Q&A: Frequently asked questions about COVID-19 vaccines for infants, toddlers
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COVID-19 vaccines are now available for children as young as age 6 months in the United States.
The FDA has authorized and the CDC has recommended Moderna’s two-dose series at 25 g per dose for children aged 6 months through 5 years and Pfizer-BioNTech’s three-dose series at 3 g per dose for children aged 6 months to 4 years.
Below, Healio Pediatrics Editorial Board Member Leonard R. Krilov, MD, FAAP, FIDSA, FPIDS, chief of pediatric infectious diseases at NYU Langone Hospital – Long Island, answers some frequently asked questions about the vaccines.
Healio: Is one vaccine preferred over the other?
Krilov: I think it's a little too soon to answer that. I think there are pros and cons to each of the two.
Moderna has the advantage that it is only two doses and will be completed in a month. On the counter side, there did seem to be more adverse reactions in terms of fever and local pain, as well as fatigue and headache or irritability and sleep disturbances with this vaccine. Will that impact compliance with the second dose or how the vaccine will be perceived? Additionally, even though it is approved as a two-dose series with follow-up, there may well be an indication for a booster for this vaccine.
On the other side of the coin, the Pfizer vaccine at one-tenth of the adult dose seems to be associated with lower rates of local reactions and fever compared with placebo. However, the Pfizer vaccine requires three doses, and would take potentially up to almost 3 months to complete the series. The preliminary data suggested minimal, if any, protection after just the first two doses.
As in any clinical trial, you cannot put two experimental products head to head. The studies were conducted at different times with differing SARS-CoV-2 infection rates in the community and the data may not be totally comparable for the two vaccines. I think it is too soon to say where the favorability is going to be. Both vaccines are recommended equally. I'll switch hats and put my parent hat on (although my children are grown) and suggest I would probably lean toward achieving protection sooner, but the most important thing is to get the children vaccinated.
Healio: As you mentioned, Pfizer’s vaccine is three doses. What are some ways a pediatrician can make sure a parent brings their child back for two follow-up vaccine appointments?
Krilov: Ensuring compliance with the vaccine series is important and needs to be emphasized to achieve the best level of protection. In a way, compliance is inversely proportional to number of doses or number of visits, so it is a concern that needs to be addressed.
I think we need to work with parents on demonstrating the significance of the infection, as well as the safety and benefits of the vaccine. The communication with the family should address the misconception that COVID-19 is a benign disease for young children and infants. Although we have not seen the mortality in young children from COVID-19 observed in the elderly and those with significant medical conditions, there have been more than 30,000 children aged younger than 5 years hospitalized with COVID-19 and more than 440 deaths in children aged younger than 4 years from this infection. More than one-half of these cases occurred in children with no pre-existing medical conditions.
The phrase I have used in these discussions is that although the infection is milder in children, it is not necessarily mild. It can still be a significant disease in terms of the acute illness and long COVID. Symptoms persisting for months have been described in children as well as in adults. Beyond this, discussing the safety and effectiveness of the vaccine in preventing severe disease should be included.
As we are trying to return to some degree of normalcy with no masks in school and increased in-person events, which is especially important for younger children’s speech development and socialization, I think vaccination is a critical part of our toolbox to help us get there safely. Telephone or text message reminders for second or third doses can be helpful in achieving compliance.
Healio: How can pediatricians counsel parents who may be hesitant about getting their young children vaccinated?
Krilov: I think there are two components to that discussion. One is certainly to emphasize that it is a safe and beneficial vaccine for their child. The other is that we need to spend some time addressing the misconception that this is a benign disease for the younger child, as described in the previous answer. In other words, we need to educate about what we're vaccinating against. We have to be able to convincingly demonstrate that what we're vaccinating against is worth preventing.
I think, in a way, for the other routine childhood vaccines, we are the victim of our own success. When people don't see a lot of the vaccine-preventable diseases, they lose track of how significant they are, or were, and so therefore, can focus on potential concerns about reactions or the vaccines not being necessary. Maybe some of that's true for COVID-19 as well, in the sense that the focus has been on older individuals and those with underlying medical issues. But I think it's still significant for young children.
We want children to be able to do more and more and interact — that this is an important part of our toolbox help get there, maintain that. So, I think that is the track we need to take in order to be able to work with parents on showing the significance of the infection, as well as the safety and benefits of the vaccine.
Healio: Should parents start scheduling appointments now, or can the COVID-19 vaccine wait until they being their children in for a well visit or some other appointment?
Krilov: Because the vaccination is going to be administered over two or three visits, it might be hard to just totally dovetail into regular scheduled visits. And given, you know, the high levels of community spread in most areas of the country right now, I see no benefit to waiting. I understand it's an extra visit, but I think the benefits are clear and the benefits should be achieved as soon as possible. It also should be noted that the COVID-19 vaccine can be given at the same time as other scheduled vaccines to avoid delays in getting vaccinated.
Healio : Do you think young children will eventually need a booster?
Krilov: Yes, I do think it is likely a booster for these children will be needed at some point, but it will require follow-up to determine if or when. Is this going to become like influenza, requiring periodic boosters for everyone? Are we going to settle into a more seasonal endemic pattern that will make timing of or need for boosters more predictable? Will there be additional waves this fall or winter, leading to recommendations for booster doses? Two and a half years ago we were talking about no hospital beds and having portable morgues in hospital parking lots, and now it’s a much more manageable disease. But again, there are still large numbers of cases.
I think the likelihood is this virus will continue to circulate, and with that, probably we will need periodic boosters. Is it going to be the same booster or, like influenza, is it going to be modified to match circulating variants? For example, omicron variant vaccines are in development now, so will the booster be with a different variant even to boost the immunity better? Will it turn out in a way down the road like influenza if we have multiple circulating variants to be a multivariant vaccine? It is still a bit premature to know the answer, but based on how immunity seems to wane for older children and adults, I do expect we will be looking at boosters for young children.
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Healio Interview.
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