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Pre-school vaccinations: guide to vaccinations from 2 to 5 years

Updated 6 April 2023

Introduction

This guide provides information on the routine immunisations that are given to children before they start school to help protect them from serious childhood diseases. It describes these diseases and explains why young children need protection against them. It also answers some of the most common questions about pre-school immunisation. If you have more questions or you want more information, talk to your doctor, practice nurse or health visitor.

You can also visit NHS.UK or call the free NHS helpline 111.

Timetable of pre-school immunisations

The first winter after your child turns 2 years of age he or she becomes eligible for the nasal flu vaccine, this will be due every winter including once your child starts school. Three immunisations are due at about 3 years and 4 months of age. These vaccines update the protection your child should have completed as a baby or at 12 months of age. You will receive an appointment for you to bring your child for their pre-school immunisations.

The table below shows the pre-school immunisations your child will be offered. These immunisations will make sure that your child has the best protection against serious childhood diseases as they grow up.

Vaccine	How and when it is given	Comments
Influenza or flu	nasal spray Each year from September	This vaccine is given at 2 and 3 years of age. Children who are in risk groups and cannot have the nasal spray will be offered a vaccination by injection
Diphtheria, tetanus, pertussis (whooping cough) and polio (dTaP/IPV/ or DTaP/IPV)	One injection at 3 years and 4 months of age	This is a booster dose of these vaccines
Measles, mumps and rubella (MMR)	One injection at 3 years and 4 months of age	This is a second dose of the MMR vaccine (if your child has not has their first dose yet, it should be given now and the second dose given one month later)

The complete immunisation schedule from February 2022 is available to view or download and includes:

• routine immunisation schedule

• selective immunisation programmes

• additional vaccines for individuals with underlying medical conditions

Common answers about pre-school immunisations

How vaccines work

Vaccines contain a small part of the bacterium or virus that causes a disease, or tiny amounts of the chemicals the bacterium produces. Vaccines work by causing the body’s immune system to make antibodies. If your child comes into contact with the infection, the antibodies will recognise it and be ready to protect them. Because vaccines have been used so successfully in the UK, diseases such as polio have all but disappeared from this country.

Immunisation at pre-school age

The pre-school immunisations, also called pre-school boosters, will update or top up your child’s level of antibodies (which their bodies produce to fight off disease and infection) and help to keep them protected. Protection (immunity) against diphtheria, tetanus, whooping cough and polio from the immunisations given to babies can fade over time. Sometimes, complete immunity to measles, mumps or rubella does not develop after a single dose of the MMR vaccine so the booster gives them a second chance to build immunity.

When you take your child for their pre-school immunisations, it is important to make sure all their other immunisations are up to date.

The flu vaccine will help protect your child against flu during the winter but will need to be given every year because the viruses that cause flu change very frequently.

If your child missed any of their immunisations as a baby or toddler, this is a good time to ask the surgery or clinic about catch-up doses. You don’t have to start the course of immunisations from the beginning again but you can catch up to make sure your child is fully protected. It is never too late to have your child immunised.

Vaccine safety

Before a vaccine is allowed to be used, its safety and effectiveness have to be thoroughly tested. After they have been licensed, the safety of vaccines continues to be monitored. Any rare side effects that are discovered can then be assessed further. All medicines can cause side effects, but vaccines are among the very safest.

Research from around the world shows that immunisation is the safest way to protect your child’s health.

Immunisation against diseases that are now uncommon in the UK

Because of the effective immunisation programmes in the UK, the number of children catching these diseases such as polio and diphtheria is now very low. But if children do not continue to be immunised, the diseases will come back, as seen recently in some parts of Europe. Many of these diseases are still around in other parts of the world and your child may be at risk if you travel with your family. With more people coming to visit this country, there is always a risk that your child could come into contact the infections.

Vaccine side effects

Any side effects that occur are usually mild. Your child may get a little redness, swelling or tenderness where the injection was given that will disappear on its own. Some children may get a fever that can be treated with paracetamol liquid. Read the instructions on the bottle carefully and give your child the correct dose for their age. If necessary, give them a second dose 4 to 6 hours later. If your child’s temperature is still high after they have had a second dose of paracetamol liquid, speak to your doctor or call the free NHS helpline 111.

