Your Child's Immunizations

Larissa Hirsch

At birth, infants have protection against certain diseases because antibodies have passed through the placenta from the mother to the unborn child. After birth, breastfed babies get the continued benefits of additional antibodies in breast milk. But in both cases, the protection is only temporary.
Immunization (vaccination) is a way of creating immunity to certain diseases by using small amounts of a killed or weakened microorganism that causes the particular disease.
Microorganisms can be viruses, such as the measles virus, or they can be bacteria, such as pneumococcus. Vaccines stimulate the immune system to react as if there were a real infection - it fends off the "infection" and remembers the organism so that it can fight it quickly should it enter the body later.
Some parents may hesitate to have their kids vaccinated because they're worried that the children will have serious reactions or may get the illness the vaccine is supposed to prevent. Because the components of vaccines are weakened or killed - and in some cases, only parts of the microorganism are used - they're unlikely to cause any serious illness. Some vaccines may cause mild reactions, such as soreness where the shot was given or fever, but serious reactions are rare.
The risks of vaccinations are small compared with the health risks associated with the diseases they're intended to prevent.
The following vaccinations and schedules are recommended by the American Academy of Pediatrics (AAP). Please note that some variations are acceptable and that changes in recommendations frequently occur as new vaccines are developed. Many of these vaccines are available as combinations to reduce the number of shots a child receives. Your doctor will determine the best vaccinations and schedule for your child.

Recommended Vaccinations:
* Hepatitis B
* Pneumococcal conjugate vaccine (PCV)
* DTaP (diphtheria, tetanus, acellular pertussis)
* Hib (meningitis)
* IPV (polio)
* Influenza
* MMR (measles, mumps, rubella)
* Varicella (chickenpox)
* MCV4 (bacterial meningitis)
* Hepatitis A

Hepatitis B
Hepatitis B virus (HBV) affects the liver. Those who are infected can become lifelong carriers of the virus and may develop long-term problems such as cirrhosis (liver disease) or cancer of the liver.

Immunization Schedule
Hepatitis B vaccine usually is given as a series of three injections. The first shot is given to infants shortly after birth. If the mother of a newborn carries the hepatitis B virus in her blood, the infant needs to receive the first shot within 12 hours after birth, along with another shot (HBIG) to immediately provide protection against the virus. If a newborn's mother shows no evidence of HBV in her blood, the infant may receive the hepatitis B vaccine any time prior to leaving the hospital. It may also be delayed until the 4- or 8-week visit to the child's doctor.
If the first dose is given shortly after birth, the second shot is given at 1 to 4 months and the third at 6 to 18 months. For infants who don't receive the first shot until 4 to 8 weeks, the second shot is given at 3 to 4 months and the third at 6 to 18 months. In either case, the second and third shots are usually given in conjunction with other routine childhood immunizations.

Why the Vaccine Is Recommended
The hepatitis B vaccine usually creates long-term immunity. Infants who receive the HBV series should be protected from hepatitis B infection not only throughout their childhood but also into the adult years. Eliminating the risk of infection also decreases risk for cirrhosis of the liver, chronic liver disease, and liver cancer. Young adults and adolescents should also receive the vaccine if they did not as infants.

Possible Risks
Serious problems associated with receiving the HBV vaccine are rare. Problems that do occur tend to be minor, such as fever or redness or tenderness at the injection site.

When to Delay or Avoid Immunization
* if your child is currently sick, although simple colds or other minor illnesses should not prevent immunization
* if a severe allergic reaction (called anaphylaxis) occurred after a previous injection of the HBV vaccine

Caring for Your Child After Immunization
The vaccine may cause mild fever, and soreness and redness in the area where the shot was given. Pain and fever may be treated with acetaminophen or ibuprofen. Check with your child's doctor about the appropriate dose.

When to Call the Doctor
* if you're not sure of the recommended schedule for the hepatitis B vaccine
* if you have concerns about your own HBV carrier state
* if moderate or serious adverse effects appear after your child has received an HBV injection

Pneumococcal Vaccine (PCV)
The pneumococcal conjugate vaccine (PCV) protects against pneumococcal infections. The bacterium is the leading cause of serious infections, including pneumonia, blood infections, and bacterial meningitis. Children under 2 years old are most susceptible to serious pneumococcal infections. The pneumococcus bacterium is spread through person-to-person contact. The vaccine not only prevents the infection in children who receive it, it also helps stop its spread.

