What is time-out?
Time-out is a way of disciplining your child for misbehavior without raising your hand or your voice. Time-out involves removing your child from those things they seem to enjoy, for a small amount of time, immediately
following misbehavior. Time-out for children is similar to penalties used for hockey players. When a hockey player has misbehaved on the ice, he is required to go to the penalty area for two minutes. The referee does not scream at, threaten, or hit the player. He merely blows the whistle and points to the penalty area. During the penalty time, the player is not allowed to play, only watch. Time-out bothers hockey players because they would rather play hockey than watch. Keep this hockey comparison in mind when using time-out for your child. Children usually do not like time-out because they would rather play than watch other kids play. So when you use time-out in response to a misbehavior, remove your child from whatever he or she is doing and have him or her sit down.
Where should the time-out area be located?
You do not have to use the same location each time. Just make sure the location is convenient for you. For example, using a downstairs chair is inconvenient when the problem behavior occurs upstairs. An adult-sized chair works best, but a step, footstool, bench, or couch will also work. Make sure the area is well-lit and free from all dangerous objects. Also make sure your child cannot watch TV or play with toys while in the time-out area.
How long should time-out last?
The upper limit should be one quiet minute for every year your child has been alive. So if you have a 2-year-old, aim for two quiet minutes. Keep in mind, children do not like time-out, and they can be very public with their opinion. So it may take some time to get those two minutes. This is especially true in the beginning when children do not know the rules and still cannot believe you are doing this to them. For some reason, the calmer you remain, the more upset they are likely to become. This is all part of the process. Discipline works best when you administer it calmly.
So, do not begin the time until your child is calm and quiet. If your child is crying or throwing a tantrum, it does not count toward the required time. If you start the time because your child is quiet but he or she starts to cry or tantrum, wait until your child is quiet again and then start the time over. Do not let your child leave time-out unless he or she is calm; your child must remain seated and be quiet to get out of time-out. Some programs suggest using timers. Timers can be helpful but are not necessary. If you use one, remember the timer is to remind parents that time-out is over, not children.
What counts as quiet time?
Generally, quiet time occurs when your child is not angry or upset, and is not yelling or crying. You must decide when your child is calm and quiet. Some children get perfectly still and quiet while in their time-out. Other children find it hard to sit still and not talk. Fidgeting and “happy talk” should usually count as being calm and quiet. For example, if your son sings or talks softly to himself, that counts as quiet time. Some children do what we call “dieseling,” which is the quiet sniffling that usually follows a tantrum. Since a “dieseling” child is usually trying to stop crying but cannot find the off switch, this also should be counted as quiet time.
What if the child leaves the chair before time is up?
Say nothing! Calmly (and physically) return your child to the chair. For children who are 2 to 4 years old, unscheduled departures from the chair are a chronic problem early in the time-out process. Stay calm and keep returning the child to the chair. If you tire or become angry, invite your spouse (or any adult who is nearby) to assist you as a tag-team partner. If you are alone and become overly tired or angry, retreat with honor. But when help arrives or when your strength returns, set the stage for another time-out.
What if my child misbehaves in the chair?
Say nothing and ignore everything that is not dangerous to the child, yourself, and the furniture. Most of your child’s behavior in the chair is an attempt to get you to react and say something, anything. So expect the unexpected, especially if you are a nagger, screamer, explainer, warner, reasoner, or just a talker. And I mean the unexpected. They may spit up, wet, blow their nose on their clothes (you may be tempted to say “Yecch” but…do not), strip, throw things, make unkind comments about your parenting skills, or simply say they do not love you anymore. Do not worry. They will love you again when their time is up, believe me.
When should I use time-out?
When you first start, use it for only one or two problem behaviors. After your child has learned to “do” time-out, you can expand the list of problem behaviors. In general, problem behaviors fall into three categories:
- Anything dangerous to self or others;
- Defiance and/or noncompliance; and
- Obnoxious or bothersome behavior.
Use time-out for “1” and “2” and ignore anything in category “3.” If you cannot ignore something, move it into category “2” by issuing a command (e.g., “Take the goldfish out of the toilet.”). Then if the child does not comply, you can use time-out for noncompliance. Be sure to use time-out as consistently as possible. For example, try to place your child in time-out each time a targeted behavior occurs. I realize you cannot be 100 percent consistent because it is in our nature to adapt. But be as consistent as you can.
In general, immediately following a problem behavior, tell your child what he or she did and take him or her to time-out. (With older children, send them to time-out.) For example, you might say, “No hitting. Go to timeout.” Say this calmly and only once. Do not reason or give long explanations to your child. If your child does not go willingly, take him or her to time-out, using as little force as needed. For example, hold your daughter gently by the hand or wrist and walk to the time-out area. Or, carry her facing away from you (so that she does not confuse a hug and a trip to time-out). As I suggested earlier, avoid giving your child a lot of attention while he or she is being put in time-out. Do not argue with, threaten, or spank your child. And what should you say? Hint: Starts with “No”’ and ends with “thing.” Answer: Say nothing!
