A 2-month-old baby is healthy and growing well, but when you begin to discuss immunizations, the parents stop you and state that they've decided not to immunize the child. How should you respond?
A 2-month-old infant is seen for the first time for a routine well baby visit. The baby is healthy and growing well, but when you begin to discuss immunizations, the parents stop you and state that they’ve decided not to immunize the child.
How should you respond?
Fortunately, the vast majority of parents in the United States choose to vaccinate their children with the belief that immunizations protect against serious diseases. However, there’s a significant proportion of parents who are deciding not to immunize their children for a variety of reasons. Most commonly, parents are worried about the safety of vaccines and possible side effects.
When confronted with parents who have differing views on vaccines, it’s important to maintain an open, non-confrontational, and ongoing dialogue with them. Remember that research shows the primary care provider is still parents’ most trusted and important source of information for making vaccine-related decisions. Respectful listening is a top priority and you should ask the parents what their concerns are.
The parents say they are worried about the safety of the vaccines. They have read and heard from friends that immunizations could overload the immune system, possibly cause autism or other autoimmune diseases, and aren’t necessary now because children are no longer getting those diseases. In addition, they state that even if their baby gets some of those diseases, they aren’t that serious and children recover. How would you try to correct misinformation?
Establishing dialogue is more important than the outcome of any single visit. You may begin by stating that there’s a shared goal — such as the health and well-being of the baby — and that it’s often difficult for parents to sort through the large volume of complex and sometimes conflicting information regarding vaccine safety.
It’s often helpful to use a mix of science and personal experience as you discuss vaccines, because some parents will be resistant to too much science. Parents want to know that you’re concerned about their child and not just following the recommendations of a government agency.
The mother expresses particular concern regarding learning disabilities such as autism and the measles, mumps, and rubella (MMR) vaccine. How would you respond?
Concerns regarding a possible link between the MMR vaccine and autism can be traced to a 1998 study from the United Kingdom. The article was retracted in 2010 and declared fraudulent in 2011. Since that time, there have been several large studies demonstrating that the MMR vaccine doesn’t cause autism.
One Danish retrospective study in particular examined the incidence of autism in 537,303 children between 1991 and 1998.1 The study authors found no association between the MMR vaccine and autism, as well as no association between the age at the time of vaccination and autism. Additionally, a study conducted in Japan which looked at the incidence of autism in 31,426 children found that the rate of autism increased despite the decline in MMR vaccination rate in 1993.2
The father states that he has learned from the Internet that any benefit of vaccinations is outweighed by the risk of mercury exposure stemming from the preservative used in all vaccines. What would your response be?
Parents can be reassured of the safety of vaccines, since mercury has been removed from all vaccines with the exception of the multi-dose flu vaccine. Multiple large and well-designed studies have found insufficient evidence to establish any association between mercury in vaccines and autism. In 2002, the World Heath Organization (WHO) reported that it’s safe to use vaccines containing mercury. Despite the fact that mercury preservative has been removed from all vaccines that are given to infants, the rate of new autism cases hasn’t decreased in the US.
The mother relates that a cousin of hers actually had a seizure following a vaccination when he was infant, and she wouldn’t want to risk her baby developing epilepsy. How can she be reassured?
As you discuss immunizations, it’s important to discuss possible risks, as well as benefits. Although vaccines are considered to be very safe, they aren’t completely risk-free. Even so, seizures aren’t a common side effect of vaccinating an infant, and many post-vaccine seizures occur as a result of high fever, which are considered febrile seizures. Thus, vaccinated infants aren’t at a greater risk of developing epilepsy compared to the general public. Furthermore, the low incidence of vaccine-related seizures has continued to decline with the development of the acellular pertussis vaccine.
The father questions whether influenza vaccination is truly needed in children. He states that the flu is only dangerous in the elderly, and he’s heard that the vaccine can cause Guillain-Barré syndrome (GBS) or multiple sclerosis (MS). How would you respond to his concerns?
The flu vaccine is recommended for children ages 6 months and older, since children who are under 2 years old are at a greater risk for severe disease and complications. In fact, the hospitalization rates for those under 2 years of age are similar to the rates among patients who are 65 years and older. Similar to the elderly population, there are a number of flu-related deaths in children every year, which is one reason why the vaccine is reformulated each year to correlate with the strains of flu that are anticipated to cause the disease that year.
