September 24, 2025 • 40 mins
Childhood vaccines raise some of the biggest questions parents face. In this episode of the Mothers of Boys Survival Guide, host Suzy Shaw welcomes back retired pediatrician Dr. Barnaby Starr, who spent decades guiding families with trusted, practical advice. Together, they cover everything from newborn vaccines like Hepatitis B to school and teen immunizations including MMR, HPV, meningococcal, flu, and COVID-19.
Dr. Starr explains how vaccines work, what side effects parents should expect, and why herd immunity is so critical. Packed with clarity and compassion, this conversation helps parents feel more confident navigating vaccine decisions for their children.
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Episode Transcript
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Ask a Pediatrician (00:01):
Parents' Top Questions About Childhood Vaccines.
Welcome to the Mothers of Boys Survival Guide podcast. I'm Suzy Shaw, author of the companion
book and boy mom of two. Now, fully adulting. Today, we're diving into a topic that's on every
(00:24):
parent's mind at some point, childhood vaccines. From the first shot your baby receives to vaccines
required for school, parents often have questions about timing, safety, and what to expect.
I'm thrilled to welcome back Dr. Barnaby Starr, a respected and now retired Baltimore
(00:48):
pediatrician with decades of experience caring for children and supporting families.
Known for his compassionate approach and medical expertise,
he is a practical and trusted voice in children's healthcare. Welcome Dr. Starr.
Thank you, Suzy. It's great to be here again.
(01:09):
You joined us for some earlier podcasts, in fact, our very first podcast on bringing your newborn
home. We really appreciate your willingness to tackle parents' top questions today about vaccines
so that they can feel more informed and confident in making decisions for their child's health.
(01:33):
Let's just jump in and start with the basics. How do you
talk with new parents about vaccines and their safety and how do they work?
The first thing to do is to make sure we all understand how vaccines
do work. To understand how they work, you have to understand the concept of
(01:57):
an antigen. An antigen is a protein and occasionally it's a carbohydrate,
but it's a substance that induces the production of antibodies by our own immune system.
Antibodies are a custom-fitted way of attacking something foreign in the body. A vaccine has
(02:22):
the ability to induce the production of antibodies. The vaccines can be live,
they can be killed, they can be portions of the outer membrane of an infectious agent.
What do you mean by killed?
Well, the agent that we're trying to induce an immunity to can be killed using formaldehyde where
(02:52):
it can be still a live vaccine. They now have what was in the COVID vaccine,
which is simply mRNA, which then uses our body cells to produce the antigens, which will cause
the protective antibodies to form. In other words, the key here is understanding that the
(03:15):
immune system is producing antibodies which will allow you to have a memory for an infection that
if you're getting a vaccine, you never really had the infection, you just had the vaccine.
This has evolved over 500 years. I mean, this is a science, immunology of its own. And so to
(03:36):
think that we could somehow learn quickly or know just from reading something on the
internet and fathom the complexity of this system, it's crazy. It's a very complicated
system. But some vaccines are so valuable that if we throw them all out quickly because of some
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risks which we're going to talk about, we'd be making a grave mistake. We'd be throwing
away 500 years of scientific development. We'll talk about different vaccines whenever you want.
So what are the earliest vaccines,
a brand new baby in the hospital? Do you get vaccines in the hospital?
Dr. Starr (04:25):
Starting in 1991, they started recommending that a one-day-old baby,
before the baby leaves the hospital, be treated with the hepatitis B vaccine. So again, that's
more than 30 years ago. And that greatly reduced the transmission of hepatitis B.
(04:49):
Mothers are generally screened for hepatitis B during their pregnancy. And if the mother
is positive for hepatitis B, not only are the babies the recipients of the hepatitis B vaccine,
but they're given an immunoglobulin specifically against hepatitis B. So
(05:10):
the highest risk group doesn't only get the vaccine, they get an immunoglobulin.
Regular babies whose mothers have been shown to be negative for hepatitis B have been
given this vaccine. Whether it's entirely safe to give a one-day-old baby a vaccine,
(05:31):
I myself felt it hadn't been tested carefully enough. So in a low-risk baby where there's
no hepatitis B in the family and no high-risk behaviors in the household,
I actually recommended waiting till the two-week checkup to receive the hepatitis B vaccine.
And that's because there is something that protects the brain from objects
(05:58):
in our bloodstream called the blood-brain barrier, and it keeps foreign things out
of the brain. And that is not well developed till five days of age. That's why a baby who
has jaundice or a very high bilirubin at one day of age, that has to be approached and treated,
(06:18):
whereas at 5 to 7 days of age, that's not a serious problem. So I extrapolated and
actually recommend waiting till two weeks for the first hepatitis B vaccine if there's low risk.
All the other vaccines are in this country held until 2 months of age.
So early, early, we're just talking about hepatitis B.
(06:41):
So how do parents keep track of the schedule of vaccines that children are supposed to receive.
Well, it's actually the responsibility of the doctor who's providing vaccines
to keep a log of all the vaccines that are given in the office. And
that should be readily available so that every visit, even a sick visit,
(07:02):
the doctor should be able to look at the chart and make sure that the patient is up to date.
Parents are usually given a little vaccine record and at every well visit or any other
visit where a shot is given, that record should be produced and the dates put in.
That doesn't always happen. People forget the books, they lose the books. So it really is
(07:26):
the doctor's responsibility to keep in the chart anything that's been given.
The notion that we could inject something into the body and not have any kind of side effect
is crazy. It is an intervention and every intervention may have some kind of side
effect. And we can talk about what side effects are expected and what are much less common. But
(07:52):
the fact of the matter is each vaccine you have to look at with a risk benefit ratio. Is
this worth the chance of any side effects? And that's what makes this topic very complicated.
There's also the import of herd immunity, where we're looking for the population as
(08:13):
a whole to have a certain percent of the population vaccinated against a disease,
particularly a very contagious disease, so the disease can't rear its ugly head.
And that's where, you know, a disease like polio
has been nearly eliminated because of herd immunity, whereas, you know,
(08:37):
I recently had an uncle pass away and he had had polio as a child. And I don't know
if anyone in my generation or since that has had that disease. Is that because of herd immunity?