Immunization Schedule
PCV immunizations are given as a series of four injections starting at 2 months of age and following at 4 months, 6 months, and 12 to 15 months. Children who miss the first dose or may have missed subsequent doses due to vaccine shortage should still receive the vaccine, and your child's doctor can give you a modified schedule for immunization.

Why the Vaccine Is Recommended
The most serious infections affect children younger than 2 years old, and the vaccine will protect them when they're at greatest risk. PCV also is recommended for kids between 2 and 5 years of age who are at high risk for serious pneumococcal infections because they have:
* sickle cell anemia
* a damaged spleen or no spleen
* HIV/AIDS
* cochlear implants
* a disease that affects the immune system, such as diabetes or cancer
* to receive medications that affect the immune system, such as steroids or chemotherapy

In addition, these high-risk children may also receive the pneumococcal polysaccharide vaccine (PPV) in addition to the PCV when they're older than 24 months.
The PCV vaccine should be considered for all other 2- to -5-year-olds, especially those who are under 3 years of age; are of Alaska Native, American Indian, or African American descent; or who attend group child-care centers.

Possible Risks
Children who receive the PCV vaccine may have redness, tenderness, or swelling where the shot was given. A child may also have a fever after receiving the shot.

When to Delay or Avoid Immunization
* if your child is currently sick, although simple colds or other minor illnesses should not prevent immunization
* if your child has had a severe allergic reaction to a previous dose of the vaccine

Caring for Your Child After Immunization
The vaccine may cause mild fever, and soreness and redness in the area where the shot was given. Pain and fever may be treated with acetaminophen or ibuprofen. Check with your child's doctor about the appropriate dose.

When to Call the Doctor
* if your child missed a dose in the series
* if a severe allergic reaction or high fever occurs after immunization

DTaP
The DTaP vaccine protects against:
* diphtheria - a serious infection of the throat that can block the airway and cause severe breathing difficulty
* tetanus (lockjaw) - a nerve disease, which can occur at any age, caused by toxin-producing bacteria contaminating a wound
* pertussis (whooping cough) - a respiratory illness with cold symptoms that progress to severe coughing (the "whooping" sound occurs when the child breathes in deeply after a severe coughing bout); serious complications of pertussis can occur in children under 1 year of age, and those under 6 months old are especially susceptible

Immunization Schedule
DTaP immunizations are given as a series of five injections and are usually administered at ages 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years (before starting school). After the initial series of immunizations, a vaccine called Tdap (the booster shot) should be given at ages 11 to 12. Then, Td (tetanus and diphtheria) boosters are recommended every 10 years.

Why the Vaccine Is Recommended
Use of the DTaP vaccine has virtually eliminated diphtheria and tetanus in childhood and has markedly reduced the number of pertussis cases.

Possible Risks
The vaccine frequently causes mild side effects: fever, mild crankiness, tiredness, loss of appetite, and tenderness, redness, or swelling in the area where the shot was given. Rarely, seizures can occur following DTaP. Most of these side effects result from the pertussis component of the vaccine. Severe complications caused by DTaP immunization are rare. Most kids have little or no problem.

When to Delay or Avoid Immunization
* if your child is currently sick, although simple colds or other minor illnesses should not prevent immunization
* if your child has an uncontrolled seizure disorder or certain neurologic diseases or seems not to be developing normally - the pertussis component of the vaccine may not be given, and your child may receive a DT (diphtheria and tetanus) vaccine instead
If your child experienced any of the following after an earlier DTaP, consult with your doctor before your child receives another injection of the vaccine:
* seizures within 3 to 7 days after injection
* worsening of seizures
* an allergic reaction after receiving the vaccine, such as mouth, throat, or facial swelling
* difficulty breathing
* temperature of 40.5° Celsius or higher during the first 2 days after injection
* shock or collapse during the first 2 days after injection
* persistent, uncontrolled crying that lasts for more than 3 hours during the first 2 days after injection

Caring for Your Child After Immunization
Your child may experience fever, soreness, and some swelling and redness in the area where the shot was given. Pain and fever may be treated with acetaminophen or ibuprofen. Check with your child's doctor about the appropriate dose. Some doctors recommend a dose just before the
immunization.
A warm, damp cloth or a heating pad also may help reduce soreness. Moving or using the limb that has received the injection often reduces the soreness.

