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Emily Oster

14 minute read Emily Oster

Emily Oster

All About Vaccines

Why they’re important and how to make them more tolerable for your child

Emily Oster

14 minute read

Vaccines are never a fun conversation with your kids. For many years, before every doctor’s visit, my kids would ask, “Are there shots?” I never wanted to commit to a no, even when I thought there were not, so I always hedged, “Oh, I’m not sure. Ask the doctor.” Which led to all visits starting with the kids accosting our lovely pediatrician, “Are there shots today?!” as soon as she came into the room. Even if you are enthusiastic about vaccines, the experience of holding your kids as they get them is not usually a high point of parenting. And in the present moment, the conversation about vaccines is increasingly fraught, and not just because our kids are sometimes afraid of needles.

We’re living in a moment where vaccines, long one of the most trusted and studied preventative medical treatments in existence, are suddenly being viewed with skepticism. Debunked theories about the relationship between vaccines and autism, for example, are taking center stage on Instagram and Facebook but also in congressional hearings. I think that part of the problem we’re facing is a lack of understanding. People don’t know quite how vaccines work or why there are more now than in the past or how we can know that they are safe. 

My guest today is Dr. Adam Davis. A pediatrician in the Bay Area, Adam was my medical editor for the book Cribsheet, and he has a lot to say about vaccines from the perspective of someone who gives them.

In the conversation, we talk about our theories on why the COVID vaccine sped up a slow-growing movement around vaccine skepticism. We talk about the role that vaccines play in public health and how to explain that. We talk about what it’s like for doctors to deal with vaccine skeptics in their own practice and what people can and can’t be talked into or out of and, because it’s a parenting podcast, some hacks for getting your kids through vaccines without too much drama. Adam is here to help cut through some of the noise and generate some real understanding.

Here are three highlights from the conversation:

Why are vaccines for diseases that have been eradicated, like polio, still important to get?

Dr. Adam Davis:

I really stress to families, look, I don’t give any of the kids polio vaccine because I’m worried they’re going to get polio. There hasn’t been a case of polio in California since the ’70s. It’s very unlikely that [your child is] going to be exposed to polio, but they’re part of a larger project, and that project is to rid the world of polio. And COVID and flu we’re probably not going to rid the world of — they’re going to be endemic until technology changes dramatically — but if everybody vaccinates themselves, we will have less of a bump every year, we will have less deaths every year. And I think that matters.

How can you make getting vaccines slightly more tolerable for your child?

Dr. Adam Davis:

For the little babies, please feed your baby while they’re getting the vaccines. Nurse them if you’re breastfeeding, give them a bottle if you’re not. It makes a huge difference. For the little bit older kids, distract them. Put them over your shoulder. Put a screen or a bright moving thing behind your shoulder that they can watch. Often kids won’t even know they’re getting vaccines. With older kids, like anybody 4 to 5 and above, I play categories while I’m giving vaccines. I don’t give the vaccines, my medical assistants do, but I hold [the kid’s] hands, they look me eye to eye, and we go through a favorite thing — animals for the younger kids, sometimes sports players for the older kids. And honestly, they sometimes ask me if they’ve got their vaccines yet. It depends a little bit if they want to concentrate.

I find that attention’s the most important thing, just getting the attention away from it. And some kids you can’t do that with. They have panic attacks while they’re getting vaccines, and then it’s hold tight, hold fast, and go fast. Don’t take time.

Why is there a warning about egg allergies with some vaccines? 

Dr. Adam Davis:

Some of the vaccines over the years have been made in egg broth because it has proteins and different enzymes that they can survive. And so the thought was that some of those proteins would get into the vaccine itself. And I’m not an expert on all of the changes in manufacturing over the years, but it is true that we are no longer worried about even people who are anaphylaxis to eggs for any of our vaccinations. Although up to two years ago, we still had that on a questionnaire in our office, but I ignore it now.

Full transcript

This transcript was automatically generated and may contain small errors.

Emily Oster:

Adam Davis, thank you for joining me on the podcast.

Dr. Adam Davis:

Thanks for having me, Emily. Great to be here.

Emily Oster:

Do you want to go ahead and introduce yourself?

Dr. Adam Davis:

Sure. I’m Adam Davis. I’m a community pediatrician in San Francisco at SF Bay Pediatrics. I also have the honor of being the medical editor of Emily’s second book, Cribsheet. And I’m here today to just chat with her.

