Ethics and Childhood Vaccination Policy in the United States.

Childhood immunization involves a balance between parents' autonomy in deciding whether to immunize their children and the benefits to public health from mandating vaccines. Ethical concerns about pediatric vaccination span several public health domains, including those of policymakers, clinicians, and other professionals. In light of ongoing developments and debates, we discuss several key ethical issues concerning childhood immunization in the United States and describe how they affect policy development and clinical practice. We focus on ethical considerations pertaining to herd immunity as a community good, vaccine communication, dismissal of vaccine-refusing families from practice, and vaccine mandates. Clinicians and policymakers need to consider the nature and timing of vaccine-related discussions and invoke deliberative approaches to policy-making.

Early cow's milk introduction is associated with failed personal-social milestones after 1 year of age.

UNLABELLED: Both the American Academy of Pediatrics (AAP) and the Institute of Medicine (IOM) recommend delaying the introduction of cow's milk until after 1 year of age due to its low absorbable iron content. We used a novel computerized decision support system to gather data from multiple general pediatrics offices. We asked families whether their child received cow's milk before 1 year of age, had a low-iron diet, or used low-iron formula. Then, at subsequent visits, we performed a modified developmental assessment using the Denver II. We assessed the effect of early cow's milk or a low-iron diet on the later failure of achieving developmental milestones. We controlled for covariates using logistic regression. Early cow's milk introduction (odds ratio (OR) 1.30, p = 0.012), as well as a low-iron diet or low-iron formula (OR 1.42, p < 0.001), was associated with increased rates of milestone failure. Only personal-social milestones (OR 1.44, p = 0.002) showed a significantly higher rate of milestone failure. Both personal-social (OR 1.42, p < 0.001) and language (OR 1.22, p = 0.009) showed higher rates of failure in children with a low-iron diet. CONCLUSIONS: There is an association between the introduction of cow's milk before 1 year of age and the rate of delayed developmental milestones after 1 year of age. This adds strength to the recommendations from the AAP and IOM to delay cow's milk introduction until after 1 year of age.

Predictors of influenza vaccination in the U.S. among children 9-13years of age.

BACKGROUND AND OBJECTIVES: U.S. estimates of seasonal influenza (flu) vaccine uptake in 2014-2015 were 62% for 5-12year olds, dropping to 47% for 13-17year olds. The Healthy People 2020 goal for these age groups is 80%. It is important to understand factors associated with influenza vaccination, especially for those ages where rates begin to decline. The objective of this study was to identify factors associated with influenza vaccination acceptance in 9-13year old children. METHODS: An online U.S. survey of mothers of children aged 9-13 assessed children's influenza vaccine uptake in the previous season, healthcare utilization, sociodemographics, and vaccine attitudes. Multivariable logistic regression identified independent predictors of influenza vaccine status. RESULTS: There were 2363 respondents (Mean age=38years old). Referent children were 57% female and 66% non-minority race/ethnicity with a mean age of 10.6years. By maternal report, 59% of children had received an influenza vaccine in the previous season. Predictors of influenza vaccine uptake included a recommendation or strong recommendation from a health care provider, seeing a health care provider in the past year, positive attitudes regarding the influenza vaccine, and being a minority race. Child gender, age, insurance coverage, and whether the child had a regular healthcare provider were not associated with influenza vaccine uptake (p=n.s.). CONCLUSIONS: This sample reported overall rates of influenza vaccine uptake similar to national surveillance data, but still lower than national goals. Provider recommendations along with health attitudes and seeing a health care provider were associated with vaccine uptake. Promising interventions may include more directive physician messaging for influenza vaccine uptake in youth, encouraging more regular well-child visits during the adolescent years, and promoting influenza vaccination at alternative sites.

Pediatricians' responses to printed clinical reminders: does highlighting prompts improve responsiveness?

