The preferred sites for the administration of vaccines are the anterolateral aspect of the upper thigh (subcutaneous or intramuscular), the deltoid area of the upper arm (intramuscular), or the upper, outer triceps area of the upper arm (subcutaneous). In children >1 year, intramuscular injections should be administered in the anterolateral aspect of the thigh. For children >1 year, the deltoid muscle is the preferred site of administration. Generally, the upper outer aspect of the buttocks should not be used for immunizing an infant.

IM: 0.5 mL. The Advisory Committee on Immunization Practices and the American Academy of Pediatrics (AAP) recommend four doses for primary immunization, with the first three administered at 4- to 8-week intervals starting at 2 months of age, and the fourth dose 6 months after the third dose and after 1 year of age. A fifth dose is recommended before school entry, at the age of 4 to 6 years. Subsequent boosters should be administered starting at 11 years of age using combined tetanus, diphtheria, and pertussis (Tdap) vaccine. Tdap should only be given once. Tetanus-diphtheria (Td) vaccine should be used for all subsequent boosters and given at 10-year intervals throughout life. An incomplete DTaP series is a common reason for vaccine delay in infants and toddlers.

IM: Three or four 0.5-mL doses are administered at 2 months, 4 months, 6 months, and 12 to 15 months of age. If a three-dose product is used, the third dose may be omitted. In situations in which the brand of vaccine used previously is not known, four doses are required. Hib vaccine is not required after 60 months of age.

IM: HAV 25U (VAQTA) or 720 EL.U (HAVRIX) in the deltoid muscle is recommended for the routine vaccine of all children beginning at 12 months of age. The second dose should be given 6 months later. For children and adolescents >23 months of age, HAV is recommended in areas where programs target older children, for those at increased risk, and for those desiring immunity.

IM: The first dose is ideally administered at birth in the neonatal nursery and must then be added to a child’s primary care vaccination record. The next dose is administered 1 to 4 months later, most commonly at 1 to 2 months of age. The third dose is recommended beginning at 6 months of age and must be given 8 weeks after the second dose and 16 weeks after the first dose. It is acceptable to administer a fourth dose of HBV if combination products are used.

Infants born to HBsAg-positive mothers: Both HBV (0.5 mL) and HBIG are recommended within 12 hours after birth. The second dose of HBV is then administered at 1 to 2 months of age and the third dose at 6 months of age. Hepatitis B surface antigen and hepatitis B surface antibody should then be checked starting at 9 months of age or the first preventive visit after completion of the series.

Infants born to mothers with HBsAg unknown: Mothers should be tested on admission for delivery. Administer HBV by 12 hours of age. HBIG should be administered as soon as possible and within 7 days of birth if the mother tests HBsAg positive.

IM: 0.5-mL doses should be administered beginning at 11 to 12 years of age. The second dose is given 1 (HPV2) or 2 months (HPV4) after the first dose, and the third dose is administered 6 months after the first. Women may receive the vaccine up to 26 years of age if they have not completed the full series and are not pregnant. The vaccine may also be offered to males in this age group to help prevent genital warts. Of all adolescent vaccines, rates of completion are currently lowest for the HPV series.

SC: 0.5 mL at age 12 to 15 months. A booster dose is recommended at 4 to 6 years of age.

Contraindications to measles, mumps, and rubella vaccination include serious illness (not simple fever or upper respiratory infections), pregnancy, anaphylactic reaction to gelatin or neomycin, low platelets, recent injection of immune globulin, high-dose steroid use for at least 14 days, and compromised immunity (see discussion of HIV later). Autism is not associated with receipt of the MMR vaccine.

IM: Meningococcal vaccine is recommended beginning at 11 to 12 years of age for all teens. One 0.5-mL dose is currently required. The vaccine should be avoided in those with a history of Guillain-Barré syndrome. MCV4 is now recommended instead of meningococcal polysaccharide vaccine (MPS4) for children between 2 and 10 years of age at increased risk of meningococcal disease. In this age group,
the primary recipients are children with terminal complement component deficiencies, those who have anatomic or functional asplenia, and those traveling to areas with especially high rates of disease. Based on developments at the time of publication, a booster dose for MCV4 is likely to be needed at age 16 years or 5 years after the first dose. Consult the current vaccine schedule.