Immunization

• Hepatitis B.
All infants should receive three doses of hepatitis B vaccine—one at birth, one between one and two months of age, and one between six and eighteen months.

• Diptheria, Tetanus, and Acellular Pertussis (Dtap).
These three immunizations are given in a combined injection. Shots are needed at two, four, six, and fifteen to eighteen months of age, with a final dose before starting school. The American Academy of Pediatrics recommends that all five injections use a newer, acellular vaccine. This vaccine is far less likely to cause side effects than the whole-cell vaccine that was the only option until 1991.

• Polio Vaccine.
Polio vaccine should be given at two, four, and six to eighteen months, with a final dose before starting school. Both oral and injected forms of the vaccine are available, but the ACIP recommends using the IVP, made from inactivated poliovirus and given by injection, for the first two doses. If the child or someone in the household is immunosuppressed, only IVP should be used.

• Hemophilus Influenze Type B.
This vaccine protects against the bacterium responsible for most cases of meningitis and epiglottitis in small children. Three different HiB vaccines are effective in infants. Either the HbOC vaccine or the PRP-T is given at two, four, six, and twelve to fifteen months of age. The HbOC vaccine also comes in a combined from with a DTaP vaccine, so only one shot is necessary. With the third type of HiB vaccine, called the PRP-OMP, only three doses are needed—a two-month dose, a four-month dose, and a final booster between twelve and fifteen months of age.

• Measles, Mumps, and Rubella (MMR). This combination vaccine is given at twelve to fifteen months of age and generally repeated just before school entry. It's safe, however, to give the second dose much earlier as long as a full month passes between the first and second doses.

• Chicken Pox (Varicella). Varicella vaccine is recommended at one year of age for all children who have not had chicken pox.

HOW DO IMMUNIZATIONS WORK?
Immunizations protect the body against disease-causing agents by triggering the immune system (the body's built-in defense against disease) to produce antibodies, which attack and neutralize bacteria and viruses.

The only other way to develop antibodies is to catch the disease. Once children have had measles, for example, they won't get it again because, during the illness, the immune system manufactured antibodies against the measles virus. Immunizations work the same way, but they bypass the acute illness by using a form of the infectious agent that is too weak to cause illness but strong enough to make the immune system respond.

WHY DO CHILDREN NEED IMMUNIZATIONS?
There are several compelling reasons to immunize all healthy children. Most important is to protect the children themselves. Diphtheria, pertussis, tetanus and polio are life threatening conditions, as is Hemophilus influenzae meningitis. Though generally less serious, measles, mumps and rubella also can make some children extremely sick and have long-lasting consequences.

In addition, widespread immunization of healthy children protects those who, because of illnesses such as cancer, cannot receive vaccines. While measles might cause a healthy child to remain home for a week or so, the same illness has a high likelihood of causing death in a child with a severely weakened immune system from AIDS, cancer or cancer treatment.

By the same token, immunization of small children protects adolescents and adults who neither had the diseases nor received vaccines and thus are vulnerable. Many of these diseases can be particularly severe in adolescents and adults. Mumps, for instance, can in rare cases cause sterility in young men. Severe birth defects are common in infants of mothers who contract rubella (German measles) during pregnancy. Measles may cause serious pneumonia and hepatitis in adults.

WHAT ARE THE POTENTIAL SIDE EFFECTS OF IMMUNIZATIONS?
The side effects are usually quite mild, consisting of swelling and tenderness at the site of the injection. Low fevers and rashes sometimes develop after the MMR vaccine, due to the measles and rubella components. Mild fever occurs even less frequently following both the HbOC and PRP-OMP vaccinations against Hemophilus influenzae. Fever, irritability and fatigue were formerly common following DTP immunization, but with the new acellular vaccines, even mild side effects are unusual. In extremely rare cases (1 in 700,000 first-time vaccine recipients), the oral polio has triggered full-blown cases of polio. For that reason, IVP is recommended for the first two doses of polio vaccine.

ARE THERE ANY CHILDREN WHO SHOULD NOT BE IMMUNIZED?
If a child has a high fever, immunization should be postponed unitl his temperature returns to normal. A child with a mild illness and slight fever, however, can be immunized. Children with suppressed immune systems (due to chemotherapy, radiation, AIDS or drugs given to protect transplanted organs) should receive the injected polio vaccine (IPV), which is made from killed virus, rather than the oral vaccine. The same precaution applies to children who live with immunosuppressed patients, who might catch the virus from a recently immunized child. Children with progressive neurological disorders or uncontrolled seizures should not receive the DTP vaccine, and any child who has had a prior, severe reaction to the pertussis component should receive only the DT in subsequent immunizations. Finally, children who are extremely allergic to eggs should be skin-tested before they receive the MMR, since portions of this vaccine are grown in cultures of chicken embryo cells.

