A 4-year-old boy is brought to the clinic for a well-child e

[nathan]

A 4-year-old boy is brought to the clinic for a well-child examination and immunizations. He is usually very healthy, but he happens to have a "cold and fever" for the past 3 days. The mother reports that he is doing well at home and in school. You notice in his chart that he has missed a few scheduled appointments in the past but he has had no serious problems. His temperature is 38.0 C (100.0 F). Physical examination shows clear nasal discharge, but is otherwise unremarkable. He is due for the measles mumps rubella, polio, and diphtheria tetanus and pertussis vaccines at this time. The most appropriate next step in management is to

A. administer all of the vaccines at this time
B. administer the inactivated polio and the diphtheria tetanus and pertussis vaccines only at this time
C. advise him to return for the vaccines when he is feeling better
D. give him the vaccines at the next scheduled well-child examination
E. prescribe azithromycin and schedule an appointment in 10 days for immunizations

[nathan]

The answer is A. A minor illness with or without fever is not a contraindication for immunizations. There are often misconceptions about this idea. According to the American Academy of Pediatrics and the Report of the Committee on Infectious Diseases, there is no evidence that indicates that immunizations should not be given during a minor febrile illness. This is important because deferring immunizations to a later date may lead to inadequately immunized children. This is especially important in this case because he has missed regularly scheduled appointments in the past.

All vaccines can be administered at this visit, including the MMR (which is a live vaccine), even though he has a minor febrile illness. A minor respiratory illness with fever is not a contraindication for live vaccines because these children have similar serologic responses to vaccines as afebrile, well children. Therefore, it is incorrect to administer the inactivated polio and the diphtheria tetanus and pertussis vaccines only at this time (choice B).

Since he has missed scheduled appointments in the past and has a minor febrile illness, this is not a contraindication for immunizations. It is incorrect to advise him to return for the vaccines when he is feeling better (choice C). If you advise him to return when he is feeling better, he may not return and this will lead to an inadequately immunized child.

It is incorrect to give him the vaccines at the next scheduled well-child examination (choice D). He has missed appointments in the past and there is no reason that he should not be given the vaccines that he is due for at this time.

Azithromycin (choice E) is not given for 3 days of "cold and fever" and clear nasal discharge. It is given for infections due to Moraxella catarrhalis and Legionella pneumophila, not for viral infections, which he most likely has. Also, he should be given the immunizations now, and not in 10 days.