What do I do when time is up?
When the time-out period is over, ask your child, “Are you ready to get up?” Your child must answer yes in some way (or nod yes) before you give permission for him or her to get up. Do not talk about why the child went into time-out, how the child behaved while in time-out, or how you want your child to behave in the future. In other words, do not nag. If your child says “No,” answers in an angry tone of voice, or will not answer all, start time-out over again. If your child chooses to stay in the chair, fine. It is hard to cause real trouble in time-out.
What do I do when my child leaves the chair?
If you placed your child in time-out for not doing what you told him or her to do, repeat the instruction. This will help teach your child you mean business. It also gives your child a chance to behave in a way that is good for business. If he or she still does not obey the instruction, then place him or her in time-out again. In addition, add in a few other easy-to-follow, one-step commands. If he or she does them, praise the performance. If not, back to time-out. Generally, use this opportunity to train your child to follow your instructions when those instructions are delivered in a normal tone of voice without being repeated.
The general rule for ending time-out is to praise a good behavior. Once time-out is over, reward your child for the kinds of behaviors you want him or her to use. Catch them being good.
Should I explain the rules of time-out to my child?
Before using time-out, you should explain the rules to your child once. At a time when your child is not misbehaving, explain what time-out is (simply), which problem behaviors time-out will be used for, and how long time-out will last. Practice using time-out with your child before using the procedure. While practicing, remind your child you are “pretending” this time. They will still go “ballistic” when you do your first real time-outs,but you will be reassured that you have done your part to explain the fine print.
Summary
- Choose time-out areas.
- Explain time-out.
- Use time-out every time the problem behaviors occur.
- Be specific and brief when you explain why your child must go to time-out.
- Do not talk to or look at your child during time-out.
- If your child gets up from the chair, return him or her to the chair with no talking.
- Your child must be calm and quiet to leave time-out once time is up.
- Your child must answer yes politely when you ask, “Would you like to get up?”
- If you wanted your child to follow an instruction, give him or her another chance after time-out is over. And, in general, deliver a few other easy-to-follow commands so your child clearly learns who is in charge and who is not.
- Catch them being good.
Male Circumcision
Male circumcision consists of the surgical removal of some, or all, of the foreskin (or prepuce) from the penis. It is one of the most common procedures performed all over the world. In the United States, the procedure is commonly performed during the newborn period.
Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks, and the benefits of newborn male circumcision justify access to this procedure for those families who choose it. However, parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families.
The three most common operative methods of circumcision for the newborn male include:
- The Gomco clamp
- The Plastibell device
- The Mogen clamp
There are also other variations derived from the same principle on which each of these devices is based.
Care Of The Circumcised Penis
One of the first decisions you will make for your new baby boy is whether or not to have him circumcised.
Taking care of your son’s circumcision is usually very easy. After the procedure is performed, your pediatrician will instruct you on how to do this. If a Plastibell ring or device was used for the procedure, there is usually nothing to do. And generaly the device will come off after a few days.
However, if one of the other methods, Gomco or Morgan clamp, was used, you will need to apply a suitable lubricant regularly to the penis after circumcision. This is usually done with each diaper change, and a non-perfumed lubricant, such as Vaseline, should be sufficient.
Care Of The Uncircumcised Penis
If you have chosen not to have your son circumcised, there are some things you should be aware of and teach your son as he gets older.
What is Foreskin Retraction?
Sometime during the first several years of your son’s life, his foreskin, which covers the head of the penis, will separate from the glans. Some foreskins separate soon after birth or even before birth, but this is rare. When it happens is different for every child. It may take a few weeks, months or years.
After the foreskin separates from the glans, it can be pulled back away from the glans toward the abdomen. This is called foreskin retraction.
Most boys will be able to retract their foreskins by the time they are 5 years old, yet others will not be able to until the teenage years. As a boy becomes more aware of his body, he will most likely discover how to retract his own foreskin. But foreskin retraction should never be forced. Until separation occurs, do not try to pull the foreskin back – especially an infant’s. Forcing the foreskin to retract before it is ready may severely harm the penis and cause pain, bleeding, and tears in the skin.
What is Smegma
When the foreskin separates from the glans, skin cells are shed. These skin cells may look like whitish lumps, resembling pearls, under the foreskin. These are called smegma. Smegma is normal and nothing to worry about.
Does my Son’s foreskin need special cleaning?
