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Immunization

By any standard, immunizations are a blessing. A generation ago, childhood diseases such as whooping cough caused serious respiratory illnesses in babies and even death. Today, many such killers are history.

But vaccines are a victim of their own success. They work so well that they have virtually obliterated the dangerous diseases they thwart. As a result, the focus has shifted from their benefits to their side effects, which range from mild to serious. This has led some people to question the wisdom of vaccines in general. For starters, let me assure you that vaccines are safe. To be approved, they have to meet strict FDA criteria for safety and efficacy. This process requires years and years of research and trials before release, and even after a vaccine’s release, safety and efficacy are constantly monitored in the several million kids that are vaccinated yearly. We doctors are required by law to report any unusual side effects. In short, the process for testing and monitoring the safety of vaccines is quite comprehensive.

Mild Side Effects
By far the most common side effect of vaccinations is the few seconds of crying after an injection. But there are others.


Pain

Injections hurt. Any doctor or nurse who tells Lucy that it feels like a little pinch is lying. These shots sting, not so much from the needle piercing the skin as from the fluid entering the muscle. Some fluids hurt more than others: The DPT vaccine, for example, hurts much more than the polio vaccine, even after the initial needle prick. The little pinch doesn’t last long, though. After a few seconds, Lucy forgets why she was crying, especially if she is distracted or fed. Before the shot, oral pain medication is largely ineffective (though it may be helpful after), and local anesthetic creams are pointless, as they numb the skin but not the muscle, which is where the fluid hurts the most.
For younger kids, breast feeding during vaccination won’t decrease the pain, and it may even increase yours if Lucy bites your nipple. For older children, the anticipation is worse than the pain itself. Don’t spend a week preparing Jimmy for the shot. During the injection, hold him gently against you instead of pinning him down. A pleasant sensation can offset painful ones, so you may want to give Jimmy his lollipop ahead of time. Seeing you in a calm, quiet mood will also help him.

Inflammation
In the hours and days following the injection, Lucy’s arm may be sore and red, especially after certain vaccines. Here, pain medication works wonderfully; repeat as often as necessary. This irritation should resolve within a few days, but it could turn into a painless hard ball the size of a nut that remains under the skin for a couple of months. In rare cases, the redness may persist or worsen, which could indicate infection and require medical attention.

Fever
Fever, despite what you may have heard, is a rare side effect of vaccinations. If it’s going to occur, it usually starts the night after the shot or the next day and is evidence of the immune reaction the vaccine has caused. With live attenuated vaccines like the MMR (measles, mumps, and rubella), the fever appears ten days after the shot, along with a mild rash on the torso. Fever from vaccines lasts twenty-four hours or less. Acetaminophen and ibuprofen should be used more for the discomfort than for the fever itself.

Serious Side Effects
As far as serious side effects go, if you were to read the full warning label on a Tylenol bottle, you’d never take one again. The same is true with vaccines. Full disclosure of all possible outcomes includes many horrible scenarios—among them severe allergic reactions and death—but these are tremendously unlikely.

Real questions from real parents
Is it safe to pump all these drugs into such a small baby at one time?
This is an understandable emotional concern but not a valid scientific one. These vaccines have been thoroughly studied and designed to be safe for very young children.
The physical size of your baby is not an issue.

Isn’t four shots too many?
Of great parental concern, administering this large a number of shots has been studied extensively and judged to be perfectly fine. Still, in my office, I try to limit it to two shots per session to reduce the cumulative side effects and decrease the emotional strain on the parents.

What about the combination of vaccines?
Vaccine combinations have proved to be safe and efficient. As a matter of fact, research is now focusing on ways to further combine vaccines, thereby decreasing the number of injections.

What about thimerosal?
Thimerosal, a mercury derivative, is no longer used in children’s vaccines. A few years ago, infinitesimal amounts of it were used in vaccines to prevent contamination in multiple-dose vials. For a while, and in spite of all tangible evidence, some people feared that even these small amounts might contribute to mental illnesses like autism. Since then, thimerosal’s use in vaccines has been discontinued, not because of any findings of toxicity but because vaccines are now stored in individual doses, and contamination is no longer an issue.


