Immunizations & Well-Child Care
The schedule, the true contraindications, and what to screen when
The routine immunization schedule
| Age | Vaccines |
|---|---|
| Birth | Hepatitis B #1 |
| 2, 4, 6 months | DTaP, IPV (polio), Hib, PCV (pneumococcal conjugate), rotavirus (oral); hepatitis B series continues |
| 6 months onward | Influenza every year |
| 12–15 months | MMR #1 and varicella #1 (live); hepatitis A series starts (12–23 months); Hib and PCV boosters |
| 4–6 years | School boosters: DTaP, IPV, MMR #2, varicella #2 |
| 11–12 years | Tdap, HPV, MenACWY |
| 16 years | MenACWY booster |
Two schedules. This table follows the AAP schedule. The January 2026 CDC schedule differs: it moved the hepatitis B birth dose (when the mother is HBsAg negative), rotavirus, hepatitis A, influenza, and meningococcal vaccines to shared clinical decision-making or high-risk use, and since 2025 ACIP prefers separate MMR and varicella over combined MMRV before age 4.
Why live vaccines wait. MMR and varicella are live viral vaccines held until about 12 months because persisting maternal antibodies would blunt the response. Hepatitis A vaccine is inactivated, but it is also started after the first birthday.
HPV dosing. Two doses if the series starts before age 15; three doses if it starts at 15 or older or the patient is immunocompromised. The series can begin as early as age 9.
Pregnancy. Tdap (in every pregnancy) and inactivated influenza are recommended during pregnancy, protecting the infant through transplacental antibodies.
Live vaccines and true contraindications
The live vaccines are MMR, varicella, rotavirus, intranasal influenza (LAIV), and yellow fever. They are contraindicated in pregnancy and in severe immunodeficiency: SCID, symptomatic HIV with a low CD4 count, active chemotherapy, and high-dose systemic steroids. MMR and varicella may still be given to children with HIV who are not severely immunocompromised, and inactivated vaccines are safe for everyone. Healthy household contacts of immunocompromised children should receive their routine live vaccines (MMR, varicella, rotavirus).
Rotavirus is a live oral vaccine: dose 1 must be given by 14 weeks 6 days (never started at 15 weeks or later), and the series must finish by 8 months. It is contraindicated in infants with a history of intussusception or with SCID, and it carries a small intussusception risk.
| Situation | Action |
|---|---|
| Anaphylaxis to a vaccine or one of its components | That vaccine is contraindicated |
| Encephalopathy within 7 days of a pertussis dose | No further pertussis-containing vaccine |
| Pregnancy or severe immunodeficiency | Hold live vaccines; give inactivated ones |
| Moderate-to-severe acute illness | Defer until improved |
| Mild illness, low-grade fever, current antibiotics | Vaccinate today |
| Breastfeeding, prematurity | Vaccinate by chronologic age |
| Egg allergy of any severity | Give influenza vaccine |
| Fever or local reaction after a prior dose; family history of seizures | Vaccinate |
Deferring for minor illness is the classic error: every missed opportunity leaves a child under-immunized. Only a moderate-to-severe acute illness justifies waiting.
Vaccine hesitancy
MMR does not cause autism. The claim came from a fraudulent 1998 study that was retracted; its author lost his medical license, and large studies have repeatedly shown no link.
How to counsel. Use empathy and a presumptive approach ("your child is due for these vaccines today") rather than confrontation. Answer the specific concern with evidence, document a refusal, and offer the vaccine again at every visit. Agreeing to skip a vaccine permanently or threatening dismissal is not the best first response.
Screening from birth to adolescence
| Age | Screen |
|---|---|
| Newborn | Heel-stick metabolic panel (PKU, congenital hypothyroidism, cystic fibrosis, galactosemia, sickle cell); pulse oximetry for critical congenital heart disease; hearing by otoacoustic emissions or ABR; red reflex |
| 9, 18, 30 months | Standardized developmental screening |
| 18 and 24 months | Autism-specific screening |
| About 12 months | Hemoglobin for iron-deficiency anemia |
| 12 and 24 months | Blood lead |
| By age 4 | Formal visual acuity (red reflex at every visit before that) |
| 9–11 and 17–21 years | Lipid screening, once in each window |
| 12 years onward | Annual depression screening |
Vision and hearing. Leukocoria (an absent or white red reflex) suggests retinoblastoma or cataract and needs urgent ophthalmology referral. The newborn hearing screen catches congenital sensorineural loss early, when amplification can still protect language development.
Anemia. Iron deficiency peaks in toddlers who drink large amounts of cow's milk, which is low in iron and can cause occult intestinal blood loss.
Lead. Screening at 12 and 24 months is risk-based, but universal for high-risk and Medicaid-enrolled children, because hand-to-mouth behavior peaks then. Lead from pre-1978 paint and dust causes microcytic anemia with basophilic stippling, abdominal pain, and neurocognitive deficits. An elevated capillary result is confirmed with a venous sample, and the first step is always removing the source.
- ≥3.5 μg/dL (CDC reference value)Find and remove the source; correct iron deficiency; recheck.
- ≥45 μg/dLOral chelation with succimer (DMSA).
- ≥70 μg/dL or encephalopathyHospitalize; dimercaprol (BAL) plus calcium EDTA.
Injury prevention and anticipatory guidance
Injuries are the leading cause of death in children over 1 year, so safety counseling belongs at every visit:
- Back to sleep on a firm surface with no soft bedding.
- Rear-facing car seat as long as the seat's height and weight limits allow.
- Water heater set below 120 °F to prevent scalds.
- Firearms stored locked and unloaded; medications and chemicals locked away.
- Helmets for anything with wheels; fencing and supervision around water.