What is the recommended dose of rabies immunoglobulin and antibiotic prophylaxis for a pediatric patient with an animal bite?

Pediatric Rabies Post-Exposure Prophylaxis for Animal Bites

For pediatric patients with animal bites, the recommended dose of rabies immunoglobulin is 20 IU/kg body weight, with the full dose infiltrated into and around the wound(s) if anatomically feasible, and any remaining volume administered intramuscularly at a site distant from vaccine administration. 1, 2

Rabies Immunoglobulin Administration

• Dosage: 20 IU/kg body weight for all pediatric patients 1, 2
• Timing: Administer at the time of the first vaccine dose (day 0) or up to day 7 after the first vaccine dose 2
• Administration technique:
  • Thoroughly infiltrate the full dose in and around the wound(s) if anatomically feasible
  • Any remaining volume should be injected intramuscularly at a site distant from vaccine administration
  • Never administer in the same syringe or at the same anatomical site as the vaccine 2

Recent research confirms that this dosing is safe and effective in pediatric patients, with a study showing that HRIG at 20 IU/kg was well-tolerated with no serious adverse events 3.

Rabies Vaccine Schedule for Pediatric Patients

For unvaccinated children:

• Standard regimen: 4 doses of 1.0 mL vaccine administered intramuscularly on days 0,3,7, and 14 1, 2
• For immunocompromised children: 5 doses on days 0,3,7,14, and 28 1, 2
• Administration site:
  • Deltoid muscle for older children
  • Anterolateral thigh acceptable for younger children
  • Never use the gluteal area (results in lower antibody titers) 1, 2

For previously vaccinated children:

• Only 2 doses (on days 0 and 3)
• No rabies immunoglobulin needed 2

Wound Care

Immediate wound management is critical:

• Thoroughly cleanse all wounds with soap and water for at least 15 minutes
• Use a virucidal agent (e.g., povidone-iodine solution) to irrigate the wounds if available 1, 2
• Avoid suturing when possible 1

Antibiotic Prophylaxis

While the guidelines don't provide specific antibiotic regimens for pediatric animal bites, they note that antibiotic prophylaxis should be individualized based on:

• The species of the biting animal
• Size and location of the wound(s)
• Time interval since the bite 1

Important Considerations

• Children receive the same vaccine dose (volume) as adults 1
• The combination of rabies immunoglobulin and vaccine is recommended for both bite and non-bite exposures in unvaccinated children 1
• If post-exposure prophylaxis has been initiated and diagnostic testing confirms the animal was not rabid, prophylaxis can be discontinued 1
• Pregnancy is not a contraindication to post-exposure prophylaxis 2

Common Pitfalls to Avoid

1. Underdosing immunoglobulin: Ensure the full calculated dose (20 IU/kg) is used, with priority given to wound infiltration
2. Improper administration site: Never use the gluteal area for vaccine administration
3. Delayed treatment: Initiate post-exposure prophylaxis as soon as possible after exposure
4. Inadequate wound cleansing: Thorough wound cleansing is essential and can significantly reduce rabies risk
5. Missing doses: While minor delays of a few days are acceptable, every effort should be made to complete the full vaccination schedule

Research suggests that local infiltration of rabies immunoglobulin into wounds may be effective even when using smaller quantities than calculated by body weight 4, 5, but the current standard of care remains 20 IU/kg as recommended by the CDC and WHO.