What is the most appropriate vaccination approach for a child with nephrotic syndrome on long-term oral corticosteroid (Prednisone) therapy who is scheduled for routine preschool vaccinations?

Vaccination Approach for Child with Nephrotic Syndrome on Long-term Corticosteroids

The most appropriate next step is to avoid live vaccines (MMR and OPV), replace OPV with inactivated polio vaccine (IPV), and administer Tdap (Option D), as live vaccines must be deferred until the prednisone dose is reduced below specific thresholds.

Key Vaccination Principles in Immunosuppressed Children

Live Vaccine Contraindications

Live vaccines must be deferred in children on long-term corticosteroid therapy for nephrotic syndrome until prednisone dose is below either 1 mg/kg daily (<20 mg/day) or 2 mg/kg on alternate days (<40 mg on alternate days). 1 This is a critical safety threshold that applies specifically to MMR and varicella-containing vaccines.

• Live vaccines are absolutely contraindicated in children receiving corticosteroid-sparing immunosuppressive agents (such as cyclosporine, tacrolimus, or mycophenolate mofetil), regardless of corticosteroid dose 1
• The rationale is to prevent vaccine-strain viral disease in immunocompromised hosts 1

Inactivated Vaccines Are Safe

Inactivated vaccines, including Tdap and IPV, can and should be administered to children on immunosuppressive therapy, though the immune response may be suboptimal 1

• Tdap (tetanus, diphtheria, acellular pertussis) is an inactivated vaccine and poses no safety risk in immunosuppressed patients 1
• IPV (inactivated polio vaccine) should replace OPV (oral polio vaccine, which is live) in all immunocompromised children 1
• These vaccines should not be withheld despite immunosuppression, as protection against these diseases is critical 1

Specific Vaccine Recommendations

Replace OPV with IPV

• OPV is a live vaccine and is contraindicated in immunosuppressed children 1
• IPV provides equivalent protection without the risk of vaccine-associated paralytic poliomyelitis in immunocompromised hosts 1
• This substitution is standard practice in developed countries and essential for this patient 1

Defer MMR Until Steroid Dose Reduced

• MMR must be delayed until the child's prednisone dose falls below the safety threshold (1 mg/kg daily or 2 mg/kg alternate days) 1
• Once the dose is reduced sufficiently, MMR can be safely administered 1
• If the child is also on calcineurin inhibitors or other immunosuppressive agents, MMR remains contraindicated regardless of steroid dose 1

Administer Tdap as Scheduled

• Tdap should be given as part of routine preschool vaccinations despite ongoing immunosuppression 1
• The pertussis component should NOT be removed, as acellular pertussis vaccine is inactivated and safe in immunocompromised children 1
• While antibody response may be reduced, the vaccine provides important protection and has an acceptable safety profile 1

Additional Vaccination Considerations

Recommended Vaccines for Nephrotic Syndrome

Children with nephrotic syndrome should receive pneumococcal and annual influenza vaccination to reduce infection risk 1

• Pneumococcal vaccination (PCV13) is specifically recommended for children with nephrotic syndrome due to increased risk of invasive pneumococcal disease 1
• Annual influenza vaccination should be given to the child and household contacts 1

Household Contact Vaccination

Healthy household contacts should receive all recommended live vaccines to create a protective cocoon around the immunosuppressed child 1

• However, the immunosuppressed child should avoid direct exposure to gastrointestinal, urinary, or respiratory secretions of recently vaccinated contacts for 3-6 weeks after vaccination 1
• This is particularly important for oral rotavirus vaccine in infant siblings 1

Common Pitfalls to Avoid

• Do not withhold all vaccines - only live vaccines need to be deferred; inactivated vaccines should proceed 1
• Do not remove the pertussis component from Tdap - acellular pertussis is inactivated and safe 1
• Do not assume all children on steroids cannot receive live vaccines - the specific dose threshold matters (1 mg/kg daily or 2 mg/kg alternate days) 1, 2
• Do not forget to reassess vaccination eligibility when immunosuppression is reduced or discontinued 1