Don’t split the vaccines

Brook asked a good question: “I am curious to learn more about the timing and combining of multiple vaccines. As a disclaimer, may I please add – I do not fear vaccines, and I certainly think they are helpful and necessary as opposed to harmful to my children. I read that the CDC recommends that the MMR, DTAP, IPV, & Varivax vaccines be administered between the ages of 4 years and 6 years. My pediatric group recommends that all four vaccines be administered at the same visit at the age of 4 years. I wonder why they aren’t spaced such that 2 shots are given at 4 years and 2 shots at 5 years or something similar. Are there advantages to spacing the vaccines? Are there risks in administering multiple vaccines in one visit? Are the shots administered in each of the limbs? Any insight you could offer would be greatly appreciated. I am not sure if I should request that the vaccines be administered over 2 or 3 visits to make sure my child’s immune system isn’t overburdened and he fully benefits from them.”

Giving these vaccines poses no added risk versus giving them all at once, and as a pediatrician who has supervised vaccinations for many years, I’ll tell you that it’s much, much easier on the child to get them all over with at once.

First, to address the idea that there are too many vaccines, or that this quantity of vaccines will somehow “overwhelm” a child’s immune system: there are several good, solid lines of evidence that show that “immune overload” isn’t something that occurs, and isn’t something to fear. Ordinary infections like the common cold expose a child to far more antigens that the immune system must process than even multiple injections. Though there are more individual vaccines now than in the past, these newer, more-refined vaccines actually have fewer immune-stimulating components. In fact, the entire combined cumulative set of all current vaccines given throughout childhood has far fewer components that challenge the immune system than a single dose of the whole-cell pertussis vaccine that was used until the mid ‘90s. Many studies have confirmed that children are not more likely to develop infections after vaccination. The immune-overload hypothesis is just the latest propaganda from the anti-vaccine crowd. Don’t fall for it.

There are two important advantages in giving these vaccines all in one visit: first, it makes it easier for children to remain up-to-date. Most children, nationwide, have a well visit at age four OR five, but not necessarily both. Splitting up the vaccines will only work if the child comes back for both visits, which depending on many circumstances (employment, insurance, health services availability) may or may not happen. For families with stable health-care access, there is still another important advantage in getting them all over with at once: it’s far easier for the child. Bring a kid in once, get the vaccines, and say afterwards “That was rough. I’m glad we don’t have to do that again! Let’s go get ice cream!” But if you drag that same kid in a few months later to catch up (or, if you insist on doing them one-by-one, every month for four months) that child is going to freak. Believe me, your pediatrician doesn’t want your child to dread coming to the office; a screaming child can’t be examined well, and we don’t like to see your child miserable any more than you do.

You also asked about the specifics of how they’re given: I can’t speak for your doctor’s office, but in my office, we put 2 vaccines in each of the child’s upper thighs. Usually, multiple nurses are available to give them essentially “all at once,” which I think is a little less rough on the kiddo than 1..2..3..4.

As far as giving them at the 4 versus the 5 year well check, we’ve found in my area that many pre-kindergarten programs require these vaccines at registration, which can be before the 5 year visit. And some insurance companies will only pay for one well check a year. So if you delay them at 4, you may be on the hook for a big bill if it turns out you need them before 5. If you’re certain they’re not needed by the school until after 5, I would much rather you delay all of them until 5 than give ½ at 4 and ½ at 5. But we’ve started encouraging all of them at 4, to avoid that insurance-preK issue.

Splitting the vaccines up puts a parent’s irrational and unfounded fears ahead of their child’s needs. Don’t do it.

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3 Comments on “Don’t split the vaccines”

  1. Brook Says:

    Thank you very much for your helpful and timely response to my question. I appreciate your time and valuable input. I learned a lot and feel confident taking my child in for his 4yo well visit.


  2. Janice Says:

    If more than one vaccine is given at the same time, how does the parent or doctor know what the culprit is if the child has an adverse reaction, such as an allergic reaction or a seizure? I understand those things are rare,but if it happened and 3 or 4 shots were given, how would you know what to avoid or further monitor for the next shot? I would never let the Pedi give my kids more than 2 shots at a time because I feared this. Our pedi never said anything about it one way or the other.


  3. Dr. Roy Says:

    Janice, while serious reactions to vaccines are very rare– I’ve never seen one, or been involved in the care of one, or had first-hand knowledge of one– they can occur. Powerful, large epidemiologic studies have been able to ferret out and document some very specific reactions that are possible, as rare as they are. Specific reactions are almost always associated with a single kind of vaccine. For instance, immune-mediated thrombocytopenia occurs in about 1 in 1 million children who receives the MMR vaccine. So if a specific adverse event occurs, its blame lies with the vaccine that is known to cause that kind of event.

    For severe allergic reactions to vaccines– again, very very rare– it’s usually to a vaccine component rather than to the vaccine itself. For instance, some vaccines are made with an antibiotic called neomycin; others contain a trace amount of gelatin. Others are packaged in a way that might bring the vaccine in contact with a rubber stopper, potentially leading to a latex reaction in a very allergic individual. These components are sometimes included in multiple different vaccines. Through testing, an allergist can determine what vaccine component(s) triggered the reaction, and thus which vaccine(s) should be avoided in the future.


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