Child immunisations

16 November 2018

First published August 2011

Why should children be immunised and when?

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ABOUT CHILDHOOD IMMUNISATIONS 

IMMUNITY

Immunisations that are given to infants from a young age are vital to help them build up their immunity which protects them from serious disease and illness. There are two basic methods for acquiring immunity-active and passive.

  • Active immunity is developed by the immune system as a result of being infected by the disease or from immunisation. Vaccines given at immunisation can provide immunity similar to that provided by the disease but without the risk of the disease or its complications.vi As active immunity is usually long­lasting, achieving it is the overall aim of any immunisation programme.
  • Passive immunity is not long-lasting and is provided by the transfer of antibodies from immune individuals. The most common example of passive immunity is during pregnancy when antibodies from the mother are passed to her baby through the placenta. As passive immunity only lasts for a few weeks or months it is important to begin immunisation at two months after birth to protect the baby against certain diseases. In the case of immunising against measles, mumps and rubella (MMR), the antibodies passed from the mother may last in the baby's body for up to one year. For this reason, the MMR vaccine is given at between 12 and 13 months of age. 

 

HOW IMMUNISATIONS WORK

Injections given at immunisation contain weakened or inactivated parts of the disease-causing organism or toxin.X After the vaccine has been given, the immune system in the body is stimulated to produce the appropriate antibodies to fight the disease. In this way, the body develops an active immunity to the disease by learning how to respond to it in the future. This is known as 'immune memory'.

WHY IMMUNISE?

The primary aim of immunisation is to protect the individual who receives the vaccine. Immunisation from two months can provide infants with valuable, long-lasting protection against certain serious diseases and without it they are much more vulnerable to infections which can result in handicap or even death. Child health specialists agree the benefits of immunisation far outweigh the small risk of side effects. 

The secondary aim of immunisation is to prevent outbreaks of disease in the community. If every child follows an immunisation programme, the spread of disease can be prevented and in tum, the number of people suffering from the disease can be reduced. Where enough people in the community are immunised and the disease is unable to spread due to a lack of hosts for it to circulate, this is known as 'herd immunity'. Herd immunity can help to eradicate infectious disease completely, such as smallpox and polio in the UK. But if compliance with the immunisation programme is not maintained within the community, it is possible for diseases which are only present at very low levels to return.

Immunised individuals are also less likely to be a source of infection to others, reducing the risk of individuals who have not been immunised being exposed to infection. In this way, infants below the age of two months can be protected from certain diseases, such as whooping cough, by older children and siblings who have been immunised. Table 1 shows the impact of immunisation on the prevalence of outbreak. 

 

A GUIDE TO THE DISEAS S PREVENTED BY IMMUNISATIONS

Immunisations are given either on a routine basis or on a selective basis according to the individual need. Before the age of five, immunisations are given on a routine basis for the following ten diseases as they are the most serious but preventable diseases for the very young.

  • Diphtheria: an acute, contagious bacterial infection, which begins with a sore throat, then leads to respiratory problems and difficulty swallowing, followed by possible damage to the heart and nervous system. Diphtheria is rare in Western countries but if active immunity against it is not maintained within the community, it is possible for the disease to return.
  • Tetanus (lowjock): an infectious disease caused by bacterial spores often found in soil, which enter the body through cuts or burns on the skin. It causes painful muscular contractions, rigidity and spasms, first in the jaw and neck and then in the chest, back and lower body. In extreme cases, there can be severe breathing difficulties.
  • Pertussis (whooping cough): an acute respiratory infection with symptoms of exhausting and severe cough, which can cause choking, vomiting and interrupted breathing. Pneumonia is a common complication.
  • Polio: an acute viral disease that attacks the nervous system. The polio virus is transmitted through human faeces, so is a problem in developing countries with poor sanitation. Immunisation has eradicated polio in the UK.
  • Haemophilus intluenzae type B (Hib): an infection that can cause several illnesses, the most important of which is bacterial meningitis. Before the introduction of the vaccine, Hib was the leading cause of meningitis in under-twos.
  • Meningitis C (Nkn C)· a type of bacteria that can cause meningitis and septicaemia. The MenC vaccine does not protect against meningitis caused by other bacteria or by viruses.
  • Pneumococcal infection (IPD): caused by any one of a number of pneumococcal bacteria, commonly found in the nose and throat, and spread principally by coughing or sneezing. It can lead to pneumococcal meningitis, septicaemia and pneumonia. The pneumococcal vaccine (PCV) protects against seven common strains of pneumococcal bacteria that cause about four-fifths of all IPD in children. The vaccine is 96 per cent effective against these forms. PCV also helps prevent pneumonia and otitis media (ear infections).
  • Measles: an infectious virus that causes a rash, high fever and in severe cases can kill. One in 15 children with measles is at risk of complications, which can include fits, chest infections and brain damage.
  • Mumps: causes fever, headache and vomiting, followed by the notorious symptoms of swollen glands in the face' and neck. The swelling usually disappears within days, but in some cases.can spread to affect other parts of the body, such as the brain (causing a form of meningitis) and the testicles. 
  • Rubella (german measles): mild and unlikely to cause harm in children. Symptoms are a swollen neck and a widespread pink rash. It's particularly important that girls are immunised against rubella because it can harm the unborn child of a pregnant woman with the disease.

