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Objective This study aims to characterize the experience of prognostic uncertainty for neonatal intensive care unit (NICU) parents. Study Design We conducted a qualitative interview study of current and former NICU parents regarding their experience with prognostic uncertainty in the NICU. Interviews were transcribed and analyzed using a grounded theory methodology. Results Twenty-four parents were interviewed before achieving thematic saturation. Three phases of the parental experience of prognostic uncertainty emerged: shock, gray daze, and looking forward. These phases often, but not always, occurred sequentially. In shock, parents felt overwhelmed by uncertainty and were unable to visualize a future for their family. In gray daze, parents felt frustrated by the continued uncertainty. While accepting the possibility of a future for their family, they could not conceptualize a path by which to achieve it. In looking forward, parents accepted uncertainty as inevitable and incorporated it into their vision of the future. Conclusion While each parent experienced the prognostic uncertainty in the neonatal intensive care unit in their own way, we found three common experiential phases. By understanding how a parent experiences prognostic uncertainty in these phases, providers may become better able to communicate and form therapeutic relationships with parents.

Shared decision making (SDM)—when clinicians and patients make medical decisions together—is moving swiftly from an ethical ideal toward widespread clinical implementation affecting millions of patients through recent policy initiatives. We argue that policy initiatives to promote SDM implementation in clinical practice carry the risk of several unintended negative consequences if limitations in defining and measuring SDM are not addressed. We urge policy makers to include prespecified definitions of desired outcomes, offer guidance on the tools used to measure SDM in the multitude of contexts in which it occurs, evaluate the impact of SDM policy initiatives over time, review that impact at regular intervals, and revise SDM measurement tools as needed.

OBJECTIVE: To evaluate the effect of vaccine hesitancy screening on childhood vaccine uptake. METHODS: We conducted a cluster randomized controlled trial in pediatric primary care clinics in Washington state. Vaccine-hesitant parents (VHPs) with a healthy newborn receiving health supervision at participating clinics were eligible. VHPs were identified by using a 4-item version of the validated Parent Attitudes About Childhood Vaccines Survey (PACV). Before their child’s 2- and 6-month health supervision visits, VHPs at intervention clinics completed the 15-item PACV embedded in a survey containing placebo items. Intervention providers received a summary of parents’ 15-item PACV responses and interpretation of their PACV score; discretion was given to providers regarding how they acted on this information. VHPs at control clinics completed only the placebo survey items, and their child’s provider received a summary of their responses; control providers remained blinded to parent VHP status. Our outcome was child immunization status at 8 months of age expressed as percent of days underimmunized. We compared outcomes in control and intervention participants using t test and linear mixed-effects regression. RESULTS: We enrolled 24 clinics (12 in each arm) and 156 parents (65 in the intervention arm). Parent characteristics were similar across arms except more intervention (versus control) parents had a first-born child (60.9% vs 44%; P = .04). No significant difference in outcome was detected between arms (25.2% [95% confidence interval: 16.0% to 34.5%] vs 19.1% [95% confidence interval: 12.0% to 26.3%] mean days underimmunized in the intervention and control arms, respectively). CONCLUSION: Vaccine hesitancy screening was not significantly associated with days underimmunized.

OBJECTIVES: To evaluate variation in resource use for children with acute respiratory tract illness (ARTI) by vaccination status. METHODS: We conducted a retrospective cohort study of children 0 to 16 years of age at 5 children’s hospitals with 1 of 4 ARTI diagnoses (pneumonia, croup, asthma, and bronchiolitis) between July 2014 and June 2016. The predictor variable was provider-documented up-to-date (UTD) vaccination status (yes or no). Outcomes were receipt of each of the following tests or treatments (yes or no): complete blood cell count, blood cultures, C-reactive protein (CRP) level testing, viral testing, influenza testing, pertussis testing, chest radiographs, neck radiographs, antibiotics, and corticosteroids. We generated multivariable logistic regression models to examine the associations between our predictor and outcomes. RESULTS: Of the 2302 participants included in analysis, 568 (25%) were diagnosed with pneumonia, 343 (15%) were diagnosed with croup, 653 (28%) were diagnosed with asthma, and 738 (32%) were diagnosed with bronchiolitis. Most (92%) vaccination statuses were documented as UTD. Across conditions, children whose vaccination status was documented as not UTD had higher adjusted odds of receiving a complete blood cell count, blood culture, CRP level testing, and influenza testing (P < .001). Children with pneumonia whose vaccination status was documented as not UTD had higher adjusted odds of receiving CRP level testing and influenza testing (P < .001). Children with croup whose vaccination status was documented as not UTD had higher adjusted odds of receiving blood cultures (P < .001). CONCLUSIONS: Children with ARTI whose vaccination status was documented as not UTD had higher odds of undergoing laboratory testing compared with children whose vaccination status was documented as UTD.

BACKGROUND AND OBJECTIVES: Pediatric dialysis is thought to be burdensome on caregivers given their need to assume dual responsibilities of parental and medical management of their child’s chronic illness. In this study, we seek to describe the experience of parental caregivers of children receiving chronic dialysis for end-stage kidney disease. METHODS: We performed semistructured interviews of primary caregivers of children with end-stage kidney disease receiving chronic peritoneal dialysis or hemodialysis for at least 8 weeks from March 2016 to April 2017 at 3 pediatric dialysis centers in the United States. We performed a thematic analysis to inductively derive and identify themes and subthemes related to positive and negative caregiver experiences. RESULTS: Thirty-five caregivers completed interviews. Four major themes were identified, each with several subthemes: (1) caregiver medicalization (subthemes: diagnosis and initiation, disease management, and the future), (2) emotional adjustment (initial and/or acute phase, acceptance, personal growth, and medical stress and psychological burden), (3) pragmatic adaptation (disruption, adaptation of life goals and/or sense of self, and financial impact), and (4) social adjustment (relationship opportunity, relationship risk, advocacy, family functioning, and intimate relationships). These themes and subthemes reflected a broad range of experiences from positive to severely burdensome. CONCLUSIONS: Caregivers of patients on dialysis report a broad range of positive and burdensome experiences. These results reveal a need for continued advocacy to support families with a child on dialysis and can be used to develop targeted measures to study and improve caregiver experience in this population.