Although the flu vaccine was thought to be associated with some cases of GBS in 1976, the risk is considered to be very rare, if it’s real at all. Aside from that, there haven’t been any other occurrences of serious side effects. While the association of flu vaccine with MS has also been studied, there wasn’t an increase in the incidence of MS in those who received the vaccine when they were compared to those who weren’t vaccinated. Therefore, the flu vaccine is considered safe to administer.
The father says he has read that an infant’s immune system is inadequately developed to handle vaccines safely and that multiple vaccines may overwhelm the immune system. He also expresses concern regarding the pain of receiving multiple vaccines. He wonders if spreading the vaccines out would be an option. Would you be comfortable with that?
Deviations can be used when all other options fail, but it’s important for parents to understand that alternative schedules aren’t founded in science and often entail multiple office visits. I often discuss the benefits and risks of each vaccine separately with parents so that some compromise can be made and that the child can be fully immunized as quickly as possible.
A very popular alternative vaccine schedule has been proposed by Robert Sears, MD. He prioritizes vaccines based on his experiences and only administers 2 vaccines at a visit, in which case only one vaccine contains aluminum. However, the problems with that alternative approach have been detailed by Paul Offit, MD.3 In addition, studies have shown that infants’ immune systems can respond to multiple antigens — possibly in the thousands. In fact, there are far fewer antigens contained in the currently-recommended immunizations than in the 7 recommended vaccines that were administered in 1980.
What problems were cited by Dr. Offit?
With the proposed alternative schedules, Dr. Offit was concerned that children either wouldn’t receive certain vaccines or would receive them in a delayed fashion that increased the time of susceptibility to vaccine-preventable diseases. Avoiding combination vaccines results in an increased number of vaccines, which requires additional office visits.
As those factors may lead to decreased immunization rates, it’s helpful sometimes to talk to parents about the difference between a causality relationship where vaccines cause autism and an association where infants who receive vaccines develop autism. It’s also important for parents to understand the idea of relative risk, which entails the very small risk of a possible side effect and the much larger risk of contracting a disease.
The parents indicate that they don’t want their baby immunized today, but they’ll give it further thought. How would you document that in the medical record?
It’s important to document each discussion regarding the risk of not immunizing an infant and the benefits of immunizations. The American Academy of Pediatrics (AAP) has developed a Refusal to Vaccinate form which you may ask the parents to sign. Vaccine information sheets produced by the Centers for Disease Control and Prevention (CDC) should also be provided to parents as they consider vaccinating their child.
The discussion with the family has been both time consuming and emotionally draining. Should you suggest that they seek care elsewhere?
Physicians often struggle with referring parents who won’t immunize their children to another doctor. Cited reasons include a lack of shared goals, an absence of trust in the physician-family relationship, and the fear of litigation if a disease gets contracted or transmitted. The AAP suggests that pediatricians shouldn’t discharge patients solely because their parents refuse immunizations. Instead, providers are encouraged to maintain relationships with those families in an attempt to educate them on immunizations and make vaccination a possibility in the future.
1. Madsen KM, et al. A population-based study of measles, mumps, and rubella vaccination and autism. NEJM. 2002 Nov. 7;347(19):1477-82. http://www.nejm.org/doi/full/10.1056/NEJMoa021134.
2. Honda H, Shimizu Y, Rutter M. No effect of MMR withdrawal on the incidence of autism: A total population study. J Child Psychol Psychiatry. 2005 June;46(6):572-9. http://onlinelibrary.wiley.com/doi/10.1111/j.1469-7610.2005.01425.x/full.
3. Offit PA, Moser CA. The problem with Dr. Bob’s alternative vaccine schedule. Pediatrics. 2009 Jan. 1;123(1):e164-9. http://pediatrics.aappublications.org/content/123/1/e164.full.
About the Author
Dennis Woo, MD, is Associate Clinical Professor of Pediatrics at the David Geffen School of Medicine at UCLA. All questions were posed by Family Practice Recertification Editor-in-Chief Martin Quan, MD.