Remember never give medicines that contain aspirin to children under 16.

Vaccinating children who have allergies

Asthma, eczema, hay fever, food intolerances and allergies should not prevent your child having the vaccines in the routine childhood immunisation programme. If your child has needed intensive care due to asthma or egg allergic anaphylaxis then further advice should be sought. If you have any questions, speak to your doctor, practice nurse or health visitor.

Remember an anaphylactic reaction is a severe and immediate allergic reaction that needs urgent medical attention.

Allergies to vaccine ingredients

Very rarely, children can have an allergic reaction soon after immunisation. This may be a rash or itching affecting part or all of the body. The doctor or nurse giving the vaccine will know how to treat this. It is not a reason to withhold further immunisations.

Even more rarely, children can have a severe reaction, within a few minutes of the immunisation, which causes breathing difficulties and can cause the child to collapse. This is called an anaphylactic reaction and occurs in only about one in a million immunisations. The people who give immunisations are trained to deal with anaphylactic reactions and children recover completely with prompt treatment.

Children who cannot be immunised

There are very few children who cannot be immunised. In general, a vaccine should not be given to children who have had a confirmed anaphylactic reaction to a previous dose of the same vaccine.

There are a very small number of children who may not be able to have one or more of the routine vaccines for health reasons. Your health visitor, practice nurse or doctor will ask you about the relevant conditions. You can also discuss with them if you are worried about a specific vaccine.

Children who cannot receive live attenuated vaccines

The MMR and nasal flu vaccines are live attenuated vaccines (they contain small amounts of viruses that have been weakened). Children who are ‘immunosuppressed’ may not be able to receive live vaccines.

Children who are immunosuppressed include those:

• whose immune system is suppressed because they are undergoing treatment for a serious condition such as a transplant or cancer

• who have any condition which affects the immune system, such as severe primary immunodeficiency

If this applies to your child, you must tell your doctor, practice nurse or health visitor before the immunisation. They will get specialist advice.

Vaccination during illness

If your child has a minor illness without a fever, such as a cold, they should have their immunisations as normal.

If your child is ill with a fever, put off the immunisation until the child has recovered. This is to avoid the fever being associated with the vaccine, or the vaccine increasing the fever your child already has.

If your child:

• has a bleeding disorder

• has had a fit not associated with fever

Speak to your doctor, practice nurse or health visitor before your child has any immunisation.

Fits and seizures following vaccination

Fits are also called seizures or convulsions. Some are associated with fever and some are not.

In the first 5 years of a child’s life, the commonest type of fit is caused by fever (this may be called a febrile seizure or febrile convulsion). Sometimes immunisation is followed by a fever that may cause a febrile seizure. Most children who have febrile seizures recover fully.

When a seizure occurs within a short time after immunisation, it might not have been caused by the vaccine or the fever. It could be due to an underlying medical condition.

If the surgery is closed or if you can’t contact your doctor, go straight to the nearest hospital emergency department

Routine immunisations for pre-school children

Flu vaccine

Influenza (flu) and its causes

Flu is an infectious disease with symptoms that come on very quickly. A bad bout of flu can be much worse than a heavy cold. In children, it causes fever, stuffy nose, dry cough, sore throat, aching muscles and joints, and extreme tiredness that can last several days. Flu can lead to painful ear infection, bronchitis and pneumonia which can be severe.

Flu is caused by influenza viruses that infect the windpipe and lungs. When an infected person coughs or sneezes, they spread the flu virus in tiny drops of saliva over a wide area. These droplets can then be breathed in by other people or they can be picked up by touching surfaces where the droplets have landed.

Nasal spray vaccination against flu

The vaccine is given as a nasal spray up each nostril. It is quick and painless. The vaccine contains viruses that have been weakened to prevent them from causing flu but will help your child to build up immunity, so that when he or she comes into contact with the flu virus they are unlikely to get ill.

Reasoning for annual flu vaccination

The viruses that cause flu change very frequently, so the vaccine has to be changed to match the viruses and may differ from year to year. The vaccine your child gets this year may well be different from the one they had last year, and next year’s may be different again.

