Children with special needs comprise a unique population in pediatric practices and meeting their holistic needs is a priority. The Maternal and Child Health Bureau (MCHB) defines children with special needs as “those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required for children generally.”1 The Centers for Disease Control and Prevention (CDC) estimates that 1 in 6 children in the United States is diagnosed with special needs, ranging from mild disabilities such as speech and language difficulties to more severe disorders.2 Findings from the 2019 American Community Survey (ACS) show that approximately 3 million children (4.8% of children 18 years and younger) have a disability.3 According to the CDC, autism spectrum disorder (ASD) affects 1 in every 68 children in the US.2 Pediatric providers are responsible for assuring children with special needs receive optimal health care.

Preventative care, including immunization, is a priority for children with special needs but comes with unique challenges. Among public health’s top 10 most outstanding achievements is vaccine development, which dramatically reduces morbidity and mortality caused by infectious disease processes.4 According to the World Health Organization (WHO), immunization is one of the most cost-effective ways to avoid disease and prevents approximately 2 to 3 million deaths each year.5 Children with physical disabilities, neurologic and neurodevelopmental disorders, and autism are at higher risk for vaccine-preventable illnesses and face significant health disparities.

Known barriers to immunizing children with special needs include allergies to food, latex, and antimicrobials. Children with special needs are 53% more likely to have allergies than children without special needs.6,7 Children with ASD are more likely to have common allergic conditions, especially food allergies.7

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Other immunization challenges include changes related to the COVID-19 global pandemic, increased use of personal protective equipment (PPE) that can cause fear or anxiety in children with special needs, and vaccine hesitancy. Parents of children with special needs may struggle with lack of confidence, mistrust in government, complacency, and inconvenience in accessing immunizations leading to hesitancy.8 Vaccine hesitancy leads to a reduction in herd immunity, the level of immunization in the community needed to protect individuals who are too young or too sick for immunization.8

The American Academy of Pediatrics (AAP) recommends vaccinating children with special needs following the same CDC immunization schedule as healthy children unless medically contraindicated.9 Health care providers must actively communicate the importance of following CDC-recommended immunization schedules and provide reliable, evidenced-based immunization information to promote optimal child health outcomes.10,11

Immunization Challenges

Health care providers may consider specific physical and psychosocial challenges when immunizing children with special needs. Positive techniques exist to assist the pediatric provider.

Physical challenges

Prior to immunization initiation, the pediatric provider should discuss any patient or family history of food or nonfood allergies to avoid potential adverse effects. Historically, an allergy to eggs was a contraindication to receiving influenza, measles-mumps-rubella (MMR), and yellow fever immunizations.6 An egg allergy is no longer a contraindication and children with egg allergies should receive routine immunizations unless a documented anaphylactic reaction exists.12 The Pfizer-BioNTech Comirnaty and Moderna Spikevax COVID-19 vaccines do not contain eggs, preservatives, latex, or metals.13,14 Gelatin, a stabilizer found in the MMR, measles-mumps-rubella-varicella (MMRV), and varicella vaccines may cause a hypersensitivity reaction in some patients.12 Patients with a severe allergy to cow’s milk or yeast may experience an immediate hypersensitivity reaction when given diphtheria, tetanus, acellular pertussis (DTaP); tetanus, diphtheria, acellular pertussis (Tdap); oral polio (OPV); and hepatitis B vaccines. Pediatric providers should immediately administer intramuscular epinephrine if an allergic reaction occurs after vaccine administration.6

Nonfood allergies such as latex found in gloves, some syringes, and packaging can cause a contact allergy but have not been shown to increase vaccine reactions in children with special needs.6 Prevalence of latex allergy may be increased in children with spina bifida or neurologic disabilities such as cerebral palsy due to multiple exposures to latex in surgeries.15 Experts recommend fully immunizing children with latex allergies followed by close observation.6 Pediatric providers can adopt a latex-free practice and use gloves produced from a synthetic material such as nitrile to minimize latex exposure when administering vaccines.16

Children with special needs are at increased risk of developing asthma.17 Early use of antibiotics, especially during the first year of life, is also associated with an increased risk of developing asthma and allergic disorders in at-risk children.18 Parents may be hesitant to vaccinate children with special needs with a history of antimicrobial allergies. Allergies to antimicrobials such as neomycin, polymyxin B, kanamycin, gentamicin, streptomycin, chlortetracycline, and amphotericin B have the potential to cause significant local reactions to various vaccines in children with special needs, hence the importance of obtaining a thorough patient and family health history.6

Positioning and restraining the child with special needs is essential to consider during immunization procedures. Rather than lying down, sitting upright during immunizations increases a child’s comfort level and sense of control.19 However, children with special needs may have physical or developmental challenges. The parent and pediatric provider will work together to develop the optimal plan for immunizing the child and reducing distress based on the child’s needs.

Psychosocial challenges

Parents of children with special needs faced new potential barriers and stressors during the COVID-19 pandemic. The increased use of PPE in hospitals and clinics, especially masks and shields, has reduced communication and increased patient anxiety, particularly among children with special needs.20 Patients and parents base their initial perceptions of pediatric providers on attire, facial expressions, and body language, and PPE can affect the patient’s comfort level and ability to cooperate.21 Children with special needs are more likely to externalize the behavioral manifestations of anxiety than children without disabilities.22 Pediatric providers must ensure parents of children with special needs have prepared their children before visiting the clinic and discussed changes that may be present.20

Patients with ASD comprise a large percentage of pediatric primary care practices.2 Autism has been rising in public consciousness since the early 1990s, when the idea emerged among the public that immunizations cause autism, despite the lack of empirical evidence.23,24 Parents of children with ASD are at increased risk of developing antivaccine beliefs, leading to vaccine delays or refusals.25,26 Parents of children with special needs also cite lack of confidence, mistrust in government, complacency, and inconvenience in accessing immunizations as hesitation factors.8,24 Pediatric providers can provide reliable, evidence-based immunization education to ensure parents receive valid information to make informed decisions.10,11 Presentation of immunization information in a calm, friendly, confident, and effective tone is necessary for optimal immunization outcomes.24