Emily Oster:

Yeah. All right, I’m super excited to have you. As you said, you were the medical editor on Cribsheet and so if anyone’s noticed any mistakes, they’re Adam’s fault, and we’ll be discussing them later. But I loved working with you on that. That was very fun to write and it was interesting. It’s always very interesting for me because I come from a place that is so data and is not seeing patients to work with someone and talk to someone about these same ideas but from the standpoint of someone who doesn’t spend their whole day thinking about causality but does actually see people. And of course people are a bit more complicated than data, even though data is people. Those perspectives, they come together.

Dr. Adam Davis:

Yeah. It was a lot of fun. And it was a great timing for me too. I was making a job transition from being a hospitalist and taking care of patients of children in the hospital that were very ill to doing primary care and deep diving into the data. And really helped hone my abilities as I moved to outpatient medicine and primary care. It served us both really well.

Emily Oster:

We’re going to talk today about vaccines, everybody’s favorite topic, but I’m actually curious, when you made that move… You moved from working with quite sick kids to working with presumably a mostly healthy population. I’m curious about what was the hardest thing about that move?

Dr. Adam Davis:

Yeah, the hardest thing was dermatology, honestly. In the hospital, there were three types of rash I would care about at all. It’d have to have blister or dying skin. And then you get into the outpatient world and everybody wants to talk about acne or these red bumps, and you’re like, “I don’t know.’ And so it took a little while to review that. But luckily most rashes and kids are quite transient, and so-

Emily Oster:

You think mostly the answer, “Rashes are fine. Yeah, who knows? Could be anything.”

Dr. Adam Davis:

I’ll tell you a funny story. One of my partners in my outpatient clinic is Dr. Alan Johnson. And he’s now in his 80s. He retired like a year and a half ago. He started in the practice in 1974, which was a year before I was born. And so when I just started back in primary care, he told me, “Adam, anytime you want, just come grab me out of a patient if you have any question.” There was a rash, and I knew what I wanted to do with it. I knew that some steroids and some moisturizer were going to get rid of the rash. And I knew it wasn’t a worrisome rash, I just didn’t know the medical terminology, the Latin root of what to call it, and so I went and I invited Alan into the room. And he looks at it, he goes, “It’s a rash.” And I was like, “Wait, that’s all you have to say?” And he is like, “Yeah. It’ll get better. It’s some irritation.” He’s like, “If it gets worse, then we’ll figure it out.”

It relieved some of the tension for me because one of the nice things about ambulatory medicine versus inpatient medicine is often you have that longer time period. In acute medicine, you need to figure out what’s going wrong and correct it shortly, but a rash you can say, “Well, let’s do this for a week. And if it’s getting much worse, we can call a friend or we can…” And that’s true for a number of things that can happen in the ambulatory world.

Emily Oster:

I like that in dermatology. Yeah. I’m often texting pictures of rashes to my pediatrician, and she does-

Dr. Adam Davis:

We love that.

Emily Oster:

She’s like, “Yeah, that’s a rash. Yep.”

Dr. Adam Davis:

Yeah, it-

Emily Oster:

“Do you have any Aquaphor? Put some Aquaphor on it.”

Dr. Adam Davis:

Totally, totally. And the pictures make it even harder because the quality of the iPhone pictures with the flash not turned on.

Emily Oster:

Yeah, I zoomed way in. She’s like, “Is that a hand? What body part is that?”

Dr. Adam Davis:

What body part is it? Is off to the next question. Exactly. But that was the hardest medically. There’s a whole different rhythm to being an ambulatory doc, both in terms of your individual days, you’re seeing many more patients than you do inpatient, but also in terms of what you’re doing with them. I remember I posted on Facebook to my friends, because at the beginning I felt a little bit like an imposter. People would come in with their well child for a well child exam. We’ll get into it, but I would give them vaccines if they were due for them and I’d talked to them about their activities at school. All your listeners have experience with their pediatrician. They left, and I was like, “What was the value of that for the families?” And it was actually really, really reassuring. I actually asked my friends. I was like, “Can you tell me, do you feel value?” Because from going to see on your well children when you knew your child was thriving in preschool or elementary school or whatever, and you didn’t really have a big concern. And universally, they were like, “Yes, a ton of value of the reassurance and having that relationship with the pediatrician.”

