What is the recommended rabies vaccine dose and post-exposure prophylaxis (PEP) regimen for a child under 2 years exposed to rabies?

Rabies Vaccine Dose for Children Under 2 Years

Children under 2 years receive the identical rabies vaccine dose and schedule as adults: 1.0 mL per dose intramuscularly on days 0,3,7, and 14, combined with Human Rabies Immunoglobulin (HRIG) 20 IU/kg on day 0 for previously unvaccinated children. 1, 2, 3

Vaccine Dosing and Administration

• The vaccine dose is NOT weight-based or age-adjusted—all children, including infants and toddlers under 2 years, receive the full 1.0 mL dose per injection, identical to adults 1, 2, 4, 3, 5

• For children under 2 years, inject the vaccine in the anterolateral thigh muscle, not the deltoid 1, 2, 4, 3, 5

• Never use the gluteal area for vaccine administration in any age group, as this produces inadequate antibody response and has been associated with vaccine failures 1, 2, 4, 3, 5

Complete Post-Exposure Prophylaxis Regimen

Immediate Wound Management (Most Critical Step)

• Wash all wounds thoroughly with soap and water for 15 minutes immediately—this single intervention is the most effective measure for preventing rabies infection 1, 2, 4

• Follow with irrigation using a virucidal agent such as povidone-iodine solution if available 1, 2, 4

• Administer tetanus prophylaxis and antibiotics as indicated 1

HRIG Administration

• Dose: 20 IU/kg body weight given once on day 0 (same weight-based dose for all ages) 1, 2, 4, 3

• Infiltrate as much of the calculated dose as anatomically possible into and around the wound(s), with any remaining volume administered intramuscularly at a site distant from vaccine administration 1, 2, 4, 3

• HRIG can be given up to day 7 after the first vaccine dose if not administered on day 0 1, 2

• Never administer HRIG in the same syringe or anatomical site as the vaccine 1, 2, 4, 3

• Do not exceed 20 IU/kg, as higher doses suppress active antibody production 1, 2, 4

Vaccine Schedule

• 4-dose schedule: days 0,3,7, and 14 (day 0 is the day the first dose is given, not necessarily the exposure date) 1, 2, 4, 3, 5

• Each dose is 1.0 mL administered intramuscularly 1, 2, 4, 3, 5

Special Considerations for Young Children

Immunocompromised Children

• Upgrade to a 5-dose schedule (days 0,3,7,14, and 28) plus HRIG 20 IU/kg for any immunocompromised child, regardless of age 1, 2, 4

• Serologic testing 7-14 days after the last dose should be considered to ensure seroconversion 1

Previously Vaccinated Children

• Only 2 doses of vaccine (days 0 and 3) are needed 1, 2, 4

• HRIG is NOT required and should NOT be given, as it will inhibit the anamnestic response 1, 2, 4

Critical Timing

• Start PEP as soon as possible after exposure, ideally within 24 hours 1, 2, 4

• However, PEP should still be initiated even if exposure was recognized months later, because rabies is almost 100% fatal after clinical symptoms appear 1, 2

Common Pitfalls to Avoid

• Do not reduce the vaccine dose for infants or young children—the 1.0 mL dose is standard for all ages 1, 2, 4, 3, 5

• Do not use the deltoid muscle in children under 2 years—use the anterolateral thigh instead 1, 2, 4, 3, 5

• Do not delay wound washing—this is the most crucial first step and should not be postponed 1, 2, 4

• Do not give HRIG to previously vaccinated children, even if they are very young 1, 2, 4

Safety Profile

• Studies demonstrate that HRIG and rabies vaccine are safe and effective in pediatric patients of all ages 1

• The majority of side effects are mild and transient; no serious events, rabies infections, or deaths have been reported in properly vaccinated children 1, 6