The following should be taken into consideration with regard to vaccinations for 0-18 yos with rheumatic or musculoskeletal disorders on immunosuppression (view list of medications).

Follow CDC pediatric vaccination schedule unless otherwise outlined below.


  • Primary PCV13/PCV20 series for all children <2 yo and PPSV23 vaccination to children ≥2 yo
Not recommended
  • Age ≥6 mo
  • If on methotrexate, recommend holding for 2 weeks after vaccination
  • Age ≥11 yo


  • Pfizer-BioNTech:
    • 6 mo-4 yo: 3 doses of vaccine including at least 1 updated COVID-19 dose
    • ≥5 yo: at least 1 updated dose
  • Moderna:
    • 6 mo-5 yo: 2 doses including at least 1 updated dose
Includes: Intranasal influenza, MMR, rotavirus, typhoid, varicella, yellow fever, zoster
  • HOLD immunosuppressive medication (view list of medications) prior to and after vaccination at discretion of a rheumatologist
    • Recommended if indicated based on patient age and/or history
  • Rotavirus:
    • GIVE within first 6 months of life if antenatal 2nd or 3rd trimester TNFi exposure
    • HOLD until >6 months of age if antenatal rituximab exposure

Special Considerations

  • Other than influenza vaccination, defer vaccinations until next rituximab dose due and delay rituximab dose for 2 weeks after vaccine administration, if disease activity allows
  • For patients taking the equivalent of prednisone ≥20 mg/d, defer vaccinations (except influenza) until tapered <20 mg/d
  • No contraindications to giving multiple vaccinations to patients on same day