vaccine Birth 1 mo 2 mos 4 mos 6 mos 9 mos 12 mos 15 Hepatitis B1 (HepB) 1st dose 2nd dose 3rd dose Rotavirus2 (RV) RV1 (2-dose 1st dose 2nd dose See series); RV5 (3-dose series) 1st dose footnote 2 1st dose Diphtheria, tetanus, & acellular 1st dose 2nd dose 3rd dose pertussis3 (DTaP: <7 yrs) 1st dose 2nd dose See 3rd or 4th do Haemophilus influenzae type b4 footnote 4 See footnot (Hib) 2nd dose 3rd dose 4th dose Pneumococcal conjugate5 3rd dose (PCV13) 2nd dose Inactivated poliovirus6 (IPV: <18 yrs) Influenza7 (IIV) Annual Measles, mumps, rubella8 (MMR) See footnote 8 1st dose Varicella9 (VAR) 1st dose Hepatitis A1 0 (HepA) 2-dose See footnote 11 Meningococcal1 1 (MenACWY-D >9 mos; MenACWY-CRM ≥2 mos) Tetanus, diphtheria, & acellular pertussis1 3 (Tdap: >7 yrs) Human papillomavirus1 4 (HPV) Meningococcal B1 2 Pneumococcal polysaccharide5 Range of recommended ages Range of recommend (PPSV23) for catch-up immunization for certain high-risk g Range of recommended ages for all children NOTE: The above recommendations must be read along with the footnotes of this s

d Safety Performance Standards G ger—United States, 2018. , provide catch-up vaccination at the earliest opportunity as indicated by the green bars in Figure 1. olescent vaccine age groups are shaded in gray. 5 mos 18 mos 19-23 2-3 yrs 4-6 yrs 7-10 yrs 11-12 yrs 13-15 yrs 16 yrs 17-18 yrs mos 4th dose 5th dose 469 ose, te 4 Appendix G: Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger l vaccination (IIV ) 1 or 2 doses 4th dose Annual vaccination (IIV ) series, See footnote 10 1 dose only 2nd dose 2nd dose 1st dose 2nd dose Tdap See footnote 14 See footnote 12 ded ages See footnote 5 No recommendation groups Range of recommended ages for non-high-risk groups that may receive vaccine, subject to schedule. individual clinical decision making Appendix G

FIGURE 2. Catch-up immunization schedule for persons aged 4 months–18 years who sta The figure below provides catch-up schedules and minimum intervals between doses for children whose vaccinations h doses. Use the section appropriate for the child’s age. Always use this table in conjunction with Figure 1 and the footnot Children age 4 mon Vaccine Minimum Dose 1 to Dose 2 Age for Dose 1 Hepatitis B1 Birth 4 weeks 8 weeks and at least 16 weeks after first d Minimum age for the final dose is 24 wee This schedule was updated for Caring for Our Children online version in 2018. Rotavirus2 6 weeks 4 weeks 4 weeks2 To check for the latest edition, go to http://www.cdc.gov/vaccines/schedules. Diphtheria, tetanus, and Maximum age Maximum age for final dose is 8 months, for first dose is acellular pertussis3 14 weeks, 6 days 4 weeks 4 weeks Haemophilus influenzae 6 weeks 4 weeks 4 weeks4 type b4 if first dose was administered if current age is younger than 12 month 6 weeks before the 1st birthday. and at least 1 previous dose was PRP-T 8 weeks (as final dose) 8 weeks and age 12 through 59 month if first dose was administered at age 12 through 14 months. • if current age is younger than 12 m No further doses needed if first months; dose was administered at age 15 OR months or older. • if current age is 12 through 59 mon second dose administered at young OR • if both doses were PRP-OMP (Pedva Pneumococcal 6 weeks 4 weeks No further doses needed if previous do conjugate5 if first dose administered before the 6 weeks 1st birthday. 4 weeks Inactivated poliovirus6 12 months 8 weeks (as final dose for healthy if current age is younger than 12 months Measles, mumps, rubella8 12 months children) 8 weeks (as final dose for healthy childr 12 months if first dose was administered at the if previous dose given between 7-11 m Varicella9 1st birthday or after. OR Hepatitis A10 6 weeks No further doses needed if current age is 12 months or older and Meningococcal11 for healthy children if first dose was No further doses needed for healthy ch (MenACWY-D ≥9 mos; administered at age 24 months or MenACWY-CRM ≥2 mos) older. 4 weeks6 if current age is < 4 years 6 months (as final dose) if current age is 4 4 weeks6 4 weeks 3 months 6 months 8 weeks11 See footnote 11 Children and adolescent Meningococcal11 Not Applicable 8 weeks11 (MenACWY-D ≥9 mos; (N/A) MenACWY-CRM ≥2 mos) Tetanus, diphtheria; 7 years13 4 weeks 4 weeks tetanus, dpieprhtuthsesirsia13, and if first dose of DTaP/DT was administered acellular 9 years 6 months 6 months (as final dose) N/A 4 weeks if first dose of DTaP/DT or Tdap/Td was Human papillomavirus14 N/A Hepatitis A10 8 weeks and at least 16 weeks after firs Hepatitis B1 Inactivated poliovirus6 N/A 4 weeks 6 months6 A fourth dose is not necessary if the third after the previous dose. Measles, mumps, rubella8 N/A 4 weeks Varicella9 N/A 3 months if younger than age 13 years. 4 weeks if age 13 years or older. NOTE: The above recommendations must be read along with the footnotes of this schedule.

G art late or who are more than 1 month behind—United States, 2018. 470 have been delayed. A vaccine series does not need to be restarted, regardless of the time that has elapsed between Appendix G: Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger tes that follow. nths through 6 years Minimum Interval Between Doses Dose 2 to Dose 3 Dose 3 to Dose 4 Dose 4 to Dose 5 dose. eks. 0 days. 6 months 6 months3 hs and first dose was administered at younger than age 7 months, 8 weeks (as final dose) (ActHib, Pentacel, Hiberix) or unknown. This dose only necessary for chil- dren age 12 through 59 months hs (as final dose)4 who received 3 doses before the 1st months and first dose was administered at age 7 through 11 birthday. nths and first dose was administered before the 1st birthday, and ger than 15 months; axHIB; Comvax) and were administered before the 1st birthday. ose was administered at age 15 months or older. s and previous dose given at <7 months old. 8 weeks (as final dose) ren) This dose only necessary for chil- months (wait until at least 12 months old); dren aged 12 through 59 months d at least 1 dose was given before age 12 months. who received 3 doses before age 12 hildren if previous dose administered at age 24 months or older. months or for children at high risk who received 3 doses at any age. 4 years or older 6 months6 (minimum age 4 years for final dose). See footnote 11 ts age 7 through 18 years before the 1st birthday. 6 months if first dose of DTaP/DT administered at or after the 1st birthday. was administered before the 1st Routine dosing intervals are recommended.14 birthday. st dose. A fourth dose of IPV is indicated if all previous doses were administered d dose was administered at age 4 years or older and at least 6 months at <4 years or if the third dose was administered <6 months after the second dose. Appendix G

Caring for Our Children: National Health Figure 3. Vaccines that might be indicated for children and adolescents aged 1 HIV infection CD4+ count† VACCINE  INDICATION  Pregnancy Immunocompromised <15% or ≥15% or status (excluding HIV total CD4 total CD4 cell count of cell count of infection) <200/mm3 ≥200/mm3 This schedule was updated for Caring for Our Children online version in 2018. Hepatitis B1 To check for the latest edition, go to http://www.cdc.gov/vaccines/schedules. Rotavirus2 SCID* Diphtheria, tetanus, & acellular pertussis3 (DTaP) Haemophilus influenzae type b4 Pneumococcal conjugate5 Inactivated poliovirus6 Influenza7 Measles, mumps, rubella8 Varicella9 Hepatitis A1 0 Meningococcal ACWY1 1 Tetanus, diphtheria, & acellular pertussis1 3 ( Tdap) Human papillomavirus1 4 Meningococcal B1 2 Pneumococcal polysaccharide5 Vaccination according to the Recommended for persons with Vaccination is r routine schedule recommended an additional risk factor for which and additional the vaccine would be indicated necessary base condition. See f *Severe Combined Immunodeficiency †For additional information regarding HIV laboratory parameters and use of live vaccines; see the General Best Prac al-recs/immunocompetence.html; and Table 4-1 (footnote D) at: www.cdc.gov/vaccines/hcp/acip-recs/general-recs NOTE: The above recommendations must be read along with the footnotes of this sched

and Safety Performance Standards G 18 years or younger based on medical indications Kidney failure, end- Heart disease, CSF leaks/ Asplenia and persistent Chronic Diabetes stage renal disease, on chronic lung disease cochlear complement component liver implants hemodialysis deficiencies disease recommended, No recommendation Contraindicated Precaution for vaccination 471 doses may be Appendix G: Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger ed on medical footnotes. ctice Guidelines for Immunization “Altered Immunocompetence” at: www.cdc.gov/vaccines/hcp/acip-recs/gener- s/contraindications.html. dule. Appendix G

This schedule was updated for Caring for Our Children online version in 2018. Footnotes — Recommended Immunization Schedule for Children an To check for the latest edition, go to http://www.cdc.gov/vaccines/schedules. For further guidance on the use of the vaccines mentioned below, see: www.cd For vaccine recommendations for persons 19 years of age and older, see the Ad Additional information • For information on contraindications and precautions for the use of a vaccine, consu statements, at www.cdc.gov/vaccines/hcp/acip-recs/index.html. • For calculating intervals between doses, 4 weeks = 28 days. Intervals of >4 months a • Within a number range (e.g., 12–18), a dash (–) should be read as “through.” • Vaccine doses administered ≤4 days before the minimum age or interval are conside interval or minimum age should not be counted as valid and should be repeated as the recommended minimum interval. For further details, see Table 3-1, Recommende Guidelines for Immunization at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/tim • Information on travel vaccine requirements and recommendations is available at ww • For vaccination of persons with immunodeficiencies, see Table 8-1, Vaccination of pe Guidelines for Immunization, at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/im Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2015 report of the Comm Pediatrics, 2015:68-107). • The National Vaccine Injury Compensation Program (VICP) is a no-fault alternative to adolescent vaccines are covered by VICP except for pneumococcal polysaccharide v index.html. 1. Hepatitis B (HepB) vaccine. (minimum age: birth) • Infants who did not receiv Birth Dose (Monovalent HepB vaccine only): begin the series as soon a • Mother is HBsAg-Negative: 1 dose within 24 hours of birth for medically stable infants >2,000 • Administration of 4 doses grams. Infants <2,000 grams administer 1 dose at combination vaccine cont chronological age 1 month or hospital discharge. the birth dose. • Mother is HBsAg-Positive: Give HepB vaccine and 0.5 mL of HBIG (at • Minimum age for the fina separate anatomic sites) within 12 hours of weeks. birth, regardless of birth weight. Test for HBsAg and anti-HBs at age 9–12 • Minimum Intervals: Dos months. If HepB series is delayed, test 1–2 Dose 2 to Dose 3: 8 weeks months after final dose. weeks. (When 4 doses are • Mother’s HBsAg status is unknown: 4” for “Dose 3” in these cal Give HepB vaccine within 12 hours of birth, regardless of birth weight. Catch-up vaccination: For infants <2,000 grams, give 0.5 mL of HBIG • Unvaccinated persons sho in addition to HepB vaccine within 12 hours of birth. series at 0, 1–2, and 6 mon Determine mother’s HBsAg status as soon as • Adolescents 11–15 years o possible. If mother is HBsAg-positive, give 0.5 mL of HBIG to infants >2,000 grams as soon as alternative 2-dose schedu possible, but no later than 7 days of age. between doses (adult form HB only). Routine Series: • For other catch-up guidan • A complete series is 3 doses at 0, 1–2, and 6–18 2. Rotavirus vaccines. (minim months. (Monovalent HepB vaccine should be Routine vaccination: used for doses given before age 6 weeks.) Rotarix: 2-dose series a RotaTeq: 3-dose series If any dose in the series is ei unknown, default to 3-dose

G nd Adolescents Aged 18 Years or Younger, UNITED STATES, 2018 472 dc.gov/vaccines/hcp/acip-recs/index.html. Appendix G: Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger dult Immunization Schedule. ult the General Best Practice Guidelines for Immunization and relevant ACIP are determined by calendar months. ered valid. Doses of any vaccine administered ≥5 days earlier than the minimum age-appropriate. The repeat dose should be spaced after the invalid dose by ed and minimum ages and intervals between vaccine doses, in General Best Practice ming.html. wwnc.cdc.gov/travel/. ersons with primary and secondary immunodeficiencies, in General Best Practice mmunocompetence.html; and Immunization in Special Clinical Circumstances. (In: mittee on Infectious Diseases. 30th ed. Elk Grove Village, IL: American Academy of o the traditional legal system for resolving vaccine injury claims. All routine child and vaccine (PPSV23). For more information; see www.hrsa.gov/vaccinecompensation/ ve a birth dose should Catch-up vaccination: as feasible (see Figure 2). • Do not start the series on or after age 15 weeks, 0 s is permitted when a days. taining HepB is used after • The maximum age for the final dose is 8 months, 0 al (3rd or 4th) dose: 24 days. • For other catch-up guidance, see Figure 2. se 1 to Dose 2: 4 weeks / s / Dose 1 to Dose 3: 16 3. Diphtheria, tetanus, and acellular pertussis (DTaP) e given, substitute “Dose vaccine. (minimum age: 6 weeks [4 years for lculations.) Kinrix or Quadracel]) Routine vaccination: ould complete a 3-dose • 5-dose series at 2, 4, 6, and 15–18 months, and 4–6 nths. years. of age may use an Prospectively: A 4th dose may be given as ule, with at least 4 months early as age 12 months if at least 6 months mulation Recombivax have elapsed since the 3rd dose. Retrospectively: A 4th dose that was nce, see Figure 2. inadvertently given as early as 12 months may mum age: 6 weeks) be counted if at least 4 months have elapsed since the 3rd dose. at 2 and 4 months. at 2, 4, and 6 months. Catch-up vaccination: ither RotaTeq or • The 5th dose is not necessary if the 4th dose was e series. administered at 4 years or older. • For other catch-up guidance, see Figure 2. Appendix G