Yes. And it's a real problem, though, because people now don't realize how necessary it is
(08:58):
to keep that disease at bay. That disease does still exist in the world. If you travel to India,
areas of Africa where there's still polio, you want to be immune to this. People don't remember
that in the 50s, right here in Baltimore, the public swimming pools were closed. People
couldn't go to the local swimming pool because of the risk of being exposed to the polio virus.
(09:24):
In some countries, they still use a live oral polio vaccine because they want the virus to still
be present in the environment to boost immunity in people who do not get the vaccine. In our country,
there's not enough polio around to want to use the live oral polio. So we use
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an injected polio. And there's very little side effect from the injected polio vaccine.
The disease where the biggest problem with herd immunity is becoming an immediate
problem is measles. And that's because it's such a contagious disease that you need 95%
(10:11):
of your population to be immune to have what's called herd immunity. And people, just because
they don't see measles as much as they used to, they don't realize how necessary it is.
So, you know, let's get just briefly, you've mentioned the side effects and safety. So,
(10:34):
you know, how do vaccines get tested before given to children?
In large populations they get tested to see what the side effects are and how often they happen?
And those studies are done before the vaccine is introduced. Sometimes they're done in other
(10:54):
countries. And occasionally there actually have been some problems with the rotavirus
vaccine that was an oral vaccine was being studied in China. It turned out there was a
problem in the slightly older infants getting the rotavirus vaccine. They were developing
a complication called intersusception, which is the obstruction of the bowel. And
(11:20):
that vaccine now is given to young babies, but not given beyond the age of eight
months. And that particular preparation of that immunization was actually taken off the market.
So, I mean, there are studies are done to make sure things are safe.
And what are the most common side effects?
(11:44):
Yeah, it varies from vaccine to vaccine. To the two, four and six month shots, which are usually
diphtheria, pertussis, polio, like we talked about, hemophilus- which is an influenza type B,
meningitis and epiglottitis vaccine, pneumococcal vaccine. The most common
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reactions are within the first 24 hours, a little bit of fever,
irritability and locally a little swelling or a little tenderness, easily treated with Tylenol.
However, different patients can have different complications depending on
what's going on with them. If you have a child, for example,
(12:33):
who has a neurological disease like a seizure disorder in the “P” in the DTP or DTAP shot,
that P can have more untoward effects in a child with a neurologic problem so that that part of
the vaccine can be left out. So you can see right away that it becomes complicated because
(12:57):
for each patient, there may be some slightly different level of possibility of side effects.
So really what I'm getting at is for good vaccine therapy,
really have to look at each case individually and each
parent should feel comfortable asking about the vaccines with their child.
(13:25):
Did you find there were more complications if the child had allergies...
There's specific recommendations, for example, some vaccines are prepared in chick embryos.
And so if there's an egg allergy, you have to avoid certain vaccines. But in general,
(13:48):
I didn't see my atopic or allergic children have more problems with the vaccines.
I think a lot of people don't understand also that the herd immunity for the adult
population can be related to the pediatric vaccines. And what I'm beginning to hear is
everyone's aware of the vaccine called MMR. Well, that R stands for rubella, rubella,
(14:16):
which is also known as three day measles. Rubella is 50% asymptomatic in the patient who gets it.
They might not even know they have it, but it causes- it wreaks havoc on the fetus. So what
we're really doing when we give the MMR vaccine to children is we're trying to create a population
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that doesn't convey rubella to pregnant women. If you drop the immunization rate of that little R,
that rubella to low levels where there's no longer herd immunity, we're going to start
seeing a lot more fetal problems. And the fetal problems from a mother having rubella during the
(15:02):
pregnancy are cardiac problems, central nervous system problems, deafness. It's a can of worms.
And I don't think people realize that if you go against things like the MMR in a matter of years,
you're going to start seeing rubella again. And this was a real problem in the 1950s.
(15:24):
And what other dangers are there for avoiding vaccines?
Well, some of the illnesses, luckily, are very rare, but very severe. So, for example,
the meningococcal vaccine, which is usually recommended to people going to college. That's
(15:45):
that quote meningitis vaccine that you hear about when your kid's getting ready to go to college and
we're like, why did they get this before? Well, it turns out it is recommended and required for
some sleepaway camps because the risk factor for meningococcal disease is if you're in a sleeping
area with a large amount of people like a dorm or they used to call them the bunks at camp 8,
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12, sometimes even 20 kids in the same space. One of those kids could be a carrier in their nose,
or one of those kids could be getting sick with this illness and it travels respiratory.
And so if you're going to live in a dorm on a college, that was considered a really high
risk. If you're a military recruit and you're going to be in a barracks, very high risk.
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So the meningococcal vaccine prevents that disease. If you get that disease, it's a terrible
disease. People lose their limbs from shock with this particular disease. Luckily, it's not common.
So you tell me, is it worth all the people who get it having a day of soreness, maybe a little fever
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when they get it to get rid of a disease that's really rare, but really devastating? I mean,
these are the questions that are confronting the immunologists who develop these vaccines.
So I have gathered the list of sort of childhood vaccines. We can call this
(17:26):
sort of the lightning round. All right. Do you mind? I will tell you what the
vaccines are and you can just give us a quick overview of what they do?
Sure.
The first is infants, early childhood. This is, you know, in the birth, the six months,
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hepatitis B. So you've already, I believe, talked about that, right?
Right. And again, that's become a requirement for some daycares. It's
certainly a requirement for school that you have to have had all three shots,
(18:10):
usually within the span of a year. So, I mean, the exact dates aren't that important.
I talked about how my own thinking is in a very low risk baby. Giving it a one day
of age might not be as safe as waiting till they're two weeks old. But hepatitis B can be
(18:30):
a fatal disease causing liver failure, and it's transmitted by tiny, tiny amounts of blood. So
if you have hepatitis B+ parent in the home, that's a risk factor. There's IV drug abuse
in the home. That's a risk factor. But. Again, it's a disease that we have greatly reduced with
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this vaccine, and the vaccine itself is very safe.And what about DTAP? Is that the way you say that?
