Measles: All about the measles vaccines

Two measles vaccines are part of the standard vaccine schedule in the US. Do you know when outbreaks change the recommendations?

In my last post I discussed why we should worry about measles. Today I’ll talk about the measles vaccines available to prevent the disease.

What measles vaccines are available?

There are two types of measles vaccines in the United States: MMR and MMRV.

There is no longer a separate measles vaccine available in the US.

MMR

The MMR includes protection against measles, mumps, and rubella. This vaccine can be used in infants 6 months and older and is the only vaccine approved over 13 years of age for those who need to catch up on vaccines.

The CDC recommends that MMR and varicella vaccines be given as separate injections for the first dose in children 12-47 months of age.

MMRV

In addition to measles, mumps, and rubella, the MMRV has protection against varicella (chicken pox). The MMRV can be used from 12 months through 12 years of age (until the 13th birthday).

Using the MMRV vaccine has the benefit of one fewer injection, but there are some downsides.

  • It cannot be used as an early dose of measles protection prior to 12 months of age.
  • The MMRV should not be used in those 13 years and older.
  • The MMRV has a higher risk of fever within 42 days after vaccination compared to the MMR and Varicella vaccines being given in separate injections, even when they’re given on the same date in children 12-24 months of age. There is less data on children 24-47 months of age, but it is likely that they also have this increased risk.
  • The MMRV has a higher risk of febrile seizures from 5-12 days after vaccination compared to the MMR + Varicella being given in separate injections, even if given on the same date.

What is the typical age of vaccination?

One of the measles vaccines is recommended routinely at 12-15 months and then again at 4-6 years.

Either the MMR or the MMRV can be used at these standard times.

If the MMR is used, a separate varicella vaccine can be used at the same time or at a different time.

Can the 2nd dose be given early?

Yes. An early 2nd dose does count as the second dose as long as it is separated by at least 28 days from other live virus vaccines.

Early second doses do count toward the required two doses after the first birthday. There is no minimum age for the second dose, as long as both doses are after the 1st birthday and a month apart.

What does the booster dose do?

Contrary to common belief, the MMR/MMRV second dose is not a booster to increase the immunity of the first dose.

About 93% of people respond to their first measles vaccine and are protected against the measles. They are protected and wouldn’t need a booster, but we can’t easily tell if any individual person is immune after the first dose. It is also possible that a person is immune to some of the MMR/MMRV components but not to all of the components, so another dose is needed for protection to be more reliable.

The second vaccine helps more people convert to being immune. After the second dose, 97% of people are immune to measles.

There are some people (3%) who are not immune despite two doses, which is why we sometimes hear of a vaccinated person still getting the disease.

Herd immunity is one reason why it is important for everyone in a community who is eligible to get the vaccine to be immunized. By immunizing the community, we can protect those in the community who are not able to be vaccinated due to young age or medical condition and those who are vaccine non-responders.

High risk situations: outbreaks and travel

It is recommended to receive an MMR (or MMRV if age indicated) if there is a local outbreak and the health department recommends an early vaccine or if an infant 6-12 months of age will be traveling to an area of increased risk.

Infants and children in high risk areas can get the second dose as early as 4 weeks after the first.

Either of the measles vaccines can be used as long as they are indicated for the age of the person being vaccinated.

More about early doses

MMR can be given to infants at least 6 months of age if they are considered high risk due to travel or outbreaks.

It is not recommended for all babies to get an early vaccine at this point.

Local health departments help to advise whether or not local conditions warrant early vaccination.

International travelers should be vaccinated against measles after 6 months of age due to the higher risk of exposure during travel.

Why not give to babies under 6 months?

Under 6 months of age an infant is considered protected from his or her mother’s antibodies. These antibodies leave the baby between 6 and 12 months after birth.

The antibodies prevent the vaccine from properly working, which is why we generally start the vaccine after the first birthday, when the antibodies have likely gone away.

Does an early dose count?

Any measles vaccine dose given before the first birthday does not count toward the two doses required after 12 months of age, but might help protect against exposure if the immunity from the mother is waning.

As mentioned above, an early 2nd dose does count as long as the first dose is after the 1st birthday and the second dose is at least 28 days later.

Is it safe to give the MMR before 12 months?

It is safe for a child to get extra doses of the vaccine if needed for increased risk of exposure between 6 and 12 months.

As discussed above, it is not because of safety that it is not routinely given earlier. It may not be effective at this age if the baby still has maternal immunity.

What’s the deal with live virus vaccines?

All live virus vaccines must be given either on the same date or a month apart. If they are given too close together on different dates they are less effective and the second one given does not count.

Other types of vaccines do not have this restriction, only live virus vaccines.

Examples of live virus vaccines include:

  • MMR
  • MMRV
  • Varicella
  • FluMist (only the nasal influenza vaccine, not the injectable flu vaccine)
  • Oral typhoid (not on the routine vaccine schedule, but recommended for international travel)
  • BCG (a vaccine against tuberculosis that is used in some countries, but not the US)
  • Oral polio (a vaccine no longer used in the US, but still in use in other countries)
  • Yellow fever (not on the routine vaccine schedule, but required prior to visiting some countries)
  • Zoster (a vaccine for older adults, not children)

For example…

If your child has FluMist (the nasal flu vaccine) on October 1st, if he or she gets the MMR or MMRV on October 15th, the MMR/MMRV won’t count.

This is becoming more difficult to track as pharmacies, work places, and other clinics offer vaccines. I can think of one instance where a parent had a child get a nasal flu vaccine a couple of weeks before the other parent brought the child in for kindergarten shots. The 2nd parent was not aware of the flu vaccine, so the live virus vaccines given at the routine well visit had to be repeated a month later. The child was not happy!

Always get documentation of the vaccines your child gets and be sure if it’s not done at your child’s primary care office that they get a copy! If you’re transferring to a new physician, request a transfer of records in writing before your first visit to your new medical home so they have what they need to best care for your family!

Tuberculosis testing with PPD

Although this is not a live virus vaccine, tuberculosis testing can also be affected by live virus vaccines.

A false negative skin test can occur if any live vaccine is given during the month BEFORE the TB skin test is done.

If MMR vaccine is given, you should wait at least 4 weeks before doing the TB skin test unless it is given on the same date.

All vaccines, live or inactivated, can be given on the same day or at any time AFTER a TB skin test is done.

What if someone who hasn’t been vaccinated is exposed to measles?

Unvaccinated people who are exposed to measles can be given post-exposure prophylaxis unless they have a vaccine contraindication.

If the MMR vaccine is given within 72 hours of initial measles exposure it may provide some protection or lead to a less severe infection.

Immunoglobulin (IG) can be given within 6 days of exposure to provide some protection.

If you think you’ve been exposed, contact your physician and/or the local health department.

Who shouldn’t be vaccinated?

The long list of medical contraindications to vaccines that some promote is not valid. There are very few contraindications to getting the MMR vaccine. These include:

  • Age less than 6 months of age
  • Anyone who has had a severe allergic reaction (anaphylaxis) after a previous dose or to a vaccine component or neomycin
  • Those with a known severe immunodeficiency (chemotherapy, congenital immunodeficiency, long-term immunosuppressive therapy, and some with human immunodeficiency virus [HIV] infection)
  • Pregnant women

Some conditions have precautions, but not true contraindications, to the MMR vaccine. The risks and benefits of vaccination should be discussed if a person has the following:

  • Moderate or severe acute illness
  • Tuberculosis testing (see separate section above)
  • Antibody-containing blood products within the previous 11 months
  • Those who have received a live virus vaccine in the previous 4 weeks
  • Seizure history

What about adults?

People born before 1957 are presumed to be immune to measles because they lived through several measles epidemics before the vaccine became available.

It is not considered necessary to check titers for these adults unless they are in a high risk group, such as healthcare providers. If their titers do not show immunity, they should be vaccinated according to current recommendations.

Adults born after 1957 should have documentation of two measles vaccines or the disease. Before 1980 it was only recommended to have one vaccine, so some adults may require another dose.

If documentation is not available, titers can be done to see if you’re immune or need a vaccine. Some may choose to simply get an MMR. Talk to your doctor.

Checking titers

Titers can show if people are at risk, but are not recommended routinely. Because of the overall high level of protection (97%), the cost-benefit ratio of testing titers routinely is not in favor of testing.

Certain persons, such as healthcare providers, may have to show immunity or get additional vaccine doses.

What are the vaccine recommendations for measles during an outbreak? How do they differ from the routine schedule? @pediatricskc

In summary

Two doses of one of the measles vaccines available is recommended for everyone after their first birthday. A dose can be given between 6 and 12 months if there is high risk but it does not count toward those two.

The MMR vaccine can be used in any person over 6 months of age if they are needing a measles vaccine, as long as they have not received another live virus vaccine in the previous 28 days.

The MMRV vaccine can be used between 12 months and 13 years of age. There is a higher risk of fever and febrile seizures with this vaccine compared to the MMR + Varicella vaccines given separately (even on the same date).

