Immunizations for NICU patients

Jolie, BSN · Feb 20, 2010

If a neonate is having apneic episoes 24 hours prior to a scheduled immunization, it seems likely that the apneic episodes are not immunization related, or at least not solely immunization related.

It is important to determine why a baby is having apnea before introducing any new stressor, whether that be moving the child to an open crib, increasing oral feedings or giving immunizations, to name a few. Undiagnosed apnea is a valid reason to delay a vaccine. We don't immunize ill children in the community. We certainly don't immunize ill children in the NICU, and any baby having unexplained apena is considered ill until proven otherwise.

Now, if you are talking about otherwise healthy, stable, growing preemies who are known to experience apnea, that's a different story. Most stable, growing NICU babies begin their immunizations when they reach the corrected age at which they would normally receive them. This is a prudent way to protect them from community acquired infections that can be deadly, such as pertussis. Waiting until a baby is discharged to begin this protection may prove too late.

If a baby has never before experienced apnea, and starts having apneic episodes shortly after receiving a vaccine, I would investgate the possibility of a vaccine reaction.

Moondance · Feb 20, 2010

Thanks Jolie, that makes sense. I just thought of another immunization question...

As I was observing a NICU patient receiving his first immunizations, the nurse (and another nurse who assisted) gave two of the immunizations at the same time in the anterolateral aspect of the same thigh. They stated it was to keep the patient from being stuck twice.

I just purchased the book "Core Curriculum for Neonatal Intensive Care Nursing" and it didn't specify giving the injections simultaneously, but did state: "When necessary, two vaccines can be given in the same limb but should be separated by at least 1 inch if possible so that local reactions are not likely to overlap."

Is it common to give the injections simultaneously in the same limb?

Thanks for insight. I'm orienting to the NICU and trying to learn from every patient interaction. It's been interesting and a LOT to learn, but well worth it.

Jolie, BSN · Feb 20, 2010

No problem with giving 2 injections simultaneously to minimize pain reponse, but I wouldn't give them both in the same leg.

First of all, there isn't that much room to aim. There's a good chance of giving the shots too close together to ascertain which one the baby is reacting to, if it comes to that. Secondly, too much risk of the nurses sticking each other. Third, babies don't localize pain very well. If the baby get 2 pokes in the same leg, it will hurt him the same as if he had gotten 2 pokes in 2 different sites. He just knows he hurts, the number of sites don't matter much to him Was he given any pain relief? Sweet-ease or Tylenol?

My oldest daughter went for her Kindergarten physical and had to have multiple vaccines. Two nurses came in to administer them simultaneously, one in each leg. They were just a few seconds off, and by the time the slower nurse injected, my daughter was so tense from the first shot that the second needle bent and bounced off her leg. Moral of the story: Your timing must be impeccable!

Moondance · Feb 20, 2010

Thanks once again Jolie :)

The infant wasn't given Tylenol and I asked about that. They said usually the doc orders it, but I don't know why it wasn't in his case. He did end up having a temperature the next day and Tylenol was ordered and administered.

Ouch! Your poor little daughter! That had to hurt! Impeccable timing is indeed crucial.

littleneoRN · Feb 22, 2010

We give immunizations at the appropriate chronological age if the infants are stable. I've asked our docs about this, and they said the research supports giving the immunizations at chronological (not corrected) age. I haven't read this research myself. I have noticed some babies who had apnea spells prior to the vaccines having a marked increase in apnea afterwards. Even some kids who had seemed to outgrow it. Unfortunately, to be thorough, these kids often get septic workupls and antibiotics. I try to advocate for separating these from other stressful activities like increasing feeds, diagnostic testing, corificeat exam, etc. And definitely for at least a couple days before expected discharge!

Of course, some kids don't seem to have any reaction...

Mimi2RN, ASN, RN · Feb 22, 2010

We frequently give the 2-month vaccinations over a few days, it seems to be easier on the babies.

And the same for one of my cats!

TiffyRN, BSN, PhD · Feb 24, 2010

Our practices regarding vaccines seem to change monthly. Currently they are trying to give the 1st Hep B vaccine by 1 month of age as long as the infant is stable. If the infant is an older gestation at birth (not specific, but generally >33wks & 1800 grams) we are being encouraged to give the 1st Hep B as soon as possible. 2month vaccines are to be given at 2 months chronological age as long as it's been at least 1 month since the 1st Hep B (or if they never got the 1st Hep B, which happens more often than you would think).

In the past the neos have ordered PRN tylenol which most nurses would give q6 around the clock x 24 hrs, or they would go ahead and order it around the clock q6hrs x 4. Recently apparently somebody read a study and they are no longer giving tylenol for 2 month vaccines. All of a sudden we have a rash of 2 month old infants getting fevers and septic work-ups, the day after their vaccines!! Big surprise there huh? I'm sure the same would apply to 4 & 6 month vaccines but thankfully there are fewer infants in that age group and this "no tylenol" thing is kind of recent.

As for the timing, we found that spacing the vaccines out too much meant sometimes some of the shots got missed. It has been further encouraged that one shift complete the whole series so as to prevent confusion and missed vaccines. It has helped a lot. Our 2 month vaccines have been reduced to 3 shots (thank you Pediarix) so most nurses will give 1 shot every 3 hours or sometimes get a partner and give 2 of the vaccines (one in each leg) at one set of cares and then complete the series with the next set of cares. When 2 nurses inject at the same time, we've always done it to 2 different legs and one of the nurses does the 3 count so the injections are as close to simultaneous as possible.

Other than the fevers I've only seen a couple of infants have issues post vaccinations. The one I remember specifically just acted completely septic the day after his 2 month vaccines. He was almost continuously apneic unless stim'd. You asked why wasn't he intubated? Yea, so did I. All they could find was a knot in one of his thighs & swollen lymph nodes on that side. Most of the nurses believed it was a vaccine reaction of some sort but the neos insisted it was just a random infection that happened to be in the leg that got the 2 injections.