And over the years, now it’s been seven years that I’ve been doing this, I feel that every day. It’s a really special honor to have a family identify you as their child’s pediatrician. It’s a huge amount of trust. It’s a very unique relationship. It’s really special and a lot different times in the child life, like when they’re born obviously, but also those teen years when you’re transitioning from being mostly talking to the parents to mostly talking to the kid and you’re trying to preserve that relationship with the parents but also know that the kid can be in some rebellion, and you want to be on their side as well. And so it’s humbling that way and it’s really special.

Emily Oster:

That’s amazing. Okay, let’s talk about vaccines.

Dr. Adam Davis:

Yeah.

Emily Oster:

Let me start with the most basic question, which is what is your stance on vaccines?

Dr. Adam Davis:

There’s very few things in pediatrics medicine that have as good evidence as vaccines, period. People think that a lot of things that doctors do, and you’ve talked about this in a number of different venues and a number of different things, are based on these really great studies all the time, and often they’re not. Often they’re based on expert advice or smaller studies that imply something. And even how many days do we give of antibiotics for infections? It’s all based on football scores to me. You either give it for seven or 10 days. Nobody ever gives it for eight or nine. That’s just because a random study that… But nobody does a comparative of these small changes.

A lot of the questions that people can ask me, there’s not a wealth of literature to go to to answer it, but vaccines is the exception there. Vaccines are really well studied and the effects, what we call the effect size, how many people you have to do something to to protect one person is quite small with vaccines. Honestly, even if you go outside of doctors, if you just think about what’s improved health over the last century or more, it’s hygiene and vaccines are number one and number two. Probably hygiene first and vaccines second. But vaccines has been life-changing for public health. And so I’m a strong believer, so much so that our practice… And not every practice has the benefit of being able to do this, but we have limited capacity to keep patients in our practice who truly refuse vaccines. We won’t do that for the long haul. And in our state, they’re required for schools.

Emily Oster:

When you say there’s a lot of evidence behind vaccines, which I agree that there is, can you say a little bit more? If a parent comes and they say, “Well, what do you mean there’s a lot of evidence? I’ve heard,” blah, blah, whatever it is. When you talk about evidence there, what does that evidence look like?

Dr. Adam Davis:

Well, then you have to get into the individual vaccines because you can’t talk about… Overall, what I would say is vaccines are one of the best studied interventions that we have in medicine, but then you have to talk about individual vaccines and what the evidence is for what they do. And there’s different things that vaccines can do. They can prevent you from getting disease, they can attenuate, which means to lessen the strength of a disease, so you still get the disease but not as strongly. They can prevent spread of the disease. Or in the best cases, they can get rid of the disease from the planet. Which we’ve done once. Right?

Emily Oster:

Smallpox.

Dr. Adam Davis:

Smallpox we’ve gotten rid of all completely. And we were pretty close to polio being gone from the planet, and now it looks like that’s not going to happen in the near future, but… I have an ability to talk about pretty much each vaccine. Some of them I know better than others just because I’ve gotten in the speech more times. I have less patients who question some vaccines than others. The ones that question more are probably the ones that I have a more refined speech about. But again, ultimately, obviously it’s a parent’s choice on whether they want to vaccinate their kids. But most parents, after I talk to them about certainly the routine childhood vaccines, maybe not the annual respiratory vaccines, they do them. Honestly still, most parents in my community want to vaccinate their kids fully, so that’s a nice benefit of happens to be the patients that I work with.

Emily Oster:

When I think about vaccine resistance… Which I will say in the populations that I talk to, I feel has noticeably gone up even in the last year. The post-COVID and even more so in the last year, but over the last four or so years, I have many more questions from people about routine vaccines. I’m curious if you hear if that’s something you get on your team also.

Dr. Adam Davis:

Absolutely, but I will say more for COVID vaccine than the other ones, but all of them in some level. And I have a theory for that. And I actually think what happened is when vaccines were being developed during COVID, we all were one in had a lot of time on our hands at home. And we were all thinking about vaccines because we were all excited about vaccines and we all wanted a vaccine to be good and come out quickly. And then when they started coming out, we had comparative analysis like should I get Moderna or Johnson&Johnson? And people spent a lot of time thinking about vaccines and trying to get their vaccines. In some communities, many communities get their vaccines as quickly as they could. And I think they got used to doing a deep analysis of the very minor differences in cost benefits of different vaccines or different vaccine schedules. You’ll remember people talked about whether you should have it at four weeks afterwards or if you should wait a little bit longer. And there was just a lot of public discussion of every nuance of giving a vaccine.