The following two immunisations are given on a selective basis: 

  • Baolle Calaunette Guerin (BCG) protects against tuberculosis (TB) and is only given to children most at risk of exposure to TB ( the BCG immunisation programme in schools was stopped as part of the most recent guidelines provided by the Department of Health in 2006).
  • Hepalltis B. The Department of Health recommends pregnant women are screened for hepatitis B and immunisation is recommended for infants born to infected mothers. 

THE UK CHILDREN'S IMMUNISATION PROGRAMME

CURRENT PRACTICE

The immunisation programme in the UK - provided free to patients on the NHS­continues to evolve, meeting the demand to improve the control of infectious disease through immunisation; therefore it is important for health visitors to keep up to date on the latest guidance and current practice. For example, health visitors should be able to help parents understand which vaccines are available to their child, when their child should be immunised, how many vaccines are needed to build up active immunity and why. Every effort should be made to ensure all children are immunised and parents are reassured and made aware of the importance of immunisation.

Information about the current immunisation programme in the UK is available on the NHS immunisation website: www.immunisation.nhs.uk

THE IMMUNISATION SCHEDULE

Immunisation should begin at two months of age. This is the guidance for all infants born either on or after their due date, and for premature babies born after 28 weeks from gestation (babies born less than 28 weeks from gestation who are in hospital should be monitored for 48-72 hours when given their first immunisation). As passive immunity provided by the mother in the womb begins to weaken after about two months of age, immunisation should not be delayed. Even if a baby or child is older than the recommended age range to commence immunisation, no opportunity to begin the programme should be missed, and if any course of immunisation is interrupted, it should be resumed and completed as soon as possible.

 

Click here for the complete routine immunisation schedule

This secondary immunisation completes the routine immunisation programme for children in the UK. When providing information to parents about the immunisation programme, it may help to provide a timeline letting them know which immunisations should have been given by the various childhood stages: 

  • By four months of age, three doses of the DTaP /IPV /Hib vaccine ( diphtheria, tetanus, pertussis (whooping cough), polio and Hib ), and two doses of the PCV and MenC vaccine should have been given 
  • By 13 months of age, a booster dose of the Hib/MenC and PCV vaccines and the first dose of MMR should have been given
  • By school entry (five years of age), a fourth dose ofDTaP/IPV or dTaP/IPV and the second dose of MMR should have been given
  • Before leaving school at 18 years of age, a fifth dose of Td/IPV and for girls, three doses of the HPV vaccine should have been given.

 

PROTECTION

Once the vaccination programme is completed, a child should have protection against polio, measles, mumps, rubella and meningitis C for life. The child should also have at least ten years protection against diphtheria and tetanus and at least three years protection against pertussis 
(whooping cough), although children immunised against pertussis that catch the disease later in life will experience a milder form.xxi To maintain a maximum level of active immunity, it is important for the child to receive booster immunisations when needed. The GP will be able to advise which boosters are required and when according to the individual need.