OBJECTIVE: Physicians typically respond to roughly half of the clinical decision support prompts they receive. This study was designed to test the hypothesis that selectively highlighting prompts in yellow would improve physicians' responsiveness. METHODS: We conducted a randomized controlled trial using the Child Health Improvement Through Computer Automation clinical decision support system in 4 urban primary care pediatric clinics. Half of a set of electronic prompts of interest was highlighted in yellow when presented to physicians in 2 clinics. The other half of the prompts was highlighted when presented to physicians in the other 2 clinics. Analyses compared physician responsiveness to the 2 randomized sets of prompts: highlighted versus not highlighted. Additionally, several prompts deemed high priority were highlighted during the entire study period in all clinics. Physician response rates to the high-priority highlighted prompts were compared to response rates for those prompts from the year before the study period, when they were not highlighted. RESULTS: Physicians did not respond to prompts that were highlighted at higher rates than prompts that were not highlighted (62% and 61%, respectively; odds ratio 1.056, P = .259, NS). Similarly, physicians were no more likely to respond to high-priority prompts that were highlighted compared to the year before, when the prompts were not highlighted (59% and 59%, respectively, χ(2) = 0.067, P = .796, NS). CONCLUSIONS: Highlighting reminder prompts did not increase physicians' responsiveness. We provide possible explanations why highlighting did not improve responsiveness and offer alternative strategies to increasing physician responsiveness to prompts.

Human Papillomavirus Vaccine Initiation among 9-13-Year-Olds in the United States.

OBJECTIVE: The quadrivalent and 9-valent human papillomavirus (HPV) vaccines are licensed for administration among 9-26-year-old males and females, with routine vaccination recommended for 11-12-year-olds. Despite the availability of the vaccine at younger ages, few studies have explored vaccine uptake prior to age 13, and national HPV vaccination surveillance data is limited to 13-17-year-olds. Our objective was to examine rates and predictors of HPV vaccine initiation among 9-13-year-olds in the United States. METHODS: A national sample of mothers of 9-13-year-olds in the United States (N=2,446) completed a 2014 Web-based survey assessing socio-demographic characteristics, child's HPV vaccination history, provider communication regarding the vaccine, and other attitudes and behaviors pertaining to vaccination and healthcare utilization. The main outcome measure was child's initiation of the HPV vaccine (i.e., receipt of one or more doses). RESULTS: Approximately 35% of the full sample and 27.5% of the 9-10-year-olds had initiated HPV vaccination. Females were more likely than males to have initiated HPV vaccination by the age of 13 but not by younger ages. Strength of health provider recommendation regarding HPV vaccination was a particularly salient predictor of vaccine initiation. CONCLUSIONS: Approximately a third of children may be initiating the HPV vaccine series before or during the targeted age range for routine administration of the vaccine. Because coverage remains below national targets, further research aimed at increasing vaccination during early adolescence is needed. Improving providers' communication with parents about the HPV vaccine may be one potential mechanism for increasing vaccine coverage.

An emerging field of research: challenges in pediatric decision making.

There is growing interest in pediatric decision science, spurred by policies advocating for children's involvement in medical decision making. Challenges specific to pediatric decision research include the dynamic nature of child participation in decisions due to the growth and development of children, the family context of all pediatric decisions, and the measurement of preferences and outcomes that may inform decision making in the pediatric setting. The objectives of this article are to describe each of these challenges, to provide decision researchers with insight into pediatric decision making, and to establish a blueprint for future research that will contribute to high-quality pediatric medical decision making. Much work has been done to address gaps in pediatric decision science, but substantial work remains. Understanding and addressing the challenges that exist in pediatric decision making may foster medical decision-making science across the age spectrum.

Screen exposure and body mass index status in 2- to 11-year-old children.