When to Call the Doctor
* if you aren't sure whether the vaccine should be postponed or avoided. Children who have had certain problems with the DTaP vaccine usually can safely receive the DT vaccine.
* if complications or severe symptoms develop after immunization, including seizures, fever above 105° Fahrenheit (40.5° Celsius), difficulty breathing or other signs of allergy, shock or collapse, or uncontrolled crying for more than 3 hours

Hib
Haemophilus influenzae type b bacteria were the leading cause of meningitis in children until the Hib vaccine became available.

Immunization Schedule
The Hib vaccine is given by injection at ages 2 months, 4 months, and 6 months (however, some of the Hib vaccines do not require a dose at 6 months). A booster dose is given at 12 to 15 months.

Why the Vaccine Is Recommended
Long-term protection from Haemophilus influenzae type b occurs in more than 90% of infants receiving three doses of the vaccine. Those immunized have protection against meningitis, pneumonia, pericarditis (an infection of the membrane covering the heart), and infections of the blood, bones, and joints caused by the bacteria.

Possible Risks
Minor problems, such as redness, swelling, or tenderness where the shot was given, may occur.

When to Delay or Avoid Immunization
* if your child is currently sick, although simple colds or other minor illnesses should not prevent immunization
* if severe allergic reaction occurs after an injection of the Hib vaccine, further Hib immunizations may not be given to your child Caring for Your Child After Immunization The vaccine may cause mild soreness and redness in the area where the shot was given. Pain may be treated with acetaminophen or ibuprofen. Check with your child's doctor about the appropriate dose.

When to Call the Doctor
* if you aren't sure whether the vaccine should be postponed or avoided
* if moderate or serious adverse reactions appear after the Hib injection

IPV
Polio is a viral infection that can result in permanent paralysis.

Immunization Schedule
The inactivated poliovirus vaccine (IPV) is usually given at ages 2 months, 4 months, 6 to 18 months, and 4 to 6 years before entering school. Until recently, the oral poliovirus vaccine (OPV) was given in the United States. Updated recommendations by the Advisory Committee on Immunization Practices now call for IPV injections. This change eliminates the previous small risk of developing polio after receiving the live oral polio vaccine.

Why the Vaccine Is Recommended
Protection against polio occurs in more than 95% of children immunized.

Possible Risks
Side effects include fever and redness or soreness at the site of injection.

When to Delay or Avoid Immunization
* IPV should not be given to kids with severe allergy to neomycin, streptomycin, or polymyxin B. Caring for Your Child After Immunization IPV may cause mild fever, and soreness and redness at the site of the injection for several days. Pain and fever may be treated with acetaminophen or ibuprofen. Check with your child's doctor about the appropriate dose.

When to Call the Doctor
* if you aren't sure whether the vaccine should be postponed or avoided
* if moderate or severe adverse reactions occur after the immunization

Influenza
Influenza, commonly known as "the flu," is a highly contagious viral infection of the respiratory tract.

Immunization Schedule
These groups, who are at increased risk of flu-related complications, should receive the flu shot every year:
* children 6 to 59 months old
* any child or adult with chronic medical conditions, such as asthma, cystic fibrosis, diabetes, sickle cell anemia, and HIV/AIDS
* children - from 6 months to 18 years - on long-term aspirin therapy
* anyone age 65 and older
* women who will be pregnant during the flu season
* anyone who lives or works with infants under 6 months old
* residents of long-term care facilities, such as nursing homes
* health-care personnel who have direct contact with patients
* out-of-home caregivers and household contacts of anyone in any of these high-risk groups

In the past, there have been times when there were vaccine shortages and delays. So talk with your doctor about availability. For kids younger than 9 who are getting a flu shot for the first time, it's given in two separate shots a month apart. It can take about 2 weeks after the shot is given for the body to build up protection to the flu.
Another non-shot option called the nasal mist vaccine came on the market in 2003 and is now approved for use in healthy 5- to 49-year-olds. But this nasal mist isn't for everyone, and can't be used by high-risk children and adults or pregnant women.

Why the Vaccine Is Recommended
The flu vaccine reduces the average person's chances of catching the flu by up to 80% during the season. Getting the shot before the flu season is in full force gives the body a chance to build up immunity to, or protection from, the virus.
The shot usually becomes available between September and mid-November. Although you can get a flu shot well into flu season, it's best to try to get it earlier rather than later, if your doctor thinks it's necessary.
However, even as late as January there are still 2 to 3 months left in the flu season, so it's still a good idea to get protection. Even if you or your child got the vaccine last year, that won't protect you from getting the flu this year, because the protection wears off and flu viruses constantly change. That's why the vaccine is updated each year to include the most current strains of the virus.