Objectives. To examine the relation of vaccine refusal and medical neglect under child welfare laws. Methods. We used the Westlaw legal database to search court opinions from 1905 to 2016 and identified cases in which vaccine refusal was the sole or a primary reason in a neglect proceeding. We also delineated if religious or philosophical exemptions from required school immunizations were available at the time of adjudication. Results. Our search yielded 9 cases from 5 states. Most courts (7 of 9) considered vaccine refusal to constitute neglect. In the 4 cases decided in jurisdictions that permitted religious exemptions, courts either found that vaccine refusal did not constitute neglect or considered it neglect only in the absence of a sincere religious objection to vaccination. Conclusions. Some states have a legal precedent for considering parental vaccine refusal as medical neglect, but this is based on a small number of cases. Each state should clarify whether, under its laws, vaccine refusal constitutes medical neglect.

We conducted a qualitative study from 2018 to 2019 to update the reasons why US parents’ refuse or delay vaccines. Four focus groups and 4 semi-structured interviews involving 33 primary care pediatric providers were conducted in Washington and Colorado. A thematic analysis was conducted to identify themes related to reasons for parental refusal or delay. Five predominant themes were identified: (1) vaccine safety, (2) relative influence of information sources, decision-makers, and timing, (3) low perceived risk of contracting vaccine-preventable disease, (4) lack of trust, and (5) religious objection. Vaccine safety was the theme mentioned most frequently by providers (N = 45 times by 26 providers) and religious objection to vaccination was referred to the least (N = 6 times by 6 providers). Provider-reported reasons for parental refusal or delay of childhood vaccines in 2018 to 2019 remain similar to those reported in previous studies.

Background. Parental trust in their child’s health care provider and the number and type of vaccine information sources are important dimensions of vaccine hesitancy and may suggest intervention components for future research. Method. We conducted secondary analysis of survey data from mothers of healthy newborns in Washington State, and examined the association between parental trust in their child’s health care provider and vaccine information sources. Results. We found that mothers with less trust in their child’s health care provider used more sources, more informal sources, and were less likely to consider their child’s pediatrician their main source of vaccine information compared with more trusting mothers. However, less trusting mothers did not report more effort to read or watch stories about vaccines than more trusting mothers, nor were they more likely to report the internet as their main vaccine information source. Conclusions. Future interventions seeking to reduce parental vaccine hesitancy should consider intervention components focused on building or improving parent trust in their child’s health care provider.

PURPOSE Despite the benefits of well-child care visits, up to one-half of these visits are missed. Little is known about why children miss them, so we undertook a qualitative study to elucidate these factors. METHODS We interviewed 17 caregivers whose children had missed well-child visits and 6 clinicians, focusing on 3 areas: the value of well-child visits, barriers to attendance, and facilitators of attendance. Transcripts were analyzed with a grounded theory approach and thematic analysis. RESULTS Caregivers and clinicians identified similar important aspects of well-child visits: immunizations, detection of disease, and monitoring of growth and development. Both groups identified similar barriers to attendance: transportation, difficulty taking time off from work, child care, and other social stressors. CONCLUSIONS Further work to explore how addressing social determinants of health might improve attendance of well-child visits is needed.

OBJECTIVES: To assess the impact of a parent educational intervention about influenza disease on child vaccine receipt. METHODS: A convenience sample of parents of children ≥6 months old with a visit at 2 New York City pediatric clinics between August 2016 and March 2017 were randomly assigned (1:1:1) to receive either usual care, an educational handout about influenza disease that was based on local data, or an educational handout about influenza disease that was based on national data. Parents received the handout in the waiting room before their visit. Primary outcomes were child influenza vaccine receipt on the day of the clinic visit and by the end of the season. A multivariable logistic regression was used to assess associations between intervention and vaccination, with adjustment for variables that were significantly different between arms. RESULTS: Parents who received an intervention (versus usual care) had greater odds of child influenza vaccine receipt by the end of the season (74.9% vs 65.4%; adjusted odds ratio 1.68; 95% confidence interval: 1.06–2.67) but not on the day of the clinic visit. Parents who received the national data handout (versus usual care) had greater odds of child influenza vaccine receipt on the day of the clinic visit (59.0% vs 52.6%; adjusted odds ratio 1.79; 95% confidence interval: 1.04–3.08) but not by the end of the season. CONCLUSIONS: Providing an educational intervention in the waiting room before a pediatric provider visit may help increase child influenza vaccine receipt.

Shared decision-making (SDM) has emerged as the preferred decision-making model in the clinician-patient relationship. Through collaboration, SDM helps to facilitate evidence-based medical decisions that are closely aligned with patient or surrogate preferences, values, and goals. How to implement SDM in clinical pediatric practice, however, remains elusive, in part because SDM in pediatrics is complicated by the involvement of parents as a special class of surrogate decision-maker. A provisional framework for the process of SDM in pediatrics was recently proposed by Opel to help facilitate its implementation. To identify aspects of the framework that require refinement, we applied it across a diverse range of clinical cases from multiple pediatric specialties. In doing so, several questions surfaced that deserve further scrutiny: (1) For which medical decisions is consideration of SDM required? (2) What is considered medically reasonable when there is variability in standard practice? (3) Can an option that is not consistent with standard practice still be medically reasonable? (4) How should public health implications be factored into SDM? (5) How should variability in preference sensitivity be approached? (6) How should the developing autonomy of adolescents be integrated into SDM?; and (7) How should SDM address parental decisional burden for emotionally charged decisions? We conduct a brief analysis of each question raised to illustrate key areas for future research.