Your son’s intact or uncircumcised penis requires no special care and is easy to keep clean. When your son is an infant, bathe or sponge him regularly and wash all body parts, including the genitals. Simply wash the penis with soap and warm water. Remember, do not try to forcibly retract the foreskin.
If your son’s foreskin is separated and retractable before he reaches puberty, an occasional retraction with cleansing beneath will do. Once your son starts puberty, he should retract the foreskin and clean beneath it on a regular basis. It should become a part of your son’s total body hygiene, just like shampooing his hair and brushing his teeth. Teach your son to clean his foreskin in the following way:
- Gently pull the foreskin back away from the glans.
- Rinse the glans and inside fold of the foreskin with soap and warm water.
- Pull the foreskin back over the head of the penis.
Is there anything else I should watch for?
While your son is still a baby, you should make sure the hole in the foreskin is large enough to allow a normal stream when he urinates. Contact our office or call your pediatrician if any of the following occurs:
- The stream of urine is never heavier than a trickle
- Your baby seems to have some discomfort while urinating
- The foreskin becomes considerably red, swollen or painful to touch.
[Adapted from the AAP www.aap.org]
Recommended Immunization Schedule for Persons Aged 0 Through 18 Years
United States, 2016
Compliant version of the schedule
Print PDF document of this schedule
These recommendations must be read with the footnotes that follow. For those who fall behind or start late, provide catch-up vaccination at the earliest opportunity as indicated by the green bars in tables below. To determine minimum intervals between doses, see the catch-up schedule. School entry and adolescent vaccine age groups are 4-6 yrs and 11-12 yrs.
Birth to 15 Months
Legend
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Range of recommended ages for all children |
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Range of recommended ages for catch-up immunization |
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Range of recommended ages for certain high-risk groups |
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Range of recommended ages for non-high-risk groups that may receive vaccine, subject to individual clinical decision making |
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No recommendation |
18 Months to 18 Years
Note: The above recommendations must be read along with the footnotes of this schedule.
Footnotes
Recommended Immunization Schedule for Persons Age 0 Through 18 Years
United States, 2016
For further guidance on the use of the vaccines mentioned below, see the ACIP Recommendations.
For vaccine recommendations for persons 19 years of age and older, see the adult immunization schedule.
- Hepatitis B (HepB) vaccine. (Minimum age: birth)
Routine vaccination:
At birth
- Administer monovalent HepB vaccine to all newborns before hospital discharge.
- For infants born to hepatitis B surface antigen (HBsAg)-positive mothers, administer HepB vaccine and 0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth. These infants should be tested for HBsAg and antibody to HBsAg (anti-HBs) at age 9 through 18 months (preferably at the next well-child visit) or 1 to 2 months after completion of the HepB series if the series was delayed; CDC recently recommended testing occur at age 9 through 12 months; see MMWR October 9, 2015;64(39):1118-20).
- If mother’s HBsAg status is unknown, within 12 hours of birth administer HepB vaccine regardless of birth weight. For infants weighing less than 2,000 grams, administer HBIG in addition to HepB vaccine within 12 hours of birth. Determine mother’s HBsAg status as soon as possible and, if mother is HBsAg-positive, also administer HBIG for infants weighing 2,000 grams or more as soon as possible, but no later than age 7 days.
Doses following the birth dose
- The second dose should be administered at age 1 or 2 months. Monovalent HepB vaccine should be used for doses administered before age 6 weeks.
- Infants who did not receive a birth dose should receive 3 doses of a HepB-containing vaccine on a schedule of 0, 1 to 2 months, and 6 months starting as soon as feasible. See Catch-up Schedule.
- Administer the second dose 1 to 2 months after the first dose (minimum interval of 4 weeks), administer the third dose at least 8 weeks after the second dose AND at least 16 weeks after the first dose. The final (third or fourth) dose in the HepB vaccine series should be administered no earlier than age 24 weeks.
- Administration of a total of 4 doses of HepB vaccine is permitted when a combination vaccine containing HepB is administered after the birth dose.
Catch-up vaccination:
- Unvaccinated persons should complete a 3-dose series.
- A 2-dose series (doses separated by at least 4 months) of adult formulation Recombivax HB is licensed for use in children aged 11 through 15 years.
- For other catch-up guidance, see Catch-up Schedule.
- Rotavirus (RV) vaccines. (Minimum age: 6 weeks for both RV1 [Rotarix] and RV5 [RotaTeq])
Routine vaccination:
- Administer a series of RV vaccine to all infants as follows:
- If Rotarix is used, administer a 2-dose series at 2 and 4 months of age.
- If RotaTeq is used, administer a 3-dose series at ages 2, 4, and 6 months.
- If any dose in the series was RotaTeq or vaccine product is unknown for any dose in the series, a total of 3 doses of RV vaccine should be administered.