DELAYING IMMUNISATION

Only in rare circumstances should immunisation be delayed. If as a health visitor you are unsure whether a child should be immunised, advice should be given for parents to seek recommendation from the GP rather than to hold-up or interrupt the immunisation programme. Delaying immunisation causes the child to remain unprotected from serious disease or illness, therefore it is important to ensure every effort is made to immunise the child at the correct time and any delay in immunisation should be kept to a minimum. The healthcare professional carrying out the immunisation will assess the child's suitability for immunisation on the day. The healthcare professional will take into account:

  • The child's health on the day 
  • Any recent illness or relevant clinical history 
  • Any previous reaction to a vaccine. 

Are immunisations safe?

As with all medicines, immunisations are extensively tested for quality and safety before being licensed and used. All immunisations given as part of the UK immunisation programme have a good safety profile. Side effects may occasionally occur but are not a reason to halt the immunisation programme.

SIDE EFFECTS

If you are concerned about pain or fever symptoms following immunisation do consult with the GP. 

Side effects resulting from immunisation are less common than many people think, and are usually mild. 

Parents may notice some redness or swelling at the site of injection but this usually, quickly disappears. Some infants may appear somewhat irritable, appear less well or have mild pyrexia after the immunisation. Table 4 provides further information about some side effects. 

 

THE MMR SCARE

In 2010, a ruling from the General Medical Council ( GMC) discredited research suggesting a link between the measles, mumps and rubella (MMR) vaccine and an increased risk of autism. This followed a verdict issued by the World Health Organisation (WHO) in 2003 that 'no evidence exists of a causal association between the MMR vaccine and autism'. Despite these rulings, the MMR scare has led to a considerable drop in MMR immunisation rates and a rise in outbreaks of measles. Figures reported by Primary Care Trusts (PCTs) in 2009-2010 show coverage for the MMR vaccine for children under two years of age is still lower than WHO targets. The Department of Health responded in 2008 by issuing its MMR Catch-up Programme - a call to action to healthcare professionals to combat the increase in outbreaks of measles by communicating to parents the risk of not having their child immunised.


It is understandable for parents to be sceptical about the safety of the MMR vaccine; however, there is no evidence to question its safety profile. There is not a single study to show a risk of the MMR vaccine causing autism even though tens of millions of children receive it worldwide. Rates of autism have not increased since the MMR immunisation was introduced.

It is now even more important for health visitors to be able to communicate with parents the benefits of immunisation, the known side effects of immunisations and the safety and efficacy of immunisations to allay fears. 

 

IMMUNISATION FOR CHILDREN ARRIVING FROM OUTSIDE THE UK

Some children may experience mild pain and fever symptoms as a result of immunisation and parents should follow the same guidelines as they would for treating such symptoms at any other time. Parents will often be able to tell when their child is feeling poorly but if in doubt, the following symptoms checker may help them:

  • Pyrexia above 37.5°C
  • Occasional vomiting
  • Irritability, refusing food or drink
  • Listlessness
  • Slight drowsiness.

A GP should always be consulted if the symptoms persist, are severe or the parent is concerned.

CHILDREN'S MEDICINES

It is not always necessary to treat pain and fever symptoms with medicine as mild symptoms usually disappear on their own. Some parents, however, may wish to give medicine to ease their child's discomfort.

Parents may be anxious about the idea of giving their child medicine, especially when they are very young, so they may seek reassurance and guidance from their health visitor. Paracetamol and ibuprofen are most commonly used to treat pain and fever in children (aspirin should not be given to children under 16 because of the risks of Reyes syndrome). Table 5 may help you to communicate to parents which medicine is most appropriate. 

 

PARACETAMOL OVER-THE-COUNTER DOSING INSTRUCTIONS

What are the new doses?

Doses for children’s liquid paracetamol were previously defined based on three age groups:

3 months to under 1 year

2.5ml of infant paracetamol suspension, given up to four times a day 

1 year to under 6 year

5 to 10ml of infant paracetamol suspension, given up to four times a day 

6 years to 12 years

5 to 10ml of paracetamol six-plus suspension, given up to four times a day 

 

However, these old dosage recommendations are now being replaced by new ones that classify children into seven more precisely defined age groups:

3 months to 6 months

2.5ml of infant paracetamol suspension, given up to four times per day 

6 months to 24 months

5ml of infant paracetamol suspension, given up to four times a day 

2 years to 4 years

7.5ml of infant paracetamol suspension, given up to four times a day 

4 years to 6 years

10ml of infant paracetamol suspension, given up to four times a day 

6 years to 8 years

5ml of paracetamol six-plus suspension, given up to four times a day 

8 years to 10 years

7.5ml of paracetamol six-plus suspension, given up to four times a day 

10 years to 12 years

10ml of paracetamol six-plus suspension, given up to four times a day 

 

The existing three-dose levels can still be used by parents, although the upcoming dosing is simply more exact and easier for parents or carers to follow.

