APGAR- / new born screening

 When is it done  done at 1 min and 5 min post birth

Each category is scored with 0, 1, or 2, depending on the observed condition.

 Breathing effort:
o If the infant is not breathing, the respiratory score is 0.
o If the respirations are slow or irregular, the infant scores 1 for respiratory effort.
o If the infant cries well, the respiratory score is 2.
 Heart rate is evaluated by stethoscope. This is the most important assessment:
o If there is no heartbeat, the infant scores 0 for heart rate.
o If heart rate is less than 100 beats per minute, the infant scores 1 for heart rate.
o If heart rate is greater than 100 beats per minute, the infant scores 2 for heart rate.
 Muscle tone:
o If muscles are loose and floppy, the infant scores 0 for muscle tone.
o If there is some muscle tone, the infant scores 1.
o If there is active motion, the infant scores 2 for muscle tone.
 Grimace response or reflex irritability is a term describing response to stimulation such as
a mild pinch:
o If there is no reaction, the infant scores 0 for reflex irritability.
o If there is grimacing, the infant scores 1 for reflex irritability.
o If there is grimacing and a cough, sneeze, or vigorous cry, the infant scores 2 for
reflex irritability.
 Skin color:
o If the skin color is pale blue, the infant scores 0 for color.
o If the body is pink and the extremities are blue, the infant scores 1 for color.
o If the entire body is pink, the infant scores 2 for color.
 * higher the score= better the baby (total 1-10)
 Normal score: 7-9
 Abnormal score : < 7--- need medical assistant
o Oxy (clear out airway); physical stimulation (get heart beating at good rate)
 Uncommon for babies to have a perfect score of 10- bc most babies will lose 1 pnt for
acrocyanosis immediately after birth which is considered normal
 ** Apgar score is not designed to predict the future health of the child.

FTT

 6% of American kids
 inability to maintain a normal growth pattern in weight, stature, and occasionally in head growth
 Most babies double their birth weight by 4 months and triple it by age 1, but kids with failure to
thrive often don't meet those milestones.
  criteria varies

o fall in wt below the 3% for age and wt
o growth deceleration that crosses 2 major percentiles
 etiology: mostly occurs in infancy
o inadeq caloric intake, inadeq caloric absorption, excessive caloric expend/increased
caloric requirements
o 50%- non organic issue; 25% organic, 25% mixed
o Non-organic issues : poor feeding technique, disturbed maternal-child interaction,
emotional deprivation, inadequate caloric intake, and child neglect.
 Dx:
o Measurement of length, wt, and head circumerference
o If the cause is low caloric intake= the head in normal but wt is low
 PE: gluteal fols (loss of subq fat)
 Labs:
o BUN, Cr, electrolytes, CBC,
 Sx: developmental delays, emotional deprivation, apathy, poor hygiene, withdrawn behavior,
and poor eye contact.
 Tx:
o 150 kcal/g/day, pedisure, high caloric formulas,

Growth


 Average wt of baby7-7 ½ lbs
 Baby will loose about 10-15% within the first few days post birth (water wt)
 Bw 24 mo and puberty a child should gain 5 ½ lbs/yr

Nutrition

 Kcal need for a FT infant= 80cal/kg/day

 Main macronutrient for infant fat
o 30% of their diet should be fat
o Need fat bc Absorption of fat soluble vit, Myelination CNS, Brain development , Cell
membrane and Synthesis of hormones
 Ist sign of malnutrition slow phycial growth

Breastfeeding

 AAP recommends exclusive breastfeeding for the first 6months.

 What percentage of breast milk is triglyceride?  98%
 If the decision to breastfeed has been determined, it should be initiated very shortly after birth.
 How freq are babies fed 8-12 x/day
  It may take several days for the breast milk to “come in”
 In the first few days, colostrum develops.
o Colostrum is rich in _abx_ which helps with immunity.
 Breast milk provides 20kcal/oz
 Breast milk containslactose, whey and casein
 When should a baby that is being breast fed start vitamin D supplementation?
 When should a baby that is being breast fed start iron supplementation?
 How to know if baby is eating enoughhow much you change a wet diaper6-8x/day

