Rabies in Children and Post-exposure Prophylaxis
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Direct answer
Rabies post-exposure prophylaxis is the urgent treatment of a person exposed to a possibly rabid animal, and it has three elements: wound washing, vaccination and, for severe wounds, rabies immunoglobulin. Clinical rabies is almost always fatal once symptoms begin, so prophylaxis must start promptly, before the virus reaches the nervous system.
What you must remember
- Wound washing: wash for 15 minutes with soap and running water, then apply an antiseptic such as povidone-iodine.
- Category I: touching or feeding animals, or licks on intact skin, which needs no prophylaxis.
- Category II: nibbling of uncovered skin or minor scratches without bleeding, which needs vaccine alone.
- Category III: single or multiple transdermal bites, licks on broken skin or saliva on mucous membranes, which needs vaccine and immunoglobulin.
- Immunoglobulin dose: 20 IU/kg of human rabies immunoglobulin, or 40 IU/kg of equine product.
- Zagreb regimen: two doses on day 0, then one each on days 7 and 21.
- Essen regimen: five intramuscular doses on days 0, 3, 7, 14 and 28.
- Negri bodies: eosinophilic intracytoplasmic inclusions in neurons, most characteristically in the hippocampus and cerebellar Purkinje cells.
A dog bite in a 7-year-old, step by step
A 7-year-old is bitten on the forearm by a street dog that is not known to be vaccinated. The team follows the same sequence used for any exposure, and wound care comes first.
- Wash the wound. Wash for 15 minutes with soap and running water, then apply an antiseptic. This is the most effective simple measure, and it is never skipped.
- Classify the wound. Assign category I, II or III from the type and depth of the exposure. The category decides whether any prophylaxis is needed.
- Give the vaccine. Start the schedule for the category as soon as possible, using the deltoid in older children and the anterolateral thigh in small infants.
- Add immunoglobulin for category III. Infiltrate 20 IU/kg into and around the wound as far as possible, and give any remainder intramuscularly at a site away from the vaccine.
- Review the animal. If the dog is available and remains healthy after a 10-day observation, national guidance may allow the course to stop. Books differ on the details, so the exam answer should name the principle.
Children receive the same vaccine dose as adults, because it is not weight-based, whereas immunoglobulin is calculated per kilogram, so weight must be recorded accurately. A missed or late dose should be given without restarting the whole course.
Where the exam tries to catch you
Rabies questions usually test wound categories, immunoglobulin use and the difference between pre- and post-exposure care.
- Trap: giving the vaccine alone for a category III bite Correct: immunoglobulin is added for category III, because the vaccine takes time to produce protective antibodies.
- Trap: giving immunoglobulin into the same site as the vaccine Correct: any remaining dose goes intramuscularly at a distant site, so the vaccine response is not blunted.
- Trap: starting prophylaxis for licks on intact skin Correct: licks on intact skin are category I and need only wound cleaning, with no prophylaxis.
Frequently asked questions
Which wound category needs both vaccine and immunoglobulin?
Category III wounds need both rabies vaccine and rabies immunoglobulin. They include single or multiple transdermal bites, scratches and licks on broken skin, as well as saliva on mucous membranes.
How much rabies immunoglobulin does a child receive?
A child receives 20 IU/kg of human rabies immunoglobulin, or 40 IU/kg of equine product when the human preparation is not available. The dose is infiltrated into the wound as far as possible, with any remainder given intramuscularly at a site away from the vaccine.
What is the difference between the Zagreb and Essen regimens?
The Zagreb regimen gives two doses on day 0, then one dose on day 7 and one on day 21. The Essen regimen gives five intramuscular doses on days 0, 3, 7, 14 and 28, and books differ on which is preferred, so national guidance should be checked.
Why must rabies prophylaxis start before symptoms appear?
Once clinical rabies develops, it is almost always fatal, so prophylaxis must start before symptoms begin. It works by stopping the virus before it reaches the nervous system.
What is the pathological hallmark of rabies?
Negri bodies are eosinophilic intracytoplasmic inclusions found in neurons, most characteristically in the hippocampus and cerebellar Purkinje cells. Their presence supports the diagnosis, although their absence does not exclude rabies.