The first measles vaccine provides protection 93% of the time. The second dose increases the protection to 97% of people.

It is very important that where you are getting your vaccines has access to previous vaccines given, especially if you are getting any live virus vaccines. Keep a copy of all your family member’s vaccines available at all times.

If you are changing primary care physicians for any reason, have your records transferred prior to your first visit. This must be done in writing, but your doctor must provide these. The cost of these records will be determined by the hospital or clinic and state laws.

Always keep records of your family’s vaccine records easily available. You will need these for school entry, many camps, some volunteer or work positions, and more.

Getting one of the measles vaccines is not the only type of vaccine to get. We’re seeing outbreaks of measles currently, but any of the vaccine preventable diseases can make a come back if given the opportunity.

Plan for Vacation – especially if you’re going outside the US

A little planning and preparation can help everyone in your group stay healthy while traveling. Some preventative treatments take up to 6 months to complete, so talk to your doctor early!

When families are able to travel, it can be a wonderful time of exploration and bonding. Don’t let illness get in the way. Many locations have diseases that you don’t typically see in your home town. Take a little bit of time to learn what you need to do to prepare for your vacation. Insurance doesn’t usually cover travel medicine, so be sure to consider these extra costs when planning a trip.

Keep track of everything

It is a great idea to take pictures of everyone each morning in case someone gets separated from the group. Not only will you have a current picture for authorities to see what they look like, but you will also know what they were wearing at the time they were lost.

Take pictures of your passport, vaccine record, medicines, and other important items to use if the originals are lost. Store the images so you have access to them from any computer in addition to your phone in case your phone is lost.

Have everyone, including young children, carry a form of identification that includes emergency contact information.

Create a medical history form that includes the following information for every member of your travel group. Save a copy so you can easily find it on any computer in case of emergency.

  • your name, address, and phone number
  • emergency contact name(s) and phone number(s)
  • immunization record
  • your doctor’s name, address, and office and emergency phone numbers
  • the name, address, and phone number of your health insurance carrier, including your policy number
  • a list of any known health problems or recent illnesses
  • a copy of current medications and supplements you are taking and pharmacy name and phone number
  • a list of allergies to medications, food, insects, and animals
  • a prescription for glasses or contact lenses

Prepare everyone for local specs

Learn what the local healthcare options are if someone in your travel group gets sick or injured. For several tips, see this travel information from the CDC.

Find out how you can use your phone overseas. Be sure to bring a charger that will work with local electrical outlets.

If you’re traveling with young children, plan ahead for where they’ll sleep. Infants will need a safe place of their own with a firm surface. Everyone will need time to adjust to new time zones.

Vehicle safety risks vary around the world. Know local travel options and risks. Only use authorized forms of public transportation. For general information, see this International Road Safety page. Learn local laws prior to traveling.

If you’re going to be somewhere above 8000 feet above sea level, prepare for the change in altitude with these tips.

Be sure to talk with your teens about drug and alcohol safety prior to travel. Many countries have laws that vary significantly from the United States, and some teens will be tempted to take advantage of the legal nature of a drug or alcohol.

Remind everyone to stay in groups and to not venture out alone.

Dress appropriately for the area. Some clothing common in the United States is inappropriate in other parts of the world. Americans are also at risk of getting robbed, so do not wear things that will make others presume you are a good target.

Wear sunscreen! It doesn’t matter if you’re on the beach or on the slopes, you need to wear sunscreen every time you’re outside. Don’t ruin a vacation with a sunburn. For sunscreen tips, see Sun and Water Safety.

For more safety tips, see this helpful brochure.

Prevent bug bites

When you travel be sure to protect against bug bites! #travel #prevention #vacation #questforhealthkc

Mosquitos, ticks and other bugs not only cause itchy rashes but they can carry diseases. Using insect repellant properly can help to prevent getting bit.

Use insect repellent with at least 20% DEET to protect against mosquito and tick bites. Follow package directions and reapply as directed. Do not use combination bug sprays with sunscreen. They should be applied separately.

Wear long sleeves and pants. Consider treating your clothes with permethrin and tucking your pants into your socks. Sleep in areas that are screened against bugs.

Vaccines

Extra vaccines may be needed when you travel, especially in infants who are too young to get a measles vaccine on our usual schedule and adults who have not gotten vaccines that are now on the regular schedule.

Before you travel you can look at destination-specific advice on the CDC’s Destination page.

MMR

The news routinely reports outbreaks of measles these days. Many of the US outbreaks are related to an unvaccinated person returning from abroad. The MMR protects against measles, mumps, and rubella.

While our standard vaccine schedule does not recommend the MMR until 12 months of age, the vaccine can be used in infants as young as 6 months. It is considered safe to use in infants, but we don’t know when their immunity from their mother goes down. If the maternal immunity is still active the vaccine won’t work. This immunity typically falls between 6 and 12 months. After 12 months the vaccine is more likely to be effective, so when the risk is lower, it is recommended to wait until that age for the vaccine.

Between 6 and 12 months of age the MMR is recommended for infants considered high risk for being exposed to measles. This is because if their immunity has fallen, we don’t want them to be unprotected. International travel is considered to be high risk. If your baby’s maternal immunity is still high, the vaccine won’t provide protection, but he or she is still protected until that maternal immunity falls.

Because we don’t trust that the vaccine is effective before a year of age, babies who get an early MMR will still need two after their first birthday.

Talk to your baby’s pediatrician about getting the MMR if your child is over 6 months of age. Ideally it will be given at least 2 weeks prior to travel to give the body time to develop immunity.

Hepatitis

Both hepatitis A and hepatitis B vaccines are now on the routine schedule for children in the US, but many adults did not get these vaccines as children. These vaccines are recommended for travel to many locations. Verify if your family has had both hepatitis A and hepatitis B vaccines before you travel.

It is recommended that infants start hepatitis B vaccines at birth. The series is completed at 6-9 months of age. There are catch up schedules for those who haven’t completed the series on time.

Children do not get the hepatitis A vaccine until 12 months of age. If they have not yet started the series and they are over a year, they can start at any time. The booster is given 6-12 months later.

It takes at least 6 months to complete each of these series, so plan early!

Typhoid

Typhoid is not a vaccine routinely given in the US but it is recommended for travel to many parts of the world. There are two main types of typhoid vaccine, injectable and oral.

Children 2 years and older can get an injectable typhoid vaccine, ideally at least 2 weeks prior to travel. It is only one dose and lasts 2 years.

The oral vaccine is only for people 5 years and older. It is given in 4 doses over a week’s time and should be completed at least a week prior to travel. It must be given on an empty stomach (1 hour before eating and 2 hours after eating). Antibiotic treatment can make this vaccine ineffective, so discuss any current medicine you are taking with your doctor. The oral vaccine lasts 5 years.

Neither vaccine is 100 % effective so even immunized people must be careful what they eat and drink in areas of risk.

Meningitis

Meningococcal disease can refer to any illness that is caused by the type of bacteria called Neisseria meningitidis. Within this family, there are several serotypes, such as A, B, C, W, X, and Y. This bacteria causes serious illness and often death, even in the United States.

In the US there is a vaccine against meningitis types A, C, W, and Y recommended at 11 and 16 years of age but it can be given as young as 9 months of age. MenACWY-CRM is approved for children 2 months and older.

There is a vaccine for meningitis B prevention recommended for high risks groups in the US but is not specifically recommended for travel.

Meningitis vaccines should be given at least 7-10 days prior to potential exposure.

Travelers to the meningitis belt in Africa or the Hajj pilgrimage in Saudi Arabia are considered high risk and should be vaccinated. Serogroup A predominates in the meningitis belt, although serogroups C, X, and W are also found. There is no vaccine against meningitis X, but if one gets the standard one that protects against ACWY, they will be protected against the majority of exposures. Boosters for people traveling to these areas are recommended every 5 years.

Yellow Fever

Yellow fever is a mosquito-borne infection that is found in sub-Saharan Africa and tropical South America. There is no treatment for the illness, but there is a vaccine to help prevent infection. Some areas of the world require vaccination against yellow fever prior to admittance. Yellow fever vaccine is recommended for people over 9 months who are traveling to or living in areas with risk for YFV transmission in South America and Africa.

Most physician offices do not offer this vaccine. A special license is required to be able to provide it. Check with your local health department or a travel clinic in your area. This vaccine should be given at least 10 days prior to travel.

Influenza

Remember that influenza hits various parts of the world at different times of the year. The southern hemisphere tends to finish their flu season just as ours is starting. Check to see when it’s flu season and vaccinate as needed.

Medications for your trip

Aside from bringing your routine prescription medications and over the counter medicines in their original prescription container, there are some medications that are recommended for traveling to various parts of the world.

Malaria

Malaria transmission occurs in large areas of Africa, Latin America, parts of the Caribbean, Asia (including South Asia, Southeast Asia, and the Middle East), Eastern Europe, and the South Pacific. Depending on the level of risk (location, time of year, availability of air conditioning, etc) no specific interventions, mosquito avoidance measures only, or mosquito avoidance measures plus prescription medication for prophylaxis might be recommended.