BACKGROUND AND OBJECTIVES: It is unclear which specific well-child visits (WCVs) are most frequently missed and whether age-specific patterns of attendance differ by race or insurance type. METHODS: We conducted a retrospective cohort study of children 0 to 6 years old between 2011 and 2016 within 2 health networks spanning 20 states. WCVs were identified by using International Classification of Diseases, Ninth and 10th Revisions and Current Procedural Terminology codes. We calculated adherence to the 13 American Academy of Pediatrics–recommended WCVs from birth to age 6 years. To address data completeness, we made 2 adherence calculations after a child’s last recorded WCV: 1 in which we assumed all subsequent WCVs were attended outside the network and 1 in which we assumed none were. RESULTS: We included 152 418 children in our analysis. Most children were either publicly insured (77%) or uninsured (14%). The 2-, 4-, and 6-month visits were the most frequently attended (63% [assuming no outside care after the last recorded WCV] to 90% [assuming outside care]), whereas the 15- and 18-months visits (41%–75%) and 4-year visit (19%–49%) were the least frequently attended. Patients who were publicly insured and uninsured (versus privately insured) had higher odds of missing WCVs. Hispanic and Asian American (versus non-Hispanic white) patients had higher odds of attending WCVs. DISCUSSION The 15- and 18-month WCVs as well as the 4-year WCV are the least frequently attended WCVs. The former represent opportunities to identify developmental delays, and the latter represents an opportunity to assess school readiness.

Globally, infant and childhood vaccine uptake rates are not high enough to control vaccine preventable diseases, with outbreaks occurring even in high-income countries. This has led a number of high-, middle-and low income countries to enact, strengthen or contemplate mandatory infant and/or childhood immunization to try to address the gap. Mandatory immunization that reduces or eliminates individual choice is often controversial. There is no standard approach to mandatory immunization. What vaccines are included, age groups covered, program flexibility and rigidity e.g. opportunities for opting out, penalties or incentives, degree of enforcement, and whether a compensation program for causally associated serious adverse events following immunization exists vary widely. We present an overview of mandatory immunization with examples in two high- and one low-income countries to illustrate variations, summarize limited outcome data related to mandatory immunization, and suggest key elements to consider when contemplating mandatory infant and/or child immunization. Before moving forward with mandatory immunization, governments need to assure financial sustainability, uninterrupted supply and equitable access to all the population. Other interventions may be more effective and less intrusive than mandatory. If mandatory is implemented, this needs to be tailored to fit the context and the country's culture.

Objective To develop and test a caregiver-reported experience measure for pediatric hospital-to-home transitions. Data sources/study setting Primary data were collected between 07/2014 and 05/2015 from caregivers within 2-8 weeks of their child's discharge from a tertiary care children's hospital. Study design/data collection We used a step-wise approach to developing the measure that included drafting de novo survey items based on caregiver interviews (n = 18), pretesting items using cognitive interviews (n = 18), and pilot testing revised items among an independent sample of caregivers (n = 500). Item reduction statistics and confirmatory factor analysis (CFA) were performed on a test sample of the pilot data to refine the measure, followed by CFA on the validation sample to test the final measure model fit. Principal findings Of 46 initial survey items, 19 were removed after pretesting and 19 were removed after conducting item statistics and CFA. This resulted in an eight-item measure with two domains: transition preparation (four items) and transition support (four items). Survey items assess the quality of discharge instructions, access to needed support and resources, care coordination, and follow-up care. Practical fit indices demonstrated an acceptable model fit: χ2 = 28.3 (df = 19); root-mean-square error of approximation = 0.04; comparative fit index = 0.99; and Tucker-Lewis index = 0.98. Conclusions An eight-item caregiver-reported experience measure to evaluate hospital-to-home transition outcomes in pediatric populations demonstrated acceptable content validity and psychometric properties.

Parents decide whether their children are vaccinated, but they rarely reach these decisions on their own. Instead parents are influenced by their social networks, broadly defined as the people and sources they go to for information, direction, and advice. This study used social network analysis to formally examine parents' social networks (people networks and source networks) related to their vaccination decision-making. In addition to providing descriptions of typical networks of parents who conform to the recommended vaccination schedule (conformers) and those who do not (nonconformers), this study also quantified the effect of network variables on parents' vaccination choices.This study took place in King County, Washington. Participation was limited to US-born, first-time parents with children aged ≤18 months. Data were collected via an online survey. Logistic regression was used to analyze the resulting data.One hundred twenty-six conformers and 70 nonconformers completed the survey. Although people networks were reported by 95% of parents in both groups, nonconformers were significantly more likely to report source networks (100% vs 80%, P.001). Model comparisons of parent, people, and source network characteristics indicated that people network variables were better predictors of parents' vaccination choices than parents' own characteristics or the characteristics of their source networks. In fact, the variable most predictive of parents' vaccination decisions was the percent of parents' people networks recommending nonconformity.These results strongly suggest that social networks, and particularly parents' people networks, play an important role in parents' vaccination decision-making.

