Vaccination in Pediatric Autoimmune Neuromuscular Disorders: Current evidence-based recommendations

Abstract

Pediatric acquired inflammatory immune-mediated neuromuscular disorders include Guillain-Barre syndrome (GBS), Chronic Inflammatory Demyelinating Polyneuropathy (CIDP), Acute mononeuropathies (Bell’s palsy and Optic Neuritis), and Myasthenia Gravis (MG).  This narrative review collates relevant evidence up to November 2025 on vaccine safety and immunogenicity/efficacy profile in these disorders. Level and grade of evidence is documented, and current recommendations for immunization are summarised. Per current recommendations, despite the small attributable risk of GBS, Influenza vaccination is strongly advocated.  GBS is a precaution for subsequent vaccination, only if GBS had ensued within the 42-day period following Tetanus toxoid containing, Influenza, Adenoviral vector COVID-19 (Vaxzevria/Covishield^TM have a higher risk of GBS similar to natural infection) and two adult licensed Respiratory Syncytial Virus vaccines- Arexvy®(GSK) and Abrysvo®(Pfizer), but not mRESVIA^TM (Moderna).  In CIDP patients, while overall potential benefits of vaccination outweigh the risk of relapse, vaccines against influenza, tetanus, SARS-CoV-2 and pneumococci could be considered with caution.  There is no current evidence of causality or aggravation of acute mononeuropathies with administration of any vaccine.  For MG patients, live attenuated vaccines are best avoided within 4 weeks of immunosuppressive therapy commencement. Prednisolone (or equivalent) <2 mg/kg/day or <20 mg/day, azathioprine ≤3.0 mg/kg/day or 6-mercaptopurine ≤1.5 mg/kg/day are not significantly immunosuppressive doses, or contraindications to any vaccine. Vaccines, except Influenza vaccine, should be avoided within six months following Rituximab therapy.  In May 2025, FDA approved expanded use of Eculizumab (human terminal complement C5 inhibitor) for pediatric patients ≥6 years with anti-acetylcholine receptor antibody positive generalized MG. Meningococcal Conjugate (MenACWY and MenB) vaccine administration should be done at least 2 weeks prior to; and live vaccines, 4 weeks prior to, the first dose of Eculizumab.  Vaccination is recommended only 8 weeks after end of Eculizumab treatment.