Caring for Our Children: National Health an For further guidance on the use of the vaccines mentioned below, see: www.c 4. Haemophilus influenzae type b (Hib) vaccine. • HIV infection (minimum age: 6 weeks) 12–59 months Unvaccinated or on This schedule was updated for Caring for Our Children online version in 2018. Routine vaccination: months: Give 2 dos To check for the latest edition, go to http://www.cdc.gov/vaccines/schedules. • ActHIB, Hiberix, or Pentacel: 4-dose series at 2, 4, 2 or more doses be dose, at least 8 wee 6, and 12–15 months. • PedvaxHIB: 3-dose series at 2, 4, and 12–15 months. Catch-up vaccination: Unimmunized* persons 5 • 1st dose at 7–11 months: Give 2nd dose at least 4 Give 1 dose weeks later and 3rd (final) dose at 12–15 months or • Immunoglobulin defic 8 weeks after 2nd dose (whichever is later). complement deficienc • 1st dose at 12–14 months: Give 2nd (final) dose at 12–59 months least 8 weeks after 1st dose. Unvaccinated or on • 1st dose before 12 months and 2nd dose before months: Give 2 dos 15 months: Give 3rd (final) dose 8 weeks after 2nd 2 or more doses be dose. dose, at least 8 wee • 2 doses of PedvaxHIB before 12 months: Give 3rd (final) dose at 12–59 months and at least 8 weeks *Unimmunized = Less than after 2nd dose. months) OR no doses (14 • Unvaccinated at 15–59 months: 1 dose. • For other catch-up guidance, see Figure 2. 5. Pneumococcal vaccines. Special Situations: [PCV13], 2 years [PPSV2 • Chemotherapy or radiation treatment Routine vaccination with 12–59 months • 4-dose series at 2, 4, 6, a Catch-up vaccination wi Unvaccinated or only 1 dose before 12 months: • 1 dose for healthy child Give 2 doses, 8 weeks apart with any incomplete* P 2 or more doses before 12 months: Give 1 dose, • For other catch-up guid at least 8 weeks after previous dose. Special situations: High- Doses given within 14 days of starting therapy or Administer PCV13 doses during therapy should be repeated at least 3 months possible. after therapy completion. Chronic heart disease (p • Hematopoietic stem cell transplant (HSCT) congenital heart disease • 3-dose series with doses 4 weeks apart starting 6 to chronic lung disease (inc 12 months after successful transplant (regardless of with high-dose, oral, cor Hib vaccination history). mellitus: • Anatomic or functional asplenia (including sickle Age 2–5 years: cell disease) • Any incomplete* sched 12–59 months 3 PCV13 doses: 1 do Unvaccinated or only 1 dose before 12 months: weeks after any prio Give 2 doses, 8 weeks apart. 2 or more doses before 12 months: Give 1 dose, <3 PCV13 doses: 2 d at least 8 weeks after previous dose. after the most recen apart. Unimmunized* persons 5 years or older • No history of PPSV23: 1 Give 1 dose weeks after any prior PC • Elective splenectomy Age 6-18 years: Unimmunized* persons 15 months or older • No history of PPSV23: 1 Give 1 dose (preferably at least 14 days before procedure). weeks after any prior PC

nd Safety Performance Standards G cdc.gov/vaccines/hcp/acip-recs/index.html. Cerebrospinal fluid leak; cochlear implant: nly 1 dose before 12 Age 2–5 years: 473 ses 8 weeks apart. • Any incomplete* schedules with: efore 12 months: Give 1 Appendix G: Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger eks after previous dose. 3 PCV13 doses: 1 dose of PCV13 (at least 8 weeks after any prior PCV13 dose). 5–18 years <3 PCV13 doses: 2 doses of PCV13, 8 weeks after the most recent dose and given 8 weeks apart. ciency, early component • No history of PPSV23: 1 dose of PPSV23 (at least 8 cy weeks after any prior PCV13 dose). nly 1 dose before 12 Age 6–18 years: ses, 8 weeks apart. • No history of either PCV13 or PPSV23: 1 dose of PCV13, 1 dose of PPSV23 at least 8 weeks later. • Any PCV13 but no PPSV23: 1 dose of PPSV23 at efore 12 months: Give 1 least 8 weeks after the most recent dose of PCV13 eks after previous dose. n routine series (through 14 • PPSV23 but no PCV13: 1 dose of PCV13 at least 8 weeks after the most recent dose of PPSV23. months or older) . (minimum age: 6 weeks Sickle cell disease and other hemoglobinopathies; 23]) anatomic or functional asplenia; congenital h PCV13: or acquired immunodeficiency; HIV infection; and 12–15 months. chronic renal failure; nephrotic syndrome; ith PCV13: malignant neoplasms, leukemias, lymphomas, dren aged 24–59 months Hodgkin disease, and other diseases associated PCV13 schedule with treatment with immunosuppressive drugs dance, see Figure 2. or radiation therapy; solid organ transplantation; -risk conditions: multiple myeloma: s before PPSV23 if Age 2–5 years: • Any incomplete* schedules with: particularly cyanotic e and cardiac failure); 3 PCV13 doses: 1 dose of PCV13 (at least 8 cluding asthma treated weeks after any prior PCV13 dose). rticosteroids); diabetes <3 PCV13 doses: 2 doses of PCV13, 8 weeks dules with: after the most recent dose and given 8 weeks ose of PCV13 (at least 8 apart. or PCV13 dose). doses of PCV13, 8 weeks • No history of PPSV23: 1 dose of PPSV23 (at least 8 nt dose and given 8 weeks weeks after any prior PCV13 dose) and a 2nd dose of PPSV23 5 years later. 1 dose of PPSV23 (at least 8 CV13 dose). Age 6–18 years: • No history of either PCV13 or PPSV23: 1 dose of 1 dose of PPSV23 (at least 8 CV13 dose). PCV13, 2 doses of PPSV23 (1st dose of PPSV23 administered 8 weeks after PCV13 and 2nd dose of PPSV23 administered at least 5 years after the 1st dose of PPSV23). • Any PCV13 but no PPSV23: 2 doses of PPSV23 (1st dose of PPSV23 to be given 8 weeks after the most recent dose of PCV13 and 2nd dose of PPSV23 administered at least 5 years after the 1st dose of PPSV23). Appendix G

Caring for Our Children: National Health an For further guidance on the use of the vaccines mentioned below, see: www.c • PPSV23 but no PCV13: 1 dose of PCV13 at least 8 7. Influenza vaccines. (min weeks after the most recent PPSV23 dose and a 2nd Routine vaccination: dose of PPSV23 to be given 5 years after the 1st dose • Administer an age-appro of PPSV23 and at least 8 weeks after a dose of PCV13. dose of influenza vaccin Children 6 months Chronic liver disease, alcoholism: receive at least 2 do before July 1, 2017 s This schedule was updated for Caring for Our Children online version in 2018. Age 6–18 years: separated by at leas To check for the latest edition, go to http://www.cdc.gov/vaccines/schedules. • No history of PPSV23: 1 dose of PPSV23 (at least 8 Persons 9 years an • Live attenuated influenz weeks after any prior PCV13 dose). recommended for the 20 *Incomplete schedules are any schedules where • For additional guidance, PCV13 doses have not been completed according to influenza vaccine recom ACIP recommended catch-up schedules. The total August 25, 2017;66(2):1- number and timing of doses for complete PCV13 volumes/66/rr/pdfs/rr66 series are dictated by the age at first vaccination. See (For the 2018–19 season, se Tables 8 and 9 in the ACIP pneumococcal vaccine influenza vaccine recomme recommendations (www.cdc.gov/mmwr/pdf/rr/ rr5911.pdf ) for complete schedule details. 8. Measles, mumps, and ru (minimum age: 12 month 6. Inactivated poliovirus vaccine (IPV). (minimum Routine vaccination: age: 6 weeks) • 2-dose series at 12–15 m Routine vaccination: • The 2nd dose may be giv • 4-dose series at ages 2, 4, 6–18 months, and 4–6 years. the 1st dose. Administer the final dose on or after the 4th birthday and at least 6 months after the previous dose. Catch-up vaccination: • In the first 6 months of life, use minimum ages and Catch-up vaccination: intervals only for travel to a polio-endemic region or • Unvaccinated children a during an outbreak. least 4 weeks apart. • If 4 or more doses were given before the 4th birthday, International travel: give 1 more dose at age 4–6 years and at least 6 • Infants 6–11 months: 1 months after the previous dose. Revaccinate with 2 dose • A 4th dose is not necessary if the 3rd dose was given months for children in h on or after the 4th birthday and at least 6 months as early as 4 weeks later. after the previous dose. • Unvaccinated children 2 doses at least 4 weeks • IPV is not routinely recommended for U.S. residents Mumps outbreak: 18 years and older. • Persons ≥12 months wh ≤2 doses of mumps-con Series Containing Oral Polio Vaccine (OPV), either identified by public heal mixed OPV-IPV or OPV-only series: increased risk during a m • Total number of doses needed to complete the series receive a dose of mump is the same as that recommended for the U.S. IPV 9. Varicella (VAR) vaccine. ( schedule. See www.cdc.gov/mmwr/volumes/66/wr/ mm6601a6.htm?s_cid=mm6601a6_w. • Only trivalent OPV (tOPV ) counts toward the U.S. vaccination requirements. For guidance to assess doses documented as “OPV” see www. Routine vaccination: cdc.gov/mmwr/volumes/66/wr/mm6606a7. • 2-dose series: 12–15 mo htm?s_cid=mm6606a7_w. • The 2nd dose may be giv • For other catch-up guidance, see Figure 2. after the 1st dose (a dose interval may be counted

nd Safety Performance Standards G cdc.gov/vaccines/hcp/acip-recs/index.html. 474 nimum age: 6 months) Catch-up vaccination: Appendix G: Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger opriate formulation and • Ensure persons 7–18 years without evidence of ne annually. immunity (see MMWR 2007;56[No. RR-4], at s–8 years who did not www.cdc.gov/mmwr/pdf/rr/rr5604.pdf ) have 2 oses of influenza vaccine doses of varicella vaccine: should receive 2 doses st 4 weeks. Ages 7–12: routine interval 3 months (minimum interval: 4 weeks). Ages 13 and older: minimum interval 4 weeks. nd older 1 dose 10. Hepatitis A (HepA) vaccine. (minimum age: 12 za vaccine (LAIV) not months) 017–18 season. Routine vaccination: , see the 2017–18 ACIP • 2 doses, separated by 6-18 months, between the 1st and 2nd birthdays. (A series begun before the mmendations (MMWR 2nd birthday should be completed even if the child -20: www.cdc.gov/mmwr/ turns 2 before the second dose is given.) 602.pdf ). Catch-up vaccination: ee the 2018–19 ACIP • Anyone 2 years of age or older may receive HepA endations.) vaccine if desired. Minimum interval between doses is 6 months. ubella (MMR) vaccine. hs for routine vaccination) Special populations: months and 4–6 years. Previously unvaccinated persons who should be ven as early as 4 weeks after vaccinated: • Persons traveling to or working in countries with and adolescents: 2 doses at high or intermediate endemicity 1 dose before departure. • Men who have sex with men es at 12–15 months (12 • Users of injection and non-injection drugs high-risk areas) and 2nd dose • Persons who work with hepatitis A virus in a . n 12 months and older: research laboratory or with non-human primates • Persons with clotting-factor disorders apart before departure. • Persons with chronic liver disease ho previously received • Persons who anticipate close, personal contact ntaining vaccine and are (e.g., household or regular babysitting) with an lth authorities to be at international adoptee during the first 60 days after mumps outbreak should arrival in the United States from a country with high ps-virus containing vaccine. or intermediate endemicity (administer the 1st dose (minimum age: 12 months) as soon as the adoption is planned—ideally at least onths and 4–6 years. 2 weeks before the adoptee’s arrival). ven as early as 3 months 11. Serogroup A, C, W, Y meningococcal vaccines. e given after a 4-week (Minimum age: 2 months [Menveo], 9 months d). [Menactra]. Routine: • 2-dose series: 11-12 years and 16 years. Catch-Up: • Age 13-15 years: 1 dose now and booster at age 16-18 years. Minimum interval 8 weeks. • Age 16-18 years: 1 dose. Appendix G