Before that, I think that most parents mindlessly went to their doc and said, “Oh, it’s vaccine time. Cool, tell me what I need to get.” And then they got in the habit of doing their own analysis on it, which led to more and more questions, which leads to longer conversations, which led to some resistance in some areas. And specifically with the COVID vaccine, I think there’s also this almost… It’s somewhat illogical, but there’s almost this thing, “I want to be done with the pandemic.” And one day being way of being done with the pandemic is just, I’m not doing the vaccine anymore either because that’s part of the pandemic.

Emily Oster:

It’s interesting. I have a different theory, although your theory is a very interesting one. I think there’s a piece here that I totally agree with, which is people got into this habit of, “Now I’m am an epidemiology expert. Now I’m a vaccine expert. I’ve spent all my time doing this.” And I think that happened.

And the other thing that happened, which I think has a portion of fault to some extent of public health, and I’ve talked about this before, is after that initial vaccine wave, when we then got into the current state of boosters, I think that people are feeling attacked when they are raising concerns that they view as very valid, and some of which I think are reasonable. For example, there are a lot of people who would say now, “I don’t know why my seven-year-old needs a fourth booster. They’ve had COVID four times. They’ve had all of the shots. Europe doesn’t give boosters. Why is the CDC saying this is so important?” And then they feel like, “Well, I don’t really agree with this, it doesn’t seem reasonable. And then let me think about it. Why do I need the measles vaccine?” And I think for me, that’s a little bit of a failure because I actually think it should be totally reasonable to say, “Your kid gets a measles vaccine, but also, they don’t need a fourth booster because the value of that for a healthy kid is small.”

Dr. Adam Davis:

Right. I guess the logical fallacy I see there is they’ve also had eight influenza vaccines in their life. The way I explain it to families is I think that today the logic behind doing their annual respiratory vaccines, which are now COVID and flu, is the same for each other. And there’s minor differences there, and we can talk through them, but they each do three things. And I think those three things are really important to keep in mind. And I mostly vaccinate for the third in the case of these healthy elementary school and high school students.

One, they make you a little bit less likely to get the disease, but not a ton less likely. And it depends a little bit on the timing, it depends on each individual booster and whether that particular booster matched the particular strain that happens to be around during the next bump. But it does. And we know that from data. Two, it attenuates the disease. And again, that means to lessen the strength of it. And I’ll give you a great example that I have just from two weeks ago. And this is from flu, but I had a 13-year-old and a 20-year-old. And flu has been brutal the last few weeks.

Emily Oster:

Flu was been bad this year. Yeah.

Dr. Adam Davis:

Yeah. And I had a 13 and 20-year-old sisters who I knew forever, and really great relationship with their family and love these two girls. And they both came with fever. The 13-year-old had had fever for one day and actually had resolved, and she was laughing at my jokes. And the 20-year-old was lying on the exam table mad at me for making her laugh because she was in so much pain. It was her sixth day of 104 fevers/ and it just turned out that she hadn’t got her flu vaccine that year because she was off at college and she forgot to, and her 13-year-old sister had. And that doesn’t get into any study, right?

Emily Oster:

Mm-hmm.

Dr. Adam Davis:

Because from a study standpoint, the outcome for those two kids is neither went to the ER, neither were hospitalized, neither ended in the ICU and neither died. But the lived experience of flu after vaccination is often much less serious. Not serious in terms of I’m worried about your long-term health, but serious that week for you as a family than it is with no vaccination that year.

And the same thing can be a said of COVID. Now COVID seems to be right now a more mild disease than flu A for kids in general. I don’t see the high fevers and the really ill. You do see really tired and a lot of cough. And the tired is out of proportion often with the height of the fever, which with fluids seems more aligned. But again, I think it’s hard to measure these things in studies because they’re not the outcome studies they’re looking at. The second thing, besides lowering the risk of getting the disease and attenuating the disease itself if you get it… And part of the attenuation is just knocking off that tail of the bell curve too of this-

Emily Oster:

The really bad tail.

Dr. Adam Davis:

The really bad tail. That I don’t know how to measure because there’s such rare outcomes, and so I get it when people are like, “Well, that’s probably not going to happen to me,” and you’re probably right. But it does knock down that tail. We know that.

But the third thing, and this is incredibly important and the main reason that I vaccinate is we know from studies prior to the pandemic that the more kids who are vaccinated with flu vaccine in a community under 18, the less elderly people die in that community that season. And we know from COVID studies in the prisons where they can look at spread really nicely between prisoners, that even if a prisoner got COVID, they were less likely to give it to their cellmate if they had the vaccine because the viral load that they were coughing out was lower.