Children’s eligibility for the flu vaccine

Children who are 2 and 3 years old are offered flu vaccination at their GP practice (provided they are aged 2 or 3 on the 31 August of the current flu season). Primary school-aged children are also offered flu vaccination at school. The programme immunises children against flu because, by doing this, we may be able to stop them passing flu to their parents, grandparents and other family members.

In addition, children with certain medical conditions who are aged 2 to 18 years are offered flu vaccine.

Flu vaccination side effects

Serious side effects are uncommon but many children can develop a runny or blocked nose, headache, some tiredness or loss of appetite that last for a short period. The vaccine is absorbed quickly in the nose so, even if your child sneezes immediately after having had the spray, there’s no need to worry that it hasn’t worked.

The nasal flu vaccine is called Fluenz tetra, you can view the Patient Information Leaflet (PIL)

Children who cannot receive the nasal flu vaccine

Children may not be able to have the nasal vaccine if they:

• are currently wheezy or have been wheezy in the past 72 hours, they should be offered a suitable inactivated influenza vaccine to avoid a delay in protection or

• have needed intensive care due to:

  • asthma
  • egg allergic anaphylaxis
  • have a condition that severely weakens their immune system

Children who are at high risk from flu due to some medical conditions or treatments and cannot have the nasal vaccine, will be offered a flu jab instead.

In these circumstances the advice of a specialist should be sought.

The nasal flu vaccine and porcine gelatine

The nasal vaccine contains a highly processed form of gelatine (derived from pigs), which is used in a range of many essential medicines. The nasal vaccine provides good protection against flu, particularly in young children.

This nasal vaccine not only protects your child against disease but, if enough children are vaccinated, the disease won’t spread from one person to another, and so their friends and family are also protected.

Some faith groups accept the use of porcine gelatine in medical products, others don’t. The decision is, up to you. Further information about porcine gelatine and the nasal flu vaccine is available.

There are also translated versions in Arabic, Bengali, Gujarati, Panjabi, and Urdu available.

dTaP/IPV or DTaP/IPV vaccine

Booster given at 3 years 4 months. This vaccine boosts the immunisations that were given to your child at 2, 3 and 4 months of age. It protects against diphtheria, tetanus, pertussis (whooping cough) and polio.

Diphtheria

Diphtheria is a serious disease that usually begins with a sore throat and can quickly develop to cause breathing problems. It can damage the heart and nervous system and, in severe cases, it can kill.

Tetanus

Tetanus is a disease affecting the nervous system which can lead to muscle spasms, cause breathing problems and can kill. It is caused when germs that are found in soil and manure get into the body through open cuts or burns. Tetanus cannot be passed from person to person.

Pertussis (whooping cough)

Whooping cough is a disease that can cause long bouts of coughing and choking, making it hard to breathe. Whooping cough can last for up to 10 weeks. It is not usually so serious in older children, but in babies it is very serious and can kill.

Polio

Polio is a virus that attacks the nervous system which can cause permanent paralysis of the muscles. If it affects the chest muscles or the brain, polio can kill.

dTaP/IPV or DTaP/IPV vaccination side effects

Your child may have some redness, swelling or tenderness where they had the injection, but this will usually disappear in a few days. A hard lump may appear in the same place but this will also go, usually over a few weeks. Occasionally, children may be unwell and irritable and develop a temperature, headache, sickness and swollen glands.

Differences between dTaP/IPV and DTaP/IPV vaccines

There are 2 different vaccines used at this age which contain slightly different strengths of some of the ingredients. Both vaccines have been shown to provide good responses, so it doesn’t matter which one your child has for their pre-school booster.

The booster offered at this age is Boostrix-IPV, for more information on this vaccine see the Patient Information Leaflet.

MMR vaccine

Booster given at 3 years 4 months

The MMR vaccine protects against measles, mumps and rubella. Since 1988, when the MMR vaccine was introduced in the UK, the numbers of cases of measles, mumps and rubella have dramatically reduced.

Measles and how it is spread

Measles is caused by a very infectious virus. Nearly everyone who catches it will have a high fever, a rash and generally be unwell. Children often have to spend about 5 days in bed and could be off school for 10 days. Adults are likely to be ill for longer. The complications of measles affect one in every 15 children. The complications include chest infections, fits, encephalitis (infection of the brain), and brain damage. Measles can kill.

