What is the recommended post‑exposure management for a child potentially exposed to rabies, including wound cleansing, administration of rabies‑specific human immune globulin, rabies vaccine dosing schedule, and animal observation?

Management of Rabies Post-Exposure Prophylaxis in Children

For any child with potential rabies exposure, immediately initiate thorough wound cleansing with soap and water for 15 minutes, then administer human rabies immune globulin (HRIG) 20 IU/kg infiltrated into and around all wounds on day 0, combined with a 4-dose rabies vaccine series (1.0 mL intramuscularly on days 0,3,7, and 14) injected in the deltoid for older children or anterolateral thigh for young children—this regimen is nearly 100% effective when started promptly. 1, 2

Immediate Wound Management

• Wash all bite wounds, scratches, and contaminated areas with soap and water for at least 15 minutes immediately after exposure—this single intervention is the most effective measure for reducing rabies transmission risk. 1, 2
• Follow wound washing with irrigation using a virucidal agent such as povidone-iodine solution if available. 1, 3
• Assess and provide tetanus prophylaxis as indicated based on the child's immunization history. 1, 2

Risk Assessment and Exposure Classification

• Any penetration of skin by teeth constitutes a bite exposure requiring evaluation, regardless of how minor it appears. 1
• Nonbite exposures include scratches, abrasions, open wounds, or mucous membranes contaminated with saliva or neural tissue from a potentially rabid animal. 1
• Dried material containing virus is considered noninfectious and does not warrant prophylaxis. 1
• Petting a rabid animal or contact with blood, urine, or feces alone does not constitute exposure. 1

Post-Exposure Prophylaxis Protocol for Previously Unvaccinated Children

Human Rabies Immune Globulin (HRIG) Administration

• Administer HRIG at exactly 20 IU/kg body weight on day 0, ideally simultaneously with the first vaccine dose—children receive the same dose per kilogram as adults. 1, 2, 4
• Infiltrate the full calculated HRIG dose around and into all detectable wound sites if anatomically feasible; inject any remaining volume intramuscularly at a site distant from vaccine administration. 1, 2, 4
• Never administer HRIG in the same syringe or at the same anatomical site as the vaccine, as this can interfere with vaccine efficacy. 1, 2
• Do not exceed 20 IU/kg—higher doses partially suppress active antibody production from the vaccine and may compromise protection. 1, 2
• If HRIG was not given on day 0, it can still be administered up to and including day 7 after the first vaccine dose, but never give HRIG after day 7 because vaccine-induced antibodies are presumed to have developed. 1, 2

Rabies Vaccine Series

• Administer four doses of 1.0 mL rabies vaccine (HDCV or PCECV) intramuscularly on days 0,3,7, and 14—day 0 is the day the first dose is given, not necessarily the exposure date. 1, 2, 5
• Inject in the deltoid muscle for older children and adolescents; use the anterolateral thigh for infants and young children depending on age and body mass. 1, 2, 4
• Never use the gluteal area for vaccine administration—this produces inadequate antibody response and has been associated with vaccine failures. 1, 2
• Children receive the same vaccine volume (1.0 mL per dose) as adults. 1, 2

Modified Regimens for Special Populations

Previously Vaccinated Children

• Administer only 2 doses of vaccine on days 0 and 3—do NOT give HRIG, as it will inhibit the anamnestic antibody response. 1, 2
• This simplified regimen applies to any child who has completed a recommended pre-exposure or post-exposure vaccination series with a cell culture vaccine. 1, 2

Immunocompromised Children

• Administer a 5-dose vaccine regimen on days 0,3,7,14, and 28, plus HRIG at 20 IU/kg on day 0, even if the child was previously vaccinated. 1, 2
• Immunosuppressive conditions include corticosteroid use, other immunosuppressive agents, antimalarials, HIV infection, chronic lymphoproliferative leukemia, or other immunosuppressive illnesses. 1
• Mandatory serologic testing is required 1-2 weeks after the final vaccine dose (day 42 for immunocompromised patients) using the rapid fluorescent focus inhibition test (RFFIT). 1
• An acceptable antibody response is complete neutralization of challenge virus at a 1:5 serum dilution. 1
• Immunosuppressive medications should not be administered during rabies PEP unless essential for treatment of other conditions. 1

