Keeping the Dialogue Open on Vaccines

Rita John has four decades of pediatric primary care experience and has worked as a nurse practitioner in the emergency department, private practice and in a nephrology clinic. We caught up with her about vaccinations in light of the recent controversy resulting from a Measles outbreak traced to Disneyland.

Q:  The recent measles outbreak reignited the debate over individual choice and public safety.  Where do you feel the boundaries lie in the immunization controversy and what would you suggest to health care providers if they encounter a parent reluctant to vaccinate their child?

No method to convince unsure parents to vaccinate their children has been proven effective. Providers who refuse to treat unvaccinated children waste opportunities to change the parent’s minds and educate them about vaccine safety.  Every parent is capable of reconsidering their position.   I treat patients whose parents don’t believe in vaccines, and I teach them about vaccinations at each visit. I assuage their fears and refer them to web sites for more information, while remaining respectful of their views.  By reeducating families at each visit, you can influence them to vaccinate their children. I explain to them that this is a public health issue: Their child could infect or even kill another child with a compromised immune system who can’t get vaccines.

I worked with a woman who refused vaccines for her six kids.  While listening to her concerns, I educated her about immunization during each visit.  I told her that I vaccinated each of my four children.  Gradually, she added more vaccines for her children at each visit.  By the time her seventh child was born, I provided every vaccine required by the national schedule to all of her children.

Q: Should pediatric primary care providers care for unvaccinated children in their facilities, even though they may be putting other patients at risk?

I would encourage other providers to treat children with compromised immune systems at set times with fewer people around and less exposure to infection. I schedule high-risk kids for appointments early in the morning before the practice opens, after the office is cleaned at night. I strongly believe in working with families wherever they are—even if their decisions compromise public health. You never know when you will have an opportunity to change their minds.

Q: Children can receive multiple shots in a single visit. Shots can distress children as well as parents. What can parents and health care providers do to make shots less scary for kids?

Several studies found that giving a taste of sugar water to babies under six months can take the sting out of vaccination pain.  Clinicians might also be able to apply sprays or creams beforehand to numb the pain. After the shot is given, parents should praise their kids and offer a small reward.

Distraction often works with toddlers and preschoolers. My kids blew bubbles when they received shots, for example. For anxious kids who need multiple shots, simultaneously administering two injections an inch apart, allows providers to finish quickly. High frequency vibrating devices designed to disrupt pain signals on their way to the brain have shown promising results in needle-averse kids. I conducted a research study using a buzzing device on 120 adolescents afraid of needles and the results showed significant pain reduction.

Q: As someone who has cared for children from multiple cultural backgrounds, what differences have you seen in attitudes toward immunizations among caregivers?

Most of the lower-income and immigrant families I have cared for accept vaccines.  Upper middle class families in my practice are much more likely to reject vaccines and question health care providers.

The irony is that low-income kids from immigrant families at government-subsidized child care centers are better protected from an outbreak of measles than kids attending private and likely more expensive facilities.

Q: You’ve been teaching for nearly two decades. What techniques have you changed and which ones have stood the test of time when working with students who will treat children, families and adolescents?

Over the last 15 years, the internet has completely changed my teaching methods.  My students develop diagnostic skills by analyzing online pediatric labs and case studies, for example.  As nurse practitioners acquire greater responsibility, advanced nursing students need to become more proficient in their analytical skills. NPs run more of their own practices, so it’s crucial for them to master differential diagnosis— distinguishing a disease or condition from others that present similar symptoms.

Patients and their families have become important partners in making medical decisions. I teach my students that if treating a child with an ear infection and his mother refuses antibiotics; a care plan can be developed without using them. They should monitor the infection and wait for the symptoms to clear up. But if the child returns with a higher fever, ask about prescribing antibiotics again.

Motivational interviewing is a technique I teach my students that was unheard of in the early 2000s. If my patient won’t quit smoking, for example, I follow up with other questions asking what I can do to help her smoke less, if we can set a goal together, and when I can follow up. Health care used to be much more paternalistic. I show my class a video of a doctor telling a smoker that he will die from lung cancer. The patient walks out of the doctor’s office unwilling to quit.