ELK GROVE VILLAGE, ILL—The American Academy of Pediatrics (AAP) has issued its 2003 childhood immunization schedule for the United States.[1] The statement represents unified recommendations from the AAP, the Advisory Committee on Immunization Practices of the CDC, and the American Academy of Family Physicians. Although there are no changes regarding specific vaccines, a new catch-up schedule for children who fall behind in their immunizations is included. Furthermore, the recommendations advocate hepatitis B vaccination for all newborns and encourage influenza immunization for infants between 6 and 24 months.

WHAT THEY SAY

The schedule indicates the recommended ages for administration of childhood vaccines (see Table 1). The catch-up schedule within the table indicates the ages at which vaccines can be given to children who fall behind on their immunizations. A combination vaccine may be administered when any component of the vaccine is indicated, as long as the vaccine’s other components are not contraindicated at that time.

Hepatitis B: All newborns should receive the first dose of the monovalent HepB vaccine only soon after birth—ideally, before hospital discharge. At least three doses of the vaccine should be administered in total; four doses are acceptable when a birth dose is given. When doses are administered depends, in part, on the mother’s hepatitis B status.

If the mother tests negative for hepatitis B surface antigen (HBsAg), the first dose may be delayed until after hospital discharge, but it should be given no later than age 2 months. The second dose should be administered at least four weeks after the first, and the third dose should be given at least 16 weeks after the first dose and eight weeks after the second. The last (third or fourth) dose must be given at age 6 months or later.

Children of HBsAg-positive mothers should receive HepB and 0.5 mL of Hepatitis B Immune Globulin (HBIG) within 12 hours of birth. The second dose of the vaccine should be administered between ages 1 and 2 months; the last dose should be given at age 6 months. When these infants are between ages 9 and 15 months, they should be tested for evidence of hepatitis B exposure.

Children of mothers whose HBsAg status is unknown should receive the first dose of the vaccine within 12 hours of birth. The mother should be tested as soon as possible; if she is positive, the infant should receive HBIG no later than age 1 week.

Diphtheria and tetanus toxoids and acellular pertussis (DTaP): Although it is preferable to give the fourth dose of this vaccine when a child is between ages 15 and 18 months, it can be given as early as 12 months as long as it has been six months since the third dose. Tetanus and diphtheria toxoid (Td) vaccination is recommended at ages 11 to 12 years if it has been at least five years since the last vaccination with a vaccine containing Td. Td boosters are recommended every 10 years thereafter.

Haemophilus influenzae type b conjugate (Hib): This vaccine comes in three formulations. If the PRP-OMP vaccine (PedvaxHIB® or ComVax®) is administered at ages 2 and 4 months, the 6-month dose is not required. Vaccines containing combinations of DTaP/Hib can be given as booster shots, but they should not be used as primary immunization in infants younger than 6 months.

Inactivated polio vaccine (IPV): Children should receive four doses of IPV: one at age 2 months, the second at age 4 months, the next between ages 6 and 18 months, and the last between ages 4 and 6 years.

Measles, mumps, and rubella (MMR): The first dose of MMR should be given between ages 12 and 15 months; the second should be given between ages 4 and 6 years. If necessary, a catch-up vaccination can be administered between ages 11 and 12 years.

Varicella: Any child older than 12 months who has not had chicken pox should receive the varicella vaccine. Persons still susceptible at 13 years or older should be given two doses of the vaccine, at least four weeks apart.

Pneumonia: Heptavalent pneumococcal conjugate vaccine (PCV) is recommended for all children ages 2 to 23 months; it may also be appropriate for some children between ages 2 and 5 years. Some high-risk children may need the pneumococcal polysaccharide vaccine (PPV) as well.

Hepatitis A: This immunization is suggested for children 24 months and older who live in certain regions or who are at risk for other reasons. Immunization can begin at any time, and the two doses should be administered six months apart.

Influenza: Vaccination of children 6 months or older with conditions such as asthma, sickle cell disease, and HIV is recommended. In addition, wherever feasible, all children ages 6 to 23 months are encouraged to receive yearly vaccinations against influenza because of the high risk of related complications in this group. Dosages must be adjusted in children; use 0.25 mL for those between ages 6 and 35 months and 0.5 mL for those 3 years or older. Children younger than 9 years should be given two doses of the vaccine, at least four weeks apart.

—Tamara Gibb