It’s been three months since the US authorized Covid vaccines for kids under five, yet uptake in this group has been extremely low. Meanwhile, Joe Biden said on Monday that the pandemic is ending – a message that could result in a continued lag. More than 1,400 children have died from Covid in the US, and at least 533 of those deaths have been in children under five, according to the US Centers for Disease Control and Prevention (CDC). That makes Covid one of the top 10 causes of child mortality in the country. Yet only about 6% of kids under five have had their first shots, according to data from the CDC – the lowest rate by far of any age demographic. A recent study demonstrates clearly that Covid vaccines save kids’ lives. An expansive study followed children aged five to 11, finding that Pfizer’s mRNA vaccine was effective at preventing infection and incredibly protective against hospitalization and death. So far, 1.19 million children under five have received at least one Covid shot, a total vaccination rate of 6.2%. This age group became eligible for the shots on 18 June, a year and a half after they were authorized for adults, but researchers found that vaccinations peaked within two weeks. About four in 10 kids aged five to 11 are vaccinated, a rate that stayed fairly flat through the summer. In comparison, about three in four adults are vaccinated. Even as some children return to school – a time when many families visit their doctors – rates have been slow to rise. The reasons have to do with hesitations over the safety, effectiveness and necessity of vaccines, as well as limited access. In addition, many families say the federal advice on when and how to vaccinate kids is confusing. Hesitancy over the safety and efficacy of the vaccines has been a major driver in the lag. Many families are concerned about the newness, side-effects, and overall safety of the vaccines, according to a survey from the Kaiser Family Foundation (KFF) in July. “One of the most commonly cited things was the sense that the vaccine is too new, that there’s not been enough testing, especially for young children, and that more research is needed,” said Lunna Lopes, a senior survey analyst at KFF. There is also the “common theme of not feeling like their child needs it, and just not being worried about Covid-19 as a threat to their child”, Lopes said. That’s largely because many parents absorbed the message that Covid doesn’t affect children, said Jessica Calarco, an associate professor of sociology at Indiana University who started tracking families’ attitudes toward vaccines in 2018. Parents reported that they heard from mainstream news outlets, national agencies like the CDC and parenting advice figures that kids are unlikely to contract, transmit or get seriously ill from Covid-19. “That laid the groundwork for parents – especially white parents with children who didn’t have pre-existing conditions, that didn’t have any high-risk household members – to feel confident sending their kids back to school and back to childcare,” Calarco said. “The problem, though, was that once parents bought into this idea that their kids were not going to be seriously hurt by Covid and that they weren’t likely to transmit it to others, many of them actually stopped following the news,” she said. Families told her that they didn’t want to know if the risk level was changing or new variants were emerging – “‘if there’s something bad that’s gonna happen, I just don’t want to know about it.’” The same belief that kids are essentially exempt from Covid has led them to think the vaccine isn’t needed, she said. And many children have already had Covid at least once, so families believe they will be protected from their infection and that future illness would be mild. More than half of parents believe the vaccine is a bigger health risk than the virus. Even those who believe the vaccines are safe for adults worry about its safety in children, according to a December 2021 KFF poll. But more than a quarter of families that haven’t gotten young kids vaccinated yet aren’t opposed to it – they just want to wait and see how the rollout goes, Lopes said. Vaccine mandates could change families’ sense of the urgency and necessity of being vaccinated. More than a third – 40% – of parents whose kids are unvaccinated now said they would get the shots if they were required, Calarco said. “If it were required for school, for childcare, for activities, that would sort of tip the balance for parents.” Especially once the pediatric vaccines move from emergency authorization to full approval – as they have for people over the ages of 12 and 18, with the Pfizer and Moderna shots respectively – more childcare centers, schools and activity providers could add them to their list of required vaccines for families, she said. Very severe Covid cases among kids are not as common as they are among adults, but some kids are still getting sick from Covid. Children under two can be at particular risk for Covid, compared with older children. Almost the same number of kids are being hospitalized now compared with this time last year during the Delta wave. The health system is also being stressed by the simultaneous re-emergence of polio, parechovirus and a respiratory virus that can cause paralysis. In some places, the pediatric intensive care units are already full. And other facets of life, including school, can be disrupted even by mild illness as cases rise and few precautions, including vaccination, are in place. While some parents are waiting to get their children vaccinated, nearly half of parents surveyed by KFF said they would “definitely not” get their under-five child vaccinated, and that resistance is even higher among conservatives, with 64% of Republicans saying they will not vaccinate their kids. That has led to geographic variability in vaccinations, with less than 2% of young kids getting vaccinated in Republican-led states. Florida, for example, doesn’t recommend the vaccines at all for “healthy” kids. And families in rural areas are twice as likely to oppose pediatric Covid vaccines, according to a CDC report from March. Nearly 40% of rural parents said their pediatrician did not recommend the vaccines, compared with 8% of urban parents. The perceived lack of urgency is also playing out in some doctors’ offices.​​ Throughout the country, of the parents who spoke with their doctors about vaccines for five- to 11-year-olds, four in 10 (15%) said they did not believe their doctor recommends the shots, according to the December KFF poll. That doesn’t necessarily mean the doctor recommended against the shots either, Lopes pointed out. And the majority – 70% – of families have not talked to their pediatricians at all. “Oftentimes, they are not actively asking their pediatricians for information about it, and then pediatricians aren’t actively providing information about it – so it seems there’s a lot of silence,” Calarco said. The messaging from doctors matters. Unlike adult vaccines, there haven’t been mass vaccination sites for young kids. Older kids have had school-based vaccination clinics, but those may not reach younger children. And most pharmacies will not vaccinate children under three. Instead, the under-five rollout depends largely on pediatricians and family doctors, because they command high levels of trust. But that plan means the vaccination rollout will be lengthier and more complicated in this age group, even among health providers and families willing or eager to vaccinate. Children under five typically go to the doctor every three, six or 12 months, depending on their age. That means families may wait up to a year to talk to their pediatrician about vaccines. There are also racial and socioeconomic disparities to vaccine access. Nearly half of Black parents of unvaccinated children under five say they are concerned about needing to take time off work for their children to receive and recover from the vaccines, and roughly the same share of Hispanic parents say they are concerned about being able to vaccinate their children at a place they trust, according to the KFF survey. And not all pediatricians have very cold freezers to store the vaccines, further compounding access issues. They may be wary of ordering the minimum number of doses if it’s not clear families will want to get them. Staff shortages have also hit doctors’ offices, making vaccine clinics more difficult to conduct. Amid messages from the White House that the urgency of the pandemic is fading and as funds for vaccines dry up, it could be even more difficult for families to understand why and how they should vaccinate their children.