Yes, that's a combination vaccine that's going to protect you against diphtheria,
tetanus, and hooping cough using AP, which is a cellular pertussis,
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because the old hooping cough, which is the pertussis vaccine,
used to be a whole cell vaccine, and it had a lot more in the way of fever and side effects.
However, like I was saying before, if there's someone with neurologic disease, you have to be
a little careful with that pertussis hooping cough component. And we can leave that out if we have
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a history of ongoing neurologic disease. So you can give a DT instead of a DTAP.
Why do you want to be? Immunized against these, well, diphtheria used to be a horrible cause
of the loss of, you know, two out of your five children if it came through your town.
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It's the appearance of a very thick, what's called a pseudo membrane in the throat. And
the children would actually suffocate from this horrible sore throat that they got. And again,
we don't want to turn back the clock and start seeing these diseases. But
because people don't see them, they don't realize the import of these vaccines.
(20:30):
So again, DTAP, a little bit of fever. You can actually use Tylenol even at two months
of age. I often recommended one or two doses preventively. And then you keep giving it
for up to 24 hours if you needed to. Most side effects from the DTAP are right away.
What about HIB, H-I-B?
(20:53):
Okay, HIB, this is more an example of a potentially very devastating infection
where the vaccine is a sugar, a polysaccharide. So you're not going to have very much in the way
of side effect at all. And meningitis, septic arthritis, which is an infection in the joints,
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and a very horrible illness that we really don't see much anymore- Epiglottitis,
which is a swelling of a little trapdoor that protects your airway. The Hib vaccine prevents
infection with a bacteria that used to cause death from that infection called epiglottitis.
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And it's been a fantastic addition to all of the humanitarian immunologically because we did used
to see in my residency just 35, 40 years ago, we had a couple of deaths due to epiglottitis,
and the Hib prevents it and has very little in the way of side effects.
(22:02):
Polio you've already mentioned.
Polio we've talked about. And again,
the injected polio is a killed polio vaccine. So it's very safe.
Then there's pneumococcal. You might see that on your list because that's given at the same time…
(22:24):
PCV (Pneumococcal Conjugate Vaccine), right?
Correct. That's the pneumococcal vaccine. And everyone thinks about pneumonia being prevented,
bacterial pneumonia is being prevented by that. But for pediatricians, it's a very important
vaccine because that was the one bacteria, pneumococcus, that would get in a child's
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bloodstream and not be located anywhere else. An infection called pneumococcal bacteremia.
So before that vaccine came out, every time we got a call from a very feverish infant under the age
of 18 months who didn't have a source, didn't have a cough or a cold or an ear infection,
(23:09):
the parents said, really, I don't know where the fever's coming from. We had to worry about that
particular infection, pneumococcal bacteremia, meaning infection of the bloodstream itself.
Once this vaccine came out, we no longer had to worry about that. And that was a fantastic advance
(23:30):
in pediatrics. And again, that's a very safe vaccine because that's a polysaccharide, a sugar.
MMR (Measles, Mumps, and Rubella vaccine), you've sort of mentioned.
MMR, we've talked about. The biggest problem with getting rid, people are really worried about the
(23:51):
MMR because there was that now proven false accusation that it was causing autism. That
set us way back. People came very dubious about whether or not they wanted the MMR.
The MMR is given at 12 to 15 months and then a booster dose has to be given at least a
(24:13):
month later. We generally give it before the kids start kindergarten at age four.
If there's an epidemic going on of measles, which is going to become more and more the
case if less and less people get this vaccine, then it can be given as early as 9 months,
but it has to be repeated two more doses after the child is 12 months to get permanent immunity.
(24:41):
And what about the chickenpox vaccine?
Chickenpox vaccine- why don't we give that right away? Well, that's kind of an interesting
question, and we don't give it until 12 months of age because most mothers have had chickenpox
during their life. So when the baby is born, if the baby's full term, the baby has received the
(25:07):
protection that is keeping the mother from getting chickenpox again. Those antibodies
travel through the placenta into the baby and protect the baby during the first year of life.
Many infants who do get chickenpox at nine to 12 months get it again because they haven't
formed their own protection. So we don't give the chickenpox vaccine until 12 months or older. And
(25:33):
again, that's one that also gets boosted later.What about Hepatitis A, Hep A?
Hep A, in the scheme of the vaccines you've been asking about, relatively new,
can be a very devastating illness. Luckily not seen very commonly, a very safe vaccine. Again,
(25:58):
one I think a parent could talk about with the doctor as to whether or not if they're
skeptical and they don't want vaccines, it might be one they could wait on.
So now we're getting into the school aged, adolescents, kids 7 to 18 years
(26:19):
of age. The first one on my list is DTAP. Is that a booster? Because tetanus is…
That’s a booster of each. As a child gets vaccines, they form a higher concentration
of antibodies, but their memory for a vaccine improves with age. So when they're an infant,
(26:44):
their memory doesn't last more than 2 to 3 months from the first or second shot.
That's why you get three in the first six months of life. But as they age,
their memory, their immune memory is better. And once you boost DTAP at age 4,
before the child starts school, you don't need another boost of immunity for five to 10 years.
(27:08):
That's incredible. Okay. What about HPV and there's a lot of,
you know- this is a newer one. And I think feel like this just came out when my boys
were reaching this age. And I was very, actually excited that this was available in the toolbox.
(27:33):
HPV, the development of a vaccine for was handed in with the discovery that some cancers are caused
by viruses. And in particular, certain serotypes of the Human Papillomavirus,
that's what the HPV stands for, cause cervical cancer in women. If you give this
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vaccine before children have become sexually active, you basically prevent their ability
to get infection with those serotypes of this virus and you greatly reduce,
if not eliminate the cervical cancers that are arising from that virus.
So we were looking for what's a good age for this to be given, where it will have a long memory. And
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it turns out it can be given as early as age 9, as late as 15 or 16, if we haven't had any sexual
activity yet. And giving it only to women, which initially was one of the thoughts doesn't work,
it has to be given to everybody. And luckily you were very receptive to the idea of having your
(28:48):
boys immunized to it. But I did have a lot of patients who didn't even want to consider it.