Caring for Our Children: National Health a For further guidance on the use of the vaccines mentioned below, see: www.c This schedule was updated for Caring for Our Children online version in 2018. Special populations and situations: 12. Serogroup B meningoco To check for the latest edition, go to http://www.cdc.gov/vaccines/schedules. Anatomic or functional asplenia, sickle cell disease, age: 10 years [Bexsero, T HIV infection, persistent complement component Clinical discretion: Adole deficiency (including eculizumab use): risk for meningococcal B • Menveo MenB vaccine. MenB vaccines may be giv 1st dose at 8 weeks: 4-dose series at 2, 4, 6, and 12 adolescents 16–23 years (p months. who are not at increased r 1st dose at 7–23 months: 2 doses (2nd dose at • Bexsero: 2 doses at leas least 12 weeks after the 1st dose and after the 1st • Trumenba: 2 doses at le birthday). 2nd dose is given earlie 1st dose at 24 months or older: 2 doses at least 8 dose at least 4 months a weeks apart. Special populations and • Menactra Anatomic or functional a Persistent complement component deficiency: disease, persistent comp deficiency (including ecu 9–23 months: 2 doses at least 12 weeks apart B meningococcal disease 24 months or older: 2 doses at least 8 weeks • Bexsero: 2-dose series a apart • Trumenba: 3-dose serie Anatomic or functional asplenia, sickle cell disease, or HIV infection: Note: Bexsero and Trume 24 months or older: 2 doses at least 8 weeks interchangeable. apart. For additional meningoco Menactra must be administered at least 4 information, see meningo weeks after completion of PCV13 series. at: www.cdc.gov/vaccines Children who travel to or live in countries where specific/mening.html. meningococcal disease is hyperendemic or epidemic, including countries in the African 13. Tetanus, diphtheria, and meningitis belt or during the Hajj, or exposure to an (Tdap) vaccine. (minimu outbreak attributable to a vaccine serogroup: routine vaccinations, 7 y • Children <24 months of age: vaccination) Menveo (2-23 months): Routine vaccination: 1st dose at 8 weeks: 4-dose series at 2, 4, 6, and • Adolescents 11–12 yea 12 months. • Pregnant adolescents: 1st dose at 7-23 months: 2 doses (2nd dose at pregnancy (preferably d least 12 weeks after the 1st dose and after the gestational weeks 27–3 1st birthday). • Tdap may be administe Menactra (9-23 months): interval since the last te 2 doses (2nd dose at least 12 weeks after the toxoid-containing vacci 1st dose. 2nd dose may be administered as Catch-up vaccination: early as 8 weeks after the 1st dose in travelers). • Adolescents 13–18 wh • Children 2 years or older: 1 dose of Menveo or 1 dose, followed by a Td Menactra. • Persons aged 7–18 yea with DTaP: 1 dose of Td Note: Menactra should be given either before or at series (preferably the fir the same time as DTaP. For MenACWY booster dose are needed, use Td. recommendations for groups listed under “Special populations and situations” above, and additional meningococcal vaccination information, see meningococcal MMWR publications at: www.cdc.gov/ vaccines/hcp/acip-recs/vacc-specific/mening.html.

and Safety Performance Standards G cdc.gov/vaccines/hcp/acip-recs/index.html. occal vaccines (minimum • Children 7–10 years who receive Tdap 475 Trumenba]. inadvertently or as part of the catch-up series may escents not at increased receive the routine Tdap dose at 11–12 years. Appendix G: Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger B infection who want ven at clinical discretion to • DTaP inadvertently given after the 7th birthday: preferred age 16–18 years) Child 7–10: DTaP may count as part of risk. catch-up series. Routine Tdap dose at 11-12 st 1 month apart. may be given. east 6 months apart. If the Adolescent 11–18: Count dose of DTaP as the er than 6 months, give a 3rd adolescent Tdap booster. after the 2nd. d situations: • For other catch-up guidance, see Figure 2. asplenia, sickle cell plement component 14. Human papillomavirus (HPV) vaccine (minimum ulizumab use), serogroup age: 9 years) e outbreak at least 1 month apart. Routine and catch-up vaccination: es at 0, 1-2, and 6 months. • Routine vaccination for all adolescents at 11–12 enba are not years (can start at age 9) and through age 18 if occal vaccination not previously adequately vaccinated. Number of ococcal MMWR publications doses dependent on age at initial vaccination: s/hcp/acip-recs/vacc- Age 9–14 years at initiation: 2-dose series at 0 and 6–12 months. Minimum interval: 5 d acellular pertussis months (repeat a dose given too soon at least um age: 11 years for 12 weeks after the invalid dose and at least 5 months after the 1st dose). years for catch-up Age 15 years or older at initiation: 3-dose ars of age: 1 dose. series at 0, 1–2 months, and 6 months. : 1 dose during each Minimum intervals: 4 weeks between 1st and during the early part of 2nd dose; 12 weeks between 2nd and 3rd 36). dose; 5 months between 1st and 3rd dose ered regardless of the (repeat dose(s) given too soon at or after the etanus- and diphtheria- minimum interval since the most recent dose). ine. ho have not received Tdap: • Persons who have completed a valid series with d booster every 10 years. any HPV vaccine do not need any additional doses. ars not fully immunized dap as part of the catch-up Special situations: rst dose). If additional doses • History of sexual abuse or assault: Begin series at age 9 years. • Immunocompromised* (including HIV) aged 9–26 years: 3-dose series at 0, 1–2 months, and 6 months. • Pregnancy: Vaccination not recommended, but there is no evidence the vaccine is harmful. No intervention is needed for women who inadvertently received a dose of HPV vaccine while pregnant. Delay remaining doses until after pregnancy. Pregnancy testing not needed before vaccination. *See MMWR, December 16, 2016;65(49):1405–1408, at www.cdc.gov/mmwr/volumes/65/wr/pdfs/ mm6549a5.pdf. CS270457-M Appendix G

Caring for Our Children: National Health and Safe Recommended Immunization Schedule for Adults A This schedule was updated for Caring for Our Children online version in 2018. In February 2018, the Recommended Immunization Schedule for Adults Aged 19 Years or Older, United Additiona To check for the latest edition, go to http://www.cdc.gov/vaccines/schedules. States, 2018 became e ective, as recommended by the Advisory Committee on Immunization Practices • Deta (ACIP) and approved by the Centers for Disease Control and Prevention (CDC). The adult immunization vacc schedule was also approved by the American College of Physicians, the American Academy of Family • Vacc Physicians, the American College of Obstetricians and Gynecologists, and the American College of vacc Nurse-Midwives. • Info CDC announced the availability of the 2018 adult immunization schedule in the Morbidity and Mortality vac/ Weekly Report (MMWR).1 The schedule is published in its entirety in the Annals of Internal Medicine.2 • Info The adult immunization schedule consists of figures that summarize routinely recommended vaccines dest for adults by age groups and medical conditions and other indications, footnotes for the figures, and • CDC a table of vaccine contraindications and precautions. Note the following when reviewing the adult vacc immunization schedule: • Adu and • The figures in the adult immunization schedule should be reviewed with the accompanying • Reco footnotes. www • The figures and footnotes display indications for which vaccines, if not previously administered, Report su should be administered unless noted otherwise. departme Reporting • The table of contraindications and precautions identifies populations and situations for which adult imm vaccines should not be used or should be used with caution. covered b is availabl • When indicated, administer recommended vaccines to adults whose vaccination history is and comm incomplete or unknown. 4636), in E The follow • Increased interval between doses of a multidose vaccine series does not diminish vaccine their app e ectiveness; it is not necessary to restart the vaccine series or add doses to the series because of an extended interval between doses. IIV RIV • Combination vaccines may be used when any component of the combination is indicated and Tdap when the other components of the combination are not contraindicated. Td MMR • The use of trade names in the adult immunization schedule is for identification purposes only and VAR does not imply endorsement by the ACIP or CDC. RZV ZVL Special populations that need additional considerations include: HPV • Pregnant women. Pregnant women should receive the tetanus, diphtheria, and acellular pertussis PCV1 vaccine (Tdap) during pregnancy and the influenza vaccine during or before pregnancy. Live PPSV vaccines (e.g., measles, mumps, and rubella vaccine [MMR]) are contraindicated. HepA • Asplenia. Adults with asplenia have specific vaccination recommendations because of their HepA increased risk for infection by encapsulated bacteria. Anatomical or functional asplenia HepB includes congenital or acquired asplenia, splenic dysfunction, sickle cell disease and other Men hemoglobinopathies, and splenectomy. Men • Immunocompromising conditions. Adults with immunosuppression should generally avoid Hib live vaccines. Inactivated vaccines (e.g., pneumococcal vaccines) are generally acceptable. High-level immunosuppression includes HIV infection with a CD4 cell count <200 cells/μL, 1. MMWR receipt of daily corticosteroid therapy with ≥20 mg of prednisone or equivalent for ≥14 days, 2. Ann Inte primary immunodeficiency disorder (e.g., severe combined immunodeficiency or complement 3. Clin Infe component deficiency), and receipt of cancer chemotherapy. Other immunocompromising 4. ACIP. Av conditions and immunosuppressive medications to consider when vaccinating adults can be found in IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host.3 Additional information on vaccinating immunocompromised adults is in General Best Practice Guidelines for Immunization.4 U.S. Department of Health and Human Services Centers for Disease Control and Prevention

ety Performance Standards H Aged 19 Years or Older, United States, 2018 476 al resources for health care providers include: Appendix H: Recommended Immunization Schedule for Adults Aged 19 Years or Older tails on vaccines recommended for adults and complete ACIP statements at www.cdc.gov/ cines/hcp/acip-recs/index.html APPENDIX H: RECOMMENDED IMMUNIZATION SCHEDULE FOR ADULTS AGED 19 YEARS OR OLDER cine Information Statements that explain benefits and risks of vaccines at www.cdc.gov/ cines/hcp/vis/index.html ormation and resources on vaccinating pregnant women at www.cdc.gov/vaccines/adults/rec- /pregnant.html ormation on travel vaccine requirements and recommendations at www.cdc.gov/travel/ tinations/list C Vaccine Schedules App for immunization service providers to download at www.cdc.gov/ cines/schedules/hcp/schedule-app.html ult Vaccination Quiz for self-assessment of vaccination needs based on age, health conditions, d other indications at www2.cdc.gov/nip/adultimmsched/default.asp ommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger at w.cdc.gov/vaccines/schedules/hcp/child-adolescent.html uspected cases of reportable vaccine-preventable diseases to the local or state health ent, and report all clinically significant postvaccination events to the Vaccine Adverse Event g System at www.vaers.hhs.gov or by telephone, 800-822-7967. All vaccines included in the munization schedule except 23-valent pneumococcal polysaccharide and zoster vaccines are by the Vaccine Injury Compensation Program. Information on how to file a vaccine injury claim le at www.hrsa.gov/vaccinecompensation or by telephone, 800-338-2382. Submit questions ments to CDC through www.cdc.gov/cdc-info or by telephone, 800-CDC-INFO (800-232- English and Spanish, 8:00am–8:00pm ET, Monday–Friday, excluding holidays. wing abbreviations are used for vaccines in the adult immunization schedule (in the order of pearance): p inactivated influenza vaccine R recombinant influenza vaccine tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine V vaccine tetanus and diphtheria toxoids 13 measles, mumps, and rubella vaccine V23 varicella vaccine A recombinant zoster vaccine A-HepB zoster vaccine live B human papillomavirus vaccine 13-valent pneumococcal conjugate vaccine nACWY 23-valent pneumococcal polysaccharide vaccine nB hepatitis A vaccine hepatitis A vaccine and hepatitis B vaccine hepatitis B vaccine serogroups A, C, W, and Y meningococcal vaccine serogroup B meningococcal vaccine Haemophilus influenzae type b vaccine Morb Mortal Wkly Rep. 2018;66(5). Available at www.cdc.gov/mmwr/volumes/67/wr/mm6705e3.htm. tern Med. 2018;168:210–220. Available at annals.org/aim/article/doi/10.7326/M17-3439. ect Dis. 2014;58:e44-100. Available at www.idsociety.org/Templates/Content.aspx?id=32212256011. vailable at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html. Appendix H

Caring for Our Children: National Health a Figure 1. Recommended immunization schedule for adults aged 19 years This figure should be reviewed with the accompanying footnotes. This figure and the footnotes describe ind Vaccine 19–21 years 22–26 years Influenza1 This schedule was updated for Caring for Our Children online version in 2018. Tdap2 or Td2 1 dose To check for the latest edition, go to http://www.cdc.gov/vaccines/schedules. MMR3 1 or 2 doses depend VAR4 RZV5 (preferred) or ZVL5 HPV–Female6 2 or 3 doses depending on age at series initiation HPV–Male6 2 or 3 doses depending on age at series initiation PCV137 PPSV237 1 or 2 HepA8 2 or HepB9 MenACWY10 1 or 2 doses depending o MenB10 2 or Hib11 1 or 3 Recommended for adults who meet the age requirement, lack documentation of vaccination, or lack evidence of past infection

and Safety Performance Standards H or older by age group, United States, 2018 dications for which vaccines, if not previously administered, should be administered unless noted otherwise. 27–49 years 50–64 years ≥65 years 1 dose annually e Tdap, then Td booster every 10 yrs ding on indication (if born in 1957 or later) 2 doses 2 doses RZV (preferred) 477 or Appendix H: Recommended Immunization Schedule for Adults Aged 19 Years or Older 1 dose ZVL 1 dose 1 dose 2 doses depending on indication r 3 doses depending on vaccine 3 doses on indication, then booster every 5 yrs if risk remains r 3 doses depending on vaccine 3 doses depending on indication Recommended for adults with other No recommendation indications Appendix H

