Pediatric Immunization Practices in Nephrotic Syndrome: An Assessment of Provider and Parental Knowledge

The 2012 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline on glomerulonephritis (GN) is intended to assist the practitioner caring for patients with GN. Two chapters of this guideline focus specifically on nephrotic syndrome in children. Guideline development followed a thorough evidence review, and management recommendations and suggestions were based on the best available evidence. Critical appraisal of the quality of evidence and strength of recommendations followed the Grades of Recommendation Assessment, Development and Evaluation (GRADE) approach. Chapters 3 and 4 of the guideline focus on the management of nephrotic syndrome in children aged 1-18 years. Guideline recommendations for children who have steroid-sensitive nephrotic syndrome (SNSS), defined by their response to corticosteroid therapy with complete remission, are addressed here. Recommendations for those with steroid-resistant nephrotic syndrome (SRNS) (i.e., do not achieve complete remission) are discussed in the companion article. Limitations of the evidence, including the paucity of large-scale randomized controlled trials, are discussed. This article provides a short description of the KDIGO process, the guideline recommendations for treatment of SSNS in children and a brief review of relevant treatment trials related to each recommendation.

To assess immunologic factors in the pathogenesis of idiopathic minimal-change nephrotic syndrome (INS), serum immunoglobulin concentrations were measured in 37 children with this syndrome and compared with those found in 36 with nephrotic syndrome secondary to chronic glomerulonephritis (CGN). Serum IgG and IgA levels were significantly reduced in nephrotic patients with either INS or CGN, IgG averaging 18.5 and 25.9 per cent of normal (P less than 0.001) and IgA 59.8 and 44.1 per cent of normal (P less than 0.01) respectively. Values increased after treatment of INS with prednisone, but mean values remained low. Serum IgM concentrations in INS averaged more than twice normal before, during, and after successful treatment with steroids. Patients with CGN did not have equivalent elevations of serum IgM. Thus, the primary defect in INS may be immunologic and could consist of deficiency in the T-cell function that mediates conversion of IgM synthesis to IgG synthesis.