Prevention medications might be recommended, depending on when and where you will be traveling. The medicines must begin before travel starts, continue during the duration of the travel, and continue once you return home. There is a lot of resistance to various drugs, so area resistance patterns will need to be evaluated before choosing a medication. Review the area-specific travel recommendations with your doctor.

Anti-diarrhea medicines

I am commonly asked to prescribe antibiotics to prevent traveler’s diarrhea. This is discouraged due to growing bacterial resistance to antibiotics. It is best to prevent by avoiding local water, choosing foods wisely, using proper handwashing techniques, and considering bismuth subsalicylate or probiotic use.

Traveler’s diarrhea is often from bacteria, but it can also be from a viral source. Maintaining hydration with clean water with electrolytes is the most important treatment. Many cases of traveler’s diarrhea do not require antibiotics. See details of treatment recommendations in the Yellow Book.

After you return…

If you’ve been in an area of the world that has increased risk for tuberculosis (TB) or if you have suspected exposure to TB, testing for exposure is recommended.

Tuberculosis occurs worldwide, but travelers who go to most countries in Latin America, the Caribbean, Africa, Asia, Eastern Europe, and Russia are at greatest risk.

Travelers should avoid exposure to TB in crowded and enclosed environments. We should all avoid eating or drinking unpasteurized dairy products.

The vaccine against TB (bacillus Calmette-Guérin (BCG) vaccine) is given at birth in most developing countries but has variable effectiveness and is not routinely recommended for use in the United States. Those who receive BCG vaccination must still follow all recommended TB infection control precautions and participate in post-travel testing for TB exposure.

It is recommended to test for exposure in healthy appearing people after travel. It is possible to have a positive test but no symptoms. This is called latent disease. One can remain in this stage for decades without any symptoms. If TB remains untreated in the body, it may activate at any time. Typically this happens when the body’s immune system is compromised, as with old age or another illness. Appropriately treating the TB before it causes active disease is beneficial for the long term.

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When vaccines are given too soon

Sometimes vaccines are given too soon to count toward the required vaccine schedule. This can easily happen if there are changes to the standard vaccine schedule for any reason, but what does that mean for the child? Are they in danger? Do they need extra shots? Is that even safe???

Early vaccines don’t count.

Don’t try to sneak in early before a recommended age.

It’s not appropriate in most cases to give vaccines at shorter intervals or before the recommended age.

The 12-15 month vaccines are occasionally given before the 1st birthday, which does not count in every state. State laws can dictate a grace period in which vaccines can be given earlier than the standard schedule, but not all do.

This is an issue with some children moving from a more lenient state to one with a lesser (or no) grace period.

In some states they can get their MMR a couple days before their first birthday.

Does this protect them against measles, mumps, and rubella?

~ Probably. (Nothing’s 100%.)

Does every school count it?

~No. If they move to a state that doesn’t, they need to repeat it.

International travel changes things.

It is recommended for international travelers over 6 months to get an MMR early due to worldwide measles outbreaks.

This dose does not count toward the 2 doses typically given after the 1st birthday because younger children do not make immunity as reliably, but is felt to potentially benefit those at higher risk due to travel.

Most babies are protected against measles for 6-12 months after birth.

If the MMR vaccine is given when they are already protected, the vaccine doesn’t work.

We don’t know if a 6-12 month old is safe or not, so when the risks increase, as with international travel, it is recommended to give a shot to help if needed.

But that shot might not work, so it should be repeated after the 1st birthday.

Minimal intervals are important.

Most vaccines are given as a series, and each vaccine within a series needs to be separated by a minimal interval.

Before vaccine logic was built into our electronic health record, it could be difficult to know which vaccines were recommended if people got off the standard schedule.

Not all EHRs have smart vaccine logic, so if you’re off schedule, be sure to discuss intervals before giving vaccines.

The hepatitis vaccines are more commonly given off an appropriate schedule than other vaccines. I’ll touch on each of them and why they’re problematic.

Hepatitis A vaccine interval problems.

My office routinely gives the first Hepatitis A vaccine at 12 months and the second at 18 months. The CDC schedule states:

Hepatitis A (HepA) vaccine. (minimum age: 12 months)

Routine vaccination:

  • 2 doses, separated by 6–18 months, between the 1st and 2nd birthdays. (A series begun before the 2nd birthday should be completed even if the child turns 2 before the 2nd dose is given.)

Despite warning parents to schedule the 18 month visit 6 months or more from the 1 year visit, sometimes they don’t have the correct spacing. This generally happens when they do the 1 year visit several weeks after the birthday but then try to “get back on track” and do the 18 month exam on time.

The good news is our smart EHR tracks minimal intervals and doesn’t suggest the vaccine if it’s too early.

I typically wait until the 24 month visit to do the 2nd Hepatitis A vaccine if it is too early at the 18 month visit, but I ask the family to come in just before the 2nd birthday. This allows the child gets the vaccine before 24 months of age and fit the main recommendation of getting both doses between the 1st and 2nd birthdays.

Sidenote about HEDIS

A delay to wait until the 2 year well visit follows the CDC recommendation to have the doses separated by 6-12 months.

Despite following the CDC guidelines, it fails to meet HEDIS benchmarks.

If a child gets the Hepatitis A vaccine after the 2nd birthday, the physician loses quality points.

These points help rank physicians for insurance company purposes.

As long as it doesn’t happen often, it’s not an issue.

But if schedules are off too often, a physician’s contracts with insurance companies could be at risk because they are seen as not high quality, regardless of why the vaccine is given after the 2nd birthday.

If you want to keep your favorite physician and use your insurance, please help them meet the standards of care for all metrics. This includes coming in for annual well visits and having regular follow up for chronic issues. It also means taking the recommended medications, such as preventative medicines for asthma and doing certain labs, such as lipid panels, or screenings, such as depression screenings.

Sidenote about vaccine shills

There are many groups sounding alarms about physicians getting paid huge amounts of money to vaccinate from Big Pharma. I wish this was true, but it’s not.

Don’t confuse the HEDIS measures and insurance contracts with this Big Pharma farce. First off, we pay pharmaceutical companies to buy their vaccines. They don’t pay us. Sometimes they buy a lunch for our staff so they can have our attention when they talk about their products, but there is no big money to be made from vaccine companies.

Insurance companies pay us for the vaccine and the costs associated with giving vaccines. These costs are not only for syringes and band aides. We must carry insurance for the vaccine inventory. There must be a dedicated refrigerator and freezer to safely store vaccines. We should use a refrigerator alarm system to alert us if the temperature is too warm or too cold. We pay staff to keep logs about refrigerator temperatures and inventory. All of these costs add up.

Trust me, no one gets rich off of vaccines.

Some insurance companies offer bonuses if we meet HEDIS measures, but more often I think they just pay less if we don’t meet measures.

Why do they pay more if we give vaccines?

Because the insurance company comes out ahead if we vaccinate. Vaccine preventable diseases cost them much more than vaccines. They want to encourage us to vaccinate to save them money.

Hepatitis B Interval problems.

Hepatitis B vaccine is given in 3 doses, with the second 4 weeks after the first, then the 3rd at least 8 weeks from the 2nd and 16 weeks after the 1st.

There are vaccines that just have hepatitis B protection (monovalent vaccines) that can be given starting at birth. They can be used for all three doses.

There are other vaccines that combine the hepatitis B vaccine with other vaccines (combination vaccines). The combination vaccines are given at different intervals, depending on what is in the vaccine. They cannot be given under 6 weeks of age, but it’s still recommended to give the first dose within 24 hours of birth.

Yes, it’s confusing.

From the CDC guidelines:
  • A complete series is 3 doses at 0, 1–2, and 6–18 months. (Monovalent HepB vaccine should be used for doses given before age 6 weeks.)
  • Infants who did not receive a birth dose should begin the series as soon as feasible.
  • Administration of 4 doses is permitted when a combination vaccine containing HepB is used after the birth dose.
  • Minimum age for the final (3rd or 4th) dose: 24 weeks.
  • Minimum intervals: Dose 1 to Dose 2: 4 weeks / Dose 2 to Dose 3: 8 weeks / Dose 1 to Dose 3: 16 weeks. (When 4 doses are given, substitute “Dose 4” for “Dose 3” in these calculations.)

There are even additional recommendations if the mother is a known Hepatitis B carrier or if her status is unknown.

If any of the doses are given too early, they need to be given again. This is considered safe.

Live viruses need special attention.

Live viruses must be given either at the same time or at least 28 days apart. If they are given at a shorter interval, the second vaccine is presumed to not be effective and must be repeated.

This is another great reason to not alter the standard vaccine schedule your provider uses. If your child gets off track, you run the risk of him or her needing additional vaccines.

Common live virus vaccines include MMR, Varicella, MMRV, and Flumist.

Some vaccines, like the oral typhoid vaccine, cannot be given at the same time as antibiotics.

Quiz yourself!

See if you know what vaccines your child needs.