Ibuprofen syrup dosages for children (5ml equals 100mg)

Age

How much

3 to 5 months 
(weighing more than 5kg)

2.5ml 3 times in 24 hours

6 to 11 months

2.5ml 3 to 4 times in 24 hours

1 to 3 years

5ml 3 times in 24 hours

4 to 6 years

7.5ml 3 times in 24 hours

7 to 9 years

10ml 3 times in 24 hours

10 to 11 years

15ml 3 times in 24 hours

12 to 17 years

15 to 20ml 3 to 4 times in 24 hours

 

 

Ibuprofen tablet dosages for children

Age

How much

7 to 9 years

200mg 3 times in 24 hours

10 to 11 years

300mg 3 times in 24 hours

12 to 17 years

300 to 400mg 3 to 4 times in 24 Hours 

 

 

Talking to parents

PROVIDING INFORMATION TO PARENTS

It is in the interest of every child to be protected against infectious disease; therefore, it is important parents are made aware of the significance of immunisation. Health visitors have a vital role in providing parents with the information they need to make the right decision regarding their child's immunisation.

The policy in the UK regarding immunisation is that parents should be able to make an informed decision about their choice to immunise; therefore, all healthcare professionals have a responsibility. 

  • To promote immunisation as the most important of all medical interventions 
  • To be reliably informed 
  • To provide not only the facts but also their informed opinion and support for immunisation 
  • To respect the questions of concerned parents 
  • To give honest and open answers. If they do not know the answer, to say so and seek further advice and information 
  • To use language that can be understood - few lay people understand medical terminology and consideration must be made of a parent's levels of understanding 
  • To communicate in the parent's chosen language, using interpreters where appropriate 
  • To respect the informed parent's decision. 

Health visitors should be able to provide parents with information around: 

  • The process of immunisation The benefits and risks 
  • Which immunisations are provided on a routine basis, and which on a selective basis 
  • The diseases immunisation protects against 
  • The risks of not proceeding with immunisation 
  • The side effects of immunisation 
  • How to recognise the side effects of immunisation and how the symptoms can be treated.

A wealth of information is available in various forms, including leaflets, posters, videos, information packs, factsheets and websites, and in various languages. Written or verbal information should be available in a form that can be easily understood by the parent or individual who will be giving consent to immunise. Where English is not the first language, translations and properly recognised interpreters should be used.

NEW RESOURCE FOR PARENTS: THE IMMUNISATION SUPPORT PACK

From September 2011, immunisation support packs will be available from all immunisation clinics throughout the UK. The immunisation support pack aims to support the healthcare professional and the parent through the immunisation process and is a new resource for practice nurses working at immunisation clinics. The packs will contain materials for the healthcare professional, such as tips for talking to anxious parents and waiting room posters, and for the parent. Materials for the parent include: 

  • A post-immunisation leaflet containing guidance on recognising pain and fever symptoms after immunisation and practical advice about treating the pain and fever symptoms associated with immunisation 
  • Stickers for the child's personal health record or Red Book
  • An immunisation schedule to help parents keep track of the dates for immunisation 
  • Next appointment cards to act as a reminder for the next immunisation.

 

As immunisation can be a confusing and worrying time for parents, the immunisation support pack can help to reassure parents, dispelling the anxiety and providing important information to help put their minds at rest. If as a health visitor, you are speaking with a parent who is apprehensive about the immunisation process, you may want to let them know they can request helpful information from the immunisation support pack from their practice nurse at immunisation.

REASSURANCE AND COUNSELLING

Health visitors can be the first point of call for anxious parents and hence need to be well informed with all the facts about individual immunisations, particularly when the media have raised fears about the safety' 6f immunisation. As parents are naturally concerned for the safety of their child, and particularly if they are a first-tim parent, their concerns and anxieties should be respected and handled gently and effectively. Parents are more likely to have their child immunised if they have a thorough understanding of why immunisations are necessary; therefore, it is important that any concerns parents have are specifically addressed and their minds put at rest.