Richard Thaler and Cass Sunstein define a nudge as "any aspect of the choice architecture that alters people's behavior in a predictable way without forbidding any options or significantly changing their economic incentives." Much has been written about the ethics of nudging competent adult patients. Less has been written about the ethics of nudging surrogates' decision-making and how the ethical considerations and arguments in that context might differ. Even less has been written about nudging surrogate decision-making in the context of pediatrics, despite fundamental differences that exist between the pediatric and adult contexts. Yet, as the field of behavioral economics matures and its insights become more established and well-known, nudges will become more crafted, sophisticated, intentional, and targeted. Thus, the time is now for reflection and ethical analysis regarding the appropriateness of nudges in pediatrics. We argue that there is an even stronger ethical justification for nudging in parental decision-making than with competent adult patients deciding for themselves. We give three main reasons in support of this: (1) child patients do not have autonomy that can be violated (a concern with some nudges), and nudging need not violate parental decision-making authority; (2) nudging can help fulfill pediatric clinicians' obligations to ensure parental decisions are in the child's interests, particularly in contexts where there is high certainty that a recommended intervention is low risk and of high benefit; and (3) nudging can relieve parents' decisional burden regarding what is best for their child, particularly with decisions that have implications for public health.

Objectives. We investigated how provider vaccine communication behaviors influence parental vaccination acceptance and visit experience. Methods. In a cross-sectional observational study, we videotaped provider–parent vaccine discussions (n = 111). We coded visits for the format providers used for initiating the vaccine discussion (participatory vs presumptive), parental verbal resistance to vaccines after provider initiation (yes vs no), and provider pursuit of recommendations in the face of parental resistance (pursuit vs mitigated or no pursuit). Main outcomes were parental verbal acceptance of recommended vaccines at visit’s end (all vs ≥ 1 refusal) and parental visit experience (highly vs lower rated). Results. In multivariable models, participatory (vs presumptive) initiation formats were associated with decreased odds of accepting all vaccines at visit’s end (adjusted odds ratio [AOR] = 0.04; 95% confidence interval [CI] = 0.01, 0.15) and increased odds of a highly rated visit experience (AOR = 17.3; 95% CI = 1.5, 200.3). Conclusions. In the context of 2 general communication formats used by providers to initiate vaccine discussions, there appears to be an inverse relationship between parental acceptance of vaccines and visit experience. Further exploration of this inverse relationship in longitudinal studies is needed.

BACKGROUND: Providing influenza vaccine to patients in the pediatric emergency department (PED) is one strategy to increase childhood influenza vaccine uptake. The Parent Attitudes about Childhood Vaccines (PACV) survey is a new tool to identify vaccine-hesitant parents that may facilitate influenza vaccine uptake in the PED. OBJECTIVE: To assess the feasibility of administering the PACV modified for influenza vaccination in the PED setting and to determine whether parental PACV scores are associated with patient receipt of influenza vaccine in the PED. METHODS: We conducted a cross-sectional study in the PED of a tertiary pediatric hospital in Seattle, WA during the 2013–2014 influenza season. English-speaking parents of children aged 6 months to 7 years who were afebrile, medically stable to be discharged home from the PED, and had not already received an influenza vaccine this season were administered a modified version of the PACV. PACV scores (0–100, higher score = higher hesitancy) were dichotomized (

Background Addressing parental vaccine hesitancy may increase adolescent vaccination acceptance. However, no validated measure exists to identify parents hesitant toward adolescent vaccines. Objective To determine if a modified version of the Parent Attitudes about Childhood Vaccines (PACV) survey, a previously validated tool to identify parental hesitancy toward vaccines in infants, predicts adolescent vaccine uptake at office visits. Methods We modified the PACV for use in the adolescent setting and distributed it to a convenience sample of parents of adolescents aged 11 to 17 presenting for care at a diverse group of six pediatric practices in Oklahoma and South Carolina. We determined the vaccination status of the parents’ adolescents for 3 vaccines (Tetanus–diphtheria–acellular pertussis [Tdap], meningococcal conjugate [MCV4], and human papillomavirus [HPV] vaccines). We used Fisher's exact tests to compare vaccination status with each survey item and with an overall general hesitancy scale that we constructed. Results We analyzed 363 surveys. At the time of the visit, vaccination coverage was 84% for Tdap, 73% for MCV, and 45% for any dose of HPV. Thirty-nine percent of parents expressed concern about vaccine efficacy and 41% expressed concern about side effects. Forty-five percent of parents disagreed with the statement that “teens can get all of the vaccines that are due at a single visit.” Two individual items were associated with not receiving a dose of HPV vaccine that was due. The overall modified PACV score failed to predict adolescent vaccine uptake at an office visit. Conclusion Several individual items were associated with vaccine uptake. The cumulative modified PACV, a general measure of vaccine hesitancy, was not associated with vaccination status despite illuminating parental hesitancy. We need to better understand vaccine-specific concerns for the adolescent population.

Objective Presumptive formats to initiate childhood vaccine discussions (eg, "Well, we have to do some shots") have been associated with increased vaccine acceptance after one visit compared to participatory formats (eg, "How do you feel about vaccines?"). We characterize discussion format patterns over time and the impact of their repeated use on vaccine acceptance. Methods We conducted a longitudinal prospective cohort study of children of vaccine-hesitant parents enrolled in a Seattle-based integrated health system. After the child's 2-, 4-, and 6-month visits, parents reported the format their child's provider used to begin the vaccine discussion (presumptive, participatory, or other). Our outcome was the percentage of days underimmunized of the child at 8 months old for 6 recommended vaccines. We used linear regression and generalized estimating equations to test the association of discussion format and immunization status. Results We enrolled 73 parent–child dyads and obtained data from 82%, 73%, and 53% after the 2-, 4-, and 6-month visits, respectively. Overall, 65% of parents received presumptive formats at ≥1 visit and 42% received participatory formats at ≥1 visit. Parental receipt of presumptive formats at 1 and ≥2 visits (vs no receipt) was associated with significantly less underimmunization of the child, while receipt of participatory formats at ≥2 visits was associated with significantly more underimmunization. Visit-specific use of participatory (vs presumptive) formats was associated with a child being 10.1% (95% confidence interval, 0.3, 19.8; P = .04) more days underimmunized (amounting to, on average, 98 more days underimmunized for all 6 vaccines combined). Conclusions Presumptive (vs participatory) discussion formats are associated with increased immunization.

