What vaccine should be administered to a child injured by a metallic object?

Tetanus Prophylaxis for Pediatric Metallic Object Injury

The answer depends on the child's age, vaccination history, and time since last tetanus-containing vaccine dose—for children <7 years use DTaP, for children ≥7 years use Tdap (preferred) or Td, but only if indicated by the specific clinical scenario below. 1

Critical Decision Algorithm

Step 1: Determine Child's Age

• Children <7 years old: Use DTaP for any indicated tetanus prophylaxis 1, 2
• Children ≥7 years old: Use Tdap (preferred) or Td 1

Step 2: Classify the Wound

Metallic object injuries are classified as contaminated/tetanus-prone wounds because they may be contaminated with dirt, feces, soil, and saliva, and puncture wounds can create anaerobic conditions favorable for Clostridium tetani growth. 3, 2 This classification is critical because it determines whether the 5-year or 10-year interval applies for booster administration.

Step 3: Assess Vaccination History

For children with ≥3 previous doses (completed primary series):

• Last dose <5 years ago: No vaccine needed 3, 2
• Last dose ≥5 years ago: Administer tetanus toxoid-containing vaccine WITHOUT tetanus immune globulin (TIG) 1, 3, 2
  • Use DTaP if child <7 years 1
  • Use Tdap if child ≥7 years and has not previously received Tdap 1

For children with <3 previous doses or unknown/uncertain history:

• Administer BOTH tetanus toxoid-containing vaccine AND TIG (250 units IM) 3, 2
• Use separate syringes at different anatomical sites 1, 2
• Complete the primary vaccination series with subsequent doses 1

Key Clinical Pearls

Do not confuse the intervals: The most common error in tetanus prophylaxis is confusing the 10-year routine booster interval with the 5-year interval required for contaminated wounds. 3 For clean, minor wounds, boosters are only needed if ≥10 years have elapsed, but for contaminated wounds like metallic object injuries, the threshold is ≥5 years. 3, 2

Tdap provides additional pertussis protection: For children ≥11 years who have not previously received Tdap, this vaccine is strongly preferred over Td alone because it provides protection against pertussis in addition to tetanus and diphtheria. 1, 3 This is particularly important given that pertussis immunity wanes over time. 1

Assume no prior vaccination if history is uncertain: Children with unknown or uncertain vaccination histories should be considered to have had no previous tetanus toxoid-containing vaccine doses and require both vaccine and TIG. 1, 2

Special Populations

Immunocompromised children: Those with HIV infection or severe immunodeficiency should receive TIG regardless of their tetanus immunization history when they have contaminated wounds. 1, 3

History of Arthus reaction: Children with a history of Arthus reaction following a previous tetanus toxoid-containing vaccine should not receive another dose until >10 years after the most recent dose, regardless of wound severity. 1 However, TIG administration should still be based on the primary vaccination history. 1

Essential Follow-Up

For children requiring both vaccine and TIG who have incomplete primary series, ensure completion of the full 3-dose primary vaccination series according to the recommended schedule. 1, 3 The complete primary tetanus vaccination is nearly 100% effective in preventing tetanus. 4