Figure 2. Recommended immunization schedule for adults aged 19 years o This figure should be reviewed with the accompanying footnotes. This figure and the footnotes describe ind Immuno- HIV infection Asplenia, compromised CD4+ count complement (excluding HIV deficiencies7,10,11 infection)3-7,11 (cells/μL)3-7,9-10 Vaccine Pregnancy1-6 <200 ≥200 This schedule was updated for Caring for Our Children online version in 2018. Influenza1 To check for the latest edition, go to http://www.cdc.gov/vaccines/schedules. Tdap2 or Td2 1 dose 1 dose T MMR3 Tdap each 1 or 2 pregnancy contraindicated VAR4 contraindicated 2 do contraindicated RZV5 (preferred) or ZVL5 HPV–Female6 3 doses through age 26 yrs HPV–Male6 3 doses through age 26 yrs PCV137 PPSV237 HepA8 HepB9 MenACWY10 1 or 2 doses depending on 2 or 3 doses d MenB10 1d Hib11 3 doses HSCT Recommended fo recipients only indications Recommended for adults who meet the age requirement, lack documentation of vaccination, or lack evidence of past infection

H or older by medical condition and other indications, United States, 2018 478 dications for which vaccines, if not previously administered, should be administered unless noted otherwise. Appendix H: Recommended Immunization Schedule for Adults Aged 19 Years or Older End-stage renal Heart or Chronic liver Diabetes7,9 Health care Men who disease, on lung disease, disease7-9 personnel3,4,9 have sex with men6,8,9 hemodialysis7,9 alcoholism7 1 dose annually Tdap, then Td booster every 10 yrs 2 doses depending on indication 2 doses oses RZV at age >50 yrs (preferred) or 1 dose ZVL at age >60 yrs 2 or 3 doses through age 26 yrs 2 or 3 doses 2 or 3 doses through age 21 yrs through age 1 dose 26 yrs 1, 2, or 3 doses depending on indication 2 or 3 doses depending on vaccine 3 doses indication , then booster every 5 yrs if risk remains depending on vaccine dose or adults with other Contraindicated No recommendation Appendix H

Caring for Our Children: National Health a Footnotes. Recommended immunization schedule for adults aged 19 years o This schedule was updated for Caring for Our Children online version in 2018. 1. Influenza vaccination • HIV infection and CD4 cell To check for the latest edition, go to http://www.cdc.gov/vaccines/schedules. www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html 6 months and no evidence or rubella: Administer 2 dos General information • Administer 1 dose of age-appropriate inactivated influenza • Students in postsecondary international travelers, an vaccine (IIV ) or recombinant influenza vaccine (RIV ) annually immunocompromised per • Live attenuated influenza vaccine (LAIV ) is not recommended MMR at least 28 days apart ( administered 1 dose of MMR for the 2017–2018 influenza season • A list of currently available influenza vaccines is available at • Health care personnel bor evidence of immunity: Adm www.cdc.gov/flu/protect/vaccine/vaccines.htm 28 days apart for measles or Special populations rubella (if born before 1957, • Administer age-appropriate IIV or RIV to: • Adults who previously rece Pregnant women containing vaccine and are Adults with hives-only egg allergy authority to be at increase Adults with egg allergy other than hives (e.g., outbreak: Administer 1 dos angioedema or respiratory distress): Administer IIV or RIV in a medical setting under supervision of a health care • MMR is contraindicated for p provider who can recognize and manage severe allergic severe immunodeficiency conditions 4. Varicella vaccination 2. Tetanus, diphtheria, and pertussis vaccination www.cdc.gov/vaccines/hcp/ac www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/tdap-td.html General information General information • Administer to adults withou varicella 2 doses of varicella • Administer to adults who previously did not receive a dose if previously received no var of tetanus toxoid, reduced diphtheria toxoid, and acellular previously received 1 dose o pertussis vaccine (Tdap) as an adult or child (routinely administer 1 dose of VAR at recommended at age 11–12 years) 1 dose of Tdap, followed by a dose of tetanus and diphtheria toxoids (Td) booster • Evidence of immunity to var every 10 years U.S.-born before 1980 (exc health care personnel, see • Information on the use of Tdap or Td as tetanus prophylaxis Documentation of receipt in wound management is available at varicella-containing vacci www.cdc.gov/mmwr/preview/mmwrhtml/rr5517a1.htm Diagnosis or verification o zoster by a health care pro Special populations Laboratory evidence of im • Pregnant women: Administer 1 dose of Tdap during each Special populations pregnancy, preferably in the early part of gestational weeks 27–36 • Administer 2 doses of VAR 4 received no varicella-contai 3. Measles, mumps, and rubella vaccination received 1 dose of varicella- www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/mmr.html dose of VAR at least 4 weeks General information • Administer 1 dose of measles, mumps, and rubella vaccine Pregnant women withou (MMR) to adults with no evidence of immunity to measles, Administer the first of the mumps, or rubella pregnancy and before dis Health care personnel w • Evidence of immunity is: • Adults with HIV infection a Born before 1957 (except for health care personnel, see May administer, based on in below) of VAR 3 months apart Documentation of receipt of MMR • VAR is contraindicated for p Laboratory evidence of immunity or disease severe immunodeficiency • Documentation of a health care provider-diagnosed disease 5. Zoster vaccination without laboratory confirmation is not considered evidence www.cdc.gov/vaccines/hcp/ac of immunity General information Special populations • Administer 2 doses of recom • Pregnant women and nonpregnant women of months apart to adults aged childbearing age with no evidence of immunity to rubella: past episode of herpes zoste Administer 1 dose of MMR (if pregnant, administer MMR after (ZVL) pregnancy and before discharge from health care facility)

and Safety Performance Standards H or older, United States, 2018 l count ≥200 cells/μL for at least 6. • Administer 2 doses of RZV 2–6 months apart to adults who of immunity to measles, mumps, previously received ZVL at least 2 months after ZVL ses of MMR at least 28 days apart • For adults aged 60 years or older, administer either RZV or y educational institutions, ZVL (RZV is preferred) nd household contacts of Special populations rsons: Administer 2 doses of • ZVL is contraindicated for pregnant women and adults with (or 1 dose of MMR if previously R) severe immunodeficiency rn in 1957 or later with no Human papillomavirus vaccination minister 2 doses of MMR at least www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hpv.html r mumps, or 1 dose of MMR for , consider MMR vaccination) General information eived ≤2 doses of mumps- • Administer human papillomavirus (HPV ) vaccine to females e identified by public health ed risk for mumps in an through age 26 years and males through age 21 years se of MMR (males aged 22 through 26 years may be vaccinated based on individual clinical decision) pregnant women and adults with • The number of doses of HPV vaccine to be administered depends on age at initial HPV vaccination cip-recs/vacc-specific/varicella.html 479 No previous dose of HPV vaccine: Administer 3-dose ut evidence of immunity to series at 0, 1–2, and 6 months (minimum intervals: 4 weeks Appendix H: Recommended Immunization Schedule for Adults Aged 19 Years or Older a vaccine (VAR) 4–8 weeks apart between doses 1 and 2, 12 weeks between doses 2 and 3, and 5 months between doses 1 and 3; repeat doses if given ricella-containing vaccine (if too soon) of varicella-containing vaccine, Aged 9–14 years at HPV vaccine series initiation and received 1 dose or 2 doses less than 5 months apart: least 4 weeks after the first dose) Administer 1 dose ricella is: Aged 9–14 years at HPV vaccine series initiation and cept for pregnant women and received 2 doses at least 5 months apart: No additional e below) dose is needed t of 2 doses of varicella or Special populations ine at least 4 weeks apart • Adults with immunocompromising conditions (including of history of varicella or herpes HIV infection) through age 26 years: Administer 3-dose ovider series at 0, 1–2, and 6 months mmunity or disease • Men who have sex with men through age 26 years: Administer 2- or 3-dose series depending on age at initial 4–8 weeks apart if previously 7. vaccination (see above); if no history of HPV vaccine, ining vaccine (if previously administer 3-dose series at 0, 1–2, and 6 months -containing vaccine, administer 1 • Pregnant women through age 26 years: HPV vaccination s after the first dose) to: is not recommended during pregnancy, but there is no ut evidence of immunity: evidence that the vaccine is harmful and no intervention e 2 doses or the second dose after needed for women who inadvertently receive HPV vaccine scharge from health care facility while pregnant; delay remaining doses until after pregnancy; without evidence of immunity pregnancy testing is not needed before vaccination and CD4 cell count ≥200 cells/μL: ndividual clinical decision, 2 doses Pneumococcal vaccination pregnant women and adults with www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/pneumo.html cip-recs/vacc-specific/shingles.html General information mbinant zoster vaccine (RZV) 2–6 • Administer to immunocompetent adults aged 65 years or d 50 years or older regardless of older 1 dose of 13-valent pneumococcal conjugate vaccine er or receipt of zoster vaccine live (PCV13), if not previously administered, followed by 1 dose of 23-valent pneumococcal polysaccharide vaccine (PPSV23) at least 1 year after PCV13; if PPSV23 was previously administered but not PCV13, administer PCV13 at least 1 year after PPSV23 • When both PCV13 and PPSV23 are indicated, administer PCV13 first (PCV13 and PPSV23 should not be administered during the same visit); additional information on vaccine timing is available at www.cdc.gov/vaccines/vpd/pneumo/ downloads/pneumo-vaccine-timing.pdf Appendix H

This schedule was updated for Caring for Our Children online version in 2018. Special populations Close, personal contact wi To check for the latest edition, go to http://www.cdc.gov/vaccines/schedules. • Administer to adults aged 19 through 64 years with the (e.g., household or regular days after arrival in the Uni following chronic conditions 1 dose of PPSV23 (at age 65 high or intermediate endem years or older, administer 1 dose of PCV13, if not previously as soon as the adoption is p received, and another dose of PPSV23 at least 1 year after Healthy adults through ag PCV13 and at least 5 years after PPSV23): been exposed to hepatiti 40 years may receive HepA Chronic heart disease (excluding hypertension) cannot be obtained Chronic lung disease Chronic liver disease 9. Hepatitis B vaccination Alcoholism www.cdc.gov/vaccines/hcp/acip Diabetes mellitus General information Cigarette smoking • Administer to adults who hav • Administer to adults aged 19 years or older with the lack a risk factor but want pro following indications 1 dose of PCV13 followed by 1 dose of antigen hepatitis B vaccine (H PPSV23 at least 8 weeks after PCV13, and a second dose of and hepatitis B vaccine (HepA PPSV23 at least 5 years after the first dose of PPSV23 (if the (minimum intervals: 4 weeks most recent dose of PPSV23 was administered before age 65 HepB and HepA-HepB; betwe years, at age 65 years or older, administer another dose of HepB and 5 months for HepA PPSV23 at least 5 years after the last dose of PPSV23): Special populations Immunodeficiency disorders (including B- and • Administer HepB or HepA-He T-lymphocyte deficiency, complement deficiencies, and indications: phagocytic disorders) Chronic liver disease (e.g. HIV infection fatty liver disease, alcoholic Anatomical or functional asplenia (including sickle cell hepatitis, alanine aminotra disease and other hemoglobinopathies) aminotransferase [AST ] lev Chronic renal failure and nephrotic syndrome limit of normal) • Administer to adults aged 19 years or older with the HIV infection following indications 1 dose of PCV13 followed by 1 dose of Percutaneous or mucosal PPSV23 at least 8 weeks after PCV13 (if the dose of PPSV23 (e.g., household contacts was administered before age 65 years, at age 65 years or [HBsAg]-positive persons; a older, administer another dose of PPSV23 at least 5 years years with diabetes mellit after the last dose of PPSV23): with diabetes mellitus base Cerebrospinal fluid leak adults in predialysis care or Cochlear implant peritoneal dialysis; recent users; health care and pu 8. Hepatitis A vaccination exposure to blood or blood www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hepa.html Sexual exposure risk (e.g. positive persons; sexually a General information monogamous relationship • Administer to adults who have a specific risk (see below), treatment for a sexually tra who have sex with men [M or lack a risk factor but want protection, 2-dose series of Receive care in settings wh single antigen hepatitis A vaccine (HepA; Havrix at 0 and adults have risks for hepa 6–12 months or Vaqta at 0 and 6–18 months; minimum providing sexually transmit interval: 6 months) or a 3-dose series of combined hepatitis abuse treatment and preve A and hepatitis B vaccine (HepA-HepB) at 0, 1, and 6 months; and end-stage renal diseas minimum intervals: 4 weeks between first and second doses, developmentally disabled 5 months between second and third doses targeting services to inject Special populations testing and treatment facil • Administer HepA or HepA-HepB to adults with the following Travel to countries with hig indications: endemicity Travel to or work in countries with high or intermediate 10. Meningococcal vaccination hepatitis A endemicity www.cdc.gov/vaccines/hcp/acip Men who have sex with men Special populations: Serogro Injection or noninjection drug use meningococcal vaccine (Men Work with hepatitis A virus in a research laboratory or with nonhuman primates infected with hepatitis A virus Clotting factor disorders Chronic liver disease