To avoid vaccines that are given too soon:

  • Be sure that whoever is giving vaccines knows any recent vaccines and medicines your child has had recently.
  • Try to stay within the recommended vaccine schedule as much as possible to avoid needing extra doses.

Vaccine schedules for children birth – 6 years and 7-18 years:

 

 

 

What happens if a vaccine booster is delayed?

A lot of parents question the timing of vaccines. What happens if a vaccine booster is delayed? Does the series need to be restarted? Is it even worth it if it’s late?

There are so many questions about delayed vaccines…

This is not about a delayed schedule.

Intentionally delaying vaccines, especially during the infant schedule, puts kids at risk for catching a disease.

I always recommend giving vaccines according the standard vaccine schedule. This helps protect our children and our communities.

A bit about insurance…

There also might be insurance issues if vaccines are given out of the standard age range. Details of coverage should be in the fine print of your individual contract with your insurance company and your physician will not know coverage specifics. You should talk to your insurance company to see if there are limitations on vaccine coverage if you are vaccinating outside the standard vaccine schedule.

Most insurance companies cover the infant series until 2 years of age. I recommend getting those done prior to the 2nd birthday if at all possible, not only for the protection of your child, but also potential increased costs to you if your insurance company has age restrictions.

The “kindergarten” vaccines are given between 4 and 6 years of age and then there are “tween/teen” vaccines at 11-12 and 16 years. These also might fall into age restrictions of your insurance company, so talk to an insurance company representative if you have questions on payment.

Life happens, and sometimes there are inadvertent delays in vaccinating.

The typical question I’m asked regarding what happens if a vaccine booster is delayed is along the lines of one of these questions:

“He is due for his kindergarten shots on July 5th, but we’re on vacation then. Is it okay to wait until the end of July?”

or

“Tweeny is getting her first HPV vaccine today, but she has a big out of town tournament the week she is due for the 2nd dose. Can she come later?”

The answer to both questions: yes.

Vaccines are recommended with minimal intervals. If there’s a delay for whatever reason (missed appointments, scheduling conflicts, temporary immune compromise-such as cancer) it’s usually recommended to catch up as soon as possible.

Vaccine series do not need to be restarted if the interval has been longer than recommended. You give the next required dose and make sure successive doses fit minimal intervals and age limitations.

Minimal intervals will be discussed in a future post.

Exceptions to completing the series

There are a few vaccines that should not be given if too much time has passed.

Rotavirus vaccine

Rotavirus vaccine is very specific as to when it can be given.

There are two types of rotavirus vaccine. One is typically given at 2, 4, and 6 months. The other is given at 2 and 4 months. Either is considered acceptable. It is recommended to use the same type to complete the series, but they can be interchanged if needed.

The minimum age for the first dose is 6 weeks and the maximum age for dose #1 is 14 weeks 6 days.

Vaccination should not be started for infants age 15 weeks or older due to safety concerns in older infants. If an infant of 15 weeks 1 day or older has not started the rotavirus vaccine, they should not start it.

The maximum age for the last dose of rotavirus vaccine is 8 months and 0 days. If an older infant has not completed the series, it is not recommended to do a catch up.

Hib vaccine

The Hib vaccine also has different versions and a variable schedule due to vaccine types and combination vaccines. It is either a 3 or 4 dose series. The earliest it can be given is 6 weeks, but it standardly starts at 2 months.

At least one dose is recommended after the first birthday for children under 5 years of age.

It is not recommend to give Hib vaccine after 5 years of age to healthy children. Some high risk people should continue to get the vaccine beyond their 5th birthday.

Pneumococcal vaccine

Again, there are various types of pneumoccal vaccine, but the one routinely given to infants is the PCV13.

The youngest an infant can receive this vaccine is 6 weeks, but it’s typically given at 2, 4, 6 and 12-15 months. If a child misses doses, they should do catch up vaccines at least 28 days apart and at least one dose after the first birthday, unless they are over 5 years of age.

Only children with underlying health risks require catch up doses if they’re over 5 years of age.

Some schools require at least one dose, so children over 5 years who have never had this vaccine may be required to be vaccinated despite the CDC guidelines. While this is safe, it may not be covered by insurance. (Another great reason to stay on the routine schedule as much as possible!)

DTaP and Tdap (D and d = diptheria, T = tetanus, P and p = pertussis/whooping cough)

The DTaP vaccine is typically given at 2, 4, 6 months and then boosters at 15-18 months and 4-6 years of age. If the full series hasn’t been given, it is okay to complete it up until the 7th birthday with the DTaP.

If the child is over age 7, the Tdap should be given instead of the Dtap. These cover the same diseases, but the Dtap has a higher diphtheria component than the Tdap (as indicated by the capital letters).

The Tdap is the booster that is usually given at 11-12 years of age, but can be used as early as 7 years if the Dtap series was not completed or if there is a wound requiring a tetanus booster.

If additional doses are needed after one Tdap, Td boosters can be used to complete the primary series.

Tetanus boosters are recommended every 10 years and with each pregnancy. The Td vaccine is recommended for most of these boosters. Exceptions are that the Tdap  should be used during pregnancy and can be used if the Td is not available.

Polio

In the US, the standard polio vaccine schedule is 4 doses at 2, 4, 6-18 months and 4-6 years.

In other countries it is given soon after birth and there are additional doses. Even if a child has had more than 4 doses, if one was not given after the 4th birthday, an additional dose is needed.

Conversely, if the 3rd dose was given after the 4th birthday and 6 months or more after the previous dose, a 4th dose is not needed.

Typhoid

The typhoid vaccine is not on the standard US vaccine schedule. It’s recommended for many travelers and it might involve at-home compliance, so I decided to include it.

The injectable typhoid vaccine is recommended for 2 years of age and up and can be repeated every 2 years. Talk to your doctor to see where it is available, since they may or may not keep it in stock.

The oral typhoid vaccine is the one that can be complicated. It can be given to children over 6 years of age through adult years. It is boosted every 5 years. Even though it is a vaccine, it is given in pill form by mouth. It should be given on an empty stomach every other day for a total of 4 doses. The pills should be kept in the refrigerator, which can make them hard to remember. Because they are a live virus vaccine, they should not be taken with antibiotics. If antibiotics are required during the week of administration, the vaccine won’t be as effective and doses might need to be repeated. If there are forgotten doses, talk to your physician to be sure the series does not need to be repeated.

So… What happens if a vaccine booster is delayed?

Talk to your pediatrician (or the people where you get your vaccines) to make a plan to catch up on immunizations.

Good news! The CDC has a catch-up schedule that gives a timeline of when to give various vaccines if you’re off the typical schedule.

What happens if a vaccine booster is delayed
Source: https://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf#page=3

There’s even a cool vaccine scheduler that you can use to estimate what vaccines your child needs.

Talk to your physician to help decide how to catch your family up on their vaccines.

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Common risks from shots: real and perceived

Parents want to keep their kids as healthy as possible, but with the overwhelming amount of information found on media these days, it’s hard to know what is safe and what risks really are when it comes to vaccines. What are the common risks from shots?

Nothing we do is without risk.

risks from vaccines
There are many unfounded fears about vaccines. What are the real risks?

The most risky thing most of us do daily is to get in a car and drive somewhere.

We can minimize the risk by wearing a seatbelt and putting our kids in the proper sized car seat, obeying the traffic laws, and adjusting our driving to the road and weather conditions, but there is always the chance of an accident.

For most of us, the risk of an accident is outweighed by the benefits of getting to where you need to go.

 

Some people want you to think we give kids green toxin-laden vaccines from huge syringes (at least if you look at the photos like I show above). But no, vaccines don’t look green, and we don’t inject them like most stock photos show.

Vaccines have risks, but more benefits.

The benefits are many, including preventing early death from infection. The risks are often overblown, but do exist.

What about package inserts?

You might have read somewhere that you should read the package insert of vaccines before allowing your child to get a vaccine, like there’s some big secret everyone’s trying to hide.

No one’s hiding anything. They’re available online.

The problem isn’t hidden information, it’s people mistaking what is written for something that it’s not.

The package insert has a lot of information, but it’s designed for legal reasons, not consumer information sharing.

Some groups who try to warn people about vaccines encourage the reading of package inserts to learn risks of the vaccines.

This can lead to undue fear and confusion because not all problems recorded in the adverse reactions section of the package insert are due to the vaccine.

If someone fell out of a tree and broke his leg after a vaccine and reported it during vaccine trials, “broken leg” could be listed as a reaction. It does not mean that the vaccine broke the leg or caused the broken leg in any way, but it is reported in a way that can make it look like there is a cause and effect relationship.

More realistically, it is common for people to have headaches or congestion, so these types of things get reported for most medicines in their package inserts. It does not mean the medicine caused the headache or congestion, just that people had those symptoms during the study period.

For a more detailed description of package inserts, see Package Inserts – Understanding What They Do (and Don’t) Say.

Common Risks from shots that are known

The risks of all vaccines are similar. Specific risks can be found on the Vaccine Information Sheets, which are designed to educate consumers about risks and benefits.
These risks include:
Pain with injection

This is very subjective.