FORMULAS

 Formula Feeding
o Most formulas have higher mineral content than does breast milk
o Formulas provide the same calorie content20kcal/oz
o Standard formulas contain: lactose, whey and casein
o Now formulas are supplemented with DHA (docosahexaenoic acid) which has been
associated with improved visual acuity and psychomotor development…especially in formula
fed premature babies.
 Other Formulas
o Premature formulas
 Provide 22-24 kcal/oz
 They contain: lactose, corn syrup, whey and casein
o Soy formulas
 Provides 20 kcal/oz
 Replace lactose with sucrose and corn syrup
 Replace casein with soy and methionine
SOLID FOODS
 Start when baby is able to sit up on own should occur at 6 mo
o If child has not reached milestone; do not give solids
o Start with cereal/rice and then add a single pureed food at a time
 Babies can consume honey at  1 yr
 Wean from bottle at  1 yr
o Give whole milk but limit to 24 oz/day
o Limit juice to < 6 oz/day
MILESTONES -2 months
Social and Emotional
 Begins to smile at people
 Can briefly calm himself (may bring hands to mouth and suck on hand)
 Tries to look at parent

Language/Communication
  Coos, makes gurgling sounds
 Turns head toward sounds
Cognitive (learning, thinking, problem-solving)
 Pays attention to faces
 Begins to follow things with eyes and recognize people at a distance
 Begins to act bored (cries, fussy) if activity doesn’t change
Movement/Physical Development
 Can hold head up and begins to push up when lying on tummy
 Makes smoother movements with arms and leg

4 MONTH MILESTONE
Social and Emotional
 Smiles spontaneously, especially at people
 Likes to play with people and might cry when playing stops
 Copies some movements and facial expressions, like smiling or frowning
Language/Communication
 Begins to babble
 Babbles with expression and copies sounds he hears
 Cries in different ways to show hunger, pain, or being tired
Cognitive (learning, thinking, problem-solving)
 Lets you know if she is happy or sad
 Responds to affection
 Reaches for toy with one hand
 Uses hands and eyes together, such as seeing a toy and reaching for it
 Follows moving things with eyes from side to side
 Watches faces closely
 Recognizes familiar people and things at a distance
Movement/Physical Development
 Holds head steady, unsupported
 Pushes down on legs when feet are on a hard surface
 May be able to roll over from tummy to back
 Can hold a toy and shake it and swing at dangling toys
 Brings hands to mouth
 When lying on stomach, pushes up to elbows

6 MONTH MILETSONES
Social and Emotional
 Knows familiar faces and begins to know if someone is a stranger
 Likes to play with others, especially parents
 Responds to other people’s emotions and often seems happy
 Likes to look at self in a mirror
Language/Communication
 Responds to sounds by making sounds
  Strings vowels together when babbling (“ah,” “eh,” “oh”) and likes taking turns with
parent while making sounds
 Responds to own name
 Makes sounds to show joy and displeasure
 Begins to say consonant sounds (jabbering with “m,” “b”)

Cognitive (learning, thinking, problem-solving)

 Looks around at things nearby
 Brings things to mouth
 Shows curiosity about things and tries to get things that are out of reach
 Begins to pass things from one hand to the other
Movement/Physical Development
 Rolls over in both directions (front to back, back to front)
 Begins to sit without support
 When standing, supports weight on legs and might bounce
 Rocks back and forth, sometimes crawling backward before moving forward

9 MONTH MILESTONES
Social and Emotional
 May be afraid of strangers
 May be clingy with familiar adults
 Has favorite toys
Language/Communication
 Understands “no”
 Makes a lot of different sounds like “mamamama” and “bababababa”
 Copies sounds and gestures of others
 Uses fingers to point at things

Cognitive (learning, thinking, problem-solving)

 Watches the path of something as it falls
 Looks for things he sees you hide
 Plays peek-a-boo
 Puts things in her mouth
 Moves things smoothly from one hand to the other
 Picks up things like cereal o’s between thumb and index finger
Movement/Physical Development
 Stands, holding on
 Can get into sitting position
 Sits without support
 Pulls to stand
 Crawls

12 MONTH MILESTONE
Social and Emotional
  Is shy or nervous with strangers
 Cries when mom or dad leaves
 Has favorite things and people
 Shows fear in some situations
 Hands you a book when he wants to hear a story
 Repeats sounds or actions to get attention
 Puts out arm or leg to help with dressing
 Plays games such as “peek-a-boo” and “pat-a-cake”
Language/Communication
 Responds to simple spoken requests
 Uses simple gestures, like shaking head “no” or waving “bye-bye”
 Makes sounds with changes in tone (sounds more like speech)
 Says “mama” and “dada” and exclamations like “uh-oh!”
 Tries to say words you say

