BNF for Children 2011-2012

600 14.1 Active immunity BNFC 2011–201214 Immunological products and vaccinessuppressive drugs 1 , and for children with malignantconditions undergoing chemotherapy or generalisedradiotherapy 1;2 . For special reference to HIV infection,see below.The Royal College of Paediatrics and Child Health hasproduced a statement, Immunisation of the ImmunocompromisedChild (2002) (available atwww.rcpch.ac.uk).Pregnancy Live vaccines should not be administeredroutinely during pregnancy because of the theoreticalrisk of fetal infection but where there is a significant riskof exposure to disease (e.g. to yellow fever), the need forvaccination usually outweighs any possible risk to thefetus. Termination of pregnancy following inadvertentimmunisation is not recommended. There is no evidenceof risk from vaccinating pregnant women withinactivated viral or bacterial vaccines or toxoids. For useof specific vaccines during pregnancy, see under individualvaccines.Breast-feeding Although there is a theoretical risk oflive vaccine being present in breast milk, vaccination isnot contra-indicated for women who are breast-feedingwhen there is significant risk of exposure to disease.There is no evidence of risk from vaccinating womenwho are breast-feeding, with inactivated viral or bacterialvaccines or toxoids. For use of specific vaccinesduring breast-feeding, see under individual vaccines.Side-effects Injection of a vaccine may be followed bylocal reactions such as pain, inflammation, redness, andlymphangitis. An induration or sterile abscess maydevelop at the injection site. Gastro-intestinal disturbances,fever, headache, irritability, loss of appetite,fatigue, myalgia, and malaise are among the most commonlyreported side-effects. Other side-effects includeinfluenza-like symptoms, dizziness, paraesthesia, asthenia,drowsiness, arthralgia, rash, and lymphadenopathy.Hypersensitivity reactions, such as bronchospasm,angioedema, urticaria, and anaphylaxis, are very rarebut can be fatal (see section 3.4.3 for management ofallergic emergencies).Oral vaccines, such as cholera, live poliomyelitis, rotavirus,and live typhoid, can also cause gastro-intestinaldisturbances such as nausea, vomiting, abdominal painand cramps, and diarrhoea.See also Predisposition to Neurological Problems,below.Some vaccines (e.g. poliomyelitis) produce very fewreactions, while others (e.g. measles, mumps and rubella)may cause a very mild form of the disease.Occasionally more serious adverse reactions canoccur—these should always be reported to the CHM(see Adverse Reactions to Drugs, p. 12).See also Preterm Birth, p. 601.1. Live vaccines should be postponed until at least 3 monthsafter stopping high-dose systemic corticosteroids and atleast 6 months after stopping other immunosuppressivedrugs or generalised radiotherapy (at least 12 months afterdiscontinuing immunosuppressants following bone-marrowtransplantation).2. Use of normal immunoglobulin should be considered afterexposure to measles (see p. 623) and varicella–zosterimmunoglobulin considered after exposure to chickenpoxor herpes zoster (see p. 625).Predisposition to neurological problemsWhen there is a personal or family history of febrileconvulsions, there is an increased risk of theseoccurring during fever from any cause includingimmunisation, but this is not a contra-indication toimmunisation. In children who have had a seizureassociated with fever without neurological deterioration,immunisation is recommended; advice on themanagement of fever (see Post-immunisationPyrexia in Infants, below) should be given beforeimmunisation. When a child has had a convulsionnot associated with fever, and the neurological conditionis not deteriorating, immunisation is recommended.Children with stable neurological disorders (e.g.spina bifida, congenital brain abnormality, andperi-natal hypoxic-ischaemic encephalopathy)should be immunised according to the recommendedschedule.When there is a still evolving neurological problem,including poorly controlled epilepsy, immunisationshould be deferred and the child referred to aspecialist. Immunisation is recommended if acause for the neurological disorder is identified. Ifa cause is not identified, immunisation should bedeferred until the condition is stable.Post-immunisation pyrexia in infantsThe parent should be advised that if pyrexia developsafter childhood immunisation and the infantseems distressed, a dose of paracetamol can begiven and, if necessary, a second dose can begiven 6 hours later; ibuprofen may be used if paracetamolis unsuitable. The parent should be warnedto seek medical advice if the pyrexia persists.For post-immunisation pyrexia in an infant aged 2–3months, the dose of paracetamol is 60 mg; the doseof ibuprofen is 50 mg (on a doctor’s advice). An oralsyringe can be obtained from any pharmacy to givethe small volume required.Further information on adverse effects associated withspecific vaccines can be found under individual vaccines.Vaccines and HIV infection HIV-positive childrenwith or without symptoms can receive the following livevaccines:MMR (but avoid if immunity significantly impaired),varicella-zoster (but avoid if immunity significantlyimpaired—consult product literature); 2and the following inactivated vaccines:anthrax, cholera (oral), diphtheria, haemophilusinfluenzae type b, hepatitis A, hepatitis B, humanpapilloma virus, influenza, meningococcal, pertussis,pneumococcal, poliomyelitis 3 , rabies,tetanus, tick-borne encephalitis, typhoid (injection).HIV-positive children should not receive:BCG, typhoid (oral), yellow fever 4Note The above advice differs from that for other immunocompromisedchildren; Immunisation of HIV-infected Childrenissued by Children’s HIV Association (CHIVA) are available atwww.chiva.org.uk3. Inactivated poliomyelitis vaccine is now used instead oforal poliomyelitis vaccine for routine immunisation ofchildren.4. If yellow fever risk is unavoidable, specialist advice shouldbe sought.