Our survey of parents attending naturopathic care found high rates of partial or unvaccinated status among their children, with only 50% of respondents having pursued all recommended pediatric vaccines. Most parents reported feeling pressure to vaccinate, primarily from their allopathic physician; 17.3% advised that discussions regarding vaccination with their family physician or pediatrician had introduced conflict into their relationship and 25.9% were less comfortable continuing care with their physician. Five percent of respondents were advised by their physician that their children would be refused care if they decided against vaccination.
Many respondents (44.2%) did not feel sufficiently informed to decide whether or not to vaccinate their children, and respondents most commonly endorsed both their allopathic and naturopathic physicians as trusted resources for information regarding vaccination. Allopathic physicians were largely seen as providing pro-vaccination material whereas discussion regarding vaccination with naturopathic physicians was seen as more balanced. Discussing vaccination with their allopathic physician influenced 28.3% of respondents to seek naturopathic care.
In our adjusted generalized linear model, feeling pressure to vaccinate or endorsing a naturopathic physician as their most trusted source of information regarding vaccination were both associated with threefold greater odds of having a partially vaccinated or unvaccinated child. Due to the cross-sectional design of our study we cannot establish if these associations are causal. For example, it may be that parent's who seek naturopathic care are more likely to reject vaccination for their children. The majority of parent's with partially or unvaccinated children (69.8%) reported a willingness to reconsider this decision.
As far as we are aware, ours is the first study to explore the association between parent's discussions with their healthcare providers regarding pediatric vaccination and the vaccination status of their children. Our high response rate, prospective design, and consecutive sample among a population with high rates of partially vaccinated or unvaccinated children strengthen our findings. There are some important limitations to this study. Our data are limited to self-report and responses were not confirmed. Our sample population was taken from a large Canadian naturopathic academic center and 6 private naturopathic clinics in Ontario, Canada, and our results may not be generalisable to other populations accessing naturopathic care.
A recent survey of 1004 American pediatricians (30.1% of surveys analyzed) suggested that approximately one third of pediatricians would discharge children from their practice if parents refused some or all pediatric vaccinations 
. As far as we are aware, it is not illegal for physicians to deny future care to children on the basis of parent's refusal to vaccinate; however, the College of Physicians and Surgeons of Ontario does advise that refusal to treat patients may be grounds for a complaint of professional misconduct 
Our survey suggests that, among Canadian parents under naturopathic care, 5% were advised their children would be refused care if they opted not to pursue full vaccination. Another 2% felt compelled to leave their physician's practice and 1 in 4 parents felt less comfortable seeking care for their children as a result of discussion regarding vaccination. This suggests that allopathic physicians are less likely to discharge partially or unvaccinated children from their actual practice than when confronted with a theoretical scenario. However, there are a number of important services that physicians managing pediatric populations provide and it seems ill-advised to compromise this role based solely on parent's decisions regarding vaccination 
. Our survey also suggests that current discussions with allopathic physicians regarding pediatric vaccination could be further optimized as many parents reported excessive pressure to vaccinate and felt that discussions were typically not balanced.
Parents who attend CAM providers, including naturopathic physicians, may have a greater risk of exposure to anti-vaccination arguments 
. Such arguments typically fall into 1 of 2 categories: vaccines are not effective and the risks of vaccination outweigh the benefits 
. No vaccine is 100% safe or 100% effective, and this is true of any health care intervention. However, opponents of vaccination frequently emphasize or exaggerate the adverse effects of vaccines, but fail to consider the consequences of compromised vaccination programs 
. Furthermore, although it is true that a number of published studies have implicated vaccines in certain disorders, these have generally not held up under investigative scrutiny. For example, an oft quoted 1998 study of 12 children by Wakefield et al. suggested a link between MMR vaccination and the development of autism 
.What antivaccinationists may fail to note is that larger trials failed to confirm these findings 
, and that Wakefield was subsequently found to have falsified his data 
leading the Lancet to retract his publication in 2010 
. Parents who attend naturopathic care are more likely to avoid vaccinating or selectively vaccinate their children; however, most of our respondents advised that they would be willing to reconsider vaccinating their children. Use of naturopathic care should be explored among parents in order to identify this high-risk group and engage them in sufficient discussion regarding pediatric vaccination to address their concerns and encourage evidence-based, shared decision making. Physicians should ensure that discussions regarding vaccination are respectful, even if parents are determined not to vaccinate their children. Furthermore, allopathic physicians should look for opportunities to develop open lines of communication with naturopathic physicians involved in their patient's care to improve pediatric vaccination rates in this population.