Catch-up vaccination:
- The maximum age for the first dose in the series is 14 weeks, 6 days; vaccination should not be initiated for infants aged 15 weeks, 0 days or older.
- The maximum age for the final dose in the series is 8 months, 0 days.
- For other catch-up guidance, see Catch-up Schedule.
- Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine. (Minimum age: 6 weeks. Exception: DTaP-IPV [Kinrix, Quadracel]: 4 years)
Routine vaccination:
- Administer a 5-dose series of DTaP vaccine at ages 2, 4, 6, 15 through 18 months, and 4 through 6 years. The fourth dose may be administered as early as age 12 months, provided at least 6 months have elapsed since the third dose.
- Inadvertent administration of 4th DTaP dose early: If the fourth dose of DTaP was administered at least 4 months, but less than 6 months, after the third dose of DTaP, it need not be repeated.
Catch-up vaccination:
- The fifth dose of DTaP vaccine is not necessary if the fourth dose was administered at age 4 years or older.
- For other catch-up guidance, see Catch-up Schedule.
- Haemophilus influenzae type b (Hib) conjugate vaccine. (Minimum age: 6 weeks for PRP-T [ACTHIB, DTaP-IPV/Hib (Pentacel) and Hib-MenCY (MenHibrix)], PRP-OMP [PedvaxHIB or COMVAX], 12 months for PRP-T [Hiberix])
Routine vaccination:
- Administer a 2- or 3-dose Hib vaccine primary series and a booster dose (dose 3 or 4 depending on vaccine used in primary series) at age 12 through 15 months to complete a full Hib vaccine series.
- The primary series with ActHIB, MenHibrix, or Pentacel consists of 3 doses and should be administered at 2, 4, and 6 months of age. The primary series with PedvaxHib or COMVAX consists of 2 doses and should be administered at 2 and 4 months of age; a dose at age 6 months is not indicated.
- One booster dose (dose 3 or 4 depending on vaccine used in primary series) of any Hib vaccine should be administered at age 12 through 15 months. An exception is Hiberix vaccine. Hiberix should only be used for the booster (final) dose in children aged 12 months through 4 years who have received at least 1 prior dose of Hib-containing vaccine.
- For recommendations on the use of MenHibrix in patients at increased risk for meningococcal disease, please refer to the meningococcal vaccine footnotes and also to MMWR February 28, 2014;63(RR01):1-13[20 pages].
Catch-up vaccination:
- If dose 1 was administered at ages 12 through 14 months, administer a second (final) dose at least 8 weeks after dose 1, regardless of Hib vaccine used in the primary series.
- If both doses were PRP-OMP (PedvaxHIB or COMVAX), and were administered before the first birthday, the third (and final) dose should be administered at age 12 through 59 months and at least 8 weeks after the second dose.
- If the first dose was administered at age 7 through 11 months, administer the second dose at least 4 weeks later and a third (and final) dose at age 12 through 15 months or 8 weeks after second dose, whichever is later.
- If first dose is administered before the first birthday and second dose administered at younger than 15 months, a third (and final) dose should be administered 8 weeks later.
- For unvaccinated children aged 15 months or older, administer only 1 dose.
- For other catch-up guidance, see Catch-up Schedule. For catch-up guidance related to MenHibrix, please see the meningococcal vaccine footnotes and also MMWR February 28, 2014;63(RR01):1-13[20 pages].
Vaccination of persons with high-risk conditions:
- Children aged 12 through 59 months who are at increased risk for Hib disease, including chemotherapy recipients and those with anatomic or functional asplenia (including sickle cell disease), human immunodeficiency virus (HIV) infection, immunoglobulin deficiency, or early component complement deficiency, who have received either no doses or only 1 dose of Hib vaccine before 12 months of age, should receive 2 additional doses of Hib vaccine 8 weeks apart; children who received 2 or more doses of Hib vaccine before 12 months of age should receive 1 additional dose.
- For patients younger than 5 years of age undergoing chemotherapy or radiation treatment who received a Hib vaccine dose(s) within 14 days of starting therapy or during therapy, repeat the dose(s) at least 3 months following therapy completion.
- Recipients of hematopoietic stem cell transplant (HSCT) should be revaccinated with a 3-dose regimen of Hib vaccine starting 6 to 12 months after successful transplant, regardless of vaccination history; doses should be administered at least 4 weeks apart.
- A single dose of any Hib-containing vaccine should be administered to unimmunized* children and adolescents 15 months of age and older undergoing an elective splenectomy; if possible, vaccine should be administered at least 14 days before procedure.
- Hib vaccine is not routinely recommended for patients 5 years or older. However, 1 dose of Hib vaccine should be administered to unimmunized* persons aged 5 years or older who have anatomic or functional asplenia (including sickle cell disease) and unvaccinated persons 5 through 18 years of age with HIV infection.
