“I’m Just In the Band”

Patient Presentation
A 13-year-old female came to clinic for her health supervision visit. She had no concerns except for a dry red rash on her chin. She said that she had it off and on but it had worsened in the past two weeks. She denied any new soaps, lotions, or cosmetics. The past medical history was non-contributory. The social history showed that she was doing well academically in 8th grade. She played the clarinet and was in a church-organization that performed community service.

The pertinent physical exam revealed a healthy female with growth parameters in the 10-25%. Her skin examination showed some dry irritated skin about 2 cm wide that extended linerally from her lip to her chin. It did not appear infected. Her left index finger and right thumb also showed some irritated skin. She denied any changes in skin sensation or pain.

The diagnosis of a healthy female with dermatitis was made. The physician asked more questions about her skin and the girl offered that she had been practicing her clarinet more because of some upcoming performances plus a high-stakes audition. She also offered that her hands and shoulders had been hurting her somewhat for the past two weeks since she had significantly increased her practice time. She denied any lip-licking or changing any equipment including her clarinet reeds. The physician explained that although she understood the need to practice more that the girl was overdoing it. “We can deal with rash on your chin from all the saliva, but you are rubbing your fingers on your clarinet and your hands and shoulders are sore. You might be able to do well in the audition, but how are you going to play after that?” she asked. She continued, “You are a performer just like any other well-trained athlete, and…” “But I’m just in the band,” the girl interrupted. “You are an athlete just like any other athlete who has to practice to perform their best. If an athlete suddenly increases their training, they often can get hurt. You need to increase your training or practicing just like an athlete does for your performances and audition. You have to work up to it and take care of your body,” the pediatrician advised. The mother didn’t know about the hand and shoulder pain and agreed that this needed to be addressed and they would talk with the music teacher. The pediatrician recommended to split her practices into two times a day for shorter amounts of time, and to change positions often between sitting and standing. She also recommended if possible using a mirror to check her positioning from time to time while practicing. “Athletes don’t do the same thing all the time and you shouldn’t too. Your music teacher probably will have other suggestions for positioning and increasing your practice time in a smart way.” In the meantime, the pediatrician recommended using emollients on her chin and hands to help with the dermatitis, and not holding her clarinet so tightly.

Discussion
Instrumental music, either as an avocation or profession, provides great pleasure for those performing and listening. Unfortunately it can also cause health problems. Many of the problems are musculoskeletal or neurological in etiology due to overuse and the musician may experience pain. Prelude to pain can include stiffness or tingling or other skin sensations. Musicians may experience weakness, loss of function, control (accuracy) and ability (speed) as well as problems with tone.

“The most prevent problems involve overuse of muscles resulting from repetitive movements of playing, often in combination with prolonged weight bearing in an awkward positions.” String players have the highest prevalence of musculoskeletal problems. Musculoskeletal strain can also be caused by transporting large or awkward instruments and equipment inappropriately. Other common health problems of instrumental musicians include peripheral neuropathies, dermatitis and other otolaryngological problems.

In prevalence studies of school-age children (7-17 years) learning and performing instrumental music, 67% reported at least one time during their lifetime an instrument-related musculoskeletal problem, 56% had an experience in the past month, and 30% reported being unable to play their instrument at least once because of the problem. Of those reporting a problem, within the past month, 5% had taken medication for the problem and 4% had sought medical attention for the issue. Females and musicians who were older reported more problems. Older musicians and those playing more instruments have increased risks of problems because of the increased exposure and use.

Musicians young and old need to be taught proper technique and reminded of proper technique to mitigate potential problems. Musicians need conditioning to strengthen the primary and secondary body areas for the instruments and to acclimate the performer to the performance levels needed. This is the same as any other well-trained athlete or performer.

The main treatment for musculoskeletal problems is rest. Other options include analgesics and anti-inflammatory medications, muscle relaxants, acupuncture, physical therapy including heat/cold, ultrasound, and electrical stimulation treatment. Also rehabilitation therapies including splinting, stretching and stabilization of various musculature, and surgeries (nerve entrapment or compression, muscular incompetence may be needed. Psychological, dermatological, dental, audiology and speech therapy professionals may also offer other help for musicians.

Learning Point
Health problems due to instrumental music performance include:

  • Musculoskeletal
    • Strain
    • Tenosynovitis
    • Musculature incompetence due to overuse and pressure – examples include due to velopharyngeal muscles, orbicular oris muscle or “Satchmo mouth” named for trumpeter Louis Armstrong, or oral muscular incompetence or “Gillespie Cheeks” named for trumpeter Dizzy Gillespie.
    • Hypermobility syndrome
    • Arthritis
    • Joint nodes – Heberden’s and Bouchard’s
    • Temporomandibular joint pain – especially in upper string and brass players
  • Neurological
    • Compressive neuropathies
    • Nerve entrapments
    • Focal dystonia – involuntary, localized motor movement that interferes with the playing ability
    • Sensory loss to specific areas of pressure
    • Visual field loss – due to high intraoral pressures in woodwind and brass musicians
    • Neuromas
  • Dermatological
    • Dermatitis – acute or chronic, due to contact of various parts of the body with the instrument or other substances. Improperly fitted instruments, friction and hygiene also add to the problem. Fiddler’s neck, cellist’s chest, flautists’s chin, guitar nipple are all examples of dermatitis.
    • Allergens – “The most frequently reported culprit substances were: colophony [rosin], exotic woods, nickel sulphate, varnishes, and propolis (bee glue).”
    • Calluses
    • Subungual hematomas and onycholysis
  • Otolaryngological
    • Hearing loss
    • Laryngocoele – due to increased air pressure
  • Dental
    • Increased tooth calculus – especially in single reed instrumentalists
    • Bruxism – especially in brass players
    • Malocclusion – i.e. cross-bite in violinists
  • Infectious Disease
    • Herpes simplex infections
    • Impetigo
  • Psychological
    • General stress
    • Performance anxiety
  • Cardiac
    • Unmasking of underlying cardiac anomalies such as patent foramen ovale due to valsalva maneuvers
    • Potential arrhythmias such as AV block