Most babies cry, but typically as soon as they are cuddled by a parent they quickly calm down.

Toddlers are more prone to longer crying times, but that often starts unrelated to the vaccine and is not solely due to pain. It’s often due to their frustration and/or fear of being in the doctor’s office.

Older kids often will say the pain was less than they feared, but some do complain for several minutes. Moving the arms or legs that were injected can help ease this pain.

You can do many things to help kids tolerate the shots with less pain.

Fever

A mild fever can occur for a day or two after many vaccines.

Most kids do not need any fever reducers for this. The fever reducers might even reduce some of the effectiveness of the vaccine, so are not routinely recommended after vaccines.

If the temperature is over 102F or the child is very fussy with the fever, it is okay to use a fever reducer. These higher fevers are not common after vaccines, but are possible.

Fussiness or feeling mildly ill

Infants can be fussy for a few days and older kids might say they feel tired or have a headache.

Some kids (and adults) will feel like they’re getting sick, but it never evolves into an illness and it stays mild.

Extra sleep would be beneficial, but typically no treatment is needed.

Non-stop crying

While unusual, it is possible that an infant will cry for hours after one or more vaccines.

If this occurs, you can try a pain reliever.

If the crying doesn’t stop, have your child examined to identify if something significant is causing the crying.

Seizure

It is not common to have a seizure after a vaccine, but whenever a child under 5-6 years of age has a fever, it’s possible to have a fever seizure.

Most fever seizures are from viral illnesses, some of which are prevented by vaccines.

Vaccines rarely cause fever seizures, but if the temperature increases rapidly after a vaccine in a susceptible child, it’s possible.

If a child has a fever seizure, it is scary to watch but does not lead to permanent brain damage.

Interestingly, studies show that delaying the MMR past 15 months increases the risk of seizures.

Any child who has a first time seizure should be evaluated for potential causes and treatments.

Pain, tenderness and swelling

vaccine side effect redness
This is my arm 2 days after a Tdap. The area was swollen, warm and red. The redness has irregular borders, looking lacy in appearance, which is common in shot reactions. I didn’t need any pain relievers. The muscle was sore from the tetanus, but the redness wasn’t uncomfortable.

Some vaccines, such as DTaP and Tdap, are more prone to swelling and redness than others.

The most swelling tends to happen after several doses of these vaccines, such as with kindergarteners, tweens, or adults.

My son’s arm was so swollen after kindergarten shots that he couldn’t fit into some of his shirts with narrow sleeves, but it was a normal shot reaction.

With a shot reaction the inflammation begins a few hours after vaccination, peaks 24 to 48 hours afterward and resolves within one week.

Tenderness is usually at its worst during the first few hours and resolves as the reaction enlarges.

The amount of swelling and redness is more significant than pain or tenderness with a classical vaccine reaction.

Infection of the injection site

Very rarely the area can become infected (cellulitis) but this is exceedingly rare now that most childhood vaccines come in single dose syringes.

Cellulitis can evolve rapidly — often within 12 to 24 hours.

Diagnosis is based on the symptoms of redness, pain, swelling and warmth, usually with fever and ill appearance.

Most redness and swelling is a normal shot reaction and not a sign of infection. If your child seems ill along with a painful red and swollen area where the vaccine was injected, it might be wise to have your doctor take a look at it.

Risk vs Benefit

The risks above must be weighed against the benefits of vaccinating.

In my family, we vaccinate against all recommended vaccine preventable diseases by following the standard schedule.

I advise that most people do the same. There are those who cannot receive vaccines due to age or health status, and they depend on us all to vaccinate.



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The flu shot doesn’t work

I’ve seen a few kids this season who have influenza despite the fact that they had the vaccine. When the family hears that the flu test is positive (or that symptoms are consistent with influenza and testing isn’t done), they often say they won’t do the flu shot again because it didn’t work.

How do they know it isn’t working?

Influenza can be deadly.

Most of the kids I’ve seen with flu who have had the shot aren’t that sick. Yes, they have a fever and cough. They aren’t well.

But they’re not in the hospital.

They’re not dying.

They tend to get better faster than those who have unvaccinated influenza.

Some kids still get very sick with influenza despite the vaccine.

That’s why there’s surveillance to see how it’s working.

When FluMist was determined to not be effective, it was removed from the market.

Studies are underway to make a new type of flu vaccine that should be more effective.

We know the shot isn’t perfect, but it’s better than nothing.

Maybe if you weren’t vaccinated you’d be a lot sicker.

Maybe you were exposed to another strain of flu and didn’t get sick at all.

I think it’s still worth it to get vaccinated each year (until they come up with a vaccine that lasts several seasons).

If everyone who’s eligible gets vaccinated against the flu, herd immunity kicks in and it doesn’t spread as easily. Historically only around 40% of people are vaccinated each year against influenza. We know that to get herd immunity we need much higher numbers.

Shot fears…

If your kids are scared of shots, check out Vaccines Don’t Have to Hurt As Much As Some Fear.

Don’t rely on Tamiflu to treat flu symptoms once you’ve gotten sick.

Tamiflu really isn’t that great of a treatment. It hasn’t been shown to decrease hospitalization or complication rates. It shortens the course by about a day. It has side effects and can be expensive. During flu outbreaks it can be hard to find.

Prevention’s the best medicine.

Learn 12 TIMELY TIPS FOR COLD AND FLU VIRUS PREVENTION.

Get your flu vaccine. #fluvaccine #vaccineswork
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Fever Is…

Fever is scary to parents.

Parents hear about fever seizures and are afraid the temperature will get so high that it will cause permanent brain damage. In reality the way a child is acting is more important than the temperature. If they’re dehydrated, having difficulty breathing,  or are in extreme pain, you don’t need a thermometer to know they’re sick.

Fever is uncomfortable.

Fever can make the body ache. It’s often associated with other pains, such as headache or muscle aches. Kids look miserable when they have a fever. They might appear more tired than normal. They breathe faster. Their heart pounds. They whine. Their face is flushed. They are sweaty. They might have chills, causing them to shake.

Fever is often feared as something bad.

Parents often fear the worst with a fever:

Is it pneumonia? Leukemia? Ear infection?

Fever is good in most cases. 

In most instances, fever in children is good. It’s a sign of a working immune system.

Fever is often associated with decreased appetite.

This decreased food intake worries parents, but if the child is drinking enough to stay hydrated, they can survive a few days without food. Kids typically increase their intake when feeling well again. Don’t force them to eat when sick, but do encourage fluids to maintain hydration.

Fever is serious in infants under 3 months, immunocompromised people, and in underimmunized kids.

These kids do not have very effective immune systems and are more at risk from diseases their bodies can’t fight. Any abnormal temperature (both too high and too low) should be completely evaluated in these at risk children.

Fever is inconvenient.

I hate to say it, but for many parents it’s just not convenient for their kids to be sick. A big meeting at work. A child’s class party. A recital. A big game or tournament.  

Whatever it is, our lives are busy and we don’t want to stop for illness. Unfortunately, there is no treatment for fever that makes it become non-infectious immediately, so it is best to stay home. Don’t expose others by giving your child ibuprofen and hoping the school nurse won’t call.

Fever is a normal response to illness in most cases.

Most fevers in kids are due to viruses and run their course in 3-5 days. Parents usually want to know what temperature is too high, but that number is really unknown (probably above 106F). The height of a fever does not tell us how serious the infection is. The higher the temperature, the more miserable a person feels. That’s why it’s recommended to use a fever reducer after 102F. The temperature doesn’t need to come back to normal, it just needs to come down enough for comfort.

Fever is most common at night.

Unfortunately most illnesses are more severe at night. This has to do with the complex system of hormones in our body. It means that kids who seem “okay” during the day have more discomfort over night. This decreases everyone’s sleep and is frustrating to parents, but is common.  

Fever is a time that illnesses are considered most contagious.

During a fever viral shedding is highest. It’s important to keep anyone with fever away from others as much as practical (in a home, confining kids to a bedroom can help). Wash hands and surfaces that person touches often during any illness. Continue these precautions until the child is fever free for 24 hours without fever reducers. (Remember that temperatures fluctuate, so a few hours without fever doesn’t prove that the infection is resolved.)

Fever is an elevation of normal temperature.

Normal temperature varies throughout the day and depends on the location the temperature was taken and the type of thermometer used. Digital thermometers have replaced glass mercury thermometers due to safety concerns with mercury. Ear thermometers are not accurate in young infants or those with wax in the ear canal. Plastic strip thermometers and pacifier thermometers give a general idea of a temperature, but are not accurate.

To identify a true fever, it’s important to note the degree temperature as well as location taken. (A kiss on the forehead can let most parents know if the child is warm or hot, but doesn’t identify a true fever and therefore the need to isolate to prevent spreading illness.) I never recommend adding or subtracting degrees to decide if it is a fever. You can look at a child to know if they’re sick.

The degree of temperature helps guide if they can go to school or daycare, not how you should treat the child.

Fevers in children are generally defined as temperatures above 100.4 F (38 C).