OBJECTIVE: To measure the relationship between screen exposure and obesity in a large, urban sample of children and to examine whether the relationship is moderated by sociodemographics. METHODS: We asked parents of 11 141 children visiting general pediatrics clinics if the child had a television (TV) in the bedroom and/or watched more than 2 hours of TV/computer daily. We measured children's height and weight, then used logistic regression to determine whether screen exposure indicators predicted obesity (body mass index ≥ 85th percentile) and interacted with race/ethnicity, sex, age, and health care payer. RESULTS: Having a TV in the bedroom predicted obesity risk (P = .01); however, watching TV/computer for more than 2 hours a day did not (P = 0.54). There were no interactions. CONCLUSIONS: Asking whether a child has a TV in the bedroom may be more important than asking about duration of screen exposure to predict risk for obesity.

Vaccine message framing and parents' intent to immunize their infants for MMR.

BACKGROUND AND OBJECTIVE: Emphasizing societal benefits of vaccines has been linked to increased vaccination intentions in adults. It is unclear if this pattern holds for parents deciding whether to vaccinate their children. The objective was to determine whether emphasizing the benefits of measles-mumps-rubella (MMR) vaccination directly to the vaccine recipient or to society differentially impacts parents' vaccine intentions for their infants. METHODS: In a national online survey, parents (N = 802) of infants <12 months old were randomly assigned to receive 1 of 4 MMR vaccine messages: (1) the Centers for Disease Control and Prevention Vaccine Information Statement (VIS), (2) VIS and information emphasizing the MMR vaccine's benefits to the child, (3) VIS and information emphasizing societal benefits, or (4) VIS and information emphasizing benefits both to the child and society. Parents reported their likelihood of vaccinating their infants for MMR on a response scale of 0 (extremely unlikely) to 100 (extremely likely). RESULTS: Compared with the VIS-only group (mean intention = 86.3), parents reported increased vaccine intentions for their infants when receiving additional information emphasizing the MMR vaccine's benefits either directly to the child (mean intention = 91.6, P = .01) or to both the child and society (mean intention = 90.8, P = .03). Emphasizing the MMR vaccine's benefits only to society did not increase intentions (mean intention = 86.4, P = .97). CONCLUSIONS: We did not see increases in parents' MMR vaccine intentions for their infants when societal benefits were emphasized without mention of benefits directly to the child. This finding suggests that providers should emphasize benefits directly to the child. Mentioning societal benefits seems to neither add value to, nor interfere with, information highlighting benefits directly to the child.

Threshold analysis of reimbursing physicians for the application of fluoride varnish in young children.

OBJECTIVE: Most state Medicaid programs reimburse physicians for providing fluoride varnish, yet the only published studies of cost-effectiveness do not show cost-savings. Our objective is to apply state-specific claims data to an existing published model to quickly and inexpensively estimate the cost-savings of a policy consideration to better inform decisions - specifically, to assess whether Indiana Medicaid children's restorative service rates met the threshold to generate cost-savings. METHODS: Threshold analysis was based on the 2006 model by Quiñonez et al. Simple calculations were used to "align" the Indiana Medicaid data with the published model. Quarterly likelihoods that a child would receive treatment for caries were annualized. The probability of a tooth developing a cavitated lesion was multiplied by the probability of using restorative services. Finally, this rate of restorative services given cavitation was multiplied by 1.5 to generate the threshold to attain cost-savings. Restorative services utilization rates, extrapolated from available Indiana Medicaid claims, were compared with these thresholds. RESULTS: For children 1-2 years old, restorative services utilization was 2.6 percent, which was below the 5.8 percent threshold for cost-savings. However, for children 3-5 years of age, restorative services utilization was 23.3 percent, exceeding the 14.5 percent threshold that suggests cost-savings. CONCLUSIONS: Combining a published model with state-specific data, we were able to quickly and inexpensively demonstrate that restorative service utilization rates for children 36 months and older in Indiana are high enough that fluoride varnish regularly applied by physicians to children starting at 9 months of age could save Medicaid funds over a 3-year horizon.

Attitudes about the use of newborn dried blood spots for research: a survey of underrepresented parents.