My child has a bad cold. Can he still get his vaccines while he has it?

Colds do not interfere with the effectiveness of vaccines, and vaccines do not make colds worse. If the cold is producing discomfort, a shot may make it a little worse, but pain medication will take care of it.


Are there other types of more natural immunizations?

“Natural” immunizations simply don’t exist.

I breast-feed my baby and she hasn’t had much contact with the outside world. Why does she need these immunizations?
Breast feeding is a good way to build up some immunities, but it is in no way an effective alternative to immunization. Unless you keep Lucy in a glass bubble, you can’t avoid contact with the outside world.


The Controversy over Vaccines

In the media and on the Internet you’ll find hundreds of experts that exaggerate or invent side effects, arguing that immunization is part of a worldwide pharmaceutical conspiracy. Very few of these claims have a scientific foundation, but the literature has certainly made people wary of injecting anything they don’t fully trust into their new baby. My simplistic theory is that any anti-vaccination theory, no matter how irrational, appeals to the vaccine-hating child in all of us, because as kids we all tried to hide under the table, but we ended up getting our shots anyway.

Having said that, if you choose to delay immunization or skip vaccines altogether, you aren’t putting your baby at a huge risk, simply because most of these diseases have been more or less eradicated, and most other people do vaccinate their children. But more or less eradicated doesn’t mean entirely eradicated.

There are still slight medical dangers. In addition, there are social and community
pressures, since most schools require immunization. And the idea of delay ing the vaccinations until the child is older and thus more docile is a flawed idea; giving shots to older children is, if anything, more difficult.

In the end, collective immunization is the only way to defeat a disease, and I recommend the full battery of standard vaccines. However, I find that many parents, despite all my explanations, are still apprehensive about immunizations and want to delay or avoid them. My approach is to discuss the issue and to respect their decision even if I don’t share their point of view. I also attempt to give them a realistic idea of the risks involved in delaying vaccinations. You will find this below, with a brief discussion of each specific vaccine as well as how necessary they are for school entrance requirements.

Immunizations (Disease by Disease):
As noted, most states require many vaccinations for school admission, and many more vaccinations are recommended. At present, four are required in all fifty states: the DTP (diphtheria-tetanus-pertussis) vaccine, the MMR (measles-mumps-rubella) vaccine, the polio vaccine, and the Hib (Haemophilus influenza b) vaccine. Here’s an overview of these and others.

Mandatory
Diphtheria-Tetanus-Pertussis
The DTP vaccine is a cocktail that handles three different diseases. The diphtheria virus, whose symptoms include a bad sore throat and heart problems, has almost disappeared. Tetanus is better known as lockjaw; unlike most other diseases, it’s not communicated by one person to another but lies dormant in the soil or on rusty nails. Pertussis, or whooping cough, causes a terrible cough and sometimes a pneumonia that is dangerous for babies and young children. It has almost disappeared, but we still see a few outbreaks in small pockets of the United States.

Years ago, this combination vaccine was less efficient and had significant side effects. These days it’s much improved and better tolerated. In fact, in the future, even more diseases will be folded into this vaccine, such as the polio and hepatitis B vaccines (this is already done in Europe).

If you do: The DTP vaccine requires five doses, starting in infants and continuing in toddlers, followed by boosters throughout life every ten years. It is mandatory for school admission. Side effects vary with age. Infants may experience a little discomfort and possibly even fever for the first twenty-four hours. In toddlers, it can produce a local reaction, with arm swelling and redness that can be impressive but that decreases in a few days. In older children it makes the shoulder and arm hurt temporarily and sometimes causes swelling.

If you don’t: Diphtheria has been almost completely eradicated. Tetanus is always a risk with a deep soiled cut, but since babies and young infants rarely incur such wounds, the risk is small (and even with a cut, tetanus can be treated by the injection of tetanus immune particles that will limit the development of the
illness). Pertussis still carries a significant risk because it flares up in outbreaks around the country every once in a while.