Measles is one of the most infectious diseases known. A cough or a sneeze can spread the measles virus over a wide area. Because it’s so infectious, the chances are your child will get measles if he or she is not protected and comes near to someone who has measles. Over 95% of children need to be immunised to prevent measles from circulating and causing outbreaks.

Mumps and how it is spread

Mumps is caused by a virus which can lead to fever, headache, and painful, swollen glands in the face, neck and jaw. It can result in permanent deafness, viral meningitis (infection of the lining of the brain) and encephalitis. Rarely, it causes painful swelling of the testicles in males and the ovaries in females. Mumps lasts about 7 to 10 days. Before the MMR vaccine was introduced, mumps was the most common cause of viral meningitis in children under 15 years of age.

Mumps is spread in the same way as measles. It is about as infectious as flu.

Rubella and how it is spread

Rubella (German measles) is a disease caused by a virus. In children it is usually mild and can go unnoticed. It causes a short-lived rash, swollen glands and a sore throat. Rubella is very serious for unborn babies. It can seriously damage their sight, hearing, heart and brain. This condition is called congenital rubella syndrome (CRS). Rubella infection in the first 3 months of pregnancy causes damage to the unborn baby in up to 9 out of 10 cases. In many of the cases, pregnant women caught rubella from their own, or their friends’, children.

Rubella is spread in the same way as measles and mumps. It is about as infectious as flu.

Reasoning for second MMR dose

Even though measles and mumps are uncommon in the UK, children who are not protected are still at risk of catching the infections. Your child needs a second dose of MMR because the vaccine doesn’t always work fully the first time. Some children who have only one dose of the vaccine might not be protected against one or more of the diseases.

Thanks to immunisation, the number of cases of measles, mumps and rubella have been reduced. However these diseases have not gone away and there have been outbreaks of measles in recent years. Two doses of the MMR vaccine are routinely given across Europe as well as in the US, Canada, Australia and New Zealand. Immunising your child with 2 doses of the MMR vaccine will give them the best protection.

Side effects from the second (pre-school) dose of the MMR vaccine

It is much less common to have side effects after the second dose than after the first dose. When side effects do happen, they are usually very mild:

• the 3 different viruses in the vaccine act at different times and produce the following side effects after the first dose of vaccine

• 6 to 10 days after the immunisation, about 1 in 10 children may develop a mild fever and some develop a measles-like rash and go off their food. This can happen when the measles part of the vaccine starts to work, and is normal

• about 1 in every 1,000 immunised children may have a fit caused by a fever. This is called a ‘febrile convulsion’, and can be caused by any fever. However, if a child who has not been immunised gets measles, they are 5 times more likely to have a fit

• rarely, children may get mumps-like symptoms (fever and swollen glands) about 3 weeks after their immunisation as the mumps part of the vaccine starts to work

• very rarely, children may get a rash of small bruise-like spots in the 6 weeks after the vaccination. This is usually caused by the measles or rubella parts of the vaccine. If you see spots like these, take your child to the doctor to be checked. He or she will tell you how to deal with the rash. As this rash could be confused with the rash caused by septicaemia you should contact your doctor urgently if your child is also unwell

• fewer than 1 child in a million develops encephalitis (inflammation of the brain) after MMR vaccine. However, if a child catches measles, the chance of developing encephalitis is about 1 in 1,000

• some years ago, there were stories suggesting a link between the MMR vaccine and autism, research since then has proved that no such link exists

Live attenuated vaccination cannot spread disease

MMR contains weakened versions of live measles, mumps and rubella viruses. Because the viruses are weakened, people who have had the vaccine cannot infect other people.

MMR and porcine gelatine

In the UK we have 2 MMR vaccines. Both work very well, one contains porcine gelatine and the other doesn’t. If you want your child to have the porcine gelatine free vaccine discuss it with your practice nurse or GP.

You can view the MMR vaccine patient information leaflets at:

• Priorix

• MMRVaxpro

Egg allergies

The MMR vaccine can safely be given to children who have had a severe allergy (anaphylactic reaction) to egg. If you have any concerns, talk to your practice nurse, health visitor or doctor.

If your child has not had an MMR vaccination before, they should have the first dose now and the second dose after one month.

