My Advice on Immunizations

Here is the blog I've been dreading, avoiding, and wishing I didn't have to write. It SHOULD be an easy one for me because it is a topic I know well, discuss daily, and am quite clear on where I stand--which is YES, you should fully vaccinate your child, on time, using the schedule recommended by the ACIP (Advisory Committee on Immunization Practices), AAP (American Academy of Pediatrics), and CDC (Centers for Disease Control), and endorsed by me and my colleagues in my pediatric practice. In fact, I believe that immunizing children is one of the most important contributions I can make to maintaining, or even improving an individual child's health as well as a vital contribution to the health of my community.

To me, this is a "no doubt about it" kind of recommendation. It's not an easy subject to write about, however, because it has become controversial. I don't like to have conflicts with families in my practice, or even with parents trying to decide if they should choose me as their pediatrician. It's hard for me to have to disagree. I don't think I'm very good at presenting my opposing point of view in a tactful way. I don't want to offend anyone, or make them feel bad. Still, I am going to write this blog, and I am going to be very clear about my recommendations for vaccinating your child.

I am asked daily to comment on the following questions or statements:

To vaccinate, or not to vaccinate...? Which vaccines are "the most important?" Do vaccines cause autism? What about thimerosol? What about mercury? Tell me about aluminum in vaccines? We were told at our new baby class to ask prospective pediatricians about vaccinations... Don't babies get too many vaccines these days? I don't what to overwhelm their immune system... We aren't taking the baby to day care, so they won't get exposed to any of these diseases. Can you look at this "alternative" vaccine schedule and make recommendations? We are going to vaccinate, we just want to "delay" the vaccines. The diseases we vaccinate for are pretty rare, right? I don't want to do anything that might hurt my child.

These are only some of the questions that come up every day. And it's understandable. After all, you should be an informed health care consumer, right? You just want to do the right thing. And vaccines are a hot topic right now for new parents. Many parents would feel they are not doing their job if they don't ask about or question their pediatrician about vaccines. However, in having these discussions, and responding to all of these details, I think we can lose sight of our goal (which, in my opinion, is a healthy and safe child).

I often get the impression that parents believe I am blindly following vaccine schedule recommendations, just spouting the "party line." When this happens, I don't think I am being given enough credit for doing my job. It is my responsibility to know about each disease and each immunization given to prevent the disease. I take this responsibility seriously.

My colleagues and I have built a schedule of vaccines for our patients that will effectively immunize them at the time when they are at most risk for the diseases. We regularly review this schedule, the type of vaccines we provide, and the benefits versus risk of every vaccine. Our decisions are made based upon scientific evidence, meaning they are supported by deliberate testing and study of the effects of each vaccine. We then recommend a routine vaccination schedule that we have created or actively given our endorsement. This schedule takes into account which vaccines can be given at the same time (to ensure a good immune response while minimizing potential side effects), proper intervals between vaccines, appropriate ages to give vaccines, and the number of actual injections given each time a patient is vaccinated. It becomes a routine part of our well child visits. Having a routine schedule helps minimize the possibility of errors such as a vaccine given at the wrong interval, or age.

Benefit versus risk is an important concept to think about. There are very few things we do that are without risk. We get used to certain risks and simply live with them. Common activities that involve some degree of risk include transporting our child in a car (what if there were an accident?), living in our homes (potential exposure to lead, radon, or carbon monoxide, burns from the stove, hot coffee, or curling irons, cuts needing stitches from falls against coffee tables, falls down the stairs...), taking any kind of medication (acetaminophen carries the rare risk of liver damage, ibuprofen can cause anaphylaxis in those who are allergic, or rarely can damage the kidneys, amoxicillin or any other antibiotic can cause an allergic reaction in some people), and allowing our children to play outdoors or participate in sports (the monkey bars are one of the most common sources of fractures in children, trampolines can lead to neck and spine injuries as well as fractures in the legs, head injuries occur all the time in sports and from falls (especially when unhelmeted) off of bikes/skateboards/scooters). There must be some kind of benefit that outweighs the risks involved in these activities, or we wouldn't be able to allow our children to live a "normal" life!

In thinking about vaccines you should think about benefit versus risk. Like any medication there are some small risks, and for most vaccines these risks are fever and the possibility of an allergic reaction. However, the benefits of the vaccines far outweigh any risk they present to a child. In looking at risks and benefits I think it is important to look at scientific evidence, not anecdotal reports. Anecdotal reports are the reports of a few individuals who tell their own story, these people may or may not have any background qualifications to lend credibility to their claims. Scientific evidence, on the other hand, is the result of deliberate study of the effects of an intervention or treatment (such as a vaccine). Scientific evidence is subject to peer review (scientific experts evaluating the evidence and methods of study), and to statistical evaluation to determine if the results could just be due to chance.

I think your child deserves to be treated according to recommendations made using scientific evidence. As an experienced, board-certified, pediatrician it is my job to do the best I can to provide this kind of care. I also think that you should expect your pediatrician to provide, at a minimum, the same level and quality of care that she would want for her own children. And my children were fully vaccinated, on time, in accordance with our recommended schedule of vaccines.

In writing this blog I also have to say something about trust, and the doctor-patient relationship. Do you trust your pediatrician? Do you value her advice on growth, developmental milestones, sleep habits and position, feeding issues, how to start solid food, pacifiers, thumbsucking, stooling, urinating, behavioral concerns, potty training, car seat recommendations, among other issues often discussed at well exams? Do you call your pediatrician for advice on what to do when your child has a fever, is vomiting, or is otherwise ill? Do you take your ill child to be evaluated by your pediatrician, and place your trust in her to determine what is wrong and how best to treat it? Do you value all of your pediatrician's education, training, ongoing efforts to keep up with current science, and her expertise in helping you raise a healthy child? If you do, then why would you so easily dismiss your pediatrician's advice on immunizing your child? And if you don't trust your pediatrician, then why do you keep bringing your child to her office? Isn't preventing meningitis, polio, measles, and pertussis (among others!) more important that the correct order in which to introduce solid food?

If you are inundated with anti-vaccine messages, considering Dr. Sears' advice on delaying or altering the vaccine schedule, feeling overwhelmed and worried about vaccinating your child, and spending a lot of time researching the issue, then you should also look at the case FOR immunizations, and at sources that use scientific evidence to back up their claims. The following websites can be very helpful:

http://www.chop.edu/service/vaccine-education-center/home.html

http://www.cdc.gov/vaccines/

http://www.aap.org/immunization/


And, for an interesting article in the lay press (not a scientific journal):

http://www.wired.com/magazine/2009/10/ff_waronscience

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