Measles-Mumps-Rubella
This is another combination vaccine that handles three diseases. Measles, a very unpleasant flu-like illness with a rash and rare serious complications, has been eradicated almost entirely, thanks to immunization. Mumps and rubella are mild diseases with potentially serious complications: Mumps can cause sterility in boys, and rubella can cause birth defects in the fetuses of infected mothers. These latter consequences constitute the primary reasons to immunize. At this point, the three diseases are almost nonexistent in the United States. The MMR vaccine is very safe, but of all the immunizations, it gets the worst press. Unlike most of the other vaccines, it is a live attenuated vaccine, which means that the viral component has been modified so that it’s nonvirulent. Still, the notion of a live virus makes many people uncomfortable. In addition, a deeply flawed but well-publicized study some years ago proposed a controversial association between the MMR virus and autism. In all likelihood, this is simple coincidence: If a child is autistic, the condition usually becomes evident in the second year, which is also the time when MMR is administered. The media were eager to report this flawed study but not as good about publicizing the numerous serious studies that invalidate the linkage. Finally, the combination of the three vaccines is erroneously perceived as toxic by parents who worry about loading up their kids with drugs and biological agents. Regrettably, people have been turning away from MMR in fear, thus giving these diseases a chance to return.

If you do: MMR has two doses, one at the toddler stage and one before kindergarten. You probably won’t see any side effects. If you do, they may consist of a rash on the body and a moderate fever that, unlike the side effects of other vaccines, occurs about ten days after the administration and lasts for one or two days. These are due to a miniature case of measles induced by the attenuated virus.

If you don’t: Measles, mumps, and rubella are currently only a remote possibility, though that may well change if the current trend against the MMR immunization persists. Giving the vaccines separately is no longer an option in the United States, as the manufacturer has discontinued all single-entity vaccines, owing to decreased demand.

Polio
Polio represents one of immunization’s most impressive successes. Once a fairly common disease that terrified generations of parents, it has almost been eradicated worldwide. When the polio vaccine was introduced by Jonas Salk a half-century ago, it was an attenuated form of the polio virus given orally on a piece of sugar. The attenuated virus could vaccinate the entire family; those who came into contact with the immunized child were, in effect, catching the vaccine rather than the virus. But a decade or so ago, doctors became worried about the extremely rare risk that people might contract the disease from the attenuated virus. By the end of the nineties, the immunization process was revised, and a dead-virus vaccine has been used ever since. If the worldwide effort to eradicate the disease continues as successfully, the polio vaccination will be discontinued altogether as the disease vanishes into extinction.

If you do: The polio vaccine is given by injection to infants and toddlers. It produces no major side effects and is one of the less painful shots.

If you don’t: The disease has been eradicated in the United States, but travel to developing nations carries a slight risk, and cases have been reported as close as the Caribbean.

Haemophilus influenza b
This dreadful bacteria once caused brain infections in children as well as a severe swollen throat infection that could result in suffocation. It has been almost eradicated through vaccine. Hib is one of the least controversial immunizations: It is not live, and it has very few side effects. It can be given in combination with the hepatitis B vaccine, and it’s mandatory for school admission.

If you do: The vaccine is injected into the muscle of infants and toddlers. Redness at the site is the most frequent side effect.

If you don’t: The risk is currently quite low because of the vaccine’s great efficacy at keeping these bacteria at bay, but it’s still a remote possibility.

Mostly Mandatory
Hepatitis B
Since Lucy is not at risk for IV drug use or promiscuous sexual behavior, there’s little chance she’ll contract hepatitis B now. Still, there is a good reason to give her this vaccine. Hepatitis B is a terrible condition. It causes jaundice, produces debilitating liver illness, and it can kill you quickly or slowly. The vaccine is efficient and creates lifelong immunity, so if we give it to every newborn for the next twenty years, we can eliminate the disease entirely (and with it, any need for the immunization). Another reason to give it early on is that hepatitis B requires three boosters a few months apart for the immunity to develop. When do people see doctors that frequently? When they’re babies, of course. Sometimes the vaccine is even given just after birth in the hospital, though I’m not sure why. Early vaccination is not detrimental, but it creates a false sense of urgency and anxiety in a new parent.