Parents who refuse or delay vaccines because of vaccine hesitancy place children at increased risk for vaccine-preventable disease. How parental vaccine hesitancy changes as their children age is not known. In 2015, we conducted a follow-up survey of 237 mothers enrolled in a 2-arm clinic-level cluster randomized trial (n = 488) in Washington State that was completed in 2013. We surveyed mothers at their baby’s birth, age 6 months, and age 24 months using a validated measure of vaccine hesitancy. Both mean hesitancy scores (mean 4.1-point reduction; 95% CI, 2.5-5.6; P = .01) and the proportion of mothers who were vaccine hesitant (9.7% at baseline vs 5.9% at 24 months; P = .01) decreased significantly from child’s birth to age 24 months. Changes from baseline were similar for first-time mothers and experienced mothers. Individual item analysis suggested that the decrease may have been driven by increases in maternal confidence about the safety and efficacy of vaccines. Our results suggest that hesitancy is a dynamic measure that may peak around childbirth and may remit as experience with vaccines accumulates.

Objective To examine how clinicians communicate with parents about influenza vaccination and the effect of these communication behaviors on parental vaccine decision-making. Study design We performed a secondary analysis of data obtained from a cross-sectional observational study in which health supervision visits between pediatric clinicians and English-speaking parents of young children were videotaped. Eligible visits occurred during the 2011–2012 and 2013–2014 influenza seasons, included children ≥6 months, and contained an influenza vaccine discussion. A coding scheme of 10 communication behaviors was developed and applied to each visit. Associations between clinician communication behaviors and parental verbal vaccine acceptance and parental visit experience were examined using bivariate analysis and generalized linear mixed models. Results Fifty visits involving 17 clinicians from 8 practices were included in analysis. The proportion of parents who accepted influenza vaccine was higher when clinicians initiated influenza vaccine recommendations using presumptive rather than participatory formats (94% vs. 28%, p

Objective Nonmedical exemptions continue to rise because of increasing proportions of vaccine-hesitant parents. The proportion of expectant parents who are vaccine-hesitant is currently unknown. We assessed the prevalence of vaccine hesitancy among expectant parents receiving care at an obstetrics clinic in Houston, Texas. Methods We conducted a cross-sectional survey of expectant parents between 12 and 31 weeks gestation who received care at Texas Children's Pavilion for Women between July 2014 and September 2015. Using convenience sampling, participants completed a questionnaire that included questions on demographic items, self-assessed pregnancy risk, receipt of annual influenza vaccine, and the 15-item Parents Attitudes About Childhood Vaccines survey, a validated tool to identify vaccine-hesitant parents. We used multivariable logistic regression to determine the association of demographic characteristics, pregnancy risk, and influenza vaccine receipt with vaccine hesitancy after controlling for variables significant in univariable analyses. Results Six hundred ten expectant mothers and 38 expectant fathers completed the Parents Attitudes About Childhood Vaccines survey. Overall, 50 of 610 expectant mothers (8.2%; 95% confidence interval [CI], 6.1%–10.7%) were vaccine-hesitant. Expectant mothers were primarily non-Hispanic white, 30 years old or older, and married. The odds of being vaccine-hesitant were 2.2 times greater (95% CI, 1.2–4.1) among expectant mothers with a college level of education or less compared with those with more than a 4-year degree. The odds of being vaccine-hesitant were 7.4 times greater (95% CI, 3.9-14.0) among expectant mothers who do not receive an annual influenza vaccine compared with those who do. Conclusions Our findings suggest the need to identify and address vaccine hesitancy among expectant parents before birth.

* Abbreviation: SDM — : shared decision-making Shared decision-making (SDM) is a decision-making model in which “both parties share information…take steps to build consensus about the preferred treatment, and [reach an agreement] on the treatment to implement.”1 It exists on a continuum between 2 extremes (decision-making driven solely by the patient or by the physician) and represents a balance between patient and physician decisional responsibility that is guided by the patient and calibrated to the clinical context.2 At its inception, SDM was proposed to be the “ideal for the physician–patient relationship” as medicine pivoted from paternalism.3 It is now the standard decision-making model in medicine. Despite SDM’s prominence, however, problems linger. The evidence to support the purported benefits of SDM (increased patient understanding and satisfaction, improved adherence, and better health outcomes) is equivocal.4 Physicians are also struggling with how to practice SDM.5 In addition, little is known about how SDM should be applied in the pediatric setting. The gap in our understanding of SDM in pediatrics exists in part because initial frameworks used to develop the concept of SDM were based on the clinical context of a competent adult patient facing an acute, one-time intervention for the treatment of disease. This single, simplistic dyadic scenario has also served as the basis for subsequent analyses of SDM, its features, and tools to facilitate it. Analyses of SDM for scenarios common in pediatrics, such … Address correspondence to Douglas J. Opel, MD, MPH, Seattle Children’s Research Institute, 1900 Ninth Ave, Mail Stop JMB-6, Seattle, WA 98101. E-mail: douglas.opel{at}seattlechildrens.org