H ith an international adoptee • Administer 2 doses of MenACWY at least 8 weeks apart and 480 babysitting) during the first 60 revaccinate with 1 dose of MenACWY every 5 years, if the risk ited States from a country with remains, to adults with the following indications: Appendix H: Recommended Immunization Schedule for Adults Aged 19 Years or Older micity (administer the first dose Anatomical or functional asplenia (including sickle cell planned) disease and other hemoglobinopathies) HIV infection ge 40 years who have recently Persistent complement component deficiency is A virus; adults older than age Eculizumab use A if hepatitis A immunoglobulin • Administer 1 dose of MenACWY and revaccinate with 1 dose p-recs/vacc-specific/hepb.html of MenACWY every 5 years, if the risk remains, to adults with ve a specific risk (see below), or the following indications: otection, 3-dose series of single Travel to or live in countries where meningococcal HepB) or combined hepatitis A disease is hyperendemic or epidemic, including A-HepB) at 0, 1, and 6 months countries in the African meningitis belt or during the Hajj At risk from a meningococcal disease outbreak between doses 1 and 2 for attributed to serogroup A, C, W, or Y een doses 2 and 3, 8 weeks for Microbiologists routinely exposed to Neisseria A-HepB) meningitidis epB to adults with the following Military recruits ., hepatitis C infection, cirrhosis, First-year college students who live in residential c liver disease, autoimmune housing (if they did not receive MenACWY at age 16 years ansferase [ALT ] or aspartate or older) vel greater than twice the upper General Information: Serogroup B meningococcal vaccine l risk of exposure to blood (MenB) of hepatitis B surface antigen May administer, based on individual clinical decision, to adults younger than age 60 young adults and adolescents aged 16–23 years (preferred tus or aged 60 years or older age is 16–18 years) who are not at increased risk 2-dose ed on individual clinical decision; series of MenB-4C (Bexsero) at least 1 month apart or r receiving hemodialysis or 2-dose series of MenB-FHbp (Trumenba) at least 6 months t or current injection drug apart ublic safety workers at risk for MenB-4C and MenB-FHbp are not interchangeable d-contaminated body fluids) ., sex partners of HBsAg- Special populations: MenB active persons not in a mutually • Administer 2-dose series of MenB-4C at least 1 month apart p; persons seeking evaluation or ansmitted infection; and men or 3-dose series of MenB-FHbp at 0, 1–2, and 6 months to MSM]) adults with the following indications: here a high proportion of atitis B infection (e.g., facilities Anatomical or functional asplenia (including sickle cell tted disease treatment, drug- disease) ention services, hemodialysis Persistent complement component deficiency se programs, institutions for Eculizumab use persons, health care settings At risk from a meningococcal disease outbreak tion drug users or MSM, HIV attributed to serogroup B lities, and correctional facilities) Microbiologists routinely exposed to Neisseria gh or intermediate hepatitis B meningitidis n p-recs/vacc-specific/mening.html 11. Haemophilus influenzae type b vaccination oups A, C, W, and Y www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hib.html nACWY ) Special populations • Administer Haemophilus influenzae type b vaccine (Hib) to adults with the following indications: Anatomical or functional asplenia (including sickle cell disease) or undergoing elective splenectomy: Administer 1 dose if not previously vaccinated (preferably at least 14 days before elective splenectomy) Hematopoietic stem cell transplant (HSCT ): Administer 3-dose series with doses 4 weeks apart starting 6 to 12 months after successful transplant regardless of Hib vaccination history Appendix H

Caring for Our Children: National Health a Table. Contraindications and precautions for vaccines recommended for adults aged The Advisory Committee on Immunization Practices (ACIP) recommendations and package inserts for vaccines provi that increase chances of a serious adverse reaction in vaccine recipients and the vaccine should not be administered recipients. Contraindications and precautions for vaccines routinely recommended for adults Vaccine(s) Contraindications All vaccines routinely • Severe reaction, e.g., anaphylaxis, after a previous dose or to a vaccine component recommended for adults This schedule was updated for Caring for Our Children online version in 2018. To check for the latest edition, go to http://www.cdc.gov/vaccines/schedules. Additional contraindications and precautions for vaccines routinely recommended for adults Vaccine(s) Additional Contraindications IIV1 RIV1 • For pertussis-containing vaccines: encephalopathy, e.g., coma, decreased level of cons Tdap, Td or prolonged seizures, not attributable to another identifiable cause within 7 days of administration of a previous dose of a vaccine containing tetanus or diphtheria toxoid pertussis MMR2 • Severe immunodeficiency, e.g., hematologic and solid tumors, chemotherapy, congen immunodeficiency or long-term immunosuppressive therapy3, human immunodeficie (HIV ) infection with severe immunocompromise • Pregnancy VAR2 • Severe immunodeficiency, e.g., hematologic and solid tumors, chemotherapy, congen immunodeficiency or long-term immunosuppressive therapy3, HIV infection with seve immunocompromise • Pregnancy ZVL2 • Severe immunodeficiency, e.g., hematologic and solid tumors, chemotherapy, congen immunodeficiency or long-term immunosuppressive therapy3, HIV infection with seve immunocompromise • Pregnancy HPV vaccine PCV13 • Severe allergic reaction to any vaccine containing diphtheria toxoid 1. For additional information on use of influenza vaccines among persons with egg allergy, see: CDC. Prevention an Practices—United States, 2016–17 influenza season. MMWR. 2016;65(RR-5):1–54. Available at www.cdc.gov/mmw 2. MMR may be administered together with VAR or ZVL on the same day. If not administered on the same day, sepa 3. Immunosuppressive steroid dose is considered to be daily receipt of 20 mg or more prednisone or equivalent for immunosuppressive steroid therapy. Providers should consult ACIP recommendations for complete information suppression because of other reasons. 4. Vaccine should be deferred for the appropriate interval if replacement immune globulin products are being adm www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html. 5. Measles vaccination may temporarily suppress tuberculin reactivity. Measles-containing vaccine may be adminis * Adapted from: CDC. Table 6. Contraindications and precautions to commonly used vaccines. General recommenda 2011;60(No. RR-2):40–1 and from: Hamborsky J, Kroger A, Wolfe S, eds. Appendix A. Epidemiology and prevention o www.cdc.gov/vaccines/pubs/pinkbook/index.html. Abbreviations of vaccines IIV inactivated influenza vaccine VAR varicella vaccine RIV recombinant influenza vaccine RZV recombinant zoste Tdap tetanus toxoid, reduced diphtheria toxoid, and ZVL zoster vaccine live Td acellular pertussis vaccine HPV vaccine human papilloma MMR tetanus and diphtheria toxoids PCV13 13-valent pneumo measles, mumps, and rubella vaccine PPSV23 23-valent pneumo

and Safety Performance Standards H 19 years or older* ide information on contraindications and precautions related to vaccines. Contraindications are conditions d when a contraindication is present. Precautions should be reviewed for potential risks and benefits for vaccine Precautions • Moderate or severe acute illness with or without fever sciousness, Additional Precautions 481 d or acellular • History of Guillain-Barré syndrome within 6 weeks after previous influenza vaccination • Egg allergy other than hives, e.g., angioedema, respiratory distress, lightheadedness, or recurrent Appendix H: Recommended Immunization Schedule for Adults Aged 19 Years or Older nital ency virus emesis; or required epinephrine or another emergency medical intervention (IIV may be nital administered in an inpatient or outpatient medical setting and under the supervision of a health ere care provider who is able to recognize and manage severe allergic conditions) nital • History of Guillain-Barré syndrome within 6 weeks after previous influenza vaccination ere • Guillain-Barré syndrome within 6 weeks after a previous dose of tetanus toxoid-containing vaccine • History of Arthus-type hypersensitivity reactions after a previous dose of tetanus or diphtheria toxoid-containing vaccine. Defer vaccination until at least 10 years have elapsed since the last tetanus toxoid-containing vaccine • For pertussis-containing vaccine, progressive or unstable neurologic disorder, uncontrolled seizures, or progressive encephalopathy (until a treatment regimen has been established and the condition has stabilized) • Recent (within 11 months) receipt of antibody-containing blood product (specific interval depends on product)4 • History of thrombocytopenia or thrombocytopenic purpura • Need for tuberculin skin testing5 • Recent (within 11 months) receipt of antibody-containing blood product (specific interval depends on product)4 • Receipt of specific antiviral drugs (acyclovir, famciclovir, or valacyclovir) 24 hours before vaccination (avoid use of these antiviral drugs for 14 days after vaccination) • Receipt of specific antiviral drugs (acyclovir, famciclovir, or valacyclovir) 24 hours before vaccination (avoid use of these antiviral drugs for 14 days after vaccination) • Pregnancy nd control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization wr/volumes/65/rr/rr6505a1.htm. arate live vaccines by at least 28 days. r 2 or more weeks. Vaccination should be deferred for at least 1 month after discontinuation of on the use of specific live vaccines among persons on immune-suppressing medications or with immune ministered. See: Best practices guidance of the Advisory Committee on Immunization Practices (ACIP). Available at stered on the same day as tuberculin skin testing, or should be postponed for at least 4 weeks after vaccination. ations on immunization: recommendations of the Advisory Committee on Immunization Practices. MMWR. of vaccine preventable diseases. 13th ed. Washington, DC: Public Health Foundation, 2015. Available at er vaccine HepA hepatitis A vaccine e HepA-HepB hepatitis A and hepatitis B vaccines avirus vaccine HepB hepatitis B vaccine ococcal conjugate vaccine MenACWY serogroups A, C, W, and Y meningococcal vaccine ococcal polysaccharide vaccine MenB serogroup B meningococcal vaccine Hib Haemophilus influenzae type b vaccine CS270457-L Appendix H

Recommendations for Preventive P Bright Futures/American Academy Each child and family is unique; therefore, these Recommendations for Preventive Pediatric Health These recommendations represent a consensus by the American Aca Care are designed for the care of children who are receiving competent parenting, have no and Bright Futures. The AAP continues to emphasize the great impor manifestations of any important health problems, and are growing and developing in a satisfactory in comprehensive health supervision and the need to avoid fragmen fashion. Developmental, psychosocial, and chronic disease issues for children and adolescents may require frequent counseling and treatment visits separate from preventive care visits. Additional Refer to the specific guidance by age as listed in the Bright Futures Gu visits also may become necessary if circumstances suggest variations from normal. Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of In 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017). INFANCY EARLY CHILDHOOD AGE1 Prenatal2 Newborn3 3-5 d4 By 1 mo 2 mo 4 mo 6 mo 9 mo 12 mo 15 mo 18 mo 24 mo 30 mo 3y 4y HISTORY l l l l l Initial/Interval l ll l l l l l l ll MEASUREMENTS l l Length/Height and Weight l ll lll l l l l l l ll Head Circumference ll lll Weight for Length ê ll lll ll l l l Body Mass Index5 ê Blood Pressure6   l8 ll l l SENSORY SCREENING l l l ll Vision7 l Hearing êê êêê ê ê ê ê ê ê ll DEVELOPMENTAL/BEHAVIORAL HEALTH l Developmental Screening11  l19 ê ê êêê ê ê ê ê ê ê ll Autism Spectrum Disorder Screening12   l9 êê ê ê ê ê ê ê êl Developmental Surveillance l Psychosocial/Behavioral Assessment13 l l ll Tobacco, Alcohol, or Drug Use Assessment14 l Depression Screening15 ll Maternal Depression Screening16 l PHYSICAL EXAMINATION17 l l lll ll l ll PROCEDURES18 l l lll Newborn Blood l l l l l l ll Newborn Bilirubin21 l l lll Critical Congenital Heart Defect22   l20 l lll l l l l l l ll Immunization23 Anemia24 l l lll l l l l l l l l ê ê ê ê ê Lead25 ê ê l ê ê ê ê Tuberculosis27 ê l or ê26 l or ê26 ê ê Dyslipidemia28 ê ê Sexually Transmitted Infections29 ê ê ê ê HIV30 Cervical Dysplasia31    l33    l33 ê ê ê ê êê ORAL HEALTH32 ê l Fluoride Varnish34 lll Fluoride Supplementation35 êê ê ê ê êê ANTICIPATORY GUIDANCE ll l l l l l l ll 1. If a child comes under care for the first time at any point on the schedule, or if any items are not accomplished at the 6. Blood pressure measurement in infants and children with specific risk condition suggested age, the schedule should be brought up-to-date at the earliest possible time. before age 3 years. 2. A prenatal visit is recommended for parents who are at high risk, for first-time parents, and for those who request a 7. A visual acuity screen is recommended at ages 4 and 5 years, as well as in coop conference. The prenatal visit should include anticipatory guidance, pertinent medical history, and a discussion of screening may be used to assess risk at ages 12 and 24 months, in addition to t benefits of breastfeeding and planned method of feeding, per “The Prenatal Visit” (http://pediatrics.aappublications.org/ See “Visual System Assessment in Infants, Children, and Young Adults by Pediat content/124/4/1227.full). org/content/137/1/e20153596) and “Procedures for the Evaluation of the Visua (http://pediatrics.aappublications.org/content/137/1/e20153597). 3. Newborns should have an evaluation after birth, and breastfeeding should be encouraged (and instruction and support should be offered). 8. Confirm initial screen was completed, verify results, and follow up, as appropria per “Year 2007 Position Statement: Principles and Guidelines for Early Hearing D 4. Newborns should have an evaluation within 3 to 5 days of birth and within 48 to 72 hours after discharge from the (http://pediatrics.aappublications.org/content/120/4/898.full). hospital to include evaluation for feeding and jaundice. Breastfeeding newborns should receive formal breastfeeding evaluation, and their mothers should receive encouragement and instruction, as recommended in “Breastfeeding and 9. Verify results as soon as possible, and follow up, as appropriate. the Use of Human Milk” (http://pediatrics.aappublications.org/content/129/3/e827.full). Newborns discharged less than 48 hours after delivery must be examined within 48 hours of discharge, per “Hospital Stay for Healthy Term Newborns” 10. Screen with audiometry including 6,000 and 8,000 Hz high frequencies once be (http://pediatrics.aappublications.org/content/125/2/405.full). 15 and 17 years, and once between 18 and 21 years. See “The Sensitivity of Ado Improves by Adding High Frequencies” (http://www.jahonline.org/article/S105 5. Screen, per “Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report” (http://pediatrics.aappublications.org/content/120/ 11. See “Identifying Infants and Young Children With Developmental Disorders in t Supplement_4/S164.full). Developmental Surveillance and Screening” (http://pediatrics.aappublications. KEY: l = to be performed ê = risk assessment to be performed with appropriate action to follow, if positive l = range during which a service may be provided