Cognitive (learning, thinking, problem-solving)

 Explores things in different ways, like shaking, banging, throwing
 Finds hidden things easily
 Looks at the right picture or thing when it’s named
 Copies gestures
 Starts to use things correctly; for example, drinks from a cup, brushes hair
 Bangs two things together
 Puts things in a container, takes things out of a container
 Lets things go without help
 Pokes with index (pointer) finger
 Follows simple directions like “pick up the toy”
Movement/Physical Development
 Gets to a sitting position without help
 Pulls up to stand, walks holding on to furniture (“cruising”)
 May take a few steps without holding on
 May stand alone

18 MONTH MILESONES
Social and Emotional
 Likes to hand things to others as play
 May have temper tantrums
 May be afraid of strangers
 Shows affection to familiar people
 Plays simple pretend, such as feeding a doll
 May cling to caregivers in new situations
 Points to show others something interesting
 Explores alone but with parent close by
Language/Communication
 Says several single words
  Says and shakes head “no”
 Points to show someone what he wants
Cognitive (learning, thinking, problem-solving)
 Knows what ordinary things are for; for example, telephone, brush, spoon
 Points to get the attention of others
 Shows interest in a doll or stuffed animal by pretending to feed
 Points to one body part
 Scribbles on his own
 Can follow 1-step verbal commands without any gestures; for example, sits when you say
“sit down”
Movement/Physical Development
 Walks alone
 May walk up steps and run
 Pulls toys while walking
 Can help undress herself
 Drinks from a cup
 Eats with a spoon

2 YEARS/24 MONTHS
Social and Emotional
 Copies others, especially adults and older children
 Gets excited when with other children
 Shows more and more independence
 Shows defiant behavior (doing what he has been told not to)
 Plays mainly beside other children, but is beginning to include other children, such as in
chase games
Language/Communication
 Points to things or pictures when they are named
 Knows names of familiar people and body parts
 Says sentences with 2 to 4 words
 Follows simple instructions
 Repeats words overheard in conversation
 Points to things in a book

Cognitive (learning, thinking, problem-solving)

 Finds things even when hidden under two or three covers
 Begins to sort shapes and colors
 Completes sentences and rhymes in familiar books
 Plays simple make-believe games
 Builds towers of 4 or more blocks
 Might use one hand more than the other
 Follows two-step instructions such as “Pick up your shoes and put them in the closet.”
 Names items in a picture book such as a cat, bird, or dog
Movement/Physical Development
  Stands on tiptoe
 Kicks a ball
 Begins to run
 Climbs onto and down from furniture without help
 Walks up and down stairs holding on
 Throws ball overhand
 Makes or copies straight lines and circles

3 YEARS OLD MILESTONES

Social and Emotional
 Copies adults and friends
 Shows affection for friends without prompting
 Takes turns in games
 Shows concern for crying friend
 Understands the idea of “mine” and “his” or “hers”
 Shows a wide range of emotions
 Separates easily from mom and dad
 May get upset with major changes in routine
 Dresses and undresses self
Language/Communication
 Follows instructions with 2 or 3 steps
 Can name most familiar things
 Understands words like “in,” “on,” and “under”
 Says first name, age, and sex
 Names a friend
 Says words like “I,” “me,” “we,” and “you” and some plurals (cars, dogs, cats)
 Talks well enough for strangers to understand most of the time
 Carries on a conversation using 2 to 3 sentences
Cognitive (learning, thinking, problem-solving)
 Can work toys with buttons, levers, and moving parts
 Plays make-believe with dolls, animals, and people
 Does puzzles with 3 or 4 pieces
 Understands what “two” means
 Copies a circle with pencil or crayon
 Turns book pages one at a time
 Builds towers of more than 6 blocks
 Screws and unscrews jar lids or turns door handle
Movement/Physical Development
 Climbs well
 Runs easily
 Pedals a tricycle (3-wheel bike)
 Walks up and down stairs, one foot on each step
4 YEARS OLD MILESTONES
Social and Emotional
 Enjoys doing new things
 Plays “Mom” and “Dad”
 Is more and more creative with make-believe play
 Would rather play with other children than by himself
 Cooperates with other children
 Often can’t tell what’s real and what’s make-believe
 Talks about what she likes and what she is interested in
Language/Communication
 Knows some basic rules of grammar, such as correctly using “he” and “she”
 Sings a song or says a poem from memory such as the “Itsy Bitsy Spider” or the “Wheels
on the Bus”
 Tells stories
 Can say first and last name