Risk is implicit in all clinical decision-making. Whether a clinician refrains from ordering a head computed tomography scan for a patient with a headache or decides to obtain blood work on a child with a fever, each decision involves a balance between accepting and limiting risk. Ideally, clinicians strive to achieve this balance. Clinicians accept some risk (eg, the risk of missing a rare disease) to avoid placing undue burden on the patient and the health care system with invasive, expensive, and/or potentially unnecessary testing. Yet, clinicians also strive not to assume too much risk so that timely diagnoses are made and morbidity and mortality prevented.1 Achieving this balance is difficult for a number of reasons. First, clinicians often lack precise estimates of the risks and harms for a given clinical scenario. There is simply an absence of or paucity of data to help quantify many of the risks, benefits, and outcomes associated with different possible therapeutic options. This confounds the ability to know whether pursuing 1 particular option corresponds to accepting too much or too little risk. As a result, decision-making is often intrinsically imperfect. Second, even if precise estimates of the involved risks are known, determining the threshold constituting acceptable risk (ie, the level above which too much risk would be assumed) is largely subjective. The issue of acceptable risk is inherently a matter of values, which, in pediatrics, includes not only the clinician’s values but also those of the parent and sometimes the child. Although there is general agreement that it is unacceptable for a parent to assume high levels of preventable risk and harm on behalf of his or her child, what constitutes a high level of risk and harm? Is it a 1 in 100 or 1 in 100 000 risk of the child …

* Abbreviations: MV — : measles vaccine NME — : nonmedical exemption VPD — : vaccine-preventable disease Efforts to restrict parents’ ability to exempt children from receiving vaccinations required for school entry have recently reached a pinnacle. The American Medical Association voiced support for eliminating nonmedical exemptions (NMEs) from school vaccine requirements,1 and California enacted legislation doing so.2 Although laudable in their objective, policies eliminating NMEs from all vaccines are scientifically and ethically problematic. In the present article, we argue for an exemption policy that eliminates NMEs just for the measles vaccine (MV) and is pursued only after other less restrictive approaches have been implemented and deemed unsuccessful. A policy to eliminate NMEs just from MV is based on the premise that the nature and scope of the immediate threat to public health posed by measles and the ability to avert that threat with MV is distinct among vaccine-preventable diseases (VPDs). There are 3 features that, when considered in combination, support this premise. First, measles virus is extraordinarily contagious. Its basic reproduction number is 12 to 18.3 Only 1 other vaccine-preventable infectious agent is as contagious ( Bordetella pertussis ); all others have a basic reproduction number that ranges from 4 to 7. Due to this contagiousness, a very high rate of community immunity (∼92%–94%) must be achieved and sustained to prevent spread of the disease.4 Second, measles remains an important public health burden.5 Although other VPDs may be more common (eg, pertussis6) or have more severe typical cases (eg, invasive Haemophilus influenzae type b disease7), measles disease is severe enough,8,9 outbreaks common enough,10 … Address correspondence to Douglas J. Opel, MD, MPH, Seattle Children’s Research Institute, 1900 Ninth Ave, M/S: JMB-6, Seattle, WA 98101. E-mail: douglas.opel{at}seattlechildrens.org

There are many forms of existing immunization surveillance in the United States and Washington state, but all are limited in their ability to provide timely identification of clusters of unimmunized individuals and assess the risk of vaccine-preventable diseases. This article aims to: (1) describe challenges to measuring immunization coverage at a local level in the United States using Washington State as a case study; and (2) propose improvements to existing surveillance systems that address the challenges identified.

I have Crohn's disease. This essay is about how my experiences with this disease have shaped my perceptions of boundaries in medicine, particularly around the issue of self-disclosure. I became a pediatrician first, then a parent, and now a patient, and with each new role, I have become increasingly confused on where boundaries regarding self-disclosures in medicine lie. I'd like to make the case for more of a reframing and a blurring of personal and professional boundaries regarding physicians’ disclosures about their own health. Although historically thought of as a way to strengthen the physician-patient relationship and therefore encouraged, physician disclosure has recently become more controversial, and boundary discussions that include it seem to increasingly begin from the edict, “Don't do it.” But why not capitalize on the shared experience of physicians and patients? It offers an opportunity to deepen our therapeutic relationship with our patients, to build trust, to help understanding, and maybe even to improve patient outcomes.

Background. The study objective was to determine Washington State childcare facility directors’ compliance with state immunization education and monitoring requirements and the role of directors’ immunization attitudes and beliefs on compliance. Methods. We mailed a self-administered survey to 2000 randomly selected childcare facility directors in Washington State. The primary outcome measures were reported compliance with state requirements to educate parents about the importance of immunizations and monitor the immunization status of enrolled children. Results. Our response rate was 28%. The majority of respondents worked at facilities with a licensed capacity of

Ethics education based upon everyday ethical dilemmas can help trainees place themselves within the situation and encourage them to reflect on their role and responsibility in reaching its resolution.• Three elements can help augment the bioethics teaching experience: (a) identifying the ethical dilemma, (b) employing methods of ethical analysis, and(c) having knowledge of additional bioethics resources.An increasing number of bioethics resources are available to clinicians, including clinical ethics consultation (CEC) and print and Web-based resources.

