As she examined 11-day-old Asher, her eighth patient of the day, Alissa Parker talked to his parents about his sleep habits, the nub of his umbilical cord that had yet to fall off and a harmless rash on his bottom.
Nine minutes into the appointment, she gently probed: Had they given any more thought to a shot that would protect Asher from respiratory syncytial virus, or R.S.V.? No, they demurred, not yet.
Dr. Parker, a pediatric nurse practitioner at Primary Plus, a community clinic in Ashland, Ky., did not push. Asher’s parents, Autumn and James Skaggs, had already declined the hepatitis B vaccine when he was born, and planned to refuse all the other routine childhood vaccinations.
“If there’s any way I can answer your questions and make you feel more comfortable about it, I’m happy to,” she said. Then she left the room.
Across the country, clinicians like Dr. Parker, who also holds a doctorate in nursing practice, are contending with a sharp rise in vaccine hesitancy. They are trying to do what is best for children’s health while staying sensitive and supportive, even as they bear the brunt of parents’ mistrust and confusion.
Skepticism about vaccines was once a fringe view, held by a small group of Americans. But the Covid-19 pandemic, with its mandates and rapid rollout of vaccines, breathed new vigor into the anti-vaccine movement and bred hostility toward the medical establishment.
Now vaccine skepticism emanates from the highest echelons of the U.S. government. Over the last year, Health Secretary Robert F. Kennedy Jr. and his associates have questioned the safety of childhood vaccines, made false statements about their effectiveness and rescinded recommendations for routine vaccination against a half-dozen diseases.
And despite the fact that pediatrics is the lowest paid medical specialty — as pediatricians are quick to point out — Mr. Kennedy and others have portrayed its practitioners as greedily promoting vaccines in order to earn fat profits.
In a survey by the health research group KFF in September, 16 percent of parents said they had skipped or delayed at least one childhood vaccine other than for flu or Covid-19. And doubts about vaccines are increasingly spilling into refusal of other mainstays of pediatric medicine, including antibiotics, medications like Tylenol and diagnostic procedures like spinal taps.
At a hospital in Boise, Idaho, for example, three infants died last year after their parents declined a shot of vitamin K, administered to newborns to prevent bleeding, said Dr. Amanda Lee, a pediatrician there.
Parents have always had questions about vaccines, but Dr. Lee and other pediatricians say they are now finding their expertise to be sometimes powerless against the flood of misinformation.
“Families are not actually interested in information or facts or rates of side effects,” Dr. Lee said.
“Logic is no longer part of the discussion,” she added. “It’s just kind of based on a feeling.”
Most parents still say they consider pediatricians the most trusted source of information. But the messaging about vaccines is straining even the strongest relationships.
“It’s getting harder and harder to maintain that connection that we have with families,” Dr. Kenneth Strzelecki, a primary care pediatrician at Children’s Wisconsin in Milwaukee, said. “We’re up against a lot of noise.”
For some practitioners, it has proved to be too much: They are contemplating leaving the profession.
“It’s just a really a sad and stressful time for pediatricians,” said Dr. Megan Schultz, a pediatric emergency physician at Children’s Wisconsin in Milwaukee. “I really worry about us a field, honestly.”
Trust is the key
Bethany Browning knows exactly what turned her away from the medical system — and what brought her back.
When her daughter, now 14, was hospitalized with a fever as an infant, she said, a series of health care workers made her feel stupid and threatened to report her to child protective services for asking questions about the treatments.She found acceptance in a “natural living” community that recommended skipping vaccines.
Four years later, after her son was born, she met Dr. Parker at a group for breastfeeding mothers. “We saw differently about the vaccine thing, but she never made me feel like she thought that I was a bad parent” Ms. Browning said.
After being hospitalized twice with the flu, she realized that the infection could quickly turn dangerous and that she would never forgive herself if her children were harmed by it.
When the Covid-19 pandemic began, she said, the influencers she had trusted “started to sound absolutely insane,” rejecting masks and precautions like staying home when sick. “It definitely made me take a big step back and be like, ‘Wait, what else have you been saying that’s horrendous?’”
She turned to Dr. Parker, whom she had come to trust, and began catching her children up on their shots.
Conferences of pediatricians now routinely hold workshops on earning parents’ trust. They are training clinicians to be less authoritarian, less judgmental and more patient, said Dr. Brandan Kennedy, a pediatric hospitalist in Kansas.
Some doctors become angry and defensive when patients question their hard-won expertise and experience, he said. The training is intended to help clinicians manage the conversations “without making ourselves crazy and angry and resentful,” Dr. Kennedy said.