Yeah. Well, you know, I have known and had friends that have gone through that sort
of cancer and I just feel as though prevention, even though I had boys was very, very important
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and I think as moms and women, we should be on board. So that's just my personal opinion.
Well, again, this is a virus that the risk factor is sexual activity and there's a very
big river called denial. And there are a lot of parents who swim in that river
and maybe hope that their children can get involved with any sexual activity.
(29:35):
Of course, no sexual activity is going to be happening.
So, you know, what is the difference between, “recommended” and “required” or…
That's a really good question. It's a very, it's actually somewhat of a gray area,
particularly this year, because I've been reading that this year's different
(29:59):
states are behaving differently in terms of enforcing school,
even school requirements. Florida has voted against having mandates and,
you know, rapidly, I think 9 other states are considering dropping mandates for immunizations.
We're rapidly going to lose what you and I were talking about with herd immunity. If
(30:24):
enough people decide they don't have to get their vaccines. Again, an honest appraisal is, yes,
you're taking a tiny little risk, but you're producing an immunity of the herd that will
protect. There are some people, for example, who can't get vaccines and if they're exposed
(30:44):
to the diseases, they're at a much higher risk of getting them. You're helping protect those people.
So requirement, it's a really question, good question. I don't know that the school systems
are going to follow requirements this year. Recommendations, again, should be given from
(31:06):
a doctor to each family individually, because there are different risk factors that make
some vaccines more dangerous than others.You know, I get the flu shot every year.
I think there is a misconception about that, that if you get an immunization
(31:31):
like the flu shot, that you won't get the flu. What, how does, how does that work?
Well, the flu is a very complicated virus in that it can mutate and when they design the flu vaccine
based on what virus is going around that year or what different types of that flu virus seem to be
(31:53):
the most common that year. When they actually make that vaccine during the summer months,
anticipating what's going to come that year, sometimes the predictions are wrong. And so
it can be as little as 30% protective. When it's at its best, it's about 70% effective. And again,
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it's against flu, influenza, not rhino virus, which causes the common cold.
So, I mean, it's, it's a way of beefing up your protection, but it's certainly not a foolproof
90% to 100% immunity like you're getting with the other childhood vaccines we talked about. And in
(32:35):
all candor, I think they're still working to produce a more effective flu vaccine.
Flu itself in most people is not as severe an illness as some of the ones we've talked
about before. So again, each patient has to decide and it depends on your age group,
whether you have underlying lung disease, things like that as to how serious the flu might be for
(32:59):
you. So once again, the flu is a great example of one where you should talk to your doctor
about whether they advise to get it.And what about the COVID-19 vaccine?
Yeah, I'm really on the fence right now about
(33:20):
each year they develop a new COVID vaccine. I'm not scared by the technology of mRNA vaccines,
where simply you're giving a little mRNA and then your own cells are using that mRNA to produce the
antigenic substances we talked about that give your immune system a memory. I think that that's
(33:43):
something that needs to be discussed depending on your age, your health with your doctor.
I mean, this really is a complicated area to oversimplify and say, oh,
vaccines can cause all kinds of troubles. I think I don't want to give any to my child
is a real disservice to your child and to yourself. But I do think there's some
(34:07):
individualization that needs to occur so that if you have questions about certain vaccines,
you should talk about them with your doctor.So what questions should parents ask, you know,
a pediatrician and how much flexibility is there really in that immunization schedule?
(34:30):
That's a great question. I mean, for those of us who were around before the rotavirus vaccine,
for example, where rotavirus causes 3 to 5 days of diarrhea, sometimes vomiting,
occasionally dehydration, tends to go around daycares. If the child is not in a daycare,
(34:51):
is being taken at home by 1 or 2 caretakers, they and they don't want the rotavirus vaccine-
they have the option of refusing, but that's just one more example of like
the lifestyle affecting whether a certain vaccine would be necessary in your child.
(35:18):
So the conversation with the pediatrician, you know, it's the parents job to advocate
and understand the health of their child and to discuss it with their pediatrician.
Absolutely. That's part of the interaction every day in the office. And I will say
(35:39):
I did have a few patients who were blanket against all vaccines,
and my own malpractice insurer said I couldn't keep those patients in my practice because they
were putting my other patients at risk by refusing all vaccines. And they advised
(36:00):
me that I had to tell patients who refused all vaccines to go elsewhere for their care.
If they were willing to take some that I felt were the most important, delay others like as
we've talked about, or if, for example, their child wasn't going to daycare and so I felt
they weren't at high risk for the rotoviral vaccine. If we made little bargains like that,
(36:23):
I could keep the patient, but if they blanket refused all vaccines,
it puts the doctor in a catch-22 situation. So it's a difficult situation for the clinician.
So do you have- we've asked you this in the last podcast too, but do you have a guiding
(36:46):
quote or mantra that parents you think should think about as they're dealing with this topic?
Don't be too quick to throw out what really has evolved over a 500-year pathway of truly
(37:06):
dedicated medical investigators. Don't be in such a hurry to throw away that kind of
knowledge. Vaccines really are preventive medicine at its best. And yes, we're not
seeing a lot of these infections yet, but if we go backward, that's what most of us fear will happen.
(37:31):
Where should parents go to get reliable information?
There are websites that are run by the NIH, ACIP, they can certainly look at those.
But again, I think if they have questions, they should ask their own
(37:53):
doctor when they're in for those visits. And that's really what we're there for.
Was there anything you feel as though we left
out of this conversation that you want to make sure you mentioned?
This is a very complicated topic. And unfortunately, in this day and age,
(38:19):
I feel there's very little trust of the authority or the knowledge that doctors have gained over
the many years of their education and training and then work experience. And that we really,
in our complex society, have to trust experts in their areas. You can't glean enough just
(38:47):
from reading an article about possible negative effects of vaccines. You can't learn enough in
that brief interaction with the computer where you are picking up this stuff to refuse these
vaccines. If you're really uneasy about a certain one, bring it up with your doctor.
(39:09):
Well, Dr. Starr, thank you for joining me for this
very important conversation. I'm sure your practical answers offered insight
and a little more peace of mind for parents about childhood vaccines.
