Opinion | Quash the Nightmarish Pediatric Vaccine Conversations

It’s the end of a pediatric visit and on your way out you announce with a smile: “Aria is growing and developing wonderfully! Today she’s due for her hemoglobin and lead screen and her 1-year vaccines — the MMR, varicella, hepatitis A, and pneumococcal vaccines. We are also recommending the COVID-19 vaccine for everyone over 6 months and she can receive that here today. I look forward to seeing you all again in 3 months!”

Then her parents’ words bounce off the shiny floors back at you: “Oh, actually — we’re not going to do the vaccines. Any of them.”

We’re All in This Together

We’ve all been there. In fact, 87% of pediatricians reported experiencing parental vaccine hesitancy or refusal in 2013, and this number has likely increased in the last decade, especially since COVID-19 vaccines became available for kids, most recently those under 5 years old.

In talking with colleagues and trainees, many dread “the vaccine conversation.” This is for good reason — it can be tense and uncomfortable, and welcoming this discussion with the appropriate time and care required is challenging within the already short well visit appointment durations. However, there may be a critical time period for addressing vaccine concerns when they arise, making this important discussion worth running late for, with high potential return-on-investment for the child’s long-term health.

Pediatricians are among the healthcare providers with the highest job satisfaction ratings. Much of this is due to the longitudinal relationships with families, which tend to nurture positive and collaborative connections. Navigating a vaccine hesitancy conversation, both for new vaccines and those that have been around for decades, is one of those rare interactions where this connection can feel threatened, and parents and the pediatrician may not feel aligned.

Vaccine Communication Is Evolving

The art and science of vaccine communication has long been a topic of importance and interest. However, the game is changing with the exceptional public interest in vaccine creation and safety surrounding the COVID-19 vaccines. Clinicians must be attuned to what the public is hearing about vaccines and their general vaccine sentiment so we are ready to provide the most useful information. We can keep our finger on the pulse by following the news and social media, asking patients and community members directly for their thoughts and concerns on vaccines formally or informally, and by following broader population-based vaccine opinion through reputable survey mechanisms and research studies.

When thinking about your potential impact, consider your circles of influence. My opportunities for vaccine advocacy include: face-to-face interactions with patients in the office; my circles of relatives and friends; within my hospital/health system as a vaccine ambassador and medical educator; social media channels; my community through interviews, webinars, and other events; and through published research. While these opportunities and interests are different for everyone, multiple studies have shown that parents trust their child’s doctor when it comes to vaccination.

Recipe for Vaccine Discussion Success

While vaccine discussions are more like sautéing without a recipe than baking with exact steps, here are some evidence- and experience-based techniques on how to ace the conversation (whether about COVID-19 vaccines or others).

Welcome the conversation. It is wonderful that the parent trusts you enough to open up and discuss this.

• Focus on de-escalating any feelings of tension if they exist within yourself and within the room, and create a safe space for the conversation.
• Remind yourself that the caregivers’ concern comes from a place of worry for their child, not from a distrust in your personal credibility or care. The family came to you today because they trust your years of training and experience.

Remind yourself it is your job to have this conversation. In fact, if you aren’t having this conversation, you aren’t doing your job.

• The CDC, AAP, ACOG, AAFP, ACIP, and many other guiding bodies strongly recommend vaccination.
• Much like a referee making a tough call or a contractor recommending extensive home repairs for safety (not the fun kind like a new backsplash), you’re doing what you are called upon to do: optimizing the child’s health.

Scripting. There are many methods and strategies for having this conversation, and everyone’s script and delivery is a bit different. Here is mine:

• Thank the parent for sharing their concerns.
• Acknowledge there is a lot of scary information out there and you can understand their concern.
• Remind the parent that you both have the same goals for the child: a healthy, happy, and long life.
• Explain your role: “My job is to provide you with the best information, so you can make the best decision possible for your child.“
• Rather than providing broad information off the bat, elicit specific concerns. For example, if a parent is worried about vaccine additives, provide specific information to answer that question. If there is a concern you aren’t sure about, explain your initial thoughts and look it up. Prior work has summarized common vaccine concerns, and these concerns are somewhat similar for the new COVID-19 vaccines.
• Circle back and make a strong recommendation for vaccination.
• If the parent is still unsure, know when to hit the pause button. But most importantly, leave the door open to continue this conversation in the future. For example, “I strongly recommend vaccination, and will provide some resources from trustworthy sources in the after-visit summary. This is such an important part of my job and your child’s health that I am going to bring it up at every visit, but I am available anytime if you have any specific questions or concerns as you are reading about this. Let’s schedule a separate visit in a few weeks to discuss again. You are welcome to bring along anyone who helps you make important decisions about your child.”

Adjust the goal posts if you need to. It may not be reasonable to expect a 100% vaccination rate after every conversation; intermediate goals should be celebrated too. These may include forming a partnership with the family, helping them access reputable information, offering a safe space for the conversation, and opening the door for future conversations.

An increasing percentage of parents have concerns about vaccines, and there is more vaccine misinformation targeted toward well-meaning parents than ever before. Rather than being surprised or caught off guard, we can welcome and prepare for these conversations in our offices. At its very core, this is an issue that stems from parents wanting the best for their children, something that resonates so very deeply with all of us who dedicate our career to caring for children.

Nina L. Alfieri, MD, MS, is an attending physician in advanced general pediatrics & primary care at Ann & Robert H. Lurie Children’s Hospital of Chicago, and an instructor of pediatrics at the Northwestern University Feinberg School of Medicine.