A 3-day-old boy is brought to the office by his mother for a weight check. The patient was born via spontaneous vaginal delivery to a 26-year-old primigravida following an uncomplicated pregnancy. Apgar scores were 9 and 9 at 1 and 5 minutes, respectively. The patient is breastfed exclusively every 3-4 hours and sleeps approximately 15 hours a day. On physical examination, he is alert and quiet in his mother's lap. The examination is unremarkable. Anticipatory guidance is given regarding the patient's expected feeding and elimination habits, as well as upcoming developmental milestones. The topic of vaccinations is raised, and the mother adamantly states that she is unwilling to have her child vaccinated. She says, "I know you might disagree with me, but I feel that vaccines can make my son autistic. I refuse to let him be exposed to them." A prolonged discussion regarding vaccine risks and benefits does not change her beliefs. She is given additional written information regarding immunization facts. Which of the following is the best next step in management of this family?

Question

A 3-day-old boy is brought to the office by his mother for a weight check.  The patient was born via spontaneous vaginal delivery to a 26-year-old primigravida following an uncomplicated pregnancy.  Apgar scores were 9 and 9 at 1 and 5 minutes, respectively.  The patient is breastfed exclusively every 3-4 hours and sleeps approximately 15 hours a day.  On physical examination, he is alert and quiet in his mother's lap.  The examination is unremarkable.  Anticipatory guidance is given regarding the patient's expected feeding and elimination habits, as well as upcoming developmental milestones.  The topic of vaccinations is raised, and the mother adamantly states that she is unwilling to have her child vaccinated.  She says, "I know you might disagree with me, but I feel that vaccines can make my son autistic.  I refuse to let him be exposed to them."  A prolonged discussion regarding vaccine risks and benefits does not change her beliefs.  She is given additional written information regarding immunization facts.  Which of the following is the best next step in management of this family?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0d3_5ac7_8f63_f582780f8bf6_MD0005_00 Vaccine hesitancy is defined as delay or refusal of immunization. Most families with vaccine hesitancy have safety concerns, some of which are known adverse events (eg, site reactions). However, many concerns are the result of misinformation. Common misconceptions and clarifications include: "Vaccines cause autism": Following the retraction of the fraudulent Wakefield study, many large-scale, systematic reviews have consistently shown no association between immunization and autism spectrum disorder. "Vaccines overload the immune system": Exposure to multiple antigens at once has not been shown to be harmful, and immunization has no impact on subsequent immune responses to other antigens. "Natural infection is better": Natural infection is associated with higher risk for complications compared to immunization. For example, the risk for hospitalization for severe dehydration from rotavirus infection is much greater than the rare chance of intussusception after the vaccination. The first step in approaching vaccine-hesitant parents is engaging in open dialogue. This should include acknowledging parental concerns, correcting misinformation, and reviewing evidence-based risks and benefits of immunization, as was done with this family. Although some vaccine-hesitant families ultimately refuse vaccination, up to 50% can be convinced, over time and using continued education and nonjudgmental, honest discussions, to immunize. Lack of vaccine acceptance at an initial visit should not deter providers from attempting to establish trust and initiating discussion at subsequent encounters (Choice D). (Choice A) Passive immunoprophylaxis (ie, injected immunoglobulin) can be considered for unimmunized individuals after certain high-risk, infectious exposures (eg, varicella) but is not a substitute for routine immunization. (Choice C) Alternate vaccine schedules are associated with delayed or incomplete immunizations. Although they can be considered for families who refuse to vaccinate despite multiple conversations, this child is only age 3 days, so continued dialogue may convince the family to vaccinate on the standard, evidence-based schedule. This option would be reasonable if the family's beliefs are unchanged after subsequent encounters. (Choice E) Parents may request a joint discussion to better understand vaccine risks and benefits. However, this mother, the decision-maker at this encounter, is adamant in her beliefs. Suggesting that both parents come for future visits would likely break trust between the provider and the mother. Educational objective: The best approach to vaccine hesitancy or refusal is an open, honest conversation that includes listening to parental concerns, correcting misinformation, and discussing the risks and benefits of immunization. Initial vaccine refusal should be followed with ongoing dialogue at subsequent visits. References: Countering vaccine hesitancy. (http://www.ncbi.nlm.nih.gov/pubmed/27573088) Identifying and addressing vaccine hesitancy. (http://www.ncbi.nlm.nih.gov/pubmed/25875982)

A 3-Day-Old Boy Is Brought to the Office by His