The conversations tend to be smoother when a family already trusts the clinician. “Definitely, I’m more successful when I have built a relationship with the family,” said Dr. Meera Nagarajan, who practices in Salt Lake City.
While many families decline vaccines for Covid and flu, the measles outbreak in Utah prompted some parents to seek out earlier doses of the measles vaccine to protect their infants, she said.
Trust is more difficult in hospitals and emergency rooms, where a doctor may be seeing a patient for the first and only time. Compounding the difficulty, those places are also where pediatricians are increasingly likely to encounter the consequences of a lack of vaccination: illnesses they were perhaps never trained to treat.
Many young pediatricians have never seen a case of measles, for example. But as the country faces multiple outbreaks of the disease, they have to prepare for the possibility that an unvaccinated child might bring the virus to their waiting rooms, exposing other patients and staff.
In Wisconsin, emergency room physicians have had to devise new guidelines for treating the increasing number of unvaccinated children who come in with fevers of unknown cause, Dr. Schultz said.
In some cases, rapid diagnosis can be a matter of life or death. Infection with Haemophilus influenzae bacteria — which is prevented by routine immunization — can lead to epiglottitis, a condition that closes the airway, causing a child to lean forward and drool. But to a pediatrician who has never encountered the condition, the illness might resemble croup.
Even old and familiar foes, like tetanus, are posing challenges. Doctors routinely recommend that children with a wound get updated tetanus shots. Having tetanus once does not provide immunity against future infections; only the vaccine can prevent illness.
But some parents of unvaccinated children still decline the protection.
At a hospital in Kansas, two unvaccinated children, a teenager and a toddler, have been hospitalized with tetanus, said Dr. Kennedy, who treated the children. The teenager’s parents opted for catch-up vaccinations; the mother of the toddler did not.
The toddler was in the hospital for three months and almost died twice. The child’s mother “seemed to listen” when Dr. Kennedy explained that the child could easily get tetanus again.
“I tried very hard to approach in a very nonthreatening manner, but at the end of the day, she refused to give a reason,” he said. “I don’t think we still fully understand how some families get to where they got.”
A fear of unknown harms
Every state requires certain vaccines to attend school, but all allow medical exemptions — if a child has cancerfor example — and nearly all honor religious reasons for refusing vaccines. Exemptions on personal or philosophical grounds are rarer, allowable in only 16 states, but the numbers are rising.
Ashland sits at the junction of Ohio, West Virginia and Kentucky, each of which has its own mix of laws.
Dr. Parker and her partner, Dr. Kelli Brown, practiced in West Virginia, which allowed only medical exemptions. (The state is in the midst of a contentious battle over religious exemptions.) Moving to Kentucky, one of the majority of states with religious exemptions, “was a really rude awakening,” Dr. Parker said.
The Skaggses, the couple in Dr. Parker’s practice, did not offer a religious reason when they announced their intention to refuse all vaccines for their son.
They have two older children, aged 15 and 12, both of whom are fully vaccinated. But they were trying “the more natural route this time around,” Mr. Skaggs said.
The older children have developed fevers from the shots but never been ill beyond that, he said. He added that he and his wife wonder now if the vaccines had any benefit or if they might have harmful ingredients that cause autism or other problems. Under Mr. Kennedy’s direction, the Centers for Disease Control and Prevention changed its website to say that “studies have not ruled out the possibility that infant vaccines cause autism.” The website previously said rigorous studies had not found a link between vaccines and autism.
The revised language, Mr. Skaggs said, was “one of the main things” that made him change his mind about vaccines.
Some shots, like those against measles, have long been a target of anti-vaccine groups, which have falsely linked them to autism. But hesitancy has now spread even to stalwarts of medical practice, like the vaccine against polio. As a result, pediatricians may find themselves spending an entire visit explaining the rationale for a single shot, shunting aside many other important topics.
Some pediatricians, like Dr. Peter Sinton in Ponca City, Okla., refuse to take on unvaccinated children as patients, worrying that having unvaccinated children in the practicecould endanger other patients who may be immunocompromised or too young for a shot.
More commonly, pediatricians opt to have parents sign a “refusal to vaccinate” form, with the understanding that they will revisit the topic periodically.
Their hope is that over time, they may slowly regain parents’ trust — as Dr. Parker did with Ms. Browning.
Looking back now, Ms. Browning said, she can see that a fear of unknown harms to her children had led her to trust the wrong people.
“I feel a little bit angry about it, because I think there is a market online where people profit from feeding off of those fears,” she said. “We were really fortunate that nothing bad happened with our kids.”
Apoorva Mandavilli reports on science and global health for The Times, with a focus on infectious diseases and pandemics and the public health agencies that try to manage them.
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