And so I do believe, and some… Again, we’ll get more data on COVID over time as these… But I do believe, first of all, more COVID deaths still today than flu deaths over the course of a year. We have more COVID deaths in this country. And so I do think that we can protect our elderly and our immunocompromised by continuing to have universal vaccination programs.

And so I really stress to families just, “Look, I don’t give any of the kids’ polio vaccine because I’m worried they’re going to get polio. There hasn’t been a case of polio in California. Maybe there will be now since New York’s had a case last year. But we haven’t had a case since the ’70s. It’s very unlikely that they’re going to be exposed to polio, but they’re part of a larger project, and that project is to rid the world of polio. And COVID and flu we’re probably not going to rid the world of, they’re going to be endemic until technology changes dramatically, but if everybody vaccinate themselves, we will have less of a bump every year, we will have less deaths every year. And I think that matters.” That’s how I explain it to them and then I let them make the decision they want to make.

Emily Oster:

But you would keep a patient even if they didn’t still…

Dr. Adam Davis:

Oh, flu and COVID? Yeah, absolutely. No, it is only the school required vaccines that we will. And part of it is it’s just a pain in the ass, right?

Emily Oster:

Right. Yeah. California has very, very sharp guidelines about what you can do to get out of vaccines.

Dr. Adam Davis:

But the way I say that to patients too is this: “Look, I’m in an area of the country that prior to the pandemic had some of the…” Marin County, which is one of the richest counties in the country-

Emily Oster:

Very low. Very, very low vaccines.

Dr. Adam Davis:

… had some of the lowest vaccination rates in the country before the pandemic. And immediately, immediately during the pandemic, it became the most vaccinated county in the entire country for COVID early on. Now, I don’t think that that’s probably still the same, but that’s a fascinating thing. And it’s fascinating how politics and vaccines have interacted.

But what I will say there is that we have doctor practices in the area, both in the city itself and surrounding the city that are very open to alternative vaccine or no vaccine families. And what I say to families is actually not, “Hey, you’re an horrible person because you’re not going to vaccinate your kid,” or even your pain in the ass. What I say to them is, “Look, we’re building a relationship of trust here, and I want you guys to trust that I’m going to give you the best information I can and that you trust me as a shepherd to help you through this. And if on the thing that I think is most evidence-based, you guys are like, ‘No,’ then there might just be a better match for you locally.” That’s what I offer up to them. I’m never like, “You’re bad people,” I’m just like, “I have a system of beliefs about medicine that you guys don’t believe, and so why wouldn’t you see somebody who matched that better?” I also don’t do crystal medicine in my practice. If they really wanted that, they should seek that out with somebody else.

Emily Oster:

Do you find these conversations frustrating?

Dr. Adam Davis:

No. Depends.

Emily Oster:

Not this conversation, but the patient population.

Dr. Adam Davis:

No, no, totally. Not always. It can be. If somebody wants to go line by line about research studies and play that game, it can be really frustrating. But that thing that I just did with you, Emily, where I said, “Here are the three reasons I vaccinated, and it’s really the third one,” and often, that ends with them still not doing the vaccination, but if I feel they heard my reasoning and they really listened to me, I feel okay about it and I don’t feel upset anymore. Now, when they come in for flu A and their kid has a fever to 104 and it’s day three of it, I’m gloaty. I always say it really sweet, but I’m always like, “Hey, one thing that I have to do here is a little I told you so.”

Emily Oster:

Going back to the routine childhood vaccination, you gave what I think is the right answer for the polio vaccine, which is probably for most people, your kid is not going to be exposed to polio.

Dr. Adam Davis:

Or measles or diphtheria. So many of the vaccines we give are, in some ways, and I want to word this carefully, not likely to affect that child because the people before them laid the groundwork for there not to be that pathogen in our environments.

Emily Oster:

And I think this feels to me like a very complicated part of this discussion, and we know what most motivate people. I have some research where you basically can see when there’s a pertussis outbreak in the county, in the next year more people get vaccinated for pertussis.

Dr. Adam Davis:

Oh, fine.

Emily Oster:

You see almost the immediate response of saying, “Oh, that’s a real disease.” Pertussis, whooping cough is an example of something where we do see it around, and getting vaccinated is a protective of you individually. But I think this is a hard piece of this for people because it feels like wouldn’t I just rather free ride?

Dr. Adam Davis:

I don’t have research, but I think much more effective than me arguing about side effects and effectiveness for their individual is talking about grandmothers and immunocompromised people.