* Patients who have not received a primary series and booster dose or at least 1 dose of Hib vaccine after 14 months of age are considered unimmunized.
- Pneumococcal vaccines. (Minimum age: 6 weeks for PCV13, 2 years for PPSV23)Routine vaccination with PCV13:
- Administer a 4-dose series of PCV13 vaccine at ages 2, 4, and 6 months and at age 12 through 15 months.
- For children aged 14 through 59 months who have received an age-appropriate series of 7-valent PCV (PCV7), administer a single supplemental dose of 13-valent PCV (PCV13).
Catch-up vaccination with PCV13:
- Administer 1 dose of PCV13 to all healthy children aged 24 through 59 months who are not completely vaccinated for their age.
- For other catch-up guidance, see Catch-up Schedule.
Vaccination of persons with high-risk conditions with PCV13 and PPSV23:
- All recommended PCV13 doses should be administered prior to PPSV23 vaccination if possible.
- For children 2 through 5 years of age with any of the following conditions: chronic heart disease (particularly cyanotic congenital heart disease and cardiac failure); chronic lung disease (including asthma if treated with high-dose oral corticosteroid therapy); diabetes mellitus; cerebrospinal fluid leak; cochlear implant; sickle cell disease and other hemoglobinopathies; anatomic or functional asplenia; HIV infection; chronic renal failure; nephrotic syndrome; diseases associated with treatment with immunosuppressive drugs or radiation therapy, including malignant neoplasms, leukemias, lymphomas, and Hodgkin disease; solid organ transplantation; or congenital immunodeficiency:
- Administer 1 dose of PCV13 if any incomplete schedule of 3 doses of PCV (PCV7 and/or PCV13) were received previously.
- Administer 2 doses of PCV13 at least 8 weeks apart if unvaccinated or any incomplete schedule of fewer than 3 doses of PCV (PCV7 and/or PCV13) were received previously.
- Administer 1 supplemental dose of PCV13 if 4 doses of PCV7 or other age-appropriate complete PCV7 series was received previously.
- The minimum interval between doses of PCV (PCV7 or PCV13) is 8 weeks.
- For children with no history of PPSV23 vaccination, administer PPSV23 at least 8 weeks after the most recent dose of PCV13.
- For children aged 6 through 18 years who have cerebrospinal fluid leak; cochlear implant; sickle cell disease and other hemoglobinopathies; anatomic or functional asplenia; congenital or acquired immunodeficiencies; HIV infection; chronic renal failure; nephrotic syndrome; diseases associated with treatment with immunosuppressive drugs or radiation therapy, including malignant neoplasms, leukemias, lymphomas, and Hodgkin disease; generalized malignancy; solid organ transplantation; or multiple myeloma:
- If neither PCV13 nor PPSV23 has been received previously, administer 1 dose of PCV13 now and 1 dose of PPSV23 at least 8 weeks later.
- If PCV13 has been received previously but PPSV23 has not, administer 1 dose of PPSV23 at least 8 weeks after the most recent dose of PCV13.
- If PPSV23 has been received but PCV13 has not, administer 1 dose of PCV13 at least 8 weeks after the most recent dose of PPSV23.
- For children aged 6 through 18 years with chronic heart disease (particularly cyanotic congenital heart disease and cardiac failure), chronic lung disease (including asthma if treated with high-dose oral corticosteroid therapy), diabetes mellitus, alcoholism, or chronic liver disease, who have not received PPSV23, administer 1 dose of PPSV23. If PCV13 has been received previously, then PPSV23 should be administered at least 8 weeks after any prior PCV13 dose.
- A single revaccination with PPSV23 should be administered 5 years after the first dose to children with sickle cell disease or other hemoglobinopathies; anatomic or functional asplenia; congenital or acquired immunodeficiencies; HIV infection; chronic renal failure; nephrotic syndrome; diseases associated with treatment with immunosuppressive drugs or radiation therapy, including malignant neoplasms, leukemias, lymphomas, and Hodgkin disease; generalized malignancy; solid organ transplantation; or multiple myeloma.
- Inactivated poliovirus vaccine (IPV). (Minimum age: 6 weeks)
Routine vaccination:
- Administer a 4-dose series of IPV at ages 2, 4, 6 through 18 months, and 4 through 6 years. The final dose in the series should be administered on or after the fourth birthday and at least 6 months after the previous dose.
Catch-up vaccination:
- In the first 6 months of life, minimum age and minimum intervals are only recommended if the person is at risk for imminent exposure to circulating poliovirus (i.e., travel to a polio-endemic region or during an outbreak).