Fever is rarely dangerous, though parents often fear the worst.

This is the time of year kids will be sick more than normal. Kids get sick more than adults. With each illness there can be fever (though not always).

What you can do:
  • Be prepared at home with a fever reducer and know your child’s proper dosage for his or her weight.
  • Use fever reducers to make kids comfortable, not to bring the temperature to normal.
  • Push water and other fluids to help kids stay hydrated.
  • Teach kids to wash their hands and cover coughs and sneezes with their elbows.
  • Stay home when sick to keep from spreading germs. It’s generally okay to return to work/school when fever – free 24 hours without the use of fever reducers.
  • Help kids rest when sick.
  • If the fever lasts more than 3-5 days, your child looks dehydrated, is having trouble breathing, is in extreme pain, or you are concerned, your child should be seen. A physical exam (and sometimes labs or x-ray) is needed to identify the source ofillness in these cases.  A phone call cannot diagnose a source of fever.
  • Any infant under 3 months or immunocompromised child should be seen to rule out serious disease if the temperature is more than 100.5.

Traveling with Kids

Many families travel when school’s out of session, which over the winter holiday season and spring break means traveling when illness is abound. I get a lot of questions this time of year about how to safely travel with kids. Traveling with kids can increase the level of difficulty, but it can be done safely and still be enjoyable!

Sleep disturbances

Sleep deprivation can make everyone miserable, especially kids (and their parents). Make sure your kids are well rested prior to travel and try to keep them on a healthy sleep schedule during your trip.
  • Bring favorite comfort items, such as a stuffed animal or blankie, to help kids relax for sleep. If possible, travel with your own pillows.
  • If you’re staying at a hotel, ask for a quiet room, such as one away from the pool and the elevator.
  • Be sure to verify that there will be safe sleeping areas for every child, especially infants, before you travel.
  • Try to keep kids on their regular sleep schedule. It’s tempting to stay up late to enjoy the most of the vacation, but in reality that will only serve to make little monsters of your children if they’re sleep deprived.
  • If your kids nap well in the car, plan on doing long stretches on the road during nap time. If kids don’t sleep well in the car, be sure to plan to be at your hotel (or wherever you’re staying) at sleep times so they can stay in their usual routine.
  • Some families leave on long trips at the child’s bedtime to let them sleep through the drive. Just be sure the driver is well rested to make it a safe trip!
  • If you’re changing time zones significantly, plan ahead. Jet lag can be worse when traveling east than when going west. Jet lag is more than just being tired from a change in sleep routine, it also involves changes to the eating schedule. Kids will often wake when they’re used to eating because the body is hungry at that time. Try to feed everyone right before they go to sleep to try to prevent this. Breastfed infants might have a harder time adjusting because mother’s milk production is also off schedule.
  • Tired, sick, and hungry all make for bad moods, so try to stay on track on all accounts. Sunlight helps regulate our circadian rhythm, so try to get everyone up and outside in the morning to help reset their inner clocks. Keep everyone active during the day so they are tired at the new night-time.

Keeping track of littles

  • Toddlers and young kids love to run and roam. Be sure that they are always within sight. Use strollers if they’ll stay in them.
  • Consider toddler leashes. I know they seem awful at first thought, but they work and kids often love them! I never needed one for my first – he was attached to parents at the hip and never wandered. My second was fast. And fearless. She would run between people in crowds and it was impossible to keep up with her without pushing people out of the way. She hated holding hands. She always figured out ways to climb out of strollers – and once had a nasty bruise on her forehead when she fell face down climbing out as I pushed the stroller. She loved the leash. It had a cute monkey backpack. She loved the freedom of being able to wander around and I loved that she couldn’t get too far.
  • Parents have a number of ways to put phone numbers on their kids in case they get separated. Some simply put in on a piece of paper and trust that it will stay in a pocket until it’s needed. Others write it in sharpie inside a piece of clothing or even on a child’s arm. You can have jewelry engraved with name and phone number, much like a medical alert bracelet. Just look at Etsy or Pinterest and you’ll come up with ideas!
  • It’s a great idea to take pictures of everyone each morning in case someone gets separated from the group. Not only will you have a current picture for authorities to see what they look like, but you will also know what they were wearing at the time they were lost.
  • If you want more, I wrote a whole blog on keeping kids from wandering.

Airplane issues

  • The great news is that air travel is much safer from an infection standpoint than it used to be. Newer airplanes have HEPA filters that make a complete air change approximately 15 to 30 times per hour, or once every 2-4 minutes. The filters are said to remove 99.9% of bacteria, fungi and larger viruses. These germs can live on surfaces though, so I still recommend using common sense and bringing along a small hand sanitizer bottle and disinfectant wipes to use as needed. Wipe down arm rests, tray tables, seat pockets, windows, and other surfaces your kids will touch. After they touch unclean items sanitize their hands. Interestingly, sitting in an aisle seat is considered more dangerous, since people touch those seats during boarding and when going to the restroom, so if you’re seated in the aisle pay attention to when surfaces need to be re-sanitized. Sitting next to a sick person increases your risk, so if there is an option to move if the person seated next to you is ill appearing, ask to be moved.
  • Most adults who have flown have experienced ear pain due to pressure changes when flying. Anyone with a cold, ear infection or congestion from allergies is more at risk of ear pain, so pre-medicating with a pain reliever (such as acetaminophen) might help. If you have allergies be sure to get control of them before air travel. The best allergy treatment is usually a nasal corticosteroid.
  • It has often been recommended to offer infants something to suck on (bottle, breast or a pacifier) during take off and landing to help with ear pressure. Start early in the landing – the higher you are, the more the pressure will change. Older toddlers and kids can be offered a drink since swallowing can help. Ask them to hold their nose closed and try to blow air out through the closed nostrils followed by a big yawn. If your kids can safely chew gum (usually only recommended for those over 4 years of age) you can allow them to chew during take off and landing.
  • Airplane cabin noise levels can range anywhere from 60 – 100 dB and tend to be louder during takeoff. (I’ve written about Hearing Loss from noise previously to help you understand what that means.) Use cotton balls or small earplugs to help decrease the exposure, especially if your kids are sensitive to loud noises.
  • The Car Seat Lady has a great page on knowing your rights when flying with kids.

Cruise ship issues

  • Learn about cruise-specific opportunities for kids of various ages. Many will offer age-specific child care, “clubs” or areas to allow safe opportunities for everyone to hang out with people of their own age group. Cruises offer the opportunity for adventurous kids to be independent and separate from parents at times, allowing each to have a separate-yet-together vacation. Travel with another family with kids the same ages as yours so your child knows a friendly face, especially if siblings are in a different age group for the cruises “clubs”.
  • Talk to kids about safety issues on the ship and make sure they follow your rules. They should always stay where they are supposed to be and not wander around. There’s safety in numbers, so have them use a buddy system and stick with their buddy. Find out how you can get a hold of them and they can get a hold of you during the cruise.
  • Of course sunscreen is a must. Reapply often!
  • Be sure kids are properly supervised near water. That means an adult who is responsible for watching the kids should not be under the influence of alcohol, shouldn’t read a book, or have other distractions.

Car seats (for planes, trains and automobiles)

  • I know it’s tempting to save money and not get a seat for your child under 2 years of age on a plane, but it is recommended that all children are seated in a proper child safety restraint system (CRS). It must be approved for flight, but then you can then use the seat for land travel.
  • I always recommend age and size appropriate car seats or boosters when traveling, even if you’re in a country that does not require them. Allowing kids to ride without a proper seat will probably lead to problems getting them back in their safe seat when they get back home. Besides, we use car seats and booster seats to protect our kids, not just to satisfy the law.
  • So… my section header was meant to be cute. Trains don’t have seatbelts, so car seats won’t work. But they are a safe way to travel. Car Seat for the Littles has a great explanation on Travel by Train.

Motion sickness

When should pregnant women and new babies avoid travel by air?

  • A surprising number of families either must travel (due to a job transfer, death in the family, out of state adoption, or other important occasion) or choose to travel during pregnancy or with young infants.
  • Newborns need constant attention, which can be difficult if the seatbelt sign is on and needed items are in the overhead bin. New parents are already sleep deprived and sleeping on planes isn’t easy. New moms might still have swollen feet and need to keep their feet up, which is difficult in flight. Newborns are at high risk of infection and the close contact with other travelers can be a concern. And traveling is hard on everyone. But the good news is that overall young infants tend to travel well.
  • It is advisable to not travel after 36 weeks of pregnancy because of concerns of preterm labor. Pregnant women should talk with their OB about travel plans.
  • Some airlines allow term babies as young as 48 hours of age to fly, but others require infants to be two weeks – so check with your airline if you’ll be traveling in the first days of your newborn’s life. There is no standard guideline, but my preference would be to wait until term babies are over 2 weeks of age due to heart circulation changes that occur the first two weeks. Waiting until after 6 weeks allows for newborns to get the first set of vaccines (other than the Hepatitis B vaccine) prior to flight would be even better. Infants ideally have their own seat so they can be placed in a car seat that is FAA approved.
  • Babies born before 36 weeks and those with special health issues should get clearance from their physicians before traveling.
  • Overall traveling with an infant is not as difficult as many parents fear. Toddlers are another story… they don’t like to sit still for any amount of time and flights make that difficult. They also touch everything and put fingers in their mouth, so they are more likely to get exposed to germs.