The management of a newborn born to a mother with chorioamnionitis is controversial. By using data collected on neonates born in the era of routine maternal screening for Group B Streptococcus , we calculate that the risk of early-onset sepsis in a hypothetical infant born at term to a mother with chorioamnionitis, who has a normal physical examination at birth, is likely substantially

OBJECTIVE:To determine the frequency of parents' requests for alternative childhood immunization schedules (ACISs) and pediatricians' comfort with and willingness to use ACISs.METHODS:Washington State primary care pediatricians were asked to complete an Internet-based survey on ACISs. The main outcome measures were the frequency of parents' requests for ACISs, pediatricians' comfort with their use, and pediatricians' willingness to use ACISs for individual vaccines. In addition, respondents were asked to characterize their practices and to provide demographic information.RESULTS:Of the 311 respondents (response rate: 65%), 209 met inclusion criteria and were included in analyses. Overall, 77% of eligible respondents reported that parents sometimes or frequently requested ACISs, and 61% were comfortable using an ACIS if requested by a parent. Pediatricians were least willing to consider using ACISs for diphtheria-tetanus toxoids-acellular pertussis vaccine, Haemophilus influenzae type b vaccine, and pneumococcal conjugate vaccine. Pediatricians who practiced in a neighborhood or community clinic were less comfortable using ACISs than were those in a 1- or 2-physician practice (odds ratio: 0.10).CONCLUSIONS:Washington State pediatricians are regularly being asked to use ACISs, and most of them are comfortable using them if requested. Pediatricians are least willing to delay H influenzae type b vaccine, diphtheria-tetanus toxoids-acellular pertussis vaccine, and pneumococcal conjugate vaccine, which suggests prioritization of immunizations that protect against potentially devastating bacterial infections of infancy and early childhood.

To develop a survey to accurately assess parental vaccine hesitancy.The initial survey contained 17 items in four content domains: (1) immunization behavior; (2) beliefs about vaccine safety and efficacy; (3) attitudes about vaccine mandates and exemptions; and (4) trust. Focus group data yielded an additional 10 survey items. Expert review of the survey resulted in the deletion of nine of 27 items and revisions to 11 of the remaining 18 survey items. Parent pretesting resulted in the deletion of one item, the addition of one item, the revision of four items, and formatting changes to enhance usability. The final survey contains 18 items in the original four content domains.An iterative process was used to develop the survey. First, we reviewed previous studies and surveys on parental health beliefs regarding vaccination to develop content domains and draft initial survey items. Focus groups of parents and pediatricians generated additional themes and survey items. Six immunization experts reviewed the items in the resulting draft survey and ranked them on a 1-5 scale for significance in identifying vaccine-hesitant parents (5 indicative of a highly significant item). The lowest third of ranked items were dropped. The revised survey was pretested with 25 parents to assess face validity, usability and item understandability.The Parent Attitudes about Childhood Vaccines survey was constructed using qualitative methodology to identify vaccine-hesitant parents and has content and face validity. Further psychometric testing is needed.

Background: The traditional approach to resolving ethics concerns may not address underlying organisational issues involved in the evolution of these concerns. This represents a missed opportunity to improve quality of care “upstream”. The purpose of this study was to understand better which organisational issues may contribute to ethics concerns. Methods: Directed content analysis was used to review ethics consultation notes from an academic children’s hospital from 1996 to 2006 (N = 71). The analysis utilised 18 categories of organisational issues derived and modified from published quality improvement protocols. Results: Organisational issues were identified in 68 of the 71 (96%) ethics consult notes across a range of patient settings and reasons for consultation. Thirteen of the 18 categories of organisational issues were identified and there was a median of two organisational issues per consult note. The most frequently identified organisational issues were informal organisational culture (eg, collective practices and approaches to situations with ethical dimensions that are not guided by policy), policies and procedures (eg, staff knows policy and/or procedural guidelines for an ethical concern but do not follow it) and communication (eg, communication about critical information, orders, or hand-offs repeatedly does not occur among services). Conclusions: Organisational issues contribute to ethical concerns that result in clinical ethics consults. Identifying and addressing organisational issues such as informal culture and communication may help decrease the recurrence of future similar ethics concerns.

Several new vaccines for children and young adults have been introduced recently and now appear on the Advisory Committee on Immunization Practices’ recommended childhood and adolescent immunization schedule (meningococcal, rotavirus, human papillomavirus). As new vaccines are introduced, states face complex decisions regarding which vaccines to fund and which vaccines to require for school or child care entry. This complexity is evidenced by the current debate surrounding the human papillomavirus vaccine. We present a critique to the approach and criteria for evaluating vaccines for inclusion in mandatory school immunization programs that have been adopted by the Washington State Board of Health by illustrating how these criteria might be applied to the human papillomavirus vaccine. We conclude that these 9 criteria can help ensure a deliberate and informed approach to important public policy decisions, but we argue that several clarifications of the review process are needed along with the addition of a 10th criterion that ensures that a new vaccine mandate relates in some manner to increasing safety in the school environment.

OBJECTIVE. The National Residency Matching Program allows match participants to recruit each other and try to influence future ranking decisions in their favor, but it also states that participants “must not make statements implying commitment.” The National Residency Matching Program cautions against statements such as, “We plan to rank you very highly on our list,” because they can be misinterpreted as an informal commitment. To avoid issues around miscommunication, the University of Washington Pediatric Residency Program instituted a postinterview no-call policy with applicants. The purpose of this study was to determine this policy's impact on applicants. METHODS. A Web-based, anonymous survey was sent after the National Residency Matching Program deadline for submitting rank lists but before match day to applicants who interviewed at our program from 2003 to 2006. Applicants were asked whether our program's position on their rank list would have been influenced more favorably, less favorably, or not at all had they received a telephone call from our program. RESULTS. The survey response rate was 53% (n = 468). A total of 10.3% (n = 48) of the applicants to our program would have been favorably influenced by a telephone call after their interview. Significantly more applicants reported that a recruiting call from our program would have caused them to rank our program more favorably in 2006 (17.2%) than in 2003–2005 combined (8.4%). CONCLUSIONS. We identified a vulnerable applicant population whose rank lists are potentially influenced by questionable postinterview communication from residency programs. To protect the integrity and fairness of the match, we call for more explicit guidelines regarding postinterview communication with applicants.