Emily Oster:

The altruistic motivation.

Dr. Adam Davis:

Yeah, I think people… At least my experience with it is people are really like, “Oh, maybe I was getting caught up in my house and I had lost track of what this is all about.” And for the childhood vaccines, it’s a little bit different because there really you’re talking about people who really sacrificed by taking the vaccine or to get to the place where it’s such low amounts of it out in the community that it’s very unlikely to bump into in the world. And for the respiratory virus, it’s a little bit different about this lowering the spread.

But it’s funny, I do think that in our world right now, just where the culture is, people feel that they need to protect themselves and protect what they have a little bit more than they did before. And it’s a coarser environment. But I think within that, when you actually say, “Hey, no, this is actually a community thing,” and they weren’t thinking of it that way, it opens up something for them. For a lot of my patients, anyhow. My front staff, they have a big joke because I do a lot more vaccinations than a lot of my partners. I just do. We will vaccinate parents for COVID and flu. I ask every parent every visit, which is not what-

Emily Oster:

Not what other people are doing.

Dr. Adam Davis:

… most of my partners do. It goes back to that value proposition. What are the things that I can do in the office that are actually going to affect people’s health? And getting vaccines into arms is something that really does. I do enjoy that talk. And I think that pediatricians really have a strong voice in the room about this. And if we do that talk well and openly and are listening to and not demanding but are rather just talking through our thought process, there’s a surprising number of people will just be like, “You know what? Yeah.” Or they’ll say, “Let me talk to my husband.” It’s the dads who are much more anti-COVID vaccine than the moms right now. But yeah.

Emily Oster:

Dads, the worst. One of the questions that I hear coming up more and more is this question of splitting vaccines. There are many vaccines should… Often, many of them are given at the same time. People want to space them out. What do you say when people want to space them out?

Dr. Adam Davis:

Yeah, it’s a great question. And I get that a lot. And I have a few things I say. One is the number of pathogens that we get in vaccines is tiny compared to what we get through walking through life. And so I don’t think there’s anything that causes great harm to children to get six or eight pathogens instead of two or four or whatever the number may be.

But actually, this is a place where I say to them, “Look, I actually think… One, there is some evidence about this. And there’s some evidence that you have increased level of febrile seizures if you split your vaccines.” And I think that data is most likely just fever’s a potential side effect of any vaccine, so if you have fevers more time, you’re more likely to have a febrile seizure. But I don’t know.

But it’s not the thing I lead with. I don’t usually talk about that. What I usually talk about is the child’s experience. And what I usually say to them is, “Look, the day you get vaccines sucks and the next day sucks. And I don’t want so many of those days for your child. If we split this day into three days, then three days suck getting the shots, and that’s more of a negative stimuli for them, for this office, and for everything. Once they get their first shot, while they’re crying for their second shot, it’s not that big of a deal to them. They’re still going to be okay five minutes later. And yes, there might get a fever tomorrow, but I don’t think it’s additive. I don’t think if you give five vaccines, the fever will be three times as high. And it means if we split it that there’s another day they might get fever.”

And actually, the other part of it is really trying to help the patient take the vaccine calmly. And we can do a lot of things about that. For the little babies, please feed your baby while they’re getting the vaccines. Nurse them if you’re breastfeeding, give them a bottle if you’re not. It makes a huge difference. For the little bit older kids, distract them. Put them over your shoulder. Put a screen or a bright moving thing behind your shoulder that they can watch. Often, kids won’t even know they’re getting vaccines. With older kids, like anybody four to five and above, I play categories while I’m giving vaccines. I don’t give the vaccines, my medical assistants do, but I hold their hands, they look me eye to eye, and we go through a favorite thing, animals for the younger kids, sometimes sports players for the older kids. And honestly, they sometimes ask me if they’ve got their vaccines yet. It depends a little bit if they want to concentrate.

Some people do the EMLA. I think it’s a little bit placebo. I don’t think it matters if you numb the skin a little bit before the vaccine. But the vibration thing, like the buzzy bee or the ice, those things all work, but I find that attention’s the most important thing, just getting the attention away from it. And some kids you can’t do that. They have panic attacks while they’re getting vaccines, and then it’s hold tight, hold fast and go fast. Don’t take time.