OBJECTIVE: To identify the relative importance of factors that impact parents' attitudes toward use of their child's dried newborn blood spots for research purposes. METHODS: Respondents were parents aged 18 and older with at least one child aged 17 or younger born in Indiana visiting an urban pediatrics clinic. They were asked to rate the acceptability of hypothetical scenarios involving the research use of blood spots. Three pieces of information varied between the scenarios: 1) who would be conducting the research; 2) whether the child's identity would be linked to the spots; and 3) whether and how often the parents' consent would be sought before the research began. RESULTS: A total of 506 predominantly black and low-income parents completed the survey. The conjoint analysis model showed good fit (Pearson's R = 0.998, P < .001). The rank order of factors affecting parents' attitudes was: 1) consent (importance score = 64.9), 2) whether the child's identity was linked to the spot (importance score = 19.4), and 3) affiliation of the researcher using the spots (importance score = 14.6). Respondents preferred being asked for their consent each time their children's spots would be used. They preferred that the children's identity not be linked to the spots and that the research be conducted by university researchers, though these issues had less impact on attitudes than consent. CONCLUSIONS: Parents strongly prefer that consent be sought for each use of their children's blood spots. These findings have implications for future research and policy-making decisions.

The role of herd immunity in parents' decision to vaccinate children: a systematic review.

BACKGROUND AND OBJECTIVE: Herd immunity is an important benefit of childhood immunization, but it is unknown if the concept of benefit to others influences parents' decisions to immunize their children. Our objective was to determine if the concept of "benefit to others" has been found in the literature to influence parents' motivation for childhood immunization. METHODS: We systematically searched Medline through October 2010 for articles on parental/guardian decision-making regarding child immunization. Studies were included if they presented original work, elicited responses from parents/guardians of children <18 years old, and addressed vaccinating children for the benefit of others. RESULTS: The search yielded 5876 titles; 91 articles were identified for full review. Twenty-nine studies met inclusion criteria. Seventeen studies identified benefit to others as 1 among several motivating factors for immunization by using interviews or focus groups. Nine studies included the concept of benefit to others in surveys but did not rank its relative importance. In 3 studies, the importance of benefit to others was ranked relative to other motivating factors. One to six percent of parents ranked benefit to others as their primary reason to vaccinate their children, and 37% of parents ranked benefit to others as their second most important factor in decision-making. CONCLUSIONS: There appears to be some parental willingness to immunize children for the benefit of others, but its relative importance as a motivator is largely unknown. Further work is needed to explore this concept as a possible motivational tool for increasing childhood immunization uptake.

Effect of an annual benefit limit on adult dental expenditure and utilization: a cross-sectional analysis.

OBJECTIVES: Despite widespread use of dental benefit limits in terms of the types of services provided, an annual maximum on claims, or both, there is a dearth of literature examining their impact on either cost to the insurer or health outcomes. This study uses a natural experiment to examine dental care utilization and expenditure changes following Indiana Medicaid's introduction of a $600 individual annual limit on adult dental expenditure in 2003. METHODS: In a before and after comparison, we use two separate cross-sections of paid claims for 96+ percent of the Medicaid adult population. Paid claims were available as a per-member-per-year (PMPY) figure. RESULTS: Between 2002 and 2007, the eligible population decreased 3 percent (from 323,209 to 313,623), yet the number of people receiving any dental services increased 60 percent and total Medicaid dental claims increased 18 percent (from $34.1 million to $40.1 million). In both years, those Dually (Medicare/Medicaid) Eligible had the largest percentage of members receiving services, about 75 percent, and the Disabled Adult group had the lowest percentage (5-8 percent), yet both populations are likely to have high dental need due to effects of chronic conditions and medications. CONCLUSIONS: The increase in the number and percentage of people receiving Diagnostic and Restorative care suggests that the expenditure limit's introduction did not impose a barrier to accessing basic dental services. However, among those receiving any service, PMPY claims fell by 37 percent and 31 percent among the Dually Eligible and Disabled Adults categories, respectively, suggesting that the benefit limit affected these generally high need populations most.