Pediatric Health Care 482 y of Pediatrics Appendix I: Recommendations for Preventive Pediatric Health Care ademy of Pediatrics (AAP) The recommendations in this statement do not indicate an exclusive course of treatment or standard APPENDIX I: RECOMMENDATIONS FOR PREVENTIVE PEDIATRIC HEALTH CARE rtance of continuity of care of medical care. Variations, taking into account individual circumstances, may be appropriate. ntation of care. Copyright © 2017 by the American Academy of Pediatrics, updated February 2017. uidelines (Hagan JF, Shaw JS, nfants, Children, and Adolescents. No part of this statement may be reproduced in any form or by any means without prior written permission from the American Academy of Pediatrics except for one copy for personal use. MIDDLE CHILDHOOD ADOLESCENCE 5y 6y 7y 8y 9y 10 y 11 y 12 y 13 y 14 y 15 y 16 y 17 y 18 y 19 y 20 y 21 y l l l l l l l l l l l llll ll l l l l l l l l l l llll lll llllll l l l l l l l l lll l lll llllll l l l l l l l l lêlêl ê l êê l êê ê êê ê l lêlêl l10 l l llllll l l l l l l l l lll llllll l l l l l l l l lll ê ê ê ê ê ê ê ê êêê llllll l l l l l l l lll l l l l l l l l lll lllll ll l l l l l l l lll êêêêê êê ê ê ê ê ê ê ê êêê êê êêêêê êê ê ê ê ê ê ê ê êêê l êê l êêêêê ê êêê êêêêêêê êêê l êêêê l êê êêêê ê êê ê ê ê ê ê l l lll llll l ll l l l l l ns should be performed at visits 12. Screening should occur per “Identification and Evaluation of Children With Autism Spectrum Disorders” (http://pediatrics.aappublications.org/content/120/5/1183.full). perative 3-year-olds. Instrument-based 13. This assessment should be family centered and may include an assessment of child social-emotional health, caregiver the well visits at 3 through 5 years of age. depression, and social determinants of health. See “Promoting Optimal Development: Screening for Behavioral and tricians” (http://pediatrics.aappublications. Emotional Problems” (http://pediatrics.aappublications.org/content/135/2/384) and “Poverty and Child Health in the al System by Pediatricians” United States” (http://pediatrics.aappublications.org/content/137/4/e20160339). 14. A recommended assessment tool is available at http://www.ceasar-boston.org/CRAFFT/index.php. ate. Newborns should be screened, 15. Recommended screening using the Patient Health Questionnaire (PHQ)-2 or other tools available in the GLAD-PC Detection and Intervention Programs” toolkit and at http://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Mental-Health/Documents/MH_ ScreeningChart.pdf. ) etween 11 and 14 years, once between 16. Screening should occur per “Incorporating Recognition and Management of Perinatal and Postpartum Depression Into olescent Hearing Screens Significantly Pediatric Practice” (http://pediatrics.aappublications.org/content/126/5/1032). 54-139X(16)00048-3/fulltext). 17. At each visit, age-appropriate physical examination is essential, with infant totally unclothed and older children the Medical Home: An Algorithm for undressed and suitably draped. See “Use of Chaperones During the Physical Examination of the Pediatric Patient” .org/content/118/1/405.full). (http://pediatrics.aappublications.org/content/127/5/991.full). 18. These may be modified, depending on entry point into schedule and individual need. (continued)

(continued) 19. Confirm initial screen was accomplished, verify results, and follow up, as appropriate. 28. See “Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children The Recommended Uniform Newborn Screening Panel (http://www.hrsa.gov/ and Adolescents” (https://www.nhlbi.nih.gov/health-topics/integrated-guidelines- advisorycommittees/mchbadvisory/heritabledisorders/recommendedpanel/ for-cardiovascular-health-and-risk-reduction-in-children-and-adolescents). uniformscreeningpanel.pdf ), as determined by The Secretary’s Advisory Committee on Heritable Disorders in Newborns and Children, and state newborn screening 29. Adolescents should be screened for sexually transmitted infections (STIs) per laws/regulations (http://genes-r-us.uthscsa.edu/sites/genes-r-us/files/ recommendations in the current edition of the AAP Red Book: Report of the nbsdisorders.pdf ) establish the criteria for and coverage of newborn screening Committee on Infectious Diseases. procedures and programs. 30. Adolescents should be screened for HIV according to the USPSTF recommendations (http://www.uspreventiveservicestaskforce.org/uspstf/uspshivi.htm) once between 20. Verify results as soon as possible, and follow up, as appropriate. the ages of 15 and 18, making every effort to preserve confidentiality of the adolescent. Those at increased risk of HIV infection, including those who are sexually 21. Confirm initial screening was accomplished, verify results, and follow up, active, participate in injection drug use, or are being tested for other STIs, should be as appropriate. See “Hyperbilirubinemia in the Newborn Infant ≥35 Weeks’ tested for HIV and reassessed annually. Gestation: An Update With Clarifications” (http://pediatrics.aappublications.org/ content/124/4/1193). 31. See USPSTF recommendations (http://www.uspreventiveservicestaskforce.org/ uspstf/uspscerv.htm). Indications for pelvic examinations prior to age 21 are noted in 22. Screening for critical congenital heart disease using pulse oximetry should be “Gynecologic Examination for Adolescents in the Pediatric Office Setting” performed in newborns, after 24 hours of age, before discharge from the hospital, (http://pediatrics.aappublications.org/content/126/3/583.full). per “Endorsement of Health and Human Services Recommendation for Pulse Oximetry Screening for Critical Congenital Heart Disease” (http://pediatrics. 32. Assess whether the child has a dental home. If no dental home is identified, perform aappublications.org/content/129/1/190.full). a risk assessment (https://www.aap.org/RiskAssessmentTool) and refer to a dental home. Recommend brushing with fluoride toothpaste in the proper dosage for age. 23. Schedules, per the AAP Committee on Infectious Diseases, are available at See “Maintaining and Improving the Oral Health of Young Children” (http:// http://redbook.solutions.aap.org/SS/Immunization_Schedules.aspx. Every visit pediatrics.aappublications.org/content/134/6/1224). should be an opportunity to update and complete a child’s immunizations. 24. See “Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in 33. Perform a risk assessment (https://www.aap.org/RiskAssessmentTool). See Infants and Young Children (0–3 Years of Age)” (http://pediatrics.aappublications. “Maintaining and Improving the Oral Health of Young Children” (http:// org/content/126/5/1040.full). pediatrics.aappublications.org/content/134/6/1224). 25. For children at risk of lead exposure, see “Low Level Lead Exposure Harms Children: 34. See USPSTF recommendations (http://www.uspreventiveservicestaskforce.org/ A Renewed Call for Primary Prevention” (http://www.cdc.gov/nceh/lead/ACCLPP/ uspstf/uspsdnch.htm). Once teeth are present, fluoride varnish may be applied Final_Document_030712.pdf ). to all children every 3–6 months in the primary care or dental office. Indications for fluoride use are noted in “Fluoride Use in Caries Prevention in the Primary Care 26. Perform risk assessments or screenings as appropriate, based on universal screening Setting” (http://pediatrics.aappublications.org/content/134/3/626). requirements for patients with Medicaid or in high prevalence areas. 27. Tuberculosis testing per recommendations of the AAP Committee on Infectious 35. If primary water source is deficient in fluoride, consider oral fluoride supplementation. Diseases, published in the current edition of the AAP Red Book: Report of the See “Fluoride Use in Caries Prevention in the Primary Care Setting” (http://pediatrics. Committee on Infectious Diseases. Testing should be performed on recognition aappublications.org/content/134/3/626). of high-risk factors. Summary of Changes Made to the Bright Futures/AAP Recommendations for Preventive Pediatric Health Care (Periodicity Schedule) This schedule reflects changes approved in February 2017 and published in April 2017. For updates, visit www.aap.org/periodicityschedule. For further information, see the Bright Futures Guidelines, 4th Edition, Evidence and Rationale chapter (https://brightfutures.aap.org/Bright%20Futures%20Documents/BF4_Evidence_Rationale.pdf ). CHANGES MADE IN FEBRUARY 2017 HEARING • Timing and follow-up of the screening recommendations for hearing during the infancy visits have been delineated. Adolescent risk assessment has changed to screening once during each time period. • Footnote 8 has been updated to read as follows: “Confirm initial screen was completed, verify results, and follow up, as appropriate. Newborns should be screened, per ‘Year 2007 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs’ (http://pediatrics.aappublications.org/content/120/4/898.full).” • Footnote 9 has been added to read as follows: “Verify results as soon as possible, and follow up, as appropriate.” • Footnote 10 has been added to read as follows: “Screen with audiometry including 6,000 and 8,000 Hz high frequencies once between 11 and 14 years, once between 15 and 17 years, and once between 18 and 21 years. See ‘The Sensitivity of Adolescent Hearing Screens Significantly Improves by Adding High Frequencies’ (http://www.jahonline.org/article/S1054-139X(16)00048-3/fulltext).” PSYCHOSOCIAL/BEHAVIORAL ASSESSMENT • Footnote 13 has been added to read as follows: “This assessment should be family centered and may include an assessment of child social-emotional health, caregiver depression, and social determinants of health. See ‘Promoting Optimal Development: Screening for Behavioral and Emotional Problems’ (http://pediatrics.aappublications.org/content/135/2/384) and ‘Poverty and Child Health in the United States’ (http://pediatrics.aappublications.org/content/137/4/e20160339).” TOBACCO, ALCOHOL, OR DRUG USE ASSESSMENT • The header was updated to be consistent with recommendations.

DEPRESSION SCREENING 483 • Adolescent depression screening begins routinely at 12 years of age (to be consistent with recommendations of the US Preventive Services Task Force [USPSTF]). Appendix I: Recommendations for Preventive Pediatric Health Care MATERNAL DEPRESSION SCREENING • Screening for maternal depression at 1-, 2-, 4-, and 6-month visits has been added. • Footnote 16 was added to read as follows: “Screening should occur per ‘Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice’ (http://pediatrics.aappublications.org/content/126/5/1032).” NEWBORN BLOOD • Timing and follow-up of the newborn blood screening recommendations have been delineated. • Footnote 19 has been updated to read as follows: “Confirm initial screen was accomplished, verify results, and follow up, as appropriate. The Recommended Uniform Newborn Screening Panel (http://www.hrsa.gov/advisorycommittees/mchbadvisory/ heritabledisorders/recommendedpanel/uniformscreeningpanel.pdf ), as determined by The Secretary’s Advisory Committee on Heritable Disorders in Newborns and Children, and state newborn screening laws/regulations (http://genes-r-us.uthscsa.edu/sites/ genes-r-us/files/nbsdisorders.pdf ) establish the criteria for and coverage of newborn screening procedures and programs.” • Footnote 20 has been added to read as follows: “Verify results as soon as possible, and follow up, as appropriate.” NEWBORN BILIRUBIN • Screening for bilirubin concentration at the newborn visit has been added. • Footnote 21 has been added to read as follows: “Confirm initial screening was accomplished, verify results, and follow up, as appropriate. See ‘Hyperbilirubinemia in the Newborn Infant ≥35 Weeks’ Gestation: An Update With Clarifications’ (http://pediatrics.aappublications.org/content/124/4/1193).” DYS L I P I D E M I A • Screening for dyslipidemia has been updated to occur once between 9 and 11 years of age, and once between 17 and 21 years of age (to be consistent with guidelines of the National Heart, Lung, and Blood Institute). SEXUALLY TRANSMITTED INFECTIONS • Footnote 29 has been updated to read as follows: “Adolescents should be screened for sexually transmitted infections (STIs) per recommendations in the current edition of the AAP Red Book: Report of the Committee on Infectious Diseases.” HIV • A subheading has been added for the HIV universal recommendation to avoid confusion with STIs selective screening recommendation. • Screening for HIV has been updated to occur once between 15 and 18 years of age (to be consistent with recommendations of the USPSTF). • Footnote 30 has been added to read as follows: “Adolescents should be screened for HIV according to the USPSTF recommendations (http://www.uspreventiveservicestaskforce.org/uspstf/uspshivi.htm) once between the ages of 15 and 18, making every effort to preserve confidentiality of the adolescent. Those at increased risk of HIV infection, including those who are sexually active, participate in injection drug use, or are being tested for other STIs, should be tested for HIV and reassessed annually.” ORAL HEALTH • Assessing for a dental home has been updated to occur at the 12-month and 18-month through 6-year visits. A subheading has been added for fluoride supplementation, with a recommendation from the 6-month through 12-month and 18-month through 16-year visits. • Footnote 32 has been updated to read as follows: “Assess whether the child has a dental home. If no dental home is identified, perform a risk assessment (https://www.aap.org/RiskAssessmentTool) and refer to a dental home. Recommend brushing with fluoride toothpaste in the proper dosage for age. See ‘Maintaining and Improving the Oral Health of Young Children’ (http:// pediatrics.aappublications.org/content/134/6/1224).” • Footnote 33 has been updated to read as follows: “Perform a risk assessment (https://www.aap.org/RiskAssessmentTool). See ‘Maintaining and Improving the Oral Health of Young Children’ (http://pediatrics.aappublications.org/ content/134/6/1224).” • Footnote 35 has been added to read as follows: “If primary water source is deficient in fluoride, consider oral fluoride supplementation. See ‘Fluoride Use in Caries Prevention in the Primary Care Setting’ (http://pediatrics.aappublications.org/ content/134/3/626).”