I hope.
I know it did. For our listeners, if you found today's episode helpful,
(39:31):
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platform for more conversations, resources, and support. And remember, moms, be kind to yourself.
Parents' Top Questions About Childhood Vaccines.
Welcome to the Mothers of Boys Survival Guide podcast. I'm Suzy Shaw, author of the companion
book and boy mom of two. Now, fully adulting. Today, we're diving into a topic that's on every
(00:24):
parent's mind at some point, childhood vaccines. From the first shot your baby receives to vaccines
required for school, parents often have questions about timing, safety, and what to expect.
I'm thrilled to welcome back Dr. Barnaby Starr, a respected and now retired Baltimore
(00:48):
pediatrician with decades of experience caring for children and supporting families.
Known for his compassionate approach and medical expertise,
he is a practical and trusted voice in children's healthcare. Welcome Dr. Starr.
Thank you, Suzy. It's great to be here again.
(01:09):
You joined us for some earlier podcasts, in fact, our very first podcast on bringing your newborn
home. We really appreciate your willingness to tackle parents' top questions today about vaccines
so that they can feel more informed and confident in making decisions for their child's health.
(01:33):
Let's just jump in and start with the basics. How do you
talk with new parents about vaccines and their safety and how do they work?
The first thing to do is to make sure we all understand how vaccines
do work. To understand how they work, you have to understand the concept of
(01:57):
an antigen. An antigen is a protein and occasionally it's a carbohydrate,
but it's a substance that induces the production of antibodies by our own immune system.
Antibodies are a custom-fitted way of attacking something foreign in the body. A vaccine has
(02:22):
the ability to induce the production of antibodies. The vaccines can be live,
they can be killed, they can be portions of the outer membrane of an infectious agent.
What do you mean by killed?
Well, the agent that we're trying to induce an immunity to can be killed using formaldehyde where
(02:52):
it can be still a live vaccine. They now have what was in the COVID vaccine,
which is simply mRNA, which then uses our body cells to produce the antigens, which will cause
the protective antibodies to form. In other words, the key here is understanding that the
(03:15):
immune system is producing antibodies which will allow you to have a memory for an infection that
if you're getting a vaccine, you never really had the infection, you just had the vaccine.
This has evolved over 500 years. I mean, this is a science, immunology of its own. And so to
(03:36):
think that we could somehow learn quickly or know just from reading something on the
internet and fathom the complexity of this system, it's crazy. It's a very complicated
system. But some vaccines are so valuable that if we throw them all out quickly because of some
(03:58):
risks which we're going to talk about, we'd be making a grave mistake. We'd be throwing
away 500 years of scientific development. We'll talk about different vaccines whenever you want.
So what are the earliest vaccines,
a brand new baby in the hospital? Do you get vaccines in the hospital?
Dr. Starr (04:25):
Starting in 1991, they started recommending that a one-day-old baby,
before the baby leaves the hospital, be treated with the hepatitis B vaccine. So again, that's
more than 30 years ago. And that greatly reduced the transmission of hepatitis B.
(04:49):
Mothers are generally screened for hepatitis B during their pregnancy. And if the mother
is positive for hepatitis B, not only are the babies the recipients of the hepatitis B vaccine,
but they're given an immunoglobulin specifically against hepatitis B. So
(05:10):
the highest risk group doesn't only get the vaccine, they get an immunoglobulin.
Regular babies whose mothers have been shown to be negative for hepatitis B have been
given this vaccine. Whether it's entirely safe to give a one-day-old baby a vaccine,
(05:31):
I myself felt it hadn't been tested carefully enough. So in a low-risk baby where there's
no hepatitis B in the family and no high-risk behaviors in the household,
I actually recommended waiting till the two-week checkup to receive the hepatitis B vaccine.
And that's because there is something that protects the brain from objects
(05:58):
in our bloodstream called the blood-brain barrier, and it keeps foreign things out
of the brain. And that is not well developed till five days of age. That's why a baby who
has jaundice or a very high bilirubin at one day of age, that has to be approached and treated,
(06:18):
whereas at 5 to 7 days of age, that's not a serious problem. So I extrapolated and
actually recommend waiting till two weeks for the first hepatitis B vaccine if there's low risk.
All the other vaccines are in this country held until 2 months of age.
So early, early, we're just talking about hepatitis B.
(06:41):
So how do parents keep track of the schedule of vaccines that children are supposed to receive.
Well, it's actually the responsibility of the doctor who's providing vaccines
to keep a log of all the vaccines that are given in the office. And
that should be readily available so that every visit, even a sick visit,
(07:02):
the doctor should be able to look at the chart and make sure that the patient is up to date.
Parents are usually given a little vaccine record and at every well visit or any other
visit where a shot is given, that record should be produced and the dates put in.
That doesn't always happen. People forget the books, they lose the books. So it really is
(07:26):
the doctor's responsibility to keep in the chart anything that's been given.
The notion that we could inject something into the body and not have any kind of side effect
is crazy. It is an intervention and every intervention may have some kind of side
effect. And we can talk about what side effects are expected and what are much less common. But
(07:52):
the fact of the matter is each vaccine you have to look at with a risk benefit ratio. Is
this worth the chance of any side effects? And that's what makes this topic very complicated.
There's also the import of herd immunity, where we're looking for the population as
(08:13):
a whole to have a certain percent of the population vaccinated against a disease,
particularly a very contagious disease, so the disease can't rear its ugly head.
And that's where, you know, a disease like polio
has been nearly eliminated because of herd immunity, whereas, you know,
(08:37):
I recently had an uncle pass away and he had had polio as a child. And I don't know
if anyone in my generation or since that has had that disease. Is that because of herd immunity?
Yes. And it's a real problem, though, because people now don't realize how necessary it is
(08:58):
to keep that disease at bay. That disease does still exist in the world. If you travel to India,
areas of Africa where there's still polio, you want to be immune to this. People don't remember
that in the 50s, right here in Baltimore, the public swimming pools were closed. People
couldn't go to the local swimming pool because of the risk of being exposed to the polio virus.