Cognitive (learning, thinking, problem-solving)

 Names some colors and some numbers
 Understands the idea of counting
 Starts to understand time
 Remembers parts of a story
 Understands the idea of “same” and “different”
 Draws a person with 2 to 4 body parts
 Uses scissors
 Starts to copy some capital letters
 Plays board or card games
 Tells you what he thinks is going to happen next in a book
Movement/Physical Development
 Hops and stands on one foot up to 2 seconds
 Catches a bounced ball most of the time
 Pours, cuts with supervision, and mashes own food

5 Y/O MILESTONES
Social and Emotional
 Wants to please friends
 Wants to be like friends
 More likely to agree with rules
 Likes to sing, dance, and act
 Shows concern and sympathy for others
 Is aware of gender
 Can tell what’s real and what’s make-believe
  Shows more independence (for example, may visit a next-door neighbor by himself
[adult supervision is still needed])
 Is sometimes demanding and sometimes very cooperative
Language/Communication
 Speaks very clearly
 Tells a simple story using full sentences
 Uses future tense; for example, “Grandma will be here.”
 Says name and address
Cognitive (learning, thinking, problem-solving)
 Counts 10 or more things
 Can draw a person with at least 6 body parts
 Can print some letters or numbers
 Copies a triangle and other geometric shapes
 Knows about things used every day, like money and food
Movement/Physical Development
 Stands on one foot for 10 seconds or longer
 Hops; may be able to skip
 Can do a somersault
 Uses a fork and spoon and sometimes a table knife
 Can use the toilet on her own
 Swings and climbs

DEVELOPMENT

Genitals (male)

 Tanner I 
o prepubertal (testicular volume less than 1.5 ml; small penis of 3 cm or less)
[typically age 9 and younger]
 Tanner II 
o testicular volume between 1.6 and 6 ml; skin on scrotum thins, reddens and
enlarges; penis length unchanged [9-11]
 Tanner III 
o testicular volume between 6 and 12 ml; scrotum enlarges further; penis begins to
lengthen to about 6 cm [11-12.5]
 Tanner IV 
o testicular volume between 12 and 20 ml; scrotum enlarges further and darkens;
penis increases in length to 10 cm and circumference [12.5-14]
 Tanner V 
o testicular volume greater than 20 ml; adult scrotum and penis of 15 cm in length
[14+]

Breasts (female)
  Tanner I 
o no glandular tissue: areola follows the skin contours of the chest (prepubertal)
[typically age 10 and younger]
 Tanner II 
o breast bud forms, with small area of surrounding glandular tissue; areola begins to
widen [10-11.5]
 Tanner III 
o breast begins to become more elevated, and extends beyond the borders of the
areola, which continues to widen but remains in contour with surrounding breast
[11.5-13]
 Tanner IV 
o increased breast size and elevation; areola and papilla form a secondary mound
projecting from the contour of the surrounding breast [13-15]
 Tanner V 
o breast reaches final adult size; areola returns to contour of the surrounding breast,
with a projecting central papilla. [15+]
 Pubic hair (both male and female)
 Tanner I 
o no pubic hair at all (prepubertal Dominic state) [typically age 10 and younger]
 Tanner II 
o small amount of long, downy hair with slight pigmentation at the base of the penis
and scrotum (males) or on the labia majora (females) [10–11.5]
 Tanner III 
o hair becomes more coarse and curly, and begins to extend laterally [11.5–13]
 Tanner IV 
o adult-like hair quality, extending across pubis but sparing medial thighs [13–15]|
 Tanner V 
o hair extends to medial surface of the thighs [15+]