- If 4 or more doses are administered before age 4 years, an additional dose should be administered at age 4 through 6 years and at least 6 months after the previous dose.
- A fourth dose is not necessary if the third dose was administered at age 4 years or older and at least 6 months after the previous dose.
- If both OPV and IPV were administered as part of a series, a total of 4 doses should be administered, regardless of the child’s current age. If only OPV were administered, and all doses were given prior to 4 years of age, one dose of IPV should be given at 4 years or older, at least 4 weeks after the last OPV dose.
- IPV is not routinely recommended for U.S. residents aged 18 years or older.
- For other catch-up guidance, see Catch-up Schedule.
- Influenza vaccines. (Minimum age: 6 months for inactivated influenza vaccine [IIV], 2 years for live, attenuated influenza vaccine [LAIV])
Routine vaccination:
- Administer influenza vaccine annually to all children beginning at age 6 months. For most healthy, nonpregnant persons aged 2 through 49 years, either LAIV or IIV may be used. However, LAIV should NOT be administered to some persons, including 1) persons who have experienced severe allergic reactions to LAIV, any of its components, or to a previous dose of any other influenza vaccine; 2) children 2 through 17 years receiving aspirin or aspirin-containing products; 3) persons who are allergic to eggs; 4) pregnant women; 5) immunosuppressed persons; 6) children 2 through 4 years of age with asthma or who had wheezing in the past 12 months; or 7) persons who have taken influenza antiviral medications in the previous 48 hours. For all other contraindications and precautions to use of LAIV, see MMWR August 7, 2015;64(30):818-25 [28 pages].
For children aged 6 months through 8 years:
- For the 2015-16 season, administer 2 doses (separated by at least 4 weeks) to children who are receiving influenza vaccine for the first time. Some children in this age group who have been vaccinated previously will also need 2 doses. For additional guidance, follow dosing guidelines in the 2015-16 ACIP influenza vaccine recommendations, MMWR August 7, 2015 ;64(30);88-25 [28 pages]
- For the 2016-17 season, follow dosing guidelines in the 2016 ACIP influenza vaccine recommendations.
For persons aged 9 years and older:
- Measles, mumps, and rubella (MMR) vaccine. (Minimum age: 12 months for routine vaccination)
Routine vaccination:
- Administer a 2-dose series of MMR vaccine at ages 12 through 15 months and 4 through 6 years. The second dose may be administered before age 4 years, provided at least 4 weeks have elapsed since the first dose.
- Administer 1 dose of MMR vaccine to infants aged 6 through 11 months before departure from the United States for international travel. These children should be revaccinated with 2 doses of MMR vaccine, the first at age 12 through 15 months (12 months if the child remains in an area where disease risk is high), and the second dose at least 4 weeks later.
- Administer 2 doses of MMR vaccine to children aged 12 months and older before departure from the United States for international travel. The first dose should be administered on or after age 12 months and the second dose at least 4 weeks later.
Catch-up vaccination:
- Ensure that all school-aged children and adolescents have had 2 doses of MMR vaccine; the minimum interval between the 2 doses is 4 weeks.
- Varicella (VAR) vaccine. (Minimum age: 12 months)
Routine vaccination:
- Administer a 2-dose series of VAR vaccine at ages 12 through 15 months and 4 through 6 years. The second dose may be administered before age 4 years, provided at least 3 months have elapsed since the first dose. If the second dose was administered at least 4 weeks after the first dose, it can be accepted as valid.
Catch-up vaccination:
- Ensure that all persons aged 7 through 18 years without evidence of immunity (see MMWR 2007;56[No. RR-4][48 pages]), have 2 doses of varicella vaccine. For children aged 7 through 12 years, the recommended minimum interval between doses is 3 months (if the second dose was administered at least 4 weeks after the first dose, it can be accepted as valid); for persons aged 13 years and older, the minimum interval between doses is 4 weeks.
- Hepatitis A (HepA) vaccine. (Minimum age: 12 months)
Routine vaccination:
- Initiate the 2-dose HepA vaccine series at 12 through 23 months; separate the 2 doses by 6 to 18 months.
- Children who have received 1 dose of HepA vaccine before age 24 months should receive a second dose 6 to 18 months after the first dose.
- For any person aged 2 years and older who has not already received the HepA vaccine series, 2 doses of HepA vaccine separated by 6 to 18 months may be administered if immunity against hepatitis A virus infection is desired.
Catch-up vaccination:
- The minimum interval between the 2 doses is 6 months.