Illness prevention

Who wants to be sick on vacation? No one. It’s easy to get exposed anywhere during the cold and flu season, so protect yourself and your family.
  • Teach kids (and remind yourself) to not touch faces – your own or others. Our eyes, nose, and mouth are the portals of entry and exit for germs.
  • Wash hands before and after eating, after blowing your nose, before and after touching eyes/nose/mouth, before and after putting in contacts, after toileting or changing a diaper, and when they’re obviously soiled.
  • Cover sneezes and coughs with your elbow unless you’re cradling an infant in your arms. Infants have their head and face in your elbow, so you should use your hands to cover, then wash your hands well.

 

Make sure all family members are up to date on vaccines.

 

Keep records

Take pictures of your passport, vaccine record, medicines, insurance cards, and other important items to use if the originals are lost. Store the images so you have access to them from any computer in addition to your phone in case your phone is lost.

Have everyone, including young children, carry a form of identification that includes emergency contact information.

Create a medical history form that includes the following information for every member of your family that is travelling. Save a copy so you can easily find it on any computer in case of emergency.

  • your name, address, and phone number
  • emergency contact name(s) and phone number(s)
  • immunization record
  • your doctor’s name, address, and office and emergency phone numbers
  • the name, address, and phone number of your health insurance carrier, including your policy number
  • a list of any known health problems or recent illnesses
  • a list of current medications and supplements you are taking and pharmacy name and phone number
  • a list of allergies to medications, food, insects, and animals
  • a prescription for glasses or contact lenses

Enjoy!

Last, but not least: Enjoy your vacation!
Be flexible.

Don’t overschedule. Your kids will remember the experience, so make moments count – don’t worry if you don’t accomplish all there is to do!

Take a look at some of the Holiday Health Hazards that come up at vacation times from Dr Christina at PMPediatrics so you can prevent accidents along the way.

Take pictures, but don’t make the vacation about the pictures. Try to stay off your phone and enjoy the moments!

10 Reasons Not To Get the Flu Vaccine, Reconsidered: Fight Flu!

Influenza is not a just a bad cold. People sick with the flu can suffer from fevers, cough, sore throat and body aches. If you want to prevent this and more complications, don’t brush off getting the flu vaccine. There are many reasons to get the flu vaccine.

Complications of flu

Flu can lead to complications, many of them severe, and death.

Complications include pneumonia, ear infections, and sinus infections.

Since 2010, influenza has resulted in between 9.2 and 35.6 million illnesses, between 140,000 and 710,000 hospitalizations and between 12,000 and 56,000 deaths each year. 

There’s good news though. There’s a vaccine to help prevent the flu.

Reasons to get the flu vaccine

There are many reasons people don’t get the flu vaccine, but many of those reasons deserve a second thought.

1. The flu vaccine doesn’t work.

While it’s true that the vaccine has variable efficacy, it’s important to get the vaccine each year. The more people vaccinated, the less likely the flu will spread through a community. Take a look at this really cool representation of how herd immunity works. How it was developed is described on IFLS.

No one claims that the vaccines against influenza work perfectly. The influenza virus can mutate by shifting and drifting.

Until there’s a universal flu vaccine, we must rely on experts to look at the viral patterns and predict the strains that will be most predominant in the upcoming season and make a vaccine against those strains.

Despite not working 100% of the time, the flu vaccine has been shown to lessen the severity of illness and decrease hospitalizations and deaths.

Even if there’s not a perfect match, it can still help those who are vaccinated have a lesser illness.

That’s worth something.

2. I got the flu from the vaccine.

The influenza vaccine that is currently available cannot cause the flu. Only live virus vaccines can lead to forms of the disease.

The vaccines available in the US this season are either an inactivated or a recombinant vaccine. These do not cause flu symptoms. The vaccines cannot mutate to cause symptoms. They simply don’t work that way.

There are many reasons you could have gotten sick after a flu vaccine that were not due to the vaccine.
  1. You were exposed to influenza before the vaccine had time to take effect and protect.
  2. You  caught a strain of influenza that wasn’t covered in the vaccine.
  3. You caught one of a number of other viruses that cause flu – like illness.
  4. The vaccine did cover the type of virus you have but your body didn’t make the proper protection from the vaccine so you were still susceptible.

In each of these scenarios, you still would have gotten sick if you hadn’t had the vaccine, but if you recently had the vaccine it’s easy to understand the concern that the vaccine caused the illness.

The FluMist is a live virus vaccine, so it could cause mild symptoms of influenza viruses, but it is not recommended for use in the US this year.

3. I can prevent the flu by being healthy.

It is important to eat right, exercise, get the proper amount of sleep, and wash hands. All of these things help keep us healthy, but they don’t prevent the flu reliably.

We cannot boost our immune system with megadoses of vitamins. (Vaccines are the best way to boost our immune system.)

Organic and non-GMO

Organic and non-GMO foods don’t offer any benefit to our immune system over other healthy foods.

If these things did as some claim, people generations ago would have been healthier since they ate locally grown organic foods, got plenty of fresh air, and exercised more in their day to day life than we do these days.

Instead of being healthier, they were much more likely to die from infections. The risk of death between the first and 20th birthday had decreased from over 3 in 100 children in 1900, to less than 2 in 1000 children today.

One of the major causes of death historically (and still today) is from influenza, but it has been shown that the flu vaccine reduces the risk of death. Why not help your body prepare for flu season with the vaccine?

4. Flu vaccines shouldn’t be used during pregnancy — they’ve never been tested and can lead to miscarriage.

Pregnancy is considered a high risk condition for severe complications of influenza disease and the vaccine can help prevent those complications.

It is recommended that all pregnant women get vaccinated against influenza. If a pregnant mother gets the vaccine, it not only helps to prevent complications during pregnancy, but it also helps prevent influenza in newborns since they can’t be vaccinated until 6 months of age.

There are some who assert that since the package inserts state the vaccines have not been studied in pregnancy that they aren’t safe, but in the next breath they say that they aren’t safe because a study showed a high rate of miscarriage after the vaccine.

The first part of the argument is one of the many ways the package insert is misused.

Package Inserts – no big secret, but don’t misuse them

Discussions about using package inserts properly are found at The Logic of Science, another at The Logic of ScienceSkeptical RaptorHarpocrates Speaks, and even this analogy of Package Insert Airline to vaccine package inserts.

Think about it… you can’t argue that it’s never been studied and then quote a study. It’s been studied.

A lot.

The Vaccine Safety Datalink is a huge database designed to document adverse events associated with vaccination, allowing researchers access to a large amount of data.

The flu vaccine has been safely given to pregnant women for over 50 years.

Despite a recent small study suggesting a potential risk of miscarriage, the flu vaccine has been studied extensively around the globe and found to be not only safe but effective at decreasing the risk of influenza disease during pregnancy and beyond.

5. I have a chronic illness and don’t want to get sick from the shot.

People with chronic illnesses (including diabetes, heart conditions, and asthma) are more at risk from serious illness from influenza disease.

The influenza vaccine can prevent hospitalizations and death among those with chronic diseases. People with chronic diseases should be vaccinated, as should those around them to protect with herd immunity.

The flu shot cannot make anyone sick, even those who are immunocompromised.

You do not need to avoid being around someone who is sick or immunocompromised if you’ve recently been vaccinated.

6. If I get the flu I’ll just take medicine to feel better.

There is no medicine that makes people with influenza feel better reliably.

There is no medicine that decreases the spread of influenza to friends and family of those infected.

We can take fever reducers and pain relievers, but they don’t treat the underlying virus.

They suppress our immune system so we don’t make as much inflammation against the virus, which decreases the symptoms and our body’s natural defenses.

Cough and cold medicines simply don’t work well.

As for antiviral medicines, I have written about Tamiflu and why I rarely recommend it.

Megadoses of vitamin C or other vitamins, homeopathic treatments, essential oils, and other at home treatments have not been shown to significantly help.

It is important if you get sick, you should limit contact with others. This means missed school and work for at least several days with influenza. Prevention with the vaccine simply is better than trying to treat the symptoms.

7. I don’t like shots. (Or my child doesn’t like shots.)

I’m a pediatrician. Most of my younger patients hate shots.

Like really hate shots.

They cry, scream, kick, try to run and hide — you name it, they’ve tried it to try to avoid shots. They fear shots, but we can help them with techniques that lessen the pain, and they often say “it wasn’t that bad” afterwards.

For more on how we can help lessen the pain, check out Vaccines don’t have to hurt as much as some fear.

8. I have an egg allergy so can’t get flu shots.

In previous years there was a concern that people with egg allergy would have a reaction from the vaccine so it was not recommended, but it has been found to be safer and still appropriate to vaccinate with proper precautions.