VISION SCREENING

 From birth to 3 years of age,

o Ck if EOMI, red reflexes, PERRLA, external eye area
 2-3 months of age
o able to track, or visually follow a moving object, with both eyes.
o When you ck corneal light reflex
 age 3 formal testing of visual acuity should be done
o Credit is given for any line on which the child gets more than 50% correct.
 Interpreting the eye exam results use a chart the take into account the age of the child (bc
visual acuity get better with age)
 When to send to an othamalogist
o any two-line discrepancy between the two eyes,
  even within the passing range (eg, 20/20 in one eye, 20/30 in the other in a child
aged 6 years or older)
o child who is unable to cooperate with exam on a f/u visit (your 2 nd try)
o down syndrome baby @ 6 months (increased risk for refractive error, strabismus, and
cataracts)
o preterm baby
o fhx of eye issues
 Age appropriate visual acuity
o Age 3-5 y.o minimal acceptable acuity: 20/40
o Age >6 minimal acceptable acuity: 20/30

HEARING

 New born hearing screening via..

o 1. evoked otoacoustic emissions or
o 2.auditory brain stem-evoked responses.
o *Because universal newborn hearing screening is sometimes associated with false-
positive test results, confirmatory audiology testing is required for abnormal tests.
 Conventional screening audiometry, in which a child raises her hand when a sound is heard,
can be performed starting at age 4.
 routine hearing screening at 4, 5, 6, 8, and 10 years of age.

WELL CHILD VISIT

 28 visits by 21 years of age

 3 Components -Age-specific
o Screening
o Health promotion and disease prevention
o Patient management & follow-up
 Review of pertinent issues since last well visit
o Nutrition, diet
o Developmental milestones
o Daily activities
o School performance
o Behavioral observation of parent-child interaction
 Getrn info about allegies,meds, immunizations, home life, pmh, fhx, surgical hx, sexual hx
 Ask- since there last visit, any signif changes occur in childs life?
 weight, length or height, & head circumference (up to age 3)
 body mass index (BMI) (for > 2 years)
 should be plotted and evaluated on gender and age specific growth charts
 Vision and hearing
 starting at 3–4 years of age
  Blood pressure at 3yo and above
 Oral health
o refer infants to a dentist for an oral examination 6 months after the first tooth erupts or
by age 12 months.
o Dental caries is the most common chronic childhood disease — five times more
common than asthma.

Vaccines

 http://www.cdc.gov/vaccines/parents/downloads/milestones-tracker.pdf
 generally- do not give vaccine of any kind if
o child is currently sick
o child has had asthma with wheezing sx in the last 6-12 mo
 Note: for all the 2,4,6 months should wait atleast 6 wks b.w shots