(09:24):
In some countries, they still use a live oral polio vaccine because they want the virus to still
be present in the environment to boost immunity in people who do not get the vaccine. In our country,
there's not enough polio around to want to use the live oral polio. So we use
(09:50):
an injected polio. And there's very little side effect from the injected polio vaccine.
The disease where the biggest problem with herd immunity is becoming an immediate
problem is measles. And that's because it's such a contagious disease that you need 95%
(10:11):
of your population to be immune to have what's called herd immunity. And people, just because
they don't see measles as much as they used to, they don't realize how necessary it is.
So, you know, let's get just briefly, you've mentioned the side effects and safety. So,
(10:34):
you know, how do vaccines get tested before given to children?
In large populations they get tested to see what the side effects are and how often they happen?
And those studies are done before the vaccine is introduced. Sometimes they're done in other
(10:54):
countries. And occasionally there actually have been some problems with the rotavirus
vaccine that was an oral vaccine was being studied in China. It turned out there was a
problem in the slightly older infants getting the rotavirus vaccine. They were developing
a complication called intersusception, which is the obstruction of the bowel. And
(11:20):
that vaccine now is given to young babies, but not given beyond the age of eight
months. And that particular preparation of that immunization was actually taken off the market.
So, I mean, there are studies are done to make sure things are safe.
And what are the most common side effects?
(11:44):
Yeah, it varies from vaccine to vaccine. To the two, four and six month shots, which are usually
diphtheria, pertussis, polio, like we talked about, hemophilus- which is an influenza type B,
meningitis and epiglottitis vaccine, pneumococcal vaccine. The most common
(12:09):
reactions are within the first 24 hours, a little bit of fever,
irritability and locally a little swelling or a little tenderness, easily treated with Tylenol.
However, different patients can have different complications depending on
what's going on with them. If you have a child, for example,
(12:33):
who has a neurological disease like a seizure disorder in the “P” in the DTP or DTAP shot,
that P can have more untoward effects in a child with a neurologic problem so that that part of
the vaccine can be left out. So you can see right away that it becomes complicated because
(12:57):
for each patient, there may be some slightly different level of possibility of side effects.
So really what I'm getting at is for good vaccine therapy,
really have to look at each case individually and each
parent should feel comfortable asking about the vaccines with their child.
(13:25):
Did you find there were more complications if the child had allergies...
There's specific recommendations, for example, some vaccines are prepared in chick embryos.
And so if there's an egg allergy, you have to avoid certain vaccines. But in general,
(13:48):
I didn't see my atopic or allergic children have more problems with the vaccines.
I think a lot of people don't understand also that the herd immunity for the adult
population can be related to the pediatric vaccines. And what I'm beginning to hear is
everyone's aware of the vaccine called MMR. Well, that R stands for rubella, rubella,
(14:16):
which is also known as three day measles. Rubella is 50% asymptomatic in the patient who gets it.
They might not even know they have it, but it causes- it wreaks havoc on the fetus. So what
we're really doing when we give the MMR vaccine to children is we're trying to create a population
(14:40):
that doesn't convey rubella to pregnant women. If you drop the immunization rate of that little R,
that rubella to low levels where there's no longer herd immunity, we're going to start
seeing a lot more fetal problems. And the fetal problems from a mother having rubella during the
(15:02):
pregnancy are cardiac problems, central nervous system problems, deafness. It's a can of worms.
And I don't think people realize that if you go against things like the MMR in a matter of years,
you're going to start seeing rubella again. And this was a real problem in the 1950s.
(15:24):
And what other dangers are there for avoiding vaccines?
Well, some of the illnesses, luckily, are very rare, but very severe. So, for example,
the meningococcal vaccine, which is usually recommended to people going to college. That's
(15:45):
that quote meningitis vaccine that you hear about when your kid's getting ready to go to college and
we're like, why did they get this before? Well, it turns out it is recommended and required for
some sleepaway camps because the risk factor for meningococcal disease is if you're in a sleeping
area with a large amount of people like a dorm or they used to call them the bunks at camp 8,
(16:13):
12, sometimes even 20 kids in the same space. One of those kids could be a carrier in their nose,
or one of those kids could be getting sick with this illness and it travels respiratory.
And so if you're going to live in a dorm on a college, that was considered a really high
risk. If you're a military recruit and you're going to be in a barracks, very high risk.
(16:37):
So the meningococcal vaccine prevents that disease. If you get that disease, it's a terrible
disease. People lose their limbs from shock with this particular disease. Luckily, it's not common.
So you tell me, is it worth all the people who get it having a day of soreness, maybe a little fever
(17:02):
when they get it to get rid of a disease that's really rare, but really devastating? I mean,
these are the questions that are confronting the immunologists who develop these vaccines.
So I have gathered the list of sort of childhood vaccines. We can call this
(17:26):
sort of the lightning round. All right. Do you mind? I will tell you what the
vaccines are and you can just give us a quick overview of what they do?
Sure.
The first is infants, early childhood. This is, you know, in the birth, the six months,
(17:50):
hepatitis B. So you've already, I believe, talked about that, right?
Right. And again, that's become a requirement for some daycares. It's
certainly a requirement for school that you have to have had all three shots,
(18:10):
usually within the span of a year. So, I mean, the exact dates aren't that important.
I talked about how my own thinking is in a very low risk baby. Giving it a one day
of age might not be as safe as waiting till they're two weeks old. But hepatitis B can be
(18:30):
a fatal disease causing liver failure, and it's transmitted by tiny, tiny amounts of blood. So
if you have hepatitis B+ parent in the home, that's a risk factor. There's IV drug abuse
in the home. That's a risk factor. But. Again, it's a disease that we have greatly reduced with
(18:55):
this vaccine, and the vaccine itself is very safe.And what about DTAP? Is that the way you say that?
Yes, that's a combination vaccine that's going to protect you against diphtheria,
tetanus, and hooping cough using AP, which is a cellular pertussis,
(19:20):
because the old hooping cough, which is the pertussis vaccine,
used to be a whole cell vaccine, and it had a lot more in the way of fever and side effects.
However, like I was saying before, if there's someone with neurologic disease, you have to be
a little careful with that pertussis hooping cough component. And we can leave that out if we have
(19:44):
a history of ongoing neurologic disease. So you can give a DT instead of a DTAP.