People who have had only hives after egg exposure can safely get flu vaccines following standard protocols.

People who have symptoms of anaphylaxis with egg exposure that requires epinephrine (respiratory distress, lightheadedness, recurrent vomiting, swelling – such as eyes or lips) should still get the vaccine, but they should be monitored at the appropriate facility (doctor’s office, hospital, health department) for 30 minutes to monitor for reactions.

9. Vaccines are only promoted to make people money. Doctors are shills.

Very little profit is made from any vaccine.

Really.

Some doctors and clinics lose money by giving vaccines.

I often tell my own patients that I don’t care if they get the vaccine at my office, the local pharmacy, or at the parent’s office – whatever works for them best. I just want everyone vaccinated.

This in the end will decrease my revenue because they will not come to the office seeking treatments for a preventable illness.

But I am a pediatrician to take care of the health of children, not to make money.

Pediatricians are consistently on the bottom of the list of physician salaries.

If I was in it for the money, I would have gone into orthopedics or another surgical specialty.

There are many things to consider when addressing this argument and the Skeptical Raptor does it well, including links to more information.

10. The flu vaccine contains mercury.

While it is true that some flu vaccines contain thimerosal, not all do.

Thimerosal was removed from the majority of childhood vaccines in 2001 due to lawmakers responding to constituent demands, not because it was shown to be a risk medically.

Since the flu vaccine is not only for children, there are multidose vials that contain thimerosal.

If that really bothers you, ask for a version without thimerosal.

But since it was removed because people thought thimerosal caused autism and the rates of autism haven’t gone down since it was removed, that’s pretty strong evidence that it never caused autism.

Just like the scientists said.

It’s a preservative that is effective.

I would gladly get a flu vaccine with thimerosal, and have over the years, but the majority of flu vaccines given to children in the US are thimerosal free.

Just ask.

Flu Vaccine Information and Recommendations for the 2017-2018 Season

  • Both trivalent (3 strain) and quadrivalent (4 strain) vaccines are approved for use this year. There is no preference officially of one over the other, but the vaccine should be appropriate for age.
  • No FluMist Nasal Spray flu vaccine is recommended. The nasal spray did not work well in the last few seasons it was used in the US. Until it is understood why it wasn’t effective then how to make it effective, it will not be recommended.
  • Pregnant women should be vaccinated to protect themselves and their baby.
  • Everyone over 6 months of age should be vaccinated. Children 6 months to 8 years who have only had one flu vaccine in their past will need two doses this season. This is because the first dose acts as a primer dose, then a booster dose boosts the immune system. Once the body has had a boost, it only needs a boost each year to improve immunity.
  • Infants under 6 months of age can gain protection if their mother is vaccinated during pregnancy and if everyone around them is vaccinated. They cannot get the flu vaccine until 6 months of age.
  • People with egg allergy can be vaccinated. If there is a history of anaphylaxis to egg, they should be monitored for 30 minutes.
  • The CDC is encouraging everyone to be vaccinated by Halloween if possible, but it’s not too late to be vaccinated after that if not yet done this season. It takes up to 2 weeks for the vaccine to be effective. Flu season typically starts in January, but the peak can be as early as November and as late as March.
  • It is acceptable and encouraged to give the flu vaccine along with other recommended vaccines needed.

 

 

Related blogs

Vaccines don’t have to hurt as much as some fear

Tamiflu: Guest blogger Dr. Mark Helm
Tamiflu Status Downgraded

Tamiflu: the not-so-great influenza treatment

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flu shot
Just do it… get your flu shot!

Vaccines Don’t Have to Hurt As Much As Some Fear

Many kids are scared of shots. Some even fight parents and nurses when it’s time to get shots. The more they fight and worry, the worse it gets. But it doesn’t have to be that way.

Increasing the fear

In general there are some things that increase anxiety about shots or just make them seem bad.

Lying

Do not tell kids it won’t hurt. Shots can hurt. Lying doesn’t help. It just minimizes their fear and makes things worse. It might hurt, but how much is variable. Pain is a very individualized feeling. You can describe it as a pinch. Some kids do better with advance warning.

No promises

Never tell kids they won’t get a shot at the doctor’s office. They might be due for one (or more) and if they were specifically told they won’t get one, they are usually more upset.

Threats

Don’t threaten kids with shots if they misbehave. This makes kids see shots as a negative.

Siblings

Siblings can increase anxiety with their teasing. Don’t share the need for shots with siblings and if it’s possible to leave siblings at home when one child will need shots, that might work best.

Your fears

Some kids worry more because parents are worried or presume the child will be worried. When the parent starts talking about shots in a worrisome manner it feeds into the fear. Try to be factual. Don’t start telling them it’s okay and not to worry. That tells them there’s something to worry about.

Building anticipation

Some kids do best if they don’t know shots are coming. If they ask if they’ll get shots at an upcoming visit, you can say you don’t know. If you think your child will lose sleep for days worrying about the shots, this is often the best way to handle it. Then the doctor and nurse at the office can deliver the news and it isn’t your fault.

How to prepare

If you want to prepare your kids before bringing them in for shots or if you just need some help when you’re at the office, follow these tips:

Risks and Benefits

I often ask kids if they’ve ever gotten hurt playing outside. They usually say yes. Then I ask if they still wanted to play outside again. They usually say yes. I might sound surprised that even though they know that they can get hurt, they still want to play, but then I “realize” that it was because the benefit (playing) outweighs the risk (getting hurt). Then we talk about the benefits of the shot are so much more than the quick poke and a little pinch feeling. This works really well for the middle school shots because they’re old enough to get the connection.

Medicine?

Don’t pre-treat with an oral pain reliever. Studies have shown that acetaminophen and ibuprofen decrease the immune response, which might make the vaccines less effective.

Crying’s okay

Don’t tell kids to not cry. It’s okay to be scared and to feel pain. Let them know what is and is not okay. If they cry it’s okay. It is not okay to kick, hit, run, or do anything that can harm others or themselves.

Education

Educate kids about how vaccines help us. There are many resources available. When they understand why the shots are good for them, it helps them to accept them.

Practice

Practice what happens when we get shots.

Have them practice sitting still and making their arms loose.

Wipe the arm with a tissue as you explain the person giving the shot will clean the area with a very cold wet tissue to clean the area. (I avoid the term alcohol swab because the term alcohol confuses younger kids who learn about drug prevention in school.)

Pinch the arm to show them there will be a small pinching feeling.

Put a bandaid on the area if they like or just explain that they can get a bandaid when it’s over. (If your child hates bandaids, tell the person giving shots that they prefer to not have them.)

Let them practice giving you a “shot” too.

Show that the poke will be fast and they can move their arms up and down afterwards to make the sting go away.

Lovies

Bring a comfort item from home, such as a stuffed animal or blankie.

Blowing

There is evidence that blowing out or coughing during the injection helps decrease the pain. We often recommend this for kids old enough to blow or cough.

Sometimes we’ll entice preschoolers with bubbles or pinwheels. It really helps!

Distraction

Other forms of distraction can help too. Telling stories, reading books, or watching a video on a smart phone or tablet are great distractions.

Sit vs Lay Down

Studies have shown that allowing kids to sit (rather than force laying down) during shots is perceived as less painful. The less restraining the child needs, the better. It makes sense that if they need to be held down they will be more scared and it will be perceived as more painful.

I have seen tweens and teens prefer to lay down if they have a history of getting light headed with needles or they’re worried about fainting.

Order of vaccines

Ask the person giving the vaccines to save the most painful vaccine for last, if applicable. (Our nurses do this routinely.)

Pain DISTRACTOR devices

Our office sometimes uses Buzzy when kids are especially afraid of shot pain. As long as the child isn’t overly worked up and they aren’t opposed to the coldness of the ice, Buzzy works fantastically! If kids have worked themselves into a frenzy it isn’t sufficient to distract in this way.

Bribery

I used to think bribery was not a good parenting technique… until I had kids. It can be very effective. If you can promise a reward for being brave, such as stopping for a smoothie or getting a favorite treat, that can work wonders.

Just do it

I like this Dr. Mom’s take on getting shots. Dr. Corriel knows that her son will just need to do it. Fear and all.

Help with anxieties in general

(great for life worries, not just shots!)

Build up bravery

After kids do things that they were afraid of, congratulate them for the attempt. Remind them that even though they were scared they did it. This helps set the pattern that they can be brave when faced with any fear.

Kids can even keep a list of things that they did despite being scared to try. Make a “Bravery Book.”

They can use the list whenever a new fear pops up to see how many things they’ve already done and how brave they really are.

video to future self

I’ve started recommending that parents take a video of kids to show their future self if they can say it didn’t hurt as much as they worried it would.

We all tend to remember the anxious phase of excessive worry, but forget that it wasn’t that bad.

Show the video the next time shots are due. Their own self stating it wasn’t bad can be reassuring!

Meditation

Use a meditation app, such as Stop, Breathe & Think. It’s free and helps with general anxieties as well as mindfulness. Download it and use it at home several times to let them get comfortable using it.

Some great articles:

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