 HepA
o 1st dose at 12-23 m/o; 2nd shot given 6-18 months later
o If was never vaccinated, they should receive one shot, regardless of age
o Shots but me 6 months apart
 Heb B
o 3 shots IM
 1st is at birth, 2nd shot b/w 1-2 m/o, 3rd shot b/w 6-18m/o
o Recombivax HB a 2 dose vaccine given to 11-15 y.o who have missed their Hep B
vaccine during infancy
o Twinirix 4 dose accelerated schedule
o Side effects: soreness at injection site, fever
 Hep A/B combo
o Do the combo if > 18 y.o
o given as three shots, over a period of six months or as three shots over one month and a
booster shot at 12 months.
 DTap- Diptheria, Td, and Pertussis
 o ower-case "a" in each vaccine indicates that the pertussis component is acellular, or cell-
free, which improves safety by dramatically reducing the incidence of side effects.
o 5 shot series, in which all of them should be completed before school starts
o ages 2 months, 4 months, 6 months, 15-18 months, and 4-6 years.
o Side effects: fever, serizures (1/14,000) and 3 hr long crying spells (1/1,000)
o Do NOT give if..
 Child is currently sick
 Had Gullain Barre syndrome within 6 wks of receiving a tetanus shot
 Tdap
o adult version contains smaller amounts of the diphtheria and pertussis components —
this is indicated in the name by the use of lower-case "d" and "p" for the adult vaccine.
 RotaVirus vaccine
o Rotavirus: #1 cause of gastroenteritis (V/D) in kids
o Administer: PO
o 2 types of rotavirius vaccines accepted in the US
o 1. Rotarix (RV1) 2 dose series at 2,4 months
o 2. RotTeq (RV5) 3 dose series at 2,4,6 months
o Youngest you can give dose #1 6 wks
o Oldest you can give dose #1 14 wks and 6 days
o Have to wait at least 4 wks between shots
o Cannot give after child is 8 Mo old
o Side effects
 Mild V/D
 Itussusception: blockage of bowel needing hospitalization/surgery
 1/20-100,000 occurs 1 wk after 1st or 2nd dose
o Rotavirus vaccine can be administered together with DTaP vaccine, Hib vaccine, IPV,
hepatitis B vaccine, and pneumococcal conjugate vaccine
o Messed up immunization schedule
 Should NOT be started if child > 15 m.o
 If one dose already given, 2nd dose should not be given if child > 28 wks old
 Flu shot
o Annually
o Can give at 6 months old.
 First time need 2 shots—2nd dose is 1 month after the first
o Contradictions: allergic to eggs, currently wheezing or have a fever
 Nasal Spray- Flu vaccine
o This is a LIVE vaccine
o Contraindications: Asthma, < 2 y.o, allergic to eggs
 HiB- haemophilus influ B
 o Protects againt Haemophilus influ type b which causes meningitis, pneumonia, and
infections of the blood, bones, and joints.
o Had not shown to work well in kids < 6 wks old
o Schedule: 2,4,6,12-15 months
o >5 y.o= do not need to get HiB, unless immunocompromised
o If > 15 m/o and never had HiB; just give ONE dose
 PCV 13- Pneumococcal Conjugated Vaccine mand PPSV 23
o Recommended for ppl <5 y/o OR > 5 y/o and immunocomp
o The pneumococcal conjugate vaccine (PCV13) is recommended for all children younger
than 59 months old.
o PCV 13 < 2y/o: give at 2,4,6, 12-15 mo
 Children who miss their shots or start the series later should still get the vaccine
o 2- 5 y.o
 Healthy and 2-4 y.o who have not been vaccinate should get 1 dose
 Medical condition and 2- 5 y.o with missed or no PCV 13 vaccine—sjould
get 1 or 2 doses
 If kids have SCD, damaged spleen, cochlear implatns, HIV/AIDS,
chronic lung, chemo/steroids
o 6-18 y.o
 Should get one dose who have never received one
o PCV13 may be given at the same time as other vaccines, except for PPSV23 and
meningococcal conjugate vaccine
o Side effects of PCV 13
 50% get drowsy; fever, irritable
o Don’t give after 5 y/o
 PPSV 23- pneumococcal polysaccharide vaccine
o The 23-valent polysaccharide vaccine (PPVSV) is recommended for children 24 months
or older who are at high risk of pneumococcal disease.
o Who should also should get the PPSV23 vaccine??
 Residents of a nursing home
 All adults > 65 y/o
 > 19 y.o with risk factors= smoker and/or asthma
 If > 2 y/o and are at a high risk for pneumococcal dz
 Hodgkin’s disease; lymphoma or leukemia; kidney failure; multiple
myeloma; nephrotic syndrome; HIV infection or AIDS; damaged spleen,
or no spleen; organ transplant.
 Prevnar 13
o four-dose seriesat 2, 4, 6, and 12-15 months of age.
 MMR- Measles, Mumps, Rubella
o 2 shot series: Given at 12-15 months and 4-6 y.o (should be given before child enters
school, but technically can be given at any time > 4y.o)
 o Reason we wait until 12 mo of age- babies still have the Antibodies against MMR
from the mom
o Who does not need MMR
 Adults born during or before 1956 are believed to be immune. Many people
within that age group had the actual diseases during childhood.
o Side effects: rash, fever, seizure, swollen gland, low platelet, joint stiffness
 MMRV- measles, mumps, rubella, varicells
o Brand name: ProQuad
o Side effect: fever, rash
o Administer 1 time dose : b/w age 12 /o and 12 yrs
o Adminiset: Subq
 Varicella Vacone
o Brand name: Varivax or Zostavax
o 2 dose series: 12-15 m/o and at 4-6 y/o
o Administer: Subcutaneously
 PV- Polio vaccine
o virus that lives in the throat and intestinal tract
o 2 types=
o IPV= inactivated polio vaccine and
 Injection in arm or leg
 4 shot series: 2,4,6-18 mo and booster at 4-6 mo
o OPV= oral polio vaccine
 No longer given in US
 Pediarix— combo
o Diptheria, Tetanis, Pertusis, Hep B, IPV