Why do you want to be? Immunized against these, well, diphtheria used to be a horrible cause
of the loss of, you know, two out of your five children if it came through your town.
(20:06):
It's the appearance of a very thick, what's called a pseudo membrane in the throat. And
the children would actually suffocate from this horrible sore throat that they got. And again,
we don't want to turn back the clock and start seeing these diseases. But
because people don't see them, they don't realize the import of these vaccines.
(20:30):
So again, DTAP, a little bit of fever. You can actually use Tylenol even at two months
of age. I often recommended one or two doses preventively. And then you keep giving it
for up to 24 hours if you needed to. Most side effects from the DTAP are right away.
What about HIB, H-I-B?
(20:53):
Okay, HIB, this is more an example of a potentially very devastating infection
where the vaccine is a sugar, a polysaccharide. So you're not going to have very much in the way
of side effect at all. And meningitis, septic arthritis, which is an infection in the joints,
(21:17):
and a very horrible illness that we really don't see much anymore- Epiglottitis,
which is a swelling of a little trapdoor that protects your airway. The Hib vaccine prevents
infection with a bacteria that used to cause death from that infection called epiglottitis.
(21:38):
And it's been a fantastic addition to all of the humanitarian immunologically because we did used
to see in my residency just 35, 40 years ago, we had a couple of deaths due to epiglottitis,
and the Hib prevents it and has very little in the way of side effects.
(22:02):
Polio you've already mentioned.
Polio we've talked about. And again,
the injected polio is a killed polio vaccine. So it's very safe.
Then there's pneumococcal. You might see that on your list because that's given at the same time…
(22:24):
PCV (Pneumococcal Conjugate Vaccine), right?
Correct. That's the pneumococcal vaccine. And everyone thinks about pneumonia being prevented,
bacterial pneumonia is being prevented by that. But for pediatricians, it's a very important
vaccine because that was the one bacteria, pneumococcus, that would get in a child's
(22:47):
bloodstream and not be located anywhere else. An infection called pneumococcal bacteremia.
So before that vaccine came out, every time we got a call from a very feverish infant under the age
of 18 months who didn't have a source, didn't have a cough or a cold or an ear infection,
(23:09):
the parents said, really, I don't know where the fever's coming from. We had to worry about that
particular infection, pneumococcal bacteremia, meaning infection of the bloodstream itself.
Once this vaccine came out, we no longer had to worry about that. And that was a fantastic advance
(23:30):
in pediatrics. And again, that's a very safe vaccine because that's a polysaccharide, a sugar.
MMR (Measles, Mumps, and Rubella vaccine), you've sort of mentioned.
MMR, we've talked about. The biggest problem with getting rid, people are really worried about the
(23:51):
MMR because there was that now proven false accusation that it was causing autism. That
set us way back. People came very dubious about whether or not they wanted the MMR.
The MMR is given at 12 to 15 months and then a booster dose has to be given at least a
(24:13):
month later. We generally give it before the kids start kindergarten at age four.
If there's an epidemic going on of measles, which is going to become more and more the
case if less and less people get this vaccine, then it can be given as early as 9 months,
but it has to be repeated two more doses after the child is 12 months to get permanent immunity.
(24:41):
And what about the chickenpox vaccine?
Chickenpox vaccine- why don't we give that right away? Well, that's kind of an interesting
question, and we don't give it until 12 months of age because most mothers have had chickenpox
during their life. So when the baby is born, if the baby's full term, the baby has received the
(25:07):
protection that is keeping the mother from getting chickenpox again. Those antibodies
travel through the placenta into the baby and protect the baby during the first year of life.
Many infants who do get chickenpox at nine to 12 months get it again because they haven't
formed their own protection. So we don't give the chickenpox vaccine until 12 months or older. And
(25:33):
again, that's one that also gets boosted later.What about Hepatitis A, Hep A?
Hep A, in the scheme of the vaccines you've been asking about, relatively new,
can be a very devastating illness. Luckily not seen very commonly, a very safe vaccine. Again,
(25:58):
one I think a parent could talk about with the doctor as to whether or not if they're
skeptical and they don't want vaccines, it might be one they could wait on.
So now we're getting into the school aged, adolescents, kids 7 to 18 years
(26:19):
of age. The first one on my list is DTAP. Is that a booster? Because tetanus is…
That’s a booster of each. As a child gets vaccines, they form a higher concentration
of antibodies, but their memory for a vaccine improves with age. So when they're an infant,
(26:44):
their memory doesn't last more than 2 to 3 months from the first or second shot.
That's why you get three in the first six months of life. But as they age,
their memory, their immune memory is better. And once you boost DTAP at age 4,
before the child starts school, you don't need another boost of immunity for five to 10 years.
(27:08):
That's incredible. Okay. What about HPV and there's a lot of,
you know- this is a newer one. And I think feel like this just came out when my boys
were reaching this age. And I was very, actually excited that this was available in the toolbox.
(27:33):
HPV, the development of a vaccine for was handed in with the discovery that some cancers are caused
by viruses. And in particular, certain serotypes of the Human Papillomavirus,
that's what the HPV stands for, cause cervical cancer in women. If you give this
(27:59):
vaccine before children have become sexually active, you basically prevent their ability
to get infection with those serotypes of this virus and you greatly reduce,
if not eliminate the cervical cancers that are arising from that virus.
So we were looking for what's a good age for this to be given, where it will have a long memory. And
(28:25):
it turns out it can be given as early as age 9, as late as 15 or 16, if we haven't had any sexual
activity yet. And giving it only to women, which initially was one of the thoughts doesn't work,
it has to be given to everybody. And luckily you were very receptive to the idea of having your
(28:48):
boys immunized to it. But I did have a lot of patients who didn't even want to consider it.
Yeah. Well, you know, I have known and had friends that have gone through that sort
of cancer and I just feel as though prevention, even though I had boys was very, very important
(29:11):
and I think as moms and women, we should be on board. So that's just my personal opinion.