J484 Caring for Our Children: National Health and Safety Performance Standards Appendix J: Selecting an Appropriate Sanitizer or Disinfectant APPENDIXSJe: lSeEcLtEinCgTIaNnGAApNprAoPpPrRiaOtePRSIaAnTiEtizSeArNoITr IDZiEsRinOfeRcDtaInSItNFECTANT One of the most important steps in reducing the spread of infectious diseases in child care settings is cleaning, sanitizing or disinfecting surfaces that could possibly pose a risk to children or staff. Routine cleaning with detergent and water is the most common method for removing some germs from surfaces in the child care setting. However, most items and surfaces in a child care setting require sanitizing or disinfecting after cleaning to further reduce the number of germs on a surface to a level that is unlikely to transmit disease. What is the difference between sanitizing and disinfecting? Sometimes these terms are used as if they mean the same thing, but they are not the same. Sanitizer is a product that reduces but does not eliminate germs on inanimate surfaces to levels considered safe by public health codes or regulations. A sanitizer may be appropriate to use on food contact surfaces (dishes, utensils, cutting boards, high chair trays), toys that children may place in their mouths, and pacifiers. See Appendix K, Routine Schedule for Cleaning, Sanitizing and Disinfecting for guidance on use of sanitizer vs. disinfectant. Disinfectant is a product that destroys or inactivates germs (but not spores) on an inanimate object. A disinfectant may be appropriate to use on hard, non-porous surfaces such as diaper change tables, counter tops, door & cabinet handles, and toilets and other bathroom surfaces. See Appendix K, Routine Schedule for Cleaning, Sanitizing and Disinfecting for guidance on use of sanitizer vs. disinfectant. The U.S. Environmental Protection Agency (EPA) recommends that only EPA-registered products be used. Only a sanitizer or disinfectant product with an EPA registration number on the label can make public health claims that they are effective in reducing or inactivating germs. Many bleach and hydrogen peroxide products are EPA- registered and can be used to sanitize or disinfect. Please see the “How to Find EPA Registration Information” section below to learn more specific information on the products. Always follow the manufactures’ instructions when using EPA-registered products described as sanitizers or disinfectants. This includes pre-cleaning, how long the product needs to remain wet on the surface or item, whether or not the product should be diluted or used as is, and if rinsing is needed. Also check to see if that product can be used on a food contact surface or is safe for use on items that may go into a child’s mouth. Please note that the label instructions on most sanitizers and disinfectants indicate that the surface must be pre- cleaned before applying the sanitizer or disinfectant. Are there alternatives to chlorine bleach? A product that is not chlorine bleach can be used in child care settings IF: • it is registered with the EPA; • it is also described as a sanitizer or as a disinfectant; • it is used according to the manufacturer’s instructions. Check the label to see how long you need to leave the sanitizer or disinfectant in contact with the surface you are treating, whether you need to rinse it off before contact by children, for any precautions when handling, and whether it can be used on a surface that may come in contact with child’s mouth. Appendix J

Caring for Our Children: National Health and Safety Performance Standards J 485 Appendix J: Selecting an Appropriate Sanitizer or Disinfectant Some child care settings are using products with hydrogen peroxide as the active ingredient instead of chlorine bleach. Check to see if the product has an EPA registration number and follow the manufacturer’s instructions for use and safe handling. (Please see the “How to Find EPA Registration Information” section below for more information.) Remember that EPA-registered products will also have available a Safety Data Sheet (SDS) that will provide instructions for the safe use of the product and guidance for first aid response to an accidental exposure to the chemical. In addition, as new sanitizer and disinfectant products appear on the market, users need to check for EPA registration. Household Bleach & Water Many household bleach products are now EPA-registered. When purchasing EPA-registered chlorine bleach, make sure that the bleach concentration is for household use, and not for industrial applications. Household chlorine bleach is typically sold in retail stores as an 8.25% sodium hypochlorite solution. EPA-registered bleach products are described as sanitizers and disinfectants. Check the label to see if the product has an EPA registration number and follow the manufacturer’s safety and use instructions. (Please see the “How to Find EPA Registration Information” section below for more information.) Pay particular attention to the mixing “recipe” and the required contact time (i.e., the time the solution must remain on a surface to be effective) for each use. Remember, the recipe and contact time are most likely different for sanitizing and disinfecting. If you are not using an EPA-registered product for sanitizing and disinfecting, please be sure you are following state or local recommendations and/or manufacturer’s instructions for creating safe dilutions necessary to sanitize and/or disinfect surfaces in your early care and education environment. Using too little (a weak concentration) bleach may make the mixture ineffective; however, using too much (a strong concentration) bleach may create a potential health hazard. To safely prepare bleach solutions: • Dilute bleach with cool water and do not use more than the recommended amount of bleach. • Select a bottle made of opaque material. • Make a fresh bleach dilution daily; label the bottle with contents and the date mixed. • Wear gloves and eye protection when diluting bleach. • Use a funnel. • Add bleach to the water rather than the water to bleach to reduce fumes. • Make sure the room is well ventilated. • Never mix or store ammonia with bleach or products that contain bleach. To safely use bleach solutions: • Apply the bleach dilution after cleaning the surface with soap or detergent and rinsing with water if visible soil is present. Appendix J

J 486 Appendix J: Selecting an Appropriate Sanitizer or Disinfectant • If using a spray bottle, adjust the setting to produce a heavy spray instead of a fine mist. • Allow for the contact time specified on the label of the bleach product. • Apply when children are not present in the area. • Ventilate the area by allowing fresh air to circulate and allow the surfaces to completely air dry or wipe dry after the required contact time before allowing children back into the area. • Store all chemicals securely, out of reach of children and in a way that they will not tip and spill. Adapted from: California Childcare Health Program. 2013. Safe and Effective Cleaning sanitizing and Disinfecting. Health and Safety Notes (March). To Review: • Determine if the surface requires sanitizing or disinfecting; • Check the labels of all products to see if they are EPA-registered; there are alternatives to chlorine bleach; • Many chlorine bleach products (8.25% sodium, hypochlorite) are now EPA-registered o If EPA-registered, you must follow the label instructions for “recipes” and contact times; • If using non-EPA-registered products, follow state or local recommendations for “recipes” and contact times; • Prepare and use the solutions safely; • Use products that are safe for oral contact when used on food contact surfaces or on items that may mouthed by children. How to Find EPA Registration Information The following information is intended to serve as a visual guide to locating EPA registration numbers and product label information. Any products featured in the examples below are used for illustrative purpose only, and do not represent an endorsement by the National Resource Center for Health and Safety in Child Care and Early Education (NRC). The NRC does not endorse specific products. 1. Locate the EPA Registration number on the product label: Appendix J

487 Appendix J: Selecting an Appropriate Sanitizer or Disinfectant 2. Go to http://iaspub.epa.gov/apex/pesticides/f?p=PPLS:1. Enter this number into the box titled “EPA Registration Number” and click the Search button: Appendix J

488 Appendix J: Selecting an Appropriate Sanitizer or Disinfectant 3. You should see the details about the product, and beneath that, a portable document file (PDF) bearing the date that this product was registered by the EPA (if there is a list, the PDF at the top of the list should show the most recent approval). Click on that most recently-approved PDF. You will need a PDF file reader to access this file. There are a variety of Appendix J

J 489 Appendix J: Selecting an Appropriate Sanitizer or Disinfectant readers available and most are free. 4. The PDF should come up on your screen. Scroll down to the section that shows the directions for using the product as a sanitizer or disinfectant. Follow the directions listed for your intended use. Appendix J

490 Appendix J: Selecting an Appropriate Sanitizer or Disinfectant A Final Note Remember that any cleaning, sanitizing or disinfecting product must always be safely stored out of reach of children. Always follow the manufacturer’s instruction for safe handling to protect yourselves and those in your care. References: 1. California Childcare Health Program. 2009. Sanitize safely and effectively: Bleach and alternatives in child care programs. Health and Safety Notes (July). http://www. ucsfchildcarehealth.org/pdfs/healthandsafety/SanitizeSafely_En0709.pdf. 2. U.S. Environmental Protection Agency. 2012. Pesticide Product Label System Website. http:// iaspub.epa.gov/apex/pesticides/f?p=PPLS:1. 3. U.S. Environmental Protection Agency. 2012. What are antimicrobial pesticides? Pesticides Website. http://www.epa.gov/oppad001/ad_info.htm. 4. U.S. Environmental Protection Agency. 2012. Selected EPA-registered disinfectants. Pesticides Website. www.epa.gov/oppad001/chemregindex.htm. 5. Grenier, D., D. Leduc, eds. 2008. Well beings: A guide to health in child care. 3rd ed. Ottawa: Canadian Paediatric Society. 6. Rutala, W. A., D. J. Weber, the Healthcare Infection Control Practices Advisory Committee (HICPAC). 2008. Guideline for disinfection and sterilization in healthcare facilities, 2008. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Preparedness, Detection, and Control of Infectious Diseases, Division of Healthcare Quality Promotion. http://www.cdc.gov/hicpac/pdf/guidelines/ Disinfection_Nov_2008.pdf. 7. U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration. 2009. Food code. College Park, MD: Food and Drug Administration. http://www.fda. gov/Food/FoodSafety/RetailFoodProtection/FoodCode/FoodCode2009/default.htm Appendix J

491 K Caring for Our ChildArpepne:ndNixaKti:oRnoaultiHneeSaclhtehdaulnedfoSr CalefeatnyinPg,eSrafnoirtimzinagn,canedSDtiasinnfdeactridngs APPENDIX K: ROUTINE SCHEDULE FOR CLEANING, SANITIZING, AND DISINFECTING Areas Before After Daily (At the Weekly Monthly Comments Each Each End of the Day) Food Areas Use Use Use a sanitizer safe for food • Food Clean, Clean, contact preparation Sanitize Sanitize If washing the surfaces dishes and utensils by hand, • Eating Clean, use a sanitizer utensils & Sanitize safe for food dishes contact as the final step in the • Tables & Clean, Clean, process; Use of an highchair Sanitize Sanitize automated trays dishwasher will sanitize • Countertops Clean Clean, Sanitize Use a sanitizer safe for food contact • Food Clean Clean, Sanitize preparation appliances Clean, Before serving Sanitize food • Mixed use tables Clean • Refrigerator Child Care Areas Clean Clean, Sanitize • Plastic Clean Clean, Sanitize Reserve for use mouthed by only one child; toys Clean Use dishwasher Clean, Disinfect or boil for one • Pacifiers minute • Hats Clean after each • Door & use if head lice present cabinet handles Appendix K

Caring for Our Children: National Health and Safety Performance Standards K 492 Sweep or vacuum, then Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting damp mop, (consider micro • Floors Clean fiber damp mop to pick up most • Machine Clean particles) washable Clean Launder cloth toys Clean Launder • Dress-up Clean, Disinfect clothes Use sanitizing Clean, wipes, do not use • Play activity Sanitize spray centers Clean Clean with • Drinking detergent, rinse, Fountains disinfect • Computer Damp mop with a keyboards floor cleaner/ disinfectant • Phone receivers Clean before use by another child Toilet & Diapering Areas Clean, Clean before use Disinfect by another child • Changing tables Clean, Disinfect • Potty chairs Clean, Disinfect • Handwashing sinks & Clean, Disinfect faucets Clean, Disinfect Clean, Disinfect • Countertops • Toilets • Diaper pails • Floors Clean, Disinfect Sleeping Areas Clean Clean • Bed sheets & pillow cases Clean • Cribs, cots, & mats • Blankets Appendix K

