The Kids

Do Your Kids Need the Flu Vaccine?


Martin Korn holds his son, Riley Korn, 2, as a H1N1 nasal flu spray vaccine is adminstered by medical assistant Joe Higdon at MD Now Urgent Care Centers.
A 2-year-old receives a nasal flu spray vaccine in 2009 in Florida. 

Photo by Joe Raedle/Getty Images

School started a month ago, which means that your child has already caught at least one cold. Viruses love classrooms like my kid loves ice cream, so with flu season right around the corner, it’s smart to get your child a flu shot. Or is it? We all know people who, after dutifully getting jabbed, wound up chained to a bed for a week anyway. And there was also that 2009 Atlantic article arguing that perhaps “everything we think we know about fighting influenza is wrong,” including the notion that flu vaccines help. So is it really worth dragging your kid to the doctor to get an inoculation this year?

Yes—but research suggests that not all ages benefit equally, and some flu vaccines do seem to work better than others. If you’re the parent of a 2- to 7-year-old, you should call your pediatrician now and make an appointment to give your kid FluMist, the flu vaccine nasal spray (yup—no needles), which is actually quite effective, much more so than the flu shot in this age group. Kids older than 7 also seem to benefit more from the nasal spray than the shot, but the vaccine’s protection isn’t quite as pronounced. The toughest decision falls on the parents of wee ones between the ages of 6 months and 2 years, because the only approved vaccine for them is the shot—yet very little research has been conducted on its safety and efficacy in babies and young toddlers.

I’ll admit that over the years, I’ve had my doubts about the flu vaccine. I was shocked to learn from that Atlantic piece—which, by the way, many experts have problems with—how ineffective the flu vaccine is compared to other vaccines. Then, when my son was an infant, I couldn’t believe how little research had been done on the effects of the flu vaccine in babies, especially since the Centers for Disease Control and Prevention now recommends that all babies over the age of 6 months get vaccinated. But now, as the mother of a 2-year-old, I am much more pro-flu vaccine, because the research on older kids suggests that the vaccine really does protect them (not just from the flu, but also from ear infections). True, the flu vaccine may not be as effective as other vaccines, but that doesn’t mean it doesn’t provide enough benefit to make it worthwhile, particularly in light of the minuscule vaccination risks. Moreover, since senior citizens don’t derive nearly as much protection from the shot—their aging immune systems are, well, lazier—it’s nice to know that by protecting my son, I may also be protecting his grandparents, who are at a much increased risk for deadly flu complications like pneumonia. (That the flu can be dangerous is not just a myth propagated by the U.S. government in collusion with Big Pharma; if you don’t believe me, read this Slate article from last year.)

First, let me explain the different flu vaccines. There are many, but they can be lumped into two main types: shots and nasal sprays. The shot contains either whole killed viruses or a mixture of viral proteins. The nasal spray is a live attenuated vaccine, which means that the viruses in it are alive, albeit weakened. They are also “cold-adapted,” which means they’re engineered so that they can replicate in your nose, where temperatures are low; they can’t, however, thrive in the warmer environment of your lungs, where flu infections usually set up shop and do damage. It’s important to note that neither the shot nor the nasal spray can actually give your kid the flu, but both can cause mild reactions such as runny noses, coughs,  headaches, and tenderness at the injection site.

If you’ve got a kid between the ages of 2 and 7, the nasal spray is definitely the way to go. According to a 2012 systematic review of the scientific literature, among kids this age, the spray has an efficacy of 83 percent. This is very high—by comparison, the flu shot, among kids this age, has only about 48 percent efficacy. But what does “83 percent efficacy” actually mean? What it doesn’t mean is that, for every 100 kids who get the inoculation, 83 are spared of the flu. Instead, it’s a relative risk comparison, which means that kids who get the vaccine are 83 percent less likely to get the flu than kids who don’t get the vaccine. If you average the data from the 10 trials included in the 2012 systematic review, 16 percent of unvaccinated kids caught the flu, whereas only 3.4 percent of those who got the nasal vaccine did. (I know it seems like a higher percentage of kids get the flu each year. But keep in mind there are many, many flu-like viruses out there that aren’t actually influenza. Flu vaccines only prevent those that are influenza, a point that some vaccine skeptics, such as Dr. Mercola, seem to miss when they argue that the flu vaccine doesn’t prevent illness in general. No—it does not.)

For some unknown reason, the benefits of the nasal spray seem to wane in older kids and adolescents, at which point the shot has an edge. In a 2009 clinical trial, researchers gave either the intranasal vaccine, the flu shot, or a placebo to a population comprised mostly of college students during the 2007­–2008 flu season. They found that 10.7 percent of unvaccinated students caught the flu, whereas 6.9 percent of those who got the nasal vaccine did and only 3.4 percent of those who got the shot did. (Same goes for older adults: The shot seems to work better.)