Well, again, this is a virus that the risk factor is sexual activity and there's a very
big river called denial. And there are a lot of parents who swim in that river
and maybe hope that their children can get involved with any sexual activity.
(29:35):
Of course, no sexual activity is going to be happening.
So, you know, what is the difference between, “recommended” and “required” or…
That's a really good question. It's a very, it's actually somewhat of a gray area,
particularly this year, because I've been reading that this year's different
(29:59):
states are behaving differently in terms of enforcing school,
even school requirements. Florida has voted against having mandates and,
you know, rapidly, I think 9 other states are considering dropping mandates for immunizations.
We're rapidly going to lose what you and I were talking about with herd immunity. If
(30:24):
enough people decide they don't have to get their vaccines. Again, an honest appraisal is, yes,
you're taking a tiny little risk, but you're producing an immunity of the herd that will
protect. There are some people, for example, who can't get vaccines and if they're exposed
(30:44):
to the diseases, they're at a much higher risk of getting them. You're helping protect those people.
So requirement, it's a really question, good question. I don't know that the school systems
are going to follow requirements this year. Recommendations, again, should be given from
(31:06):
a doctor to each family individually, because there are different risk factors that make
some vaccines more dangerous than others.You know, I get the flu shot every year.
I think there is a misconception about that, that if you get an immunization
(31:31):
like the flu shot, that you won't get the flu. What, how does, how does that work?
Well, the flu is a very complicated virus in that it can mutate and when they design the flu vaccine
based on what virus is going around that year or what different types of that flu virus seem to be
(31:53):
the most common that year. When they actually make that vaccine during the summer months,
anticipating what's going to come that year, sometimes the predictions are wrong. And so
it can be as little as 30% protective. When it's at its best, it's about 70% effective. And again,
(32:14):
it's against flu, influenza, not rhino virus, which causes the common cold.
So, I mean, it's, it's a way of beefing up your protection, but it's certainly not a foolproof
90% to 100% immunity like you're getting with the other childhood vaccines we talked about. And in
(32:35):
all candor, I think they're still working to produce a more effective flu vaccine.
Flu itself in most people is not as severe an illness as some of the ones we've talked
about before. So again, each patient has to decide and it depends on your age group,
whether you have underlying lung disease, things like that as to how serious the flu might be for
(32:59):
you. So once again, the flu is a great example of one where you should talk to your doctor
about whether they advise to get it.And what about the COVID-19 vaccine?
Yeah, I'm really on the fence right now about
(33:20):
each year they develop a new COVID vaccine. I'm not scared by the technology of mRNA vaccines,
where simply you're giving a little mRNA and then your own cells are using that mRNA to produce the
antigenic substances we talked about that give your immune system a memory. I think that that's
(33:43):
something that needs to be discussed depending on your age, your health with your doctor.
I mean, this really is a complicated area to oversimplify and say, oh,
vaccines can cause all kinds of troubles. I think I don't want to give any to my child
is a real disservice to your child and to yourself. But I do think there's some
(34:07):
individualization that needs to occur so that if you have questions about certain vaccines,
you should talk about them with your doctor.So what questions should parents ask, you know,
a pediatrician and how much flexibility is there really in that immunization schedule?
(34:30):
That's a great question. I mean, for those of us who were around before the rotavirus vaccine,
for example, where rotavirus causes 3 to 5 days of diarrhea, sometimes vomiting,
occasionally dehydration, tends to go around daycares. If the child is not in a daycare,
(34:51):
is being taken at home by 1 or 2 caretakers, they and they don't want the rotavirus vaccine-
they have the option of refusing, but that's just one more example of like
the lifestyle affecting whether a certain vaccine would be necessary in your child.
(35:18):
So the conversation with the pediatrician, you know, it's the parents job to advocate
and understand the health of their child and to discuss it with their pediatrician.
Absolutely. That's part of the interaction every day in the office. And I will say
(35:39):
I did have a few patients who were blanket against all vaccines,
and my own malpractice insurer said I couldn't keep those patients in my practice because they
were putting my other patients at risk by refusing all vaccines. And they advised
(36:00):
me that I had to tell patients who refused all vaccines to go elsewhere for their care.
If they were willing to take some that I felt were the most important, delay others like as
we've talked about, or if, for example, their child wasn't going to daycare and so I felt
they weren't at high risk for the rotoviral vaccine. If we made little bargains like that,
(36:23):
I could keep the patient, but if they blanket refused all vaccines,
it puts the doctor in a catch-22 situation. So it's a difficult situation for the clinician.
So do you have- we've asked you this in the last podcast too, but do you have a guiding
(36:46):
quote or mantra that parents you think should think about as they're dealing with this topic?
Don't be too quick to throw out what really has evolved over a 500-year pathway of truly
(37:06):
dedicated medical investigators. Don't be in such a hurry to throw away that kind of
knowledge. Vaccines really are preventive medicine at its best. And yes, we're not
seeing a lot of these infections yet, but if we go backward, that's what most of us fear will happen.
(37:31):
Where should parents go to get reliable information?
There are websites that are run by the NIH, ACIP, they can certainly look at those.
But again, I think if they have questions, they should ask their own
(37:53):
doctor when they're in for those visits. And that's really what we're there for.
Was there anything you feel as though we left
out of this conversation that you want to make sure you mentioned?
This is a very complicated topic. And unfortunately, in this day and age,
(38:19):
I feel there's very little trust of the authority or the knowledge that doctors have gained over
the many years of their education and training and then work experience. And that we really,
in our complex society, have to trust experts in their areas. You can't glean enough just
(38:47):
from reading an article about possible negative effects of vaccines. You can't learn enough in
that brief interaction with the computer where you are picking up this stuff to refuse these
vaccines. If you're really uneasy about a certain one, bring it up with your doctor.
(39:09):
Well, Dr. Starr, thank you for joining me for this
very important conversation. I'm sure your practical answers offered insight
and a little more peace of mind for parents about childhood vaccines.
I hope.
I know it did. For our listeners, if you found today's episode helpful,
(39:31):
please share it with another parent and subscribe so you don't miss future episodes. And consider
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Mothers and Boy Survival Guide on Facebook, Instagram, YouTube, and your favorite podcast
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