Special populations:
- Administer 2 doses of HepA vaccine at least 6 months apart to previously unvaccinated persons who live in areas where vaccination programs target older children, or who are at increased risk for infection. This includes persons traveling to or working in countries that have high or intermediate endemicity of infection; men having sex with men; users of injection and non-injection illicit drugs; persons who work with HAV-infected primates or with HAV in a research laboratory; persons with clotting-factor disorders; persons with chronic liver disease; and persons who anticipate close, personal contact (e.g., household or regular babysitting) with an international adoptee during the first 60 days after arrival in the United States from a country with high or intermediate endemicity. The first dose should be administered as soon as the adoption is planned, ideally 2 or more weeks before the arrival of the adoptee.
- Meningococcal vaccines. (Minimum age: 6 weeks for Hib-MenCY [MenHibrix], 9 months for MenACWY-D [Menactra], 2 months for MenACWY-CRM [Menveo], 10 years for serogroup B meningococcal [MenB] vaccines: MenB-4C [Bexsero] and MenB-FHbp [Trumenba])
Routine vaccination:
- Administer a single dose of Menactra or Menveo vaccine at age 11 through 12 years, with a booster dose at age 16 years.
- Adolescents aged 11 through 18 years with human immunodeficiency virus (HIV) infection should receive a 2-dose primary series of Menactra or Menveo with at least 8 weeks between doses.
- For children aged 2 months through 18 years with high-risk conditions, see below.
Catch-up vaccination:
- Administer Menactra or Menveo vaccine at age 13 through 18 years if not previously vaccinated.
- If the first dose is administered at age 13 through 15 years, a booster dose should be administered at age 16 through 18 years with a minimum interval of at least 8 weeks between doses.
- If the first dose is administered at age 16 years or older, a booster dose is not needed.
- For other catch-up guidance, see Catch-up Schedule.
Clinical discretion:
- Young adults aged 16 through 23 years (preferred age range is 16 through 18 years) may be vaccinated with either a 2-dose series of Bexsero or a 3-dose series of Trumenba vaccine to provide short-term protection against most strains of serogroup B meningococcal disease. The two MenB vaccines are not interchangeable; the same vaccine product must be used for all doses.
Vaccination of persons with high-risk conditions and other persons at increased risk of disease:
- Children with anatomic or functional asplenia (including sickle cell disease):Meningococcal conjugate ACWY vaccines:
- Menveo
- Children who initiate vaccination at 8 weeks. Administer doses at 2, 4, 6 and 12 months of age.
- Unvaccinated children who initiate vaccination at 7 through 23 months. Administer two doses, with the second dose at least 12 weeks after the first dose AND after the first birthday.
- Children 24 months and older who have not received a complete series. Administer two primary doses at least 8 weeks apart.
- MenHibrix
- Children who initiate vaccination at 6 weeks. Administer doses at 2, 4, 6 and 12 through 15 months of age.
- If the first dose of MenHibrix is given at or after 12 months of age, a total of 2 doses should be given at least 8 weeks apart to ensure protection against serogroups C and Y meningococcal disease.
- Menactra
- Children 24 months and older who have not received a complete series. Administer two primary doses at least 8 weeks apart. If Menactra is administered to a child with asplenia (including sickle cell disease), do not administer Menactra until 2 years of age and at least 4 weeks after the completion of all PCV13 doses.
Meningococcal B vaccines:
- Bexsero or Trumenba
- Persons 10 years or older who have not received a complete series. Administer a 2 dose series of Bexsero, at least 1 month apart. Or a 3-dose series of Trumenba, with the second dose at least 2 months after the first and the third dose at least 6 months after the first. The two MenB vaccines are not interchangeable; the same vaccine product must be used for all doses.
- Children with persistent complement component deficiency (includes persons with inherited or chronic deficiencies in C3, C5-9, properidin, factor D, factor H, or taking eculizumab (Soliris®):Meningococcal conjugate ACWY vaccines:
- Menveo
- Children who initiate vaccination at 8 weeks. Administer doses at 2, 4, 6 and 12 months of age.
- Unvaccinated children who initiate vaccination at 7 through 23 months. Administer two doses, with the second dose at least 12 weeks after the first dose AND after the first birthday.
- Children 24 months and older who have not received a complete series. Administer two primary doses at least 8 weeks apart.
- MenHibrix
- Children who initiate vaccination at 6 weeks. Administer doses at 2, 4, 6 and 12 through 15 months of age.
- If the first dose of MenHibrix is given at or after 12 months of age, a total of 2 doses should be given at least 8 weeks apart to ensure protection against serogroups C and Y meningococcal disease.
- Menactra
- Children 9 through 23 months; Administer two primary doses at least 12 weeks apart.
- Children 24 months and older who have not received a complete series: Administer two primary doses at least 8 weeks apart.
Meningococcal B vaccines:
- Bexsero or Trumenba
- Persons 10 years or older who have not received a complete series. Administer a 2-dose series of Bexsero, at least 1 month apart, or a 3-dose series of Trumenba®, with the second dose at least 2 months after the first and the third dose at least 6 months after the first. The two MenB vaccines are not interchangeable; the same vaccine product must be used for all doses.
