COVID-19 and Influenza Vaccine Hesitancy Among Parents of Children aged 5 to 11 Years

Harrington JW. COVID-19 and influenza vaccine hesitancy among parents of children aged 5 to 11 years. Consultant360. Published online November 17, 2021.


Pediatricians and pediatric health care providers are applauding the approval from the US Food and Drug Administration (FDA) and now the Centers for Disease Control and Prevention (CDC) for allowing the emergency use authorization (EUA) of the Pfizer-BioNTech COVID-19 vaccine in children aged 5 years or older.

The parent/guardian now needs to take the next step and get their school-aged child vaccinated against COVID-19. Results of a recent Kaiser Family Foundation survey showed that for children younger than age 12 years, about a third of parents/guardians will get the vaccine for their child. However, the rest of the parents/guardians stated that they had varying degrees of hesitancy and will wait or likely will never get it.1 This degree of vaccine hesitancy is common and mimics what we generally see every year with the influenza vaccine. Although there are similarities, there are also several differences between the influenza vaccines and the Pfizer-BioNTech COVID-19 vaccine, and the reasons for hesitancy will require additional vigilance by the frontline health care provider to incorporate new data as it becomes available in order to increase the uptake of this new vaccine in the pediatric population. 

Interestingly, hesitant parents/guardians may have received a COVID-19 vaccine but somehow feel reticent to vaccinate their susceptible child. They may justify their decision because they believe a younger child does not get as sick as an adult and, therefore, does not need vaccination. The data to the contrary is precise, with more than 8300 children aged 5 to 11 years hospitalized with severe COVID-19 symptoms, and 172 children have died because of COVID-19 infection in this age category.2 Therefore, the decision to wait could be costly for their child. Many parents/guardians are familiar with multisystem inflammatory syndrome in children (MIS-C) but may not realize that the median age for experiencing this disorder is 9 years.2 Parents/guardians also have sometimes misunderstood the origins of this disorder and have falsely believed that the vaccine can cause MIS-C. Because the media may break information into smaller sound bites, it is easy to see how the public can confuse myocarditis's rare vaccine adverse effect with MIS-C. Although myocarditis after vaccination is extremely rare and resolves quickly when encountered, it appears to be significantly more common in the sex hormone-producing adolescent age group than in children aged 5 to 11 years.2

Practitioners need to understand how the vaccine is different for this younger age group. The dose for children aged 5 to 11 years is 10 μg and in 0.2-mL aliquots, which is a third of the concentration of the adult and adolescent 30-μg dose. This intentional lower dose is to help minimize adverse effects in children, but it does not appear to influence its effectiveness, with immune responses generated at more than 90%.3 The common adverse effects are similar to what we have seen in the adult population, such as pain at the injection site, fatigue, headaches, and muscle aches. These adverse effects are generally amenable to a small dose of a nonsteroidal anti-inflammatory drugs as needed and/or using simple comfort strategies such as a cool washcloth to the vaccinated arm, drinking plenty of fluids, and exercising the arm that received the injection. 

Parents/guardians are now seeing fewer cases of the delta variant and may consider waiting to get their child vaccinated against COVID-19. There are multiple reasons for getting the vaccine promptly vs delaying. Some children in this age group may be at high risk and illuminate those risks for parents/guardians such as obesity, asthma, chronic lung disease, hypertension, and kidney disease. Additionally, ahead of the holidays immunizations will allow safer family gatherings, which are likely to have generational contacts and could put grandma and grandpa at risk. The idea of fully vaccinated families for both influenza and COVID-19 has a cocooning effect and is the only way to provide maximal protection to everyone. Lastly, we are not immune to an additional surge in COVID-19 that would once again reduce in-person learning, and this has already differentially affected children and families from racial and ethnic minorities.4

Nevertheless, the same communication barriers for all types of vaccine hesitancy are still essential to assess. Being specific to ask parents/guardians why they are hesitant and providing evidenced-based information in a nonjudgemental way works best. Breaking down parental perceived barriers, emphasizing the health of their child, and getting everyone's life back to normal both at home and in school will likely gain more traction as we move further along. 

Here are 10 steps to help alleviate hesitancy:

  1. Mention the need for vaccines that are due at every visit.
  2. Use a presumptive approach when discussing giving vaccines.
  3. Welcome questions but do not patronize.
  4. Do not seem offended by discussing hesitancy and do not offend.
  5. Acknowledge both the apparent benefits and minimal risks of each vaccine.
  6. Use clear and straightforward language.
  7. Stress that this is a shared decision-making process but emphasize that you do have some expertise in this area.
  8. Use anecdotes in terms of outcomes that you are familiar with for not vaccinating, which may resonate: "I have a patient right now in the intensive care unit with COVID-19.”
  9. Use analogies: “I like using the seatbelt in a car to have constant protection in case I am unexpectedly in an accident.”
  10. Make sure your office staff emphasize and maximize pain-decreasing strategies for vaccines.

Although it may seem overwhelming to be offering both the COVID-19 and influenza vaccines, it is clear this will likely become an annual event. 

Therefore, it behooves the pediatric health care provider to stay informed while sharpening their communication skills on this new vaccine and conveying this message to vaccine-hesitant parents/guardians. 


  1. Hamel L, Lopes L, Sparks G, et al. KFF COVID-19 Vaccine Monitor: October 2021. Keiser Family Foundation. Published October 28, 2021. Accessed November 17, 2021.
  2. Woodworth KR, Moulia D, Collins JP, et al. The Advisory Committee on Immunization Practices' interim recommendation for use of Pfizer-BioNTech COVID-19 vaccine in children aged 5-11 years - United States, November 2021. MMWR Morb Mortal Wkly Rep. 2021;70(45):1579-1583.
  3. Find a COVID-19 vaccine near you. Centers for Disease Control and Prevention. Accessed November 17, 2021.
  4. White A, Liburd LC, Coronado F. Addressing racial and ethnic disparities in COVID-19 among school-aged children: are we doing enough? Prev Chronic Dis. 2021;18:E55.