If you do: This immunization comprises three doses, all administered within the first year. It is mandatory for school admission in most states, and older children who were not required to get it as babies must get it before starting classes.

If you don’t: If you decide to put off the hepatitis B vaccine, you’re not creating any substantial risk for hepatitis B until Jimmy is much older. But it’s not necessarily any easier to give an immunization then; dragging a wily teenager to the doctor three times—for shots, no less—may prove a daunting task.

Chicken Pox (Varicella) [See also: Chicken Pox]
Since this relatively new vaccine was introduced, we’ve seen a dramatic decrease in the number of cases. Yet some parents still don’t see the wisdom of vaccinating for a disease that is relatively harmless in most children. Varicella is not as harmless as it seems. Those little poxes are uncomfortable, especially on the eyeball and on or inside the genitals. The poxes can also get infected, and in highly rare cases can lead to the flesh-eating bacteria so popular in tabloid newspapers. And then there are the extreme cases, which can lead to pneumonia, neurological complications, and even death. Vaccinating against chicken pox early in life decreases the chances that Lucy will contract this disease, which is unpleasant at a young age, more severe in older kids, and potentially debilitating for adults.
The chicken pox vaccine is a live attenuated virus that is safe and efficient, though not as efficient as other vaccines; a vaccinated person can still get chicken pox, but if he or she does, it’s almost always a mild case. The immunity decreases over time (unlike the actual post-disease immunity, which is permanent), so future boosters may be added to the vaccine regimen. The chicken pox immunization is becoming increasingly mandatory for school admission.

If you do: So far, the vaccine is given once in toddlers. Side effects, which are rare and minimal, may include a few poxes on the body.

If you don’t: Chicken pox remains, for infants and toddlers at least, a mild illness in general. But as the vaccine becomes more common, the virus becomes rarer and therefore harder to come in contact with even if you want to. If Lucy doesn’t catch it as a young tot, she’ll eventually have to be vaccinated later, because the severity of the actual illness increases with age.


Recommended
Pneumococcal Vaccine

This is the most recent addition to the immunization schedule. Known as the “ear-infection vaccine,” it technically prevents a rare form of meningitis that is particular to young children, and to a lesser degree it also decreases the occurrence of some pneumonias and ear infections. There has been no controversy surrounding this vaccine so far; it is very safe and well tolerated.

If you do: It is given in several doses before the second birthday. The most common side effect is temporary redness at the site.

If you don’t: The disease is rare and even rarer now that we give the vaccine, but it’s not yet fully eradicated.

Others
Hepatitis A

Doctors increasingly recommend this shot, although it’s more of a comfort vaccine. Hepatitis A is a very mild disease in children that has flu-like symptoms or none at all. In adults it is more tiring, with jaundice and fatigue that can last for weeks. Hepatitis A is most prevalent in countries with poor hygiene and contaminated food. You may consider this vaccine if you travel abroad, more for yourself and your peace of mind than for your child’s health [See: Travel in Exotic Places].

Flu Vaccine
By far the most problematic of immunizations, the flu vaccine has to be given every year, and even then it doesn’t work all that well. The protection rate fluctuates between 30 and 60 percent, depending on the year’s virus (the vaccine must be reformulated each year to immunize against the newest strain of the virus). Because of its relatively limited effectiveness, it should be reserved for kids who cannot afford to get the flu, such as asthmatics or children with other chronic conditions.

Rotavirus
An oral vaccine that protects your child from the rotavirus. The virus can cause fever, vomiting, and diarrhea which can be quite severe and lead to dehydration. Nearly all children become infected with the rotavirus by the time they are 5 years old. The vaccine has no side effect.

Meningococcal Vaccine
This vaccine protects against a serious bacterial brain infection. There is no side effect.

Human Papilloma Virus (HPV)
This vaccine protects against the Human Papilloma Virus which is an unpleasant genital infection that can cause uterine cancer later in life. It is recommended for both girls and boys between the ages of 9 and 12 years old before they become sexually active. There is no side effect.