Preterm babies should be vaccinated according to the recommended schedule, without correction for prematurity, provided that they are well and that there are no contraindications.
Preterm babies have a special need for protection against infectious agents such as pertussis. Other points to note:
- Vaccination commenced before discharge ensures the development of some degree of protection from infectious agents prevalent within the community.
- Preterm babies do not have a higher incidence of adverse reactions following immunisation and despite their immunological immaturity they generally respond satisfactorily to vaccines.
- All preterm babies born before 32 weeks gestation or <2000g birth weight do not mount as effective an antibody response following immunisation with hepatitis B, thus it is recommended to give Hepatitis B vaccination at birth followed by three doses of Hepatitis B containing vaccine at two, four and six months and an additional paediatric hepatitis B vaccine at 12 months of age.
- In addition to Hepatitis B vaccine all preterm babies born at <28 weeks gestation are recommended to be given 4 doses of 13-valent pneumococcal conjugate vaccine, at 2, 4, 6 and 12 months of age. A single booster dose of 23-valent pneumococcal polysaccharide vaccine at 4-5 years of age is also recommended.
- It is particularly important to assess for the presence of underlying conditions that make preterm infants eligible for influenza vaccination. Vaccination should be provided annually from ≥6 months of age. Two vaccine doses, at least 4 weeks apart, are required in the first year that influenza vaccine is received.
- Babies whose mothers are hepatitis B surface antigen positive (HbsAg +ve,) should receive the hepatitis B vaccine on the day of birth. They should also be given hepatitis B immunoglobulin (HBIG 100 units, 0.5 mL intramuscularly) within 12 hours of birth.
Adverse events following immunisation
Surveillance for adverse events following vaccination is an integral part of the national vaccination program. An adverse event is a serious, uncommon or unexpected event following immunisation. Such an event may be caused by the vaccine or may occur by chance after immunisation.
Any event that is considered serious or unexpected and possibly related to the vaccination should be reported to the Victorian vaccine safety service (SAEFVIC) on phone 1300 882 924 (option 1).
Observation after vaccination
Recipients of vaccines should remain under observation for a minimum of 15 minutes. Most life-threatening adverse events will begin within 15 minutes of vaccination.
The most serious immediate reaction to vaccination is anaphylaxis.
Hypotonic, unresponsive episodes in children do not usually occur immediately after vaccination (usually four to 24 hours post vaccination).
Cardiorespiratory monitoring after vaccination
There is an increased incidence of cardiorespiratory instability following immunisation of preterm infants.
Immunisation has been associated with an increased risk of apnoea in preterm infants vaccinated in hospital, especially those still requiring complex care and with an existing history of apnoea.
It is recommended that the cardiorespiratory function of hospitalised preterm infants is monitored for 48 hours post immunisation.
If there is a history of apnoea following immunisation, consideration must be given to administering future vaccines under medical supervision.
Immunisation has been associated with an increased risk of apnoea in preterm infants vaccinated in hospital, particularly those still requiring complex medical care and/or with an existing history of apnoea. Although in this setting, apnoea is generally self-limiting, measures to manage this anticipated AEFI should be taken.74-76 Specifically, hospitalised preterm infants should be monitored for apnoea or bradycardia for up to 48 hours post vaccination.76,77 If there is a history of apnoea post vaccination, consideration should be given to administering future immunisations under medical supervision.78,79 Vaccination has not been associated with an increased risk of sudden infant death syndrome (SIDS).80,8
Anaphylaxis following immunisation
Anaphylaxis following immunisation is very rare.
Anaphylaxis is a severe adverse event of rapid onset, characterised by circulatory collapse.
Signs of anaphylaxis include:
- circulatory collapse
- pallor, loss of consciousness, weak pulse
- rapid development of urticarial lesions (elevated red lumps with raised edges and pale centres)
- signs of upper airway obstruction
- stridor, weak cry.
Management of anaphylaxis
- Call for help.
- Administer oxygen (6 litres per minute via face mask).
- Commence positive pressure ventilation if the respirations are slow or stop.
- Administer adrenaline if the baby is unconscious and commence external cardiac massage if the heart rate is < 60 beats per minute.
|Dose||0.05 to 0.1 ml (0.01 ml/kg)|
|Route of administration||IM|
|Frequency||Every five minutes until cardiac output is established|
Use of adrenaline
The use of 1:1,000 adrenaline is recommended because it is universally available. Adrenaline 1:1,000 (one in one thousand) contains 1 mg of adrenaline per mL of solution in a 1 mL glass vial. Adrenaline 1 in 10,000 is no longer recommended for the treatment of anaphylaxis. A 1 mL syringe should be used to improve the accuracy of measurement when drawing up small doses of adrenaline. The recommended dose of 1:1,000 adrenaline is 0.01 mL/kg body weight (equivalent to 0.01 mg/kg) given by deep IM injection preferably in the anterolateral (upper outer) thigh. The anterolateral thigh is the preferred site because there is a more predictable dispersal of adrenaline from this site. Administration of adrenaline in the anterolateral thigh is also in accordance with recommendations from various emergency medicine, anaesthetic and immunology professional bodies.
Note: Adrenaline 1: 1,000 must not be given intravenously.
Common minor adverse events
The following adverse events are common but not serious although they can be distressing for parents. These adverse events do not contraindicate further vaccination and do not need to be reported. Transient minor events include:
- soreness, redness or pain at the injection site (5-15 per cent)
- fever (2-3 per cent - usually low grade)
- sleepier or more grizzly than usual.
Storage of vaccines
The 'cold-chain' is the system of transporting and storing vaccines within the safe temperature range (2-8°C) from the place of manufacture until administration.
Maintenance of the cold chain is essential to maintaining the effectiveness of the vaccines.
Cold chain breach is the exposure of vaccines to temperatures outside the recommended range of 2°C to 8°C, excluding fluctuations up to 12°C lasting less than 15 minutes when restocking, cleaning the fridge or stock taking.
In most cases, cold chain breaches must be reported to the Immunisation Section at the department as soon as possible using the Cold Chain Breach Report form. This form is also used to report light exposure breaches for light-sensitive vaccines.
Areas of uncertainty in clinical practice
Areas of uncertainty regarding preterm immunisation include the following:
- There is little data regarding the immunological responses of extremely preterm infants receiving steroids for the treatment of chronic lung disease.
- Live vaccines should not be administered to babies receiving prednisolone (2 mg/kg/day for more than one week or 1 mg/kg/day for more than one month) or the equivalent dose of dexamethasone as this is associated with significant immunocompromise.
- For further advice about the safe use of vaccines for preterm babies contact the Victorian vaccine safety service (SAEFVIC) on telephone 1300 882 924 (option 1).
- Australian Technical Advisory Group on Immunisation (ATAGI). The Australian immunisation handbook 10th ed (2017 update). Canberra: Australian Government Department of Health, 2017.
- American Academy of Pediatrics Childhood Immunization Support Program
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First published: August 2017
Last web updated: October 2018
Review by: August 2020
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Page last updated: 21 Nov 2018