Emily Oster:

You don’t want to do it again next week and next week and-

Dr. Adam Davis:

Yeah, that’s re-traumatizing the kid. As parents, the thing I would ask is once you make the decision, make the decision solid. Don’t negotiate with your five-year-old of whether you’re going to get vaccines that day. They’re not able to make that decision. You need to make that decision and hold it.

But it’s funny, I have families that after they get the vaccines, the kids will be like, “Oh, the worst part was thinking about the vaccine beforehand.” Or the parents will be like, “Oh my god, that wasn’t nearly as bad as I thought it would be.” So many parents come in with their own needle phobia that they project it down to their kids. If you can take a moment and think of a strategy to keep your kid distracted during vaccines, I think that everybody ends up not hating vaccines as much.

Emily Oster:

My kids, when they got the first COVID vaccine, there was this place that they got it. And I don’t know what was the deal with this person, but she was a very good vaccinator, and they still talk about how that was the least painful. That was their favorite vaccine. Then the place closed, and they’re always like, “Oh, it’s so sad it’s closed. That person was such a great vaccine giver.”

Dr. Adam Davis:

I’ve been through this with my own kids. My son at his three-year-old appointment cried because he was not scheduled to get a vaccine and he thought that he was getting ripped off at the doctor’s office. My daughter had been one of the more resistant vaccine receivers that my practice had to the point… I was not involved in her vaccines for many of the years, but she would run away and need to be held down. And one year, she said, “Daddy, I want you to give me the vaccines.” And I’m like, “Are you sure? I don’t do it nearly as often as the medical assistants.”

Emily Oster:

“I’m not very good at it. It’s not really my job.”

Dr. Adam Davis:

I was like, “But if you want.” And it’s always a little bit of joy to give your kid a little bit negative stimuli after all the things they’ve done to you over the years. I did do it, and then she’s like, “Never again.” And this year, I was so proud of her, she’s 11, and in our office 11 years is you get your three childhood vaccines plus your two rest. She had five and she sat there stoically. I was a really proud dad after I heard about it from the medical assistants. I’d been anxious about what it was going to be like. One piece of advice I have for parents too is just because your kid was scared at your X doesn’t mean they’ll be scared at your X plus one or have the same reaction. And allowing them growth and telling them that they are getting braver is really powerful for them, just like it would be in any other activity they’re a part of.

Emily Oster:

All right, lightning round. Short answers. Are you ready?

Dr. Adam Davis:

Yeah.

Emily Oster:

What is your favorite vaccine?

Dr. Adam Davis:

It’s not a vaccine, but this year I’m loving the RSV immunoglobulin.

Emily Oster:

Oh yeah, that is good.

Dr. Adam Davis:

This, wow. What’s cool, and I’m sorry I’m making it too long because I’m not good at lightning rounds, but there are three vaccines that weren’t available to me when I was a resident and that had tons of hospitalizations even when I was a hospitalist, and that’s pneumococcal, rotavirus, and RSV. And watching diseases drastically decrease their impact on kids is really fun. The ones that have come out since my training held a special place for me because they’re the kids that I remember spending all that time taking care of in the hospital.

Emily Oster:

Excellent. All right, why did they warn you about egg allergies when they do some vaccines, and then your doctor’s like, “It’s fine, actually. That’s made up.” Could you please say more about the-

Dr. Adam Davis:

Yeah, some of the vaccines over the years have been made in egg broth because it has proteins and different enzymes that they can survive. And so the thought was that some of those proteins would get into the vaccine itself. And I’m not an expert on all of the changes in manufacturing over the years, but it is true that we are no longer worried about even people who are anaphylaxis to eggs for any of our vaccinations. Although up to two years ago, we still had that on a questionnaire in our office, but I ignore it now.

Emily Oster:

Tylenol, ibuprofen after vaccines.

Dr. Adam Davis:

Ibuprofen. Just better at lowering fevers and better controlling pain than acetaminophen. Let’s not brand anything today.

Emily Oster:

Right. Okay, better immunity from vaccines or getting sick?

Dr. Adam Davis:

Oh. It depends on the individual illness. I’d rather not get sick. You got polio, you got great immunity, but you’re paralyzed.

Emily Oster:

Yes. It’s not a good trade-off. Have needles gotten smaller or am I just larger? To give you background, I recall vaccine needles from my childhood being like a PVC pipe, and now they seem very small. 

Dr. Adam Davis:

Yeah. Your childhood was about 15 or 20 years ago, I imagine, right? I don’t-

Emily Oster:

Yeah, no, it was more like 12 years ago, but yeah, that’s fine. Yeah. Yeah.

