What is the recommended post-exposure prophylaxis for an 8-9 year old patient exposed to rabies?

Rabies Post-Exposure Prophylaxis for 8-9 Year Old Children

For an 8-9 year old child exposed to rabies who has never been vaccinated, administer wound cleansing, human rabies immune globulin (HRIG) at 20 IU/kg body weight infiltrated around the wound, and a 4-dose vaccine series given intramuscularly on days 0,3,7, and 14. 1

Complete Post-Exposure Prophylaxis Regimen for Previously Unvaccinated Children

Immediate Wound Care

• Begin with thorough cleansing of all wounds with soap and water, and if available, use a virucidal agent such as povidone-iodine solution to irrigate the wounds 1

HRIG Administration

• Administer HRIG at 20 IU/kg body weight—this formula applies to all age groups including children 1, 2
• If anatomically feasible, infiltrate the full dose around and into the wound(s), with any remaining volume administered intramuscularly at a site distant from vaccine administration 1
• HRIG should never be administered in the same syringe or same anatomical site as the rabies vaccine 1, 2
• If HRIG was not given on day 0, it can still be administered up to and including day 7 of the prophylaxis series, but is not indicated beyond day 7 3

Vaccine Schedule

• Administer 1.0 mL of HDCV or PCECV intramuscularly on days 0,3,7, and 14 1
• Children receive the same vaccine dose (1.0 mL) as adults—do not reduce the volume 1, 2
• For 8-9 year old children, the deltoid area is the appropriate injection site 1
• Never administer vaccine in the gluteal area as this produces inadequate antibody responses 1, 2

Critical Timing Considerations

• Initiate prophylaxis as soon as possible after exposure—day 0 is defined as the day the first vaccine dose is administered 1
• Treatment remains indicated regardless of time elapsed since exposure 4
• Minor delays of a few days for individual doses are considered unimportant 3

Special Circumstances for Children

If the Child is Immunocompromised

• Administer the full 5-dose vaccine regimen on days 0,3,7,14, and 28 (not the standard 4-dose regimen) 1
• Still give HRIG at 20 IU/kg body weight 4
• Perform serologic testing to confirm adequate antibody response 4
• Conditions causing immunosuppression include corticosteroid use, other immunosuppressive medications, HIV/AIDS, and other immunosuppressive illnesses 4

If the Child Was Previously Vaccinated

• Only 2 doses of vaccine are required (1.0 mL each on days 0 and 3) 1, 4
• Do not administer HRIG in previously vaccinated persons 1, 4
• "Previously vaccinated" means the child received a complete ACIP-recommended pre-exposure or post-exposure prophylaxis regimen with cell-culture vaccines, regardless of how long ago 4

Common Pitfalls to Avoid

• Do not exceed the recommended HRIG dose of 20 IU/kg as this may interfere with active antibody production 1, 2
• Do not use the gluteal area for vaccine administration in children of any age 1
• Do not give HRIG to previously vaccinated children—this is unnecessary and wasteful 1, 4
• Do not restart the entire vaccine series if a dose is missed—simply administer the missed dose when the patient presents and continue the schedule 3

Post-Treatment Monitoring

• Routine serologic testing after completing the vaccine series is not necessary for healthy, immunocompetent children 4
• Serologic testing is indicated only in unusual circumstances, such as when the patient is known to be immunosuppressed 2