At its October 2019 meeting, the Advisory Committee on Immunization Practices (ACIP)* approved the 2020 Recommended Child and Adolescent Immunization Schedule for Ages 18 Years or Younger. The 2020 child and adolescent immunization schedule summarizes ACIP recommendations, including several changes from the 2019 immunization schedule † on the cover page, three tables, and notes found on the CDC immunization schedule website (https://www.cdc.gov/vaccines/schedules/index.html). Health care providers are advised to use the tables and the notes together. This immunization schedule is recommended by ACIP (https://www.cdc.gov/vaccines/acip/index.html) and approved by the CDC Director, the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and, for the first time, the American College of Nurse-Midwives. ACIP’s recommendations on use of each vaccine are developed after in-depth reviews of vaccine-related data, including the epidemiology and burden of the vaccine-preventable disease, vaccine efficacy and effectiveness, vaccine safety, quality of evidence, feasibility of program implementation, and economic analyses of immunization policy ( 1 ). The child and adolescent immunization schedule is published annually to consolidate and summarize updates to ACIP recommendations on vaccination of children and adolescents and to assist health care providers in implementing current ACIP recommendations. The use of vaccine trade names in this report and in the child and adolescent immunization schedule is for identification purposes only and does not imply endorsement by ACIP or CDC. For further guidance on the use of each vaccine, including contraindications and precautions, health care providers are referred to the respective ACIP vaccine recommendations at https://www.cdc.gov/vaccines/hcp/acip-recs/index.html. Providers should be aware that changes in recommendations for specific vaccines can occur between annual updates to the child and adolescent immunization schedule. If errors or omissions are discovered within the child and adolescent schedule, CDC posts revised versions on the CDC immunization schedule website. § Printable versions of the 2020 child and adolescent immunization schedule and ordering instructions are available on the immunization schedule website at https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html. Changes in the 2020 Child and Adolescent Immunization Schedule Changes in the 2020 child and adolescent immunization schedule for persons aged 18 years or younger include new or updated ACIP recommendations for hepatitis A vaccine (HepA) ( 2 ); influenza vaccine ( 3 ); meningococcal B vaccine (MenB) ( 2 ); and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) ( 4 ). Changes also include clarification of the recommendations for diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP), Haemophilus influenzae type b vaccine (Hib), hepatitis B vaccine (HepB), meningococcal ACWY vaccine (MenACWY), and poliovirus vaccine. Following are the changes to the cover page, Tables 1–3, and the Vaccine Notes. Cover page The American College of Nurse-Midwives has been added to the list of organizations that approve the child and adolescent immunization schedule. Trademark symbols (®) were added to all vaccine trade names. Table 1 HepA row: The bar for persons aged 2–18 years has been changed to solid green to denote the recommendation for routine catch-up immunization for all persons in this age group. HPV row: An asterisk has been added to the blue bar that appears for children aged 9–10 years to indicate that for this group, the HPV vaccine series can be started at the clinician’s discretion. The text that defines the blue box in the table’s legend has been edited and now reads “Recommended based on shared clinical decision-making or *can be used in this age group.” Legend: The text that defines the gray box has been edited and now reads “No recommendation/not applicable.” Table 2 Meningococcal rows: The letters “ACWY” were added to clarify that these catch-up intervals apply only to MenACWY and not to MenB. Table 3 Hep A row: All boxes now appear yellow to denote the recommendation for routine vaccination for all persons aged 18 years or younger, including those with the medical indications outlined in the table. MenACWY row: The pregnancy box is now yellow, because the meningococcal vaccine may be administered to pregnant women, if indicated. Legend: The text that defines the red box has been edited and now reads “Not recommended/contraindicated—vaccine should not be administered.” The text that defines the gray box has been edited and now reads “No recommendation/not applicable.” Vaccine Notes DTaP: To clarify the recommendations for catch-up vaccination, the note has been updated to indicate that dose 5 is not necessary if dose 4 was administered at age 4 years or older AND at least 6 months after dose 3. Hib: A bullet has been added to note that catch-up vaccination is not recommended for previously unvaccinated children aged 5 years (60 months) or older who are not at high risk. HepA: The note was revised to include the recommendation that all children and adolescents aged 2 through 18 years who have not previously received Hep A should receive catch-up vaccination and complete a 2-dose series. HepB: A “Special situations” section has been added which contains information regarding populations for whom revaccination might be recommended. The ACIP HepB recommendations are referenced for detailed revaccination recommendations. Influenza vaccine: The note has been updated to reflect the recommendations for the 2019–20 influenza season. The “Routine vaccination” section was reformatted to more clearly outline circumstances under which 1 or 2 doses of influenza vaccine are recommended. In addition, the bullet that outlines circumstances under which live attenuated influenza vaccine (LAIV) should not be used was reformatted into a bulleted list. MenACWY: Guidance regarding adolescent vaccination for children who received MenACWY before age 10 years has been added to the note. MenB: Booster doses are now recommended for persons aged ≥10 years with complement deficiency, those who use complement inhibitors, persons with asplenia, persons who are microbiologists, and persons determined by public health officials to be at increased risk during an outbreak. The MenB note has been updated to include a link to the detailed recommendations. Poliovirus vaccination: Detailed information has been added regarding which oral poliovirus vaccine (OPV) doses may be counted toward the U.S. vaccination requirements. Tdap: The note has been updated to allow either Td or Tdap, as an option for decennial tetanus booster doses and catch-up series doses in persons who have previously received Tdap. In addition, the note has been edited to reflect recent updates to the clinical guidance for children aged 7 through 18 years who received doses of Tdap or DTaP at age 7 through 10 years. A dose of Tdap or DTaP administered at age 10 years may now be counted as the adolescent Tdap booster. A dose of Tdap or DTaP administered at age 7 through 9 years should not be counted as the adolescent dose, and Tdap should be administered at age 11–12 years. Additional Information The Recommended Child and Adolescent Immunization Schedule, United States, 2020 is available at https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html. The full ACIP recommendations for each vaccine are also available at https://www.cdc.gov/vaccines/hcp/acip-recs/index.html. All vaccines identified in Tables 1, 2, and 3 (except DTaP, rotavirus, and poliovirus vaccines) also appear in the Recommended Adult Immunization Schedule for Ages 19 Years or Older, United States, 2020. ¶ The notes for vaccines that appear in both the adult immunization schedule and the child and adolescent immunization schedule have been harmonized to the greatest extent possible.