L Caring for Our Children: National Health and Safety Performance Standa4r9d3s Appendix L: Cleaning Up Body Fluids APPENDCIXleLa:nCiLnEgAUNpINBGoUdPy BFOluDidYsFLUIDS Treat urine, stool, vomit, blood, and body fluids, j) Mops and other equipment used to clean up except for human milk, as potentially infectious. Spills body fluids should be: of body fluid should be cleaned up and surfaces disinfected immediately. 1) Cleaned with detergent and rinsed with water; a) For small amounts of urine and stool on smooth surfaces, wipe off and clean away visible soil 2) Rinsed with a fresh disinfectant solution; with a little detergent solution. Then rinse the surface with clean water. 3) Wrung as dry as possible; b) Apply a disinfectant following the 4) Air-dried. manufacturer’s instructions. See Appendix J. k) Wash your hands afterward, even though you For larger spills on floors, or any spills on rugs or wore gloves; carpets: l) Remove and bag clothing (yours and those c) Wear gloves while cleaning. While disposable worn by children) soiled by body fluids; gloves can be used, household rubber gloves are adequate for all spills except blood and m) Put on fresh clothes after washing the soiled bloody body fluids. Disposable gloves should skin and hands of everyone involved. be used when blood may be present in the spill; For guidance on sanitizers and disinfectants, please d) Take care to avoid splashing any contaminated refer to Appendix J, Selecting an Appropriate material onto the mucous membranes of your Sanitizer or Disinfectant. eyes, nose or mouth, or into any open sores you may have; References: 1. Grenier, D., D. Leduc, eds. 2008. Well beings: A e) Wipe up as much of the visible material as guide to health in child care. 3rd ed. Ottawa: Canadian possible with disposable paper towels and Paediatric Society. carefully place the soiled paper towels and 2. Centers for Disease Control and Prevention, other soiled disposable material in a leak- National Institute for Occupational Safety and Health. proof, plastic bag that has been securely tied 2010. Preventing exposures to bloodborne pathogens or sealed. Use a wet/dry vacuum on carpets, if among paramedics. http://www.cdc.gov/niosh/docs/ such equipment is available; wp-solutions/2010-139/pdfs/2010-139.pdf. 3. Centers for Disease Control and Prevention. 2010. f) Immediately use a detergent, or a combination Bloodborne infectious diseases: HIV/AIDS, hepatitis detergent/disinfectant to clean the spill area. B, hepatitis C. http://www.cdc.gov/niosh/topics/bbp/. Then rinse the area with clean water. Additional 4. Pickering, L. K., C. J. Baker, D. W. Kimberlin, S. S. cleaning by shampooing or steam cleaning the Long, eds. 2009. Infections spread by blood and body contaminated surface may be necessary; fluids. In Red book: 2009 report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: g) For blood and body fluid spills on carpeting, American Academy of Pediatrics. blot to remove body fluids from the fabric 5. Occupational Safety and Health Administration as quickly as possible. Then disinfect by (OSHA). 2008. Bloodborne pathogens. 29 CFR spot-cleaning with a combination detergent/ 1910.1030. http://www.osha.gov/pls/oshaweb/ disinfectant, and shampooing, or steam- owadisp.show_document?p_table=standards& cleaning the contaminated surface; p_id=10051. 6. Clark, Roger A. 1992. Standard interpretations: h) If directed by the manufacturer’s instructions, 1910.1030, written at the request of Marjorie P. Alloy. dry the surface; Occupational Safety and Health Administration (OSHA). http://www.osha.gov/pls/oshaweb/owadisp. i) Clean and rinse reusable household rubber show_document?p_table=INTERPRETATIONS& gloves, then apply disinfectant. Remove, dry p_id=20952. and store these gloves away from food or food surfaces. Discard disposable gloves; Appendix L

494 M Appendix M: Recognizing Child Abuse and Neglect: Signs and Symptoms Caring for OuAr CPhPilEdrNenD: INXatMion:aRl HEeCaOlthGaNndIZSIaNfeGtyCPHerIfoLrDmaAnBceUSStaEnAdaNrdDs NEGLECT: SIGNS AND SYMPTOMS Appendix M

MRecognizing Child Abuse and Neglect: Signs and Symptoms www.childwelfare.gov 495 Appendix M: Recognizing Child Abuse and Neglect: Signs and Symptoms help for the family. Any concerned person • Lacks adult supervision can report suspicions of child abuse and neglect. Some people (typically certain types • Is overly compliant, passive, or of professionals) are required by law to withdrawn make a report of child maltreatment under specific circumstances—these are called • Comes to school or other activities early, mandatory reporters. For more information, stays late, and does not want to go home see the Child Welfare Information Gateway publication, Mandatory Reporters of Child The Parent: Abuse and Neglect: www.childwelfare.gov/ systemwide/laws_policies/statutes/manda. • Shows little concern for the child cfm • Denies the existence of—or blames the For more information about where and child for—the child’s problems in school how to file a report, contact your local or at home child protective services agency or police department. An additional resource • Asks teachers or other caregivers to use for information and referral is the harsh physical discipline if the child Childhelp® National Child Abuse Hotline misbehaves (800.4.A.CHILD). • Sees the child as entirely bad, worthless, Recognizing child abuse or burdensome The following signs may signal the presence • Demands a level of physical or academic of child abuse or neglect. performance the child cannot achieve The Child: • Looks primarily to the child for care, attention, and satisfaction of emotional • Shows sudden changes in behavior or needs school performance The Parent and Child: • Has not received help for physical or medical problems brought to the parents’ • Rarely touch or look at each other attention • Consider their relationship entirely • Has learning problems (or difficulty negative concentrating) that cannot be attributed to specific physical or • State that they do not like each other psychological causes types of abuse • Is always watchful, as though preparing for something bad to happen The following are some signs often associated with particular types of child abuse and neglect: physical abuse, neglect, sexual abuse, and emotional abuse. It is important to note, however, that these ThAis pmpateenriadl imxaMy be freely reproduced and distributed. However, when doing so, please credit Child Welfare  Information Gateway. Available online at www.childwelfare.gov/pubs/factsheets/signs.cfm.

Recognizing Child Abuse and Neglect: Signs and Symptoms Mwww.childwelfare.gov 496 Appendix M: Recognizing Child Abuse and Neglect: Signs and Symptoms types of abuse are more typically found Signs of Neglect in combination than alone. A physically abused child, for example, is often Consider the possibility of neglect when emotionally abused as well, and a sexually the child: abused child also may be neglected. • Is frequently absent from school • Begs or steals food or money Signs of Physical abuse • Lacks needed medical or dental care, Consider the possibility of physical abuse immunizations, or glasses when the child: • Is consistently dirty and has severe • Has unexplained burns, bites, bruises, body odor broken bones, or black eyes • Lacks sufficient clothing for the weather • Abuses alcohol or other drugs • Has fading bruises or other marks • States that there is no one at home to noticeable after an absence from school provide care • Seems frightened of the parents and Consider the possibility of neglect when the protests or cries when it is time to parent or other adult caregiver: go home • Appears to be indifferent to the child • Seems apathetic or depressed • Shrinks at the approach of adults • Behaves irrationally or in a bizarre • Reports injury by a parent or another manner adult caregiver • Is abusing alcohol or other drugs Consider the possibility of physical abuse Signs of Sexual abuse when the parent or other adult caregiver: Consider the possibility of sexual abuse • Offers conflicting, unconvincing, or no when the child: explanation for the child’s injury • Has difficulty walking or sitting • Suddenly refuses to change for gym or to • Describes the child as “evil,” or in some other very negative way participate in physical activities • Reports nightmares or bedwetting • Uses harsh physical discipline with the child • Has a history of abuse as a child This material may be freely reproduced and distributed. However, when doing so, please credit Child Welfare Appendix M Information Gateway. Available online at www.childwelfare.gov/pubs/factsheets/signs.cfm.

MRecognizing Child Abuse and Neglect: Signs and Symptoms ¬ www.childwelfare.gov 497 Appendix M: Recognizing Child Abuse and Neglect: Signs and Symptoms • Experiences a sudden change in appetite • Has attempted suicide • Demonstrates bizarre, sophisticated, or • Reports a lack of attachment to the parent unusual sexual knowledge or behavior Consider the possibility of emotional • Becomes pregnant or contracts a venere al maltreatment when the parent or other disease, particularly if under age 14 adult caregiver: • Runs away • Constantly blames, belittles, or berates the child • Reports sexual abuse by a parent or another adult caregiver • Is unconcerned about the child and refuses to consider offers of help for the Consider the possibility of sexual abuse child’s problems when the parent or other adult caregiver: • Overtly rejects the child • Is unduly protective of the child or severely limits the child’s contact ResouRCes on the ChIld with other children, especially of the WelfaRe InfoRmatIon opposite sex GateWay WebsIte ¬ • Is secretive and isolated Child Abuse and Neglect www.childwelfare.gov/can/index.cfm • Is jealous or controlling with family members Defining Child Abuse and Neglect www.childwelfare.gov/can/defining/ Signs of emotional Maltreatment Preventing Child Abuse and Neglect www.childwelfare.gov/preventing/ Consider the possibility of emotional maltreatment when the child: Reporting Child Abuse and Neglect www.childwelfare.gov/responding/ • Shows extremes in behavior, such as reporting.cfm overly compliant or demanding behavior, extreme passivity, or aggression This factsheet was adapted, with permission, from Recognizing Child Abuse: What Parents • Is either inappropriately adult (parenting Should Know. Prevent Child Abuse America. other children, for example) or © 00. inappropriately infantile (frequently rocking or head-banging, for example) • Is delayed in physical or emotional development This material may be freely reproduced and distributed. However, when doing so, please credit Child Welfare Information Gateway. 4 Available online at www.childwelfare.gov/pubs/factsheets/signs.cfm. ThiAs mpapteerniadl mixayMbe freely reproduced and distributed. However, when doing so, please credit Child Welfare Information Gateway. Available online at www.childwelfare.gov/pubs/factsheets/signs.cfm.

Caring for Our Children: National Health and Safety Performance Standards N 498 Appendix N: Protective Factors Regarding Child Abuse and Neglect Protective Factors Regarding Child Abuse and Neglect APPENDIX N: PROTECTIVE FACTORS REGARDING CHILD ABUSE AND NEGLECT Reproduced with permission from: Strengthening Families – Center for Study of Social Policy. htttpp:s//:w//wwww.wst.rcesnsgpth.oerngin/rgeFfaomrmilie/sst.rneent.gthening-families/resources/body/LiteratureReview.pdf Appendix N

N 499 Appendix N: Protective Factors Regarding Child Abuse and Neglect Protective factors that quality child care can enhance: 1. Parental resilience • value and support parents/guardians, assist development of parental self-efficacy, link to community resources including mental health professionals when needed 2. Social connections • provide a place where parents/guardians may develop positive social interactions in a child-friendly environment 3. Parenting skills and knowledge about normal child development • model and teach positive, effective parenting/discipline techniques, educate parents/guardians about child development and appropriate expectations 4. Support structures in place during times of need • identify needs and connect families stressed or in crisis with center and/or community resources 5. Children’s social and emotional competence • provide childrenwith a healthy, nurturing environment that encourages trust and attachment Reference: The Child Welfare Information Gateway. Stay connected! U.S. Department of Health and Human Services, Administration for Children and Families, Children’s Bureau. http://www.childwelfare.org Additional Resources: 1. The Child Welfare Information Gateway. Enhancing protective factors. U.S. Department of Health and Human Services, Administration for Children and Families, Children's Bureau. http://www.childwelfare.gov/preventing/promoting/protectfactors/. 2. Strengthening Families. About Strengthening Families. Center for the Study of Social Policy. http://www.strengtheningfamilies.net/index.php/about/. 3. American Academy of Pediatrics. Connected kids: Safe, strong, secure. http://www.aap.org/connectedkids/. 4. American Academy of Pediatrics. 2010. What to know about child abuse. Healthy Children. http://www.healthychildren.org/English/safety-prevention/at-home/pages/ What-to-Know-about-Child-Abuse.aspx. 5. American Academy of Pediatrics. 2007. Policy statement: Assessment of maltreatment of children with disabilities. Pediatrics 108:508-12. Appendix N

500 ACpapreinndgixfoOr: COaruerPClahniflodrrCehnil:dNreantWioitnhaSlpHeceiaalltHheaaltnhdNSeeadfsety Performance Standards O APPENDIX O: CARE PLAN FOR CHILDREN WITH SPECIAL HEALTH NEEDS CARE PLAN FOR CHILDREN WITH SPECIAL HEALTH NEEDS -To be completed by a Health Care Provider- Today’s Date Child’s Full Name Date of Birth Parent’s/Guardian’s Name Telephone No. Primary Health Care Provider () Specialty Provider Specialty Provider Telephone No. Diagnosis(es) () Telephone No. () Telephone No. () Allergies Medication To Be ROUTINE CARE Route Reason Possible Given at Child Care Schedule/Dose (How?) Prescribed Side E ects (When and How Much?) List medications given at home: Page 1 of 2 Pages. NEEDED ACCOMMODATION(S) Appendix O Describe any needed accommodation(s) the child needs in daily activities and why: Diet or Feeding: Classroom Activities: Naptime/Sleeping: Toileting: Outdoor or Field Trips: Transportation: Other: Additional comments: CH-15 MAR 05 Source: New Jersey Department of Health and Senior Services, 2005.

O Caring for Our Children: National Health and Safety Performance Standar5d0s1 Appendix O: Care Plan for Children With Special Health Needs CARE PLAN FOR CHILDREN WITH SPECIAL HEALTH NEEDS Continued SPECIAL EQUIPMENT / MEDICAL SUPPLIES 1. EMERGENCY CARE 2. if the following symptoms are present: 3. CALL PARENTS/GUARDIANS CALL 911 (EMERGENCY MEDICAL SERVICES) if the following symptoms are present, as well as contacting the parents/guardians: TAKE THESE MEASURES while waiting for parents or medical help to arrive: SUGGESTED SPECIAL TRAINING FOR STAFF Health Care Provider Signature Date PARENT NOTES (OPTIONAL) ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ I hereby give consent for my child’s health care provider or specialist to communicate with my child’s child care provider or school nurse to discuss any of the information contained in this care plan. Parent/Guardian Signature Date Important: In order to ensure the health and safety of your child, it is vital that any person involved in the care of your child be aware of your child’s special health needs, medication your child is taking, or needs in case of a health care emergency, and the speci c actions to take regarding your child’s special health needs. CH-15 Page 2 of 2 Pages. MAR 05 New Jersey Department of Health and Senior Services Appendix O