Animal Observation and Testing

Domestic Dogs, Cats, and Ferrets

• If the animal is healthy and available, confine and observe for 10 days—a dog, cat, or ferret that remains healthy for 10 days after exposure would not have been infectious at the time of the bite or scratch. 6, 7, 2
• Begin PEP immediately at the first sign of rabies in the animal during the observation period; if the animal exhibits clinical signs of rabies, it should be euthanized immediately and tested. 2
• Initiate PEP immediately without waiting for observation if: the animal is unavailable for observation, its vaccination status is unknown or not up-to-date, the exposure occurred in a rabies-endemic area, the animal shows any signs of illness, or the animal dies or is euthanized before completing the 10-day period. 6, 7

Stray or Wild Animals

• For stray dog bites, begin PEP immediately when the animal cannot be observed or tested—do not delay PEP initiation while attempting to locate an escaped stray dog. 7
• If the stray animal can be captured, either confine and observe for 10 days or euthanize immediately and submit the head for rabies testing. 7
• For wildlife exposures (bats, raccoons, skunks, foxes), initiate PEP immediately unless the animal is available for testing and public health authorities are facilitating expeditious laboratory testing. 2
• The 10-day observation period is reliable only for healthy domestic dogs, cats, and ferrets—not for other animals. 7

Timing and Efficacy

• Initiate PEP as soon as possible after exposure, ideally within 24 hours—however, treatment remains indicated even if weeks or months have elapsed since exposure, as there is no absolute cutoff for starting prophylaxis. 1, 8
• Delays of even a few hours matter because rabies is nearly 100% fatal once clinical symptoms develop. 1
• When administered promptly and appropriately, PEP is nearly 100% effective in preventing human rabies—no failures of post-exposure prophylaxis have been documented in the United States since modern cell culture vaccines and HRIG were licensed. 1, 8, 9
• The rabies incubation period is typically 1-3 months but can range from days to over a year. 1

Schedule Flexibility and Adherence

• Delays of a few days for individual vaccine doses are unimportant and do not compromise protection—every attempt should be made to adhere to the recommended schedule, but minor deviations do not require restarting the series. 1
• For substantial deviations of weeks or more, immune status should be assessed by serologic testing 7-14 days after the final dose. 1
• If PEP has been initiated and laboratory testing (direct fluorescent antibody test) confirms the animal was not rabid, PEP can be discontinued. 2

Safety Profile in Children

• Modern cell culture rabies vaccines (HDCV and PCECV) are well tolerated in pediatric patients. 4, 5
• Mild systemic reactions (fever, headache, dizziness, gastrointestinal symptoms) occur in 6.8-55.6% of recipients and typically resolve spontaneously. 1
• Local injection-site reactions (pain, redness, swelling) occur in 60-89.5% of recipients and resolve within a few days. 1
• No serious adverse events have been documented in multiple pediatric studies of rabies PEP that included both vaccine and HRIG. 1, 4
• Immediate hypersensitivity reactions (anaphylaxis) are extremely rare (~1 in 10,000 vaccinees). 1

Critical Pitfalls to Avoid

• Never use the gluteal area for vaccine administration—this is associated with inadequate immune response and vaccine failure. 1, 2
• Never give HRIG to previously vaccinated children—this will inhibit the anamnestic antibody response. 1, 2
• Never exceed 20 IU/kg of HRIG—higher doses suppress active antibody production. 1, 2
• Never delay PEP while waiting for animal observation results if the exposure occurred in a rabies-endemic area or the animal is unavailable. 6, 7
• Do not fail to infiltrate HRIG into the wound site—inadequate wound infiltration reduces effectiveness. 7, 9
• Do not discontinue the vaccine series for mild systemic reactions such as fever—continuation is essential for protection against a uniformly fatal disease. 1