4-5 Shots at a Time; Not Just for Babies Anymore

The science of immunization continues apace. New vaccines are developed and new recommendations for old ones are elaborated. Back when I started my practice, the most shots an infant usually got at once was no more than three. Nowadays it can be easily be five. Still, once you got past the first year, which included the so-called primary series', toddlers rarely got more than one or two boosters per visit and adolescents hardly ever more than one at a time.

Times change.

Nowadays infants can routinely get up to five shots at a time: DaPT, Hib, Prevnar (PCV), polio (IPV), and Hepatitis B. There are all kinds of combination vaccines available, but with my relatively small pediatric population it's not economically viable to stock them all; hence, more needles per visit. Toddler visits can also generate up to four shots at once: MMR, Varivax (chickenpox) and Hepatitis A (brand new recommendation) along with some combination of DaPT, Hib, Polio and Prevnar boosters. I do my best to limit it to no more than 2-3 needles per visit, given that I get a shot at them (if you'll pardon the pun) at 12, 15 and 18 months.

This isn't really all that big a deal. Little kids are much more easily restrained, and they really don't remember the trauma of shots from one visit to the next. Even so, they generally forget about it by the time they've reached school age. I like to reassure the parents that it's really much more traumatic for them than it is for their child.

Times keep on changing, though.

First came the change in the recommendation for chickenpox vaccination: instead of a single dose at age 12 months, now everyone needs a booster at age 4. This means that for everyone over 4 who's only had one Varivax, they're "due" for their booster.

Next came the shift in the recommended age for the meningococcus vaccine. Previously recommended at entrance to college (and dorm life), it's now recommended at age 11.

Then came the new and improved dTap. It was known that immunity to whooping cough (pertussis) waned rapidly after vaccination, but it wasn't thought to be that common a disease. This was wrong. Upon the realization that adults and older kids really did still get whooping cough, an "adult" (over age 7) formulation of dTap was developed. dT boosters were always recommended at 10 year intervals, though if a patient sustained an open wound or burn AND it was more than 5 years since the last dT shot, a booster was due. With the last childhood dose due at age 4, once a kid turned 9 he was in the 5-10 year "window" when he didn't really "need" a booster right then, but if he got hurt he would. I used to offer the shot to kids as an option then; now, with the new dTap it's a good idea to get them the dose as soon as possible, to enhance their pertussis protection. Hence, eveyone over 9 really ought to get their dTap. That's 3 shots, in case anyone lost count.

Finally, the makers of Hepatitis A vaccine American Council on Immunization Practices decided that Hepatitis A was now dangerous enough to recommend that all children be immunized against it at age 12 months. This means that everyone over 12 months of age now needs the two-shot series.

What all this means is that a perfectly healthy 11-year-old, previously up-to-date on all his immunizations as of his last checkup, now "needs" 4 shots. If it's a girl, there's also HPV vaccination (Gardasil) which I now discuss at length with my patients even though I have made the business decision not to provide it in my office. Hypothetically, that makes 5 shots.

One of the principles of vaccination is to jab 'em while you have 'em. That is, you're supposed to give all vaccines for which a patient is eligible at once; that day; without delaying.

You try explaining that to a frightened fifth grader, who's now big enough to run and hide; or at least make your life very difficult if he chooses not to cooperate. He's really too big for a parent to physically hold him down, so if he doesn't want shots, there's no realistic way you're going to be able to force him. Suffice it to say, it's much more traumatic than it was when he was four months old, with nice, plump, juicy thunder thighs you could jab in a moment and then let mom give him a great big hug.

I do my best to split the difference, and limit the kids to two shots this year and wait until next year. I feel the meningitis and dTap are important enough not to wait on. Meningitis is rare but catastrophic; I'm looking forward to the inevitable point when the age is shifted downward yet again and it gets added to the infant series, thus cutting down on the last major cause of bacterial meningitis. Pertussis is annoying enough -- and hard enough to diagnose -- that I think the dTap is also a good idea. The chickenpox booster is meant to theoretically cover the 10% of kids with suboptimal response to their first dose. I'm willing to take the 90% chance in order to limit the trauma of my interaction with them by putting off the Varivax booster until the next visit. Ditto Hepatitis A. Of course you never know where and when the next Hepatitis outbreak is going to be, but in my humble opinion they're still rare enough in this country to allow me to put off universal immunization; at least until it means the poor kid doesn't need 5 shots at once.

I'm well aware that my opinion is not shared by many pediatricians, who prefer to follow the letter of the recommendations and just perforate the kids at will. More power to them. For what it's worth, I prefer to be a kinder and gentler dinosaur that I hope my patients appreciate.

(By the way, for purposes of commenting, anti-vaxxers: go to hell.)