Dr. Adam Davis:

Yeah, I don’t remember the gauge needles that they were using. Vaccine needles are pretty small. They’re 25 gauge needles. They’re pretty tiny. But-

Emily Oster:

No comment.

Dr. Adam Davis:

No comment.

Emily Oster:

Did you go to chicken pox parties when you were a kid?

Dr. Adam Davis:

No, but I remember having chicken pox. And that’s a great example of a vaccine that we get a little bit of a resistance from because people remember it. But I like to remind people that 100 American kids died every year of chicken pox before we had the vaccine, and 10 to 100 times that were in the hospital with pneumonitis, which is like an inflammation of the lungs. But yeah, I have natural immunity to chicken pox.

Emily Oster:

I will also say that for me, chicken pox is a good illustration of what you said at the top about just even if things are totally fine, it ruins stuff. My brother had chicken pox on a family vacation in Greece, and it totally ruined it because he was incredibly uncomfortable and we couldn’t do anything. And it was this vacation my parents had planned and it was a big deal and there were three kids and they were dragging us to Europe and we were going to do all this fun stuff and he had chicken pox the entire time. He was totally fine, but it was definitely not great.

Dr. Adam Davis:

Yeah, if you could have timed that with a sore arm on a day that he wasn’t going to pitch in a little league game the next day, it would’ve been nicer.

Emily Oster:

Exactly. That’s all. What’s the vaccine that the people are most hesitant about other than the COVID flu respiratory space?

Dr. Adam Davis:

I think hep B at birth because the baby’s so little.

Emily Oster:

What do you tell people about hep B at birth? That’s the one I hear about all the time.

Dr. Adam Davis:

Yeah, I don’t fight it that much because I think in the population I’m dealing with, it has universal… Well, if they didn’t have universal prenatal care, I would fight it. But the reason we give hep B at birth, we have to bookend that, is because you can’t develop very good immunity at day zero of life. Your immune system is not ready to develop immunity. And so it’s not very effective at building up your long-term antibodies. But what it does do is it allows… If you have hepatitis B as a mom, which all ladies who get prenatal care have been tested for. But if they got it afterwards or if their test was wrong, then it very much lowers the risk of transmission. Now, if you actually had hepatitis B, they give you hepatitis B immunoglobulin as well, which is the proteins that the vaccine helps your body create to supercharge that immunity. And we can block vertical transmission of hepatitis B through that combination, but we get 70% of the effect with just the vaccine alone. And most hepatitis B is gotten through vertical transmission between mother and child in the world.

Again, on a public health basis, like worldwide, giving it at day zero absolutely makes sense. And Vietnam is where the major studies in hepatitis B have been. We’ve cut down on liver cancer in a single generation. Hepatitis B over time puts you at high risk of liver cancer. We’ve been able to cut down on that significantly, 80%, 90% from a previous generation because of hepatitis B vaccine.

On the other hand, most of my families, the reason they say no is they’re like, “Oh, this baby’s so tiny. I’m so worried about them getting a shot.” And then they come to my office because… And they also don’t trust the hospital system, but they’ve already decided they trust me, so they’ll just get it a few days later. And again, the likelihood that they got hepatitis B and either tested negative for it or got it in between the time they got tested and the time they delivered is so low that it’s not one I put a ton of energy in fighting.

Emily Oster:

Last question, did you get a flu shot this year?

Dr. Adam Davis:

I got flu and COVID. I gave my kids flu and COVID. I would get two. I love vaccines. I dream about new vaccines for new things. When the RSV vaccine got… I wish-

Emily Oster:

You wish you had the RSV vaccine.

Dr. Adam Davis:

Yes. I think that if we didn’t have the pandemic and all the anti-vaccine sentiment after the pandemic, they would’ve gone for a universal RSV vaccine. All of us get RSV at least once a year, maybe twice. I’d get a vaccine just to avoid two colds. That’d be awesome. Yeah, it’s not going to change whether I get hospitalized or die like it does for elderly patients and little kids, but I don’t love being sick, and vaccines are a really cool way to avoid that.

Emily Oster:

That is a great note to end on. Adam, thank you so much for being here. It was a delight. And I think that everyone will find it incredibly useful.

Dr. Adam Davis:

Oh, well, thanks for having me. It was super fun. And hopefully we can talk about a less controversial topic next time.

Emily Oster:

Absolutely. Next time, we can do breastfeeding or starting solids. Something good, something easy.

Dr. Adam Davis:

Awesome.

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