BAD MEMORIES
Before the advent of immunization, these diseases killed and disabled large numbers of children each year.

• Diphtheria.
This highly contagious bacterial infection is spread through airborne droplets expelled when an infected person coughs, sneezes or breathes. When diptheria-causing bacteria attack the respiratory tract, a gray membrane forms over the throat and nasal passages, and breathing may be obstructed. One strain of the causative bacteria produces a toxin that causes the neck to swell and leads to widespread organ damage.

• Pertussis.
This bacterial infection spreads rapidly through the same airborne route as diphtheria. The chief symptom is violent coughing brought on by eating, drinking or exertion and occurring several times a day, so the child becomes exhausted. After the first several weeks, the frequency of coughing bouts diminishes, but they can recur for six weeks or longer. Infants may suffer nervous system damage, malnutrition and poor growth. Unfortunately, this disease is on the rise, affecting older children who have lost immunity from early vaccines and infants who have not yet been vaccinated.

• Polio.
This viral infection has been almost abolished since the first vaccine was introduced in 1955. Most cases of polio are mild, similar to the flu and other viral illnesses, but a small number affect the central nervous system, leading to brain inflammation, paralysis and even death, especially among infants under age one. Symptoms of paralytic polio include muscle weakness and spasms, pain, loss of certain reflexes and retention of urine. Permanent paralysis occurs most often in the legs, although other parts of the body—including the muscles that control breathing—can be paralyzed as well.

• Tetanus.
This infection is caused by bacteria found in soil, dust and the intestinal tracts of humans and animals. The bacteria typically enter the body through a wound such as a severe burn or puncture. When the bacteria multiply, they produce a substance that is toxic to the nervous system, causing muscle stiffness, which starts in the neck and jaw. In four out of every ten cases, tetanus is fatal.

NEWER VACCINES
Several new vaccines, some specifically for children, are at various stages in the testing process. They include:

• Rotavirus vaccine.
This recently licensed immunization, intended to be given in three oral doses at two, four and six months of age, protects against rotavirus gastroenteritis, the most common cause of severe diarrhea in children.

• Pneumococcal vaccine.
This experimental vaccine has been proven safe and effective against the bacterium responsible for many middle-ear infections, as well as for some cases of pneumonia and meningitis in children. The pneumococcal vaccines already in use are ineffective in children.

• Lyme disease vaccine.
A vaccination that protects against this tick-borne disease that can cause arthritis and heart problems was recently approved for adults. The manufacturer is currently conducting studies of the vaccine in children.

CARING FOR A CHILD AFTER A VACCINE
Mild fever, achiness, crankiness and pain at the injection site are common side effects of some vaccines, and they may appear immediately or a few days days later. Ask your pediatrician for specific recommendations on how to soothe these discomforts. Generally, it is safe to give infants' or children's acetaminophen (Tylenol, Panadol, Tempra and other brands) in age-appropriate doses to relieve fever. Some pediatricians even recommend administering these medications before the DTP vaccine if the child has had a previous reaction. Warm compresses can ease pain at the site of the injection.

GETTING A SHOT: HOW TO HELP
Many children hate injections. Not only may some hurt, but they also make children feel uniquely powerless. Preschool children, who tend to worry about possible harm to their bodies, are particularly distressed by injections.

Parents can help by adopting a calm, matter-of-fact attitude. Since immunizations are usually given during routine well-child checkups, focus instead on other aspects of the visit such as the toys in the waiting room or the trinket the pediatrician will hand out at the end of the visit.

Extremely anxious children need more reassurance. Before this visit, they should be allowed to handle a syringe and practice giving shots to stuffed animals. A step-by-step explanation of what is going to happen is also helpful.

Most immunizations, with the exception of the MMR, are injected into the muscle rather than under the skin, so they are somewhat uncomfortable. Babies generally receive shots in the large muscle running down the backside of the thigh. After children start to walk, shots are given in the upper arm, but some large shots still need to be given in the thigh muscles or the buttocks.

Children handle shots better if a parent holds them and diverts their attention. For babies and toddlers, a brightly colored toy will do. Older children can recite a nursery rhyme, count, blow bubbles or look out the window.

GETTING HELP
Call your doctor if your child:

• Develops fever over 104 degrees Fahrenheit after an immunization

• Cries more than three hours

• Has convulsions

• Becomes extremely listless or undergoes other changes in behavior

• Loses muscle tone, breathes shallowly and has a weak pulse