The Parent Attitudes about Childhood Vaccines (PACV) survey for identifying vaccine-hesitant parents was recently validated in Washington State but did not include all recommended childhood vaccines. The current study compares vaccination rates for all recommended childhood vaccines and PACV scores at one pediatric practice in Tennessee. Children were enrolled at the 2-week well visit, and vaccination rates were assessed at 19 months of age. Outcomes at 19 months of age included mean percentage of days underimmunized and up-to-date status (yes/no) compared with PACV scores. The impact of provider on immunization status was assessed. Complete vaccination data were available for 158 children of 183 enrolled (86%). Higher PACV scores were associated with more days underimmunized ( P < .001) and being overdue for vaccine doses at 19 months of age ( P < .001). No difference was seen between providers and up-to-date status. Our study supports the predictive validity of the PACV for underimmunization.

Conventional wisdom suggests that if there is a vaccine that is effective in preventing a disease, vaccine uptake will increase when the disease risk is high. Recent evidence, however, suggests that this may not always be the case. In a study we conducted in Washington State, we found no population-level increase in pertussis vaccination of infants during a pertussis epidemic. In this paper, we aim to review what is known about the history of vaccine uptake during epidemics of vaccine-preventable disease, the challenges facing public health campaigns responding to these epidemics, and how the effect of a vaccine-preventable disease epidemic on vaccine uptake can be studied.

BACKGROUND AND OBJECTIVES: Physicians have a major influence on parental vaccine decisions. We tested a physician-targeted communication intervention designed to (1) reduce vaccine hesitancy in mothers of infants seen by trained physicians and (2) increase physician confidence in communicating about vaccines. METHODS: We conducted a community-based, clinic-level, 2-arm cluster randomized trial in Washington State. Intervention clinics received physician-targeted communications training. We enrolled mothers of healthy newborns from these clinics at the hospital of birth. Mothers and physicians were surveyed at baseline and 6 months. The primary outcome was maternal vaccine hesitancy measured by Parental Attitudes on Childhood Vaccines score; secondary outcome was physician self-efficacy in communicating with parents by using 3 vaccine communication domains. RESULTS: We enrolled 56 clinics and 347 mothers. We conducted intervention trainings at 30 clinics, reaching 67% of eligible physicians; 26 clinics were randomized to the control group. Maternal vaccine hesitancy at baseline and follow-up changed from 9.8% to 7.5% in the intervention group and 12.6% to 8.0% in the control group. At baseline, groups were similar on all variables except maternal race and ethnicity. The intervention had no detectable effect on maternal vaccine hesitancy (adjusted odds ratio 1.22, 95% confidence interval 0.47–2.68). At follow-up, physician self-efficacy in communicating with parents was not significantly different between intervention and control groups. CONCLUSIONS: This physician-targeted communication intervention did not reduce maternal vaccine hesitancy or improve physician self-efficacy. Research is needed to identify physician communication strategies effective at reducing parental vaccine hesitancy in the primary care setting.

The tension between individual choice and public health is both long established and enduring. It also appears to be at a breaking point. With Ebola still crisp in our collective consciousness, health care professionals, public health practitioners, and the public have been captivated by a domestic measles outbreak and confounded by the variation on this timeless tension that it embodies: more parents are exercising their choice to refuse or delay vaccination for their child, yet continued widespread acceptance of vaccination is critical to maintain herd immunity and protect the community from diseases that still circulate.

Policies to remove parents' ability to opt-out from school immunization requirements on the basis of religious or personal beliefs (ie, nonmedical exemptions) may be a useful strategy to increase immunization rates and prevent outbreaks of vaccine-preventable disease. However, there is uncertainty about the effectiveness of this strategy and the range of possible outcomes. We advocate for a more deliberative process through which a broad range of outcomes is scrutinized and the balance of values underlying the policy decision to eliminate nonmedical exemptions is clearly articulated. We identify 3 outcomes that require particular consideration before policies to eliminate nonmedical exemptions are implemented widely and outline a process for making the values underlying such policies more explicit.

BACKGROUND AND OBJECTIVES: Washington State experienced a pertussis epidemic from October 2011 to December 2012. There was wide variation in incidence by county. The objectives of this study were to determine how the pertussis epidemic affected infant vaccination in Washington State and whether the incidence in counties modified this effect. METHODS: We conducted an ecologic before–after study to compare the proportion of infants up to date (UTD) with a pertussis-containing vaccine at time points before (September 30, 2011), during (September 30, 2012), and after (September 30, 2013) the epidemic. Children aged 3 to 8 months enrolled in the Washington State Immunization Information System with documented county of residence were included. UTD status was determined as ≥1, ≥2, or ≥3 doses of a pertussis-containing vaccine at ages 3, 5, and 7 months, respectively. Generalized linear models with extension to the binomial family and clustered robust standard errors were used to examine differences in the proportion of UTD infants between preepidemic and either epidemic or postepidemic points. The potential modifying effect of pertussis incidence by county was examined. RESULTS: We found no significant difference in statewide UTD status with a pertussis-containing vaccine between preepidemic and either epidemic (absolute difference 2.1%; 95% confidence interval, −1.6 to 5.9) or postepidemic (absolute difference 0.2%; 95% confidence interval, −4.0 to 4.5) time points. There was no significant modification by county pertussis incidence. There was wide variation in the absolute difference in UTD status across counties. CONCLUSIONS: A statewide pertussis epidemic does not appear to have significantly changed the proportion of infants who were UTD with a pertussis-containing vaccine.