Possible Risks
Given as one injection in the upper arm, the flu shot contains killed flu viruses that will not cause someone to get the flu, but will cause the body to fight off infection by the live flu virus. Getting a shot of the killed virus offers protection against that particular type of live flu virus if someone comes into contact with it.
Some of the most common side effects from the flu shot are soreness, redness, or swelling at the site of the injection. A low-grade fever and aches are also possible. Because the nasal spray flu vaccine is made from live viruses, it may cause mild flu-like symptoms, including runny nose, headache, vomiting, muscle aches, and fever. Very rarely, the flu vaccine can cause serious side effects such as a severe allergic reaction.

When to Delay or Avoid Immunization
People who should not get the flu shot include:
* infants under 6 months old
* anyone who's severely allergic to eggs and egg products because the ingredients for flu shots are grown inside eggs. Tell the doctor if your child is allergic before he or she gets a flu shot.
* anyone who's ever had a severe reaction to a flu vaccination
* anyone who's had Guillain-Barré syndrome (GBS, a rare medical condition that affects the nerves) within 6 weeks of getting a flu shot
* anyone with a fever

Caring for Your Child After Immunization
Pain and fever may be treated with acetaminophen or ibuprofen. Check with your child's doctor about the appropriate dose. Some doctors recommend a dose just before the immunization. A warm, damp cloth or a heating pad also may help minimize soreness. Moving or using the limb that has received the injection often reduces the soreness as well.

When to Call the Doctor
* if you aren't sure if the vaccine should be postponed or avoided
* if there are problems after the immunization

MMR (measles, mumps, rubella)
The MMR vaccine protects against measles, mumps, and rubella (German measles). MMR vaccinations are given by injection in two doses. The first is administered at age 12 to 15 months; the second generally is given prior to school entry at age 4 to 6 years.

Why the Vaccine Is Recommended
Measles, mumps, and rubella are infections that can lead to significant illness. More than 95% of children receiving MMR will be protected from the three diseases throughout their lives.

Possible Risks
Serious problems are rare. Potential mild to moderate adverse effects include rash, fever, swollen cheeks, febrile seizures, and mild joint pain.

When to Delay or Avoid Immunization
* if your child is currently sick, although simple colds or other minor illnesses should not prevent immunization
* if your child has an allergy to eggs, gelatin, or to the antibiotic neomycin that has required medical treatment
* if your child has received gamma globulin
* if your child has immune system problems related to cancer, leukemia, or lymphoma
* if your child is taking prednisone, steroids, or immunosuppressive drugs
* if your child is undergoing chemotherapy or radiation therapy

Caring for Your Child After Immunization
If a rash develops without other symptoms, no treatment is necessary and it should resolve within several days. Pain and fever may be treated with acetaminophen or ibuprofen. Check with your child's doctor about the appropriate dose.

When to Call the Doctor
* if you aren't sure if the vaccine should be postponed or avoided
* if there are problems after the immunization

Varicella (chickenpox)
The varicella vaccine protects against chickenpox (varicella), a common and very contagious childhood viral illness.

Immunization Schedule
The varicella vaccine is given by injection between the ages of 12 and 18 months. Older children who have not had chickenpox may also receive the vaccine. Kids 13 years or older who have not had either chickenpox or the vaccine would need two vaccine doses at least 1 month apart.

Why the Vaccine Is Recommended
The varicella vaccine prevents severe illness in 95% of children who are immunized. It's up to 85% effective in preventing mild illness. Vaccinated kids who do get chickenpox generally have a mild case.

Possible Risks
Serious reactions are extremely rare. Possible mild effects are tenderness and redness where the shot was given, fever, fatigue, and a varicella-like illness. A rash can occur where the shot was given or elsewhere on the body up to 1 month after the injection. It may last for several days but will disappear on its own without treatment.

When to Delay or Avoid Immunization
* if your child is ill with anything more serious than a cold, immunization should be delayed
* if your child has an allergy to gelatin or to the antibiotic neomycin that has required medical treatment
* if your child has received gamma globulin
* if your child has immune system problems related to cancer, leukemia, or lymphoma; is taking prednisone, steroids, or immunosuppressive drugs; or is undergoing chemotherapy or radiation therapy

Caring for Your Child After Immunization
Pain and fever may be treated with acetaminophen or ibuprofen. Check with your child's doctor about the appropriate dose.