The following technique may be useful when providing reassurance to parents:

  • Allow time to listen to parents' questions and worries 
  • Listen attentively, remembering eye contact and body language are as important as what is said 
  • Use open questions to enable discussion 
  • Reflect back to the parents what they have said as this often helps to clear their minds about the issues, e.g. "You seem to be saying ...."
  • Offer to see them again for further discussion when they have looked at any information that has been given to them. 

CONSENT

Immunisations are not compulsory in the UK and a valid consent must be attained for each child before immunisation can be carried out. The consent can either be written or verbal but must be acquired from both parents or individuals who have been granted parental responsibility for the child.

Consent is needed for two main reasons:

  • To foster trust and co-operation with patients 
  • To ensure the parents' right to autonomy has been addressed in order to prevent a charge of battery. 

 

Health visitors have a responsibility to make parents aware of the benefits and risks of proceeding and not proceeding with immunisation before their decision about consent is made. The giving and obtaining of consent is viewed as a process, not a one-off event. Consent may still be sought on the occasion of each immunisation visit; however, consent remains valid unless the individual who gave it withdraws it.

HELPFUL TIPS FOR ANXIOUS PARENTS OR GUARDIANS AT IMMUNISATION

It is important for the parent or guardian to remain calm at the point of immunisation, providing reassurance and comfort to the child being immunised. 

Parents are more likely to remain calm if they have a good understanding of the immunisation process. You can share the following techniques with parents which can help to reduce the pain of immunisation as they may be useful when accompanying the child on the day. 

  • Appropriate use of humour and distraction at the time of immunisation 
  • Pressure at the site, applied with either a device or a finger, immediately before immunisation
  • When more than one injection is being given, it may help to give the injections simultaneously rather than sequentially.

 

Learn more about NMC revalidation here.

References

ANDRE, FE ET AL. Bulletin of the World Health Organisation, Vaccination greatly reduces disease, disability, death and inequity worldwide, Vol 86 (No. 2), 2008, pages 81-160 http://www.who.int/bulletin/ volumes/86/2/07-040089/en/ Last accessed 24 April 2011

BABYCENTRE, Immunisations: an overview http://www.babycentre.co.uk/ baby/health/immunisations/ Last accessed 27 April 2011m

THE NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE, First NICE guidance on immunisation http://www.nice.org.uk/newsroom/ guidanceinfocus/FirstNICEguidanceOnimmunisation.jsp Last accessed 27 April 2011 

NHS IMMUNISATION STATISTICS FOR ENGLAND, 2009-2010 (2010), page 6 vDEPARTMENT OF HEALTH, Green Book; Immunisation against infectious disease (2006), page 1 
IBID. 
WILLCOX, A. 'Immunization and Vaccination: Principles and practice of vaccination', Practice Nursing 2011, Vol 24 (No. 4), page 190

DEPARTMENT OF HEALTH, Green Book; Immunisation against infectious disease (2006), page 2 

CHILDHOOD VACCINATION FACTFILE (2004), page 28 

DEPARTMENT OF HEALTH, Green Book; Immunisation against infectious disease (2006), page 4 

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UK GUIDANCE ON BEST PRACTICE IN VACCINE ADMINISTRATION (2001),page 7 

DEPARTMENT OF HEALTH, Green Book; Immunisation against infectious disease (2006), page 4 

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JBJD. Page 79 rnm. Page 80 

JBJD. Page 79 

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JBJD. Page 65 

DEPARTMENT OF HEALTH, Birth to Five Manual (2010), page 104 xxviiBBC HEALTH, Babies and immunisation http:/ /www.bbc.eo.uk/health/ physical_health/child_development/babies_immunisation.shtml Last accessed 20 April 2011 

WORLD HEALTH ORGANISATION, Global Advisory Committee on 12 August 2011 Vaccine Safety; MMR and autism http://www.who.int/vaccine_safety/ topics/mmr/mmr_autism/en/ Last accessed 27 April 2011 

NHS CHOICES, Ruling on doctor in MMR scare http://www.nhs.uk/ news/2010/0 lJanuary/Pages/MMR-vaccine-autism-scare-doctor.aspx Last accessed 27 April 2011 
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