Watch out for meningitis and septicaemia

Meningitis and septicaemia

Meningitis is infection of the lining of the brain. The same germs that cause meningitis may cause septicaemia (blood poisoning). Both meningitis and septicaemia are very serious in young children and the signs can come on quickly.

If you suspect meningitis or septicaemia get help urgently.

Although your child was immunised as an infant against Hib, MenB, MenC and some forms of pneumococcal bacteria, all of which cause meningitis and septicaemia, these vaccines will not protect them against other types of meningitis and septicaemia. So it’s important to know the signs and symptoms.

Meningitis and septicaemia signs and symptoms

Early symptoms of meningitis and septicaemia are mild and are similar to the symptoms of flu (for example, fever, vomiting, being irritable and pain in the back or joints).

The most important signs of meningitis to look out for in children are:

• a stiff neck (check that your child can kiss their knee, or touch their forehead with their knees)

• a bad headache (this alone is not a reason to get medical help)

• a dislike of bright lights

• vomiting

• fever

• drowsy, less responsive and confused

• stiff with jerky movements (convulsions/fits)

• a rash

The main signs of septicaemia are:

• sleepiness, less responsive, vacant or confused (a late sign)

• severe pains and aches in the arms, legs and joints

• very cold hands and feet

• shivering

• rapid breathing

• red or purple spots that don’t fade when you press them (information on the glass test below)

• vomiting

• a fever

• diarrhoea and stomach cramps

What to do with suspected meningitis and septicaemia

If your child develops one or more of the symptoms described above, get medical help urgently. If you can’t get in touch with your doctor, or are still worried after getting advice, trust your instincts and take your child to the nearest hospital with an emergency department.

What you should do

Not all of these symptoms will develop and they can appear in any order and be mixed between the 2 illnesses. Meningococcal disease can be hard to identify at first because it can be like a bad case of flu.

However, anyone affected with meningococcal disease will usually become seriously ill within a few hours. You should contact your GP (family doctor) or NHS 111 for advice if you have any concerns about your own or a friend’s health.

If you become worried about yourself or a friend, particularly if symptoms are getting worse, seek medical help urgently at the closest Accident and Emergency (A&E) Department or by dialling 999. Early treatment can be life-saving.

The ‘glass test’

Press the side of a clear drinking glass firmly against the rash so you can see if the rash fades and loses colour under pressure. If it doesn’t change colour, contact your doctor immediately.

On dark skin, check inside the eyelids or roof of the mouth where the spots maybe more visible.

Travel advice for children

If your child is going abroad, make sure their routine immunisations are up to date. Your child may also need extra immunisations and you may also need to take other precautions.

Contact your doctor’s surgery or a travel clinic well in advance for up-to-date information on the immunisations your child may need.

You can get more information from NHS.UK and Travel Health Pro.

Vaccine Damage Payment Scheme

Current immunisations are extremely safe but, very rarely, an individual may suffer from a problem after vaccination.

The Vaccine Damage Payment Scheme is designed to ease the present and future burdens of the person who, on that very rare occasion, may be affected by the vaccination.

There are several conditions that need to be met before a payment can be made. More information on Vaccine Damage Payment is available.

Vaccine Damage Payments Unit
Department for Work and Pensions
Palatine House, Lancaster Road
Preston
PR1 1HB

You can contact them by phone on 01772 899944 or by email at
cau-vdpu@dwp.gsi.gov.uk.

If you want advice on immunisation, speak to your doctor, practice nurse, health visitor or pharmacist, or call the NHS helpline 111.

Find more information on vaccinations on NHS.UK.

Further information

For non-urgent advice, call the free NHS helpline 111.

From NHS.UK, you will find information on:

• measles, mumps and rubella and the MMR vaccine

• the 4 in 1 preschool booster

For meningitis, the following charities provide information, advice and support:

• Meningitis Research Foundation, free helpline 0808 8003 344 - Monday to Friday, 9am to 5pm

• Meningitis Now, free helpline 0808 8010 388 Monday to Thursday 9am to 4pm and Fridays 9am to 1pm

If you have any questions or want more information, talk to your doctor, school nurse or the practice nurse at your doctor’s surgery.

Order or download print copies

Paper copies of this leaflet are available free to order or download.