When to Call the Doctor
* if you aren't sure if the vaccine should be postponed or avoided
* if there are problems after the immunization

MCV4
The meningitis vaccine protects against meningococcal disease, a serious bacterial infection that can lead to bacterial meningitis. The vaccine is recommended for kids at age 11 or 12 years, at age 15 years if not previously vaccinated (before entering high school), and for older teens who are entering college and will be living in a dormitory setting.

Why the Vaccine Is Recommended
Bacterial meningitis, an inflammation of the membrane that protects the brain and spinal cord, is a rare but highly contagious disease that can spread rapidly among kids who are in close quarters. It can be life-threatening if it's not promptly treated.

Possible Risks
Some of the most common side effects are swelling, redness, and pain at the site of the injection, along with headache, fever, fatigue, and a rash.

When to Delay or Avoid Immunization
* if your child tends to have allergic reactions to the DTaP vaccine or to latex
* if your child is currently sick, although simple colds or other minor illnesses should not prevent immunization

Caring for Your Child After Immunization
Your child may experience fever, soreness, and some swelling and redness in the area where the shot was given. Pain and fever may be treated with acetaminophen or ibuprofen. Check with your child's doctor about the appropriate dose. Some doctors recommend a dose just before the
immunization.
A warm, damp cloth or a heating pad also may help reduce soreness. Moving or using the limb that has received the injection often reduces the soreness.

When to Call the Doctor
* if you aren't sure if the vaccine should be postponed or avoided
* if there are problems after the immunization

Hepatitis A
The hepatitis A virus (HAV) causes fever, nausea, vomiting, and jaundice, and can lead to community-wide epidemics. Child care centers are a common site of outbreaks.
The vaccine is recommended for children 12-23 months old, followed by a second dose 6 months later. The vaccine is also recommended for older kids and adults who are at high risk for the disease, including those who are traveling to locations where there are high rates of HAV.

Why the Vaccine Is Recommended
Vaccination against HAV can help stop epidemics from developing in the community. Some infected children do not have any symptoms, and can spread the virus to others. The more young children who are vaccinated against HAV, the more limited the spread of disease will be in a community.

Possible Risks
Side effects are usually mild fever, and tenderness, swelling, and redness at the site of the injection.

When to Delay or Avoid Immunization
* if your child is currently sick, although simple colds or other minor illnesses should not prevent immunization
* if your child had an allergic reaction to the first dose of hepatitis A vaccine

Caring for Your Child After Immunization
Your child may experience fever, soreness, and some swelling and redness in the area where the shot was given. Pain and fever may be treated with acetaminophen or ibuprofen. Check with your child's doctor about the appropriate dose.

When to Call the Doctor
* if you aren't sure if the vaccine should be postponed or avoided
* if there are problems after the immunization

Types of Vaccines
Four different types of vaccines are currently available:
1. Attenuated (weakened) live viruses are used in some vaccines such as in the measles, mumps, and rubella (MMR) vaccine.
2. Killed (inactivated) viruses or bacteria are used in some vaccines, such as in IPV.
3. Toxoid vaccines contain a toxin produced by the bacterium. For example, the diphtheria and tetanus vaccines are toxoid vaccines.
4. Biosynthetic vaccines (such as Hib) contain synthetic substances.

Immunizations for Travel
Specific information about which immunizations are required by travelers to each country worldwide is available directly from the Centers for Disease Control and Prevention (CDC). Ask your doctor for more information.
Depending on the type and length of travel, some vaccines may be recommended. Most immunizations should be given at least 1 month before travel. Take your child's immunization records with you when you travel internationally.

Helping Your Child Through Vaccine Injections
Sometimes it's hard to tell who dreads immunizations more - parents or kids. Here are some tips to help make the procedure easier for everyone:
* Tell older kids what's going to happen and that the shot helps to keep them healthy.
* Tell younger kids that it's OK to cry, but also encourage them to be brave.
* Try to be calm yourself. Your child can pick up on your concerns.
* Distraction at the moment of the injection is helpful. Try having kids count, sing a song with you, or look away (perhaps at a picture on the wall). You may want to have a joke or funny comment ready.
* Offer praise after the injection is over.
* Plan something fun for after the appointment. A trip to the park or playground can make the overall immunization experience less unpleasant.

As uneasy as getting vaccinated may make both you and your child, remember
that immunizations are one of the best means of protection against
contagious diseases. [AAFP]