- For children who travel to or reside in countries in which meningococcal disease is hyperendemic or epidemic, including countries in the African meningitis belt or the Hajj:
- Administer an age-appropriate formulation and series of Menactra or Menveo for protection against serogroups A and W meningococcal disease. Prior receipt of MenHibrix is not sufficient for children traveling to the meningitis belt or the Hajj because it does not contain serogroups A or W.
- For children at risk during a community outbreak attributable to a vaccine serogroup:
- Administer or complete an age- and formulation-appropriate series of MenHibrix, Menactra, Menveo, Bexsero, or Trumenba.
For booster doses among persons with high-risk conditions, refer to MMWR 2013;62(RR02):1-22.
For other catch-up recommendations for these persons, and complete information on use of meningococcal vaccines, including guidance related to vaccination of persons at increased risk of infection, see MMWR March 22, 2013;62(RR02):1-22[32 pages] and MMWR Ocutober 23, 2015;64(41):1171-1176 [24 pages].
- Tetanus and diphtheria toxoids and acellular pertussis (Tdap) vaccine. (Minimum age: 10 years for both Boostrix and Adacel)
Routine vaccination:
- Administer 1 dose of Tdap vaccine to all adolescents aged 11 through 12 years.
- Tdap may be administered regardless of the interval since the last tetanus and diphtheria toxoid-containing vaccine.
- Administer 1 dose of Tdap vaccine to pregnant adolescents during each pregnancy (preferred during 27 through 36 weeks gestation) regardless of time since prior Td or Tdap vaccination.
Catch-up vaccination:
- Persons aged 7 years and older who are not fully immunized with DTaP vaccine should receive Tdap vaccine as 1 (preferably the first) dose in the catch-up series; if additional doses are needed, use Td vaccine. For children 7 through 10 years who receive a dose of Tdap as part of the catch-up series, an adolescent Tdap vaccine dose at age 11 through 12 years should NOT be administered. Td should be administered instead 10 years after the Tdap dose.
- Persons aged 11 through 18 years who have not received Tdap vaccine should receive a dose followed by tetanus and diphtheria toxoids (Td) booster doses every 10 years thereafter.
- Inadvertent doses of DTaP vaccine:
- If administered inadvertently to a child aged 7 through 10 years may count as part of the catch-up series. This dose may count as the adolescent Tdap dose, or the child can later receive a Tdap booster dose at age 11 through 12 years.
- If administered inadvertently to an adolescent aged 11 through 18 years, the dose should be counted as the adolescent Tdap booster.
- For other catch-up guidance, see Catch-up Schedule.
- Human papillomavirus (HPV) vaccines. (Minimum age: 9 years for 2vHPV [Cervarix], 4vHPV [Gardasil], and 9vHPV [Gardasil 9])
Routine vaccination:
- Administer a 3-dose series of HPV vaccine on a schedule of 0, 1-2, and 6 months to all adolescents aged 11 through 12 years. 9vHPV, 4vHPV or 2vHPV may be used for females, and only 9vHPV or 4vHPV may be used for males.
- The vaccine series may be started at age 9 years,
- Administer the second dose 1 to 2 months after the first dose (minimum interval of 4 weeks), administer the third dose 16 weeks after the second dose (minimum interval of 12 weeks) and 24 weeks after the first dose.
- Administer HPV vaccine beginning at age 9 years to children and youth with any history of sexual abuse or assault who have not initiated or completed the 3-dose series.
Catch-up vaccination:
- Administer the vaccine series to females (2vHPV, 4vHPV, or 9vHPV) and males (4vHPV or 9vHPV) at age 13 through 18 years if not previously vaccinated.
- Use recommended routine dosing intervals (see above) for vaccine series catch-up.
See additional notes for Recommended Immunization Schedule for Persons Age 0 Through 18 Years and Catch-up Immunization Schedule.
This schedule includes recommendations in effect as of January 1, 2016. Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and feasible. The use of a combination vaccine generally is preferred over separate injections of its equivalent component vaccines. Vaccination providers should consult the relevant Advisory Committee on Immunization Practices (ACIP) statement for detailed recommendations. Clinically significant adverse events that follow vaccination should be reported to Vaccine Adverse Event Reporting System (VAERS) online or by telephone (800-822-7967). Suspected cases of vaccine-preventable diseases should be reported to the state or local health department. Additional information, including precautions and contraindications for vaccination, is available from CDC’s Vaccines and Immunizationonline site or by telephone (800-CDC-INFO [800-232-4636]).
This schedule is approved by the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), and the American College of Obstetricians and Gynecologists (ACOG).