What about kids between the ages of 7 and 18? It’s unclear which vaccine is best, because there’s been very little research on the nasal spray in this age group. A 2006 trial in asthmatic kids aged 6 to 17 found that the nasal vaccine had an edge over the shot—4.1 percent of kids given the nasal spray caught the flu, compared to 6.2 percent of kids who got the shot—but it’s impossible to say whether asthmatic kids’ responses are representative of the larger pediatric population. When Taiwanese researchers compared the effects of a live nasal vaccine versus an inactivated shot in a 1991 clinical trial, they found that the nasal spray worked best for kids under 9, but that the shot worked better in kids aged 10 through 18. But it’s also hard to extrapolate from these findings, as the nasal spray used in this study protected against half as many types of flu as the one approved in the U.S. today.

Indeed, the flu vaccines used this year are new and improved compared to the ones used (and tested) in years past. It used to be that U.S. flu shots and nasal vaccines protected against two types of influenza A viruses (the viruses that have wild birds as natural hosts) and one type of influenza B virus (the virus that primarily infects humans). But as scientists have known for decades, two distinct types of influenza B viruses circulate and sicken people, so last year, the Food and Drug Administration approved new versions of the shot and nasal spray containing two influenza B viruses and two influenza A viruses, which in theory should protect kids against more flu strains. Research suggests these “quadrivalent” vaccines are just as safe for kids as the former trivalent ones. (All the nasal sprays this year are quadrivalent; some, but not all, of the shots are.)

Speaking of safety, yes: Flu vaccines can pose risks. There are the mild side effects I already mentioned, and there can be rare complications, too: 1 or 2 in every million kids develops an immune condition called Guillain-Barré syndrome; another 1 in 1 million has a severe allergic reaction. But these reactions are far less common than the serious complications associated with the flu infection itself. Estimating that there are approximately 75 million kids living in the U.S. today, if they all got flu shots this year (last year only about half did), only about 225 children would suffer one of these major reactions. By contrast, about 20,000 children are hospitalized each year for flu complications such as pneumonia, meningitis, acute bronchitis, acute kidney failure, and sepsis. (As for the use of thimerosal, a form of mercury, as a preservative: Many, many studies have refuted any link between thimerosal and autism. Plus, five out of six flu vaccine manufacturers make at least one formulation that is thimerosal-free or contains only trace amounts.) 

Now, what if you’re a parent to a child under the age of 2? The nasal spray is only approved for kids over 2, so you’re stuck with the shot. Yet only one controlled trial has tested the flu shot in infants, and scientists differ in their interpretations of what it found. Some researchers concluded from this trial that the flu shot is no more effective than a placebo in children under the age of 2. Yet the shot did work well at preventing flu in the first season assessed in the trial—its vaccine efficacy that year was 66 percent. Infants and young toddlers didn’t, however, derive much benefit from the vaccine the following year, when the flu happened to be much less common. When you combine the evidence from the two flu seasons, the overall benefits of the vaccine seem negligible, but the trial showed that the vaccine did provide protection in one out of the two years.

This raises another important point about the flu vaccine: Its efficacy varies from year to year, because it’s different from year to year. About nine months before flu season starts, scientists at the World Health Organization make an educated guess as to which viruses are likely to circulate the following year (influenza evolves rapidly), and they aren’t always right. When they’re wrong, the vaccine can still provide some cross-protection, but it often doesn’t work that well, and vaccinated people still get sick. Clinical trials on flu vaccines are, of course, affected by the luck of this draw, too—trials conducted during well-matched years conclude the vaccine is more effective than do trials conducted in mismatched years, which is why many trials try to test the vaccine over multiple flu seasons.

If all this information is starting to make you feel feverish, here’s some simple advice. Get your kid inoculated. If she’s over 2 but under 18, request the nasal spray, which seems to work much better than the shot and will certainly incite fewer screams—and you may want to do it soon, because supplies are limited: Less than a quarter of this year’s vaccine stock is the spray. (If you can’t get the spray, do the shot. Luckily, overall flu vaccine supply shouldn’t be affected by the government shutdown.) If you’re the mother of a baby or a 1-year-old—as I was last year—then yes, the science is less clear, but I think it’s still worth vaccinating. Absence of evidence doesn’t mean evidence of absence; if more trials were conducted on infants, scientists might find more evidence of benefit. Or they might not. But it’s a risk/benefit calculation, and the risks associated with inoculation seem quite low compared to the potential benefits of protection, especially since infants are at a high risk of suffering complications from the flu. Is it possible that the vaccine won’t work well this year or that this flu season will be extremely mild? Sure. But there’s no way to know. And I’d rather waste a morning at my pediatrician’s office—and yes, I’ve already made an appointment—than gamble with my family’s health.