Questions for Further Discussion
1. What are some health problems in other performing arts such as dance or vocal music?
2. What health related problems are seen in the visual arts?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: http://www.nlm.nih.gov/medlineplus/rashes.html, http://www.nlm.nih.gov/medlineplus/ergonomics.html, http://www.nlm.nih.gov/medlineplus/sportsfitness.html and http://www.nlm.nih.gov/medlineplus/exerciseandphysicalfitness.html.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Liu S, Hayden GF. Maladies in musicians. South Med J. 2002 Jul;95(7):727-34.

Lombardi C, Bottello M, Caruso A, Gargioni S, Passalacqua G. Allergy and skin diseases in musicians. Eur Ann Allergy Clin Immunol. 2003 Feb;35(2):52-5.

Ranelli S, Straker L, Smith A. Prevalence of playing-related musculoekeltal symptoms and disorders in children learning instrumental music. Med Probl Perform Arts. 2008;23:178-185.

Ranelli S, Straker L, Smith A. Playing-related musculoskeletal problems in children learning instrumental music: the association between problem location and gender, age, and music exposure factors. Med Probl Perform Art. 2011 Sep;26(3):123-39.

Rodriguez-Lozano FJ, Saez-Yuguero MR, Bermejo-Fenoll A. Orofacial problems in musicians: a review of the literature. Med Probl Perform Art. 2011 Sep;26(3):150-6.

Lee HS, Park HY, Yoon JO, Kim JS, Chun JM, Aminata IW, Cho WJ, Jeon IH. Musicians’ medicine: musculoskeletal problems in string players. Clin Orthop Surg. 2013 Sep;5(3):155-60.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • “Which is More Accurate, the Hemoglobin or the Hematocrit?”

    Patient Presentation
    A 14-month-old female came to clinic for her health supervision visit and was found to be healthy and developmentally appropriate. She was drinking 16 ounces of whole milk/day and eating table foods. The family received assistance through federal food programs. Her screening laboratories showed a normal lead test, and a hemoglobin of 11.0 g/dl and hematocrit of 31%. The pediatrician decided to treat her with iron because of the low hematocrit despite the normal hemoglobin because of her social risk factors for iron deficiency anemia. The patient was seen back 6 weeks later by another pediatrician in the practice who obtained additional laboratories including a complete blood count and iron studies which were consistent with iron deficiency anemia. A discussion about when to begin empiric iron therapy and how much iron to treat with occurred with both pediatricians discussing the merits of different options. During the conversation, one asked the other, “Which is more accurate, the hemoglobin or the hematocrit?” Both of them did not know the answer to the specific question.

    Discussion

    Iron is an essential nutrient needed for oxygen transport, storage and utilization. There are 3 stages of insufficient iron in the body which form a continuum. Iron deficiency (ID) is absence of measurable iron stores and is the first stage. The second is iron deficient erythropoiesis which is a low iron supply but with no anemia and the third stage is iron deficiency anemia (IDA) where the hemoglobin concentration falls below the normal threshold for age and sex. IDA responds to treatment with iron supplementation with at least 10 g/l in hemoglobin or 3% in hematocrit after 1 or 2 months of supplementation.

    ID and IDA are common in every country in the world and are known to cause impaired motor and cognitive development as well as impairing physical growth. Iron deficiency is not the only cause of anemia. Other common causes include vitamin A deficiency, folic acid, Vitamin B12 and riboflavin deficiencies. Infectious diseases such as malaria or inherited conditions that affect red cell production such as alpha- or beta-thalassemia also cause anemia.

    According to the World Health Organization, “Iron status can be determined by several well-established tests in addition to measurement of haemoglobin or haematocrit. Unfortunately, however, there is no single standard test to assess iron deficiency without anaemia. The use of multiple tests only partially overcomes the limitation of a single test… and is not an option in resource-poor settings.” The results’ variation in many of the tests used is relatively large including hemoglobin and hematocrit. When arbitrary statistical methods are applied to a population (often 2 standards deviations below the normative value) there will be a number of healthy individuals who will be falsely determined to be ID or have IDA.

    For a review of the potential side effects of iron therapy click here.
    For a review of iron deficiency anemia and lead poisoning, click here.
    For a review of non-correcting causes of anemia, click here.

    Learning Point
    The World Health Organization has recommendations for assessing iron status based on resource availability in the country (see Table 5 of the first reference below). Hemoglobin or hematocrit in intermediate or adequate resourced countries are tests that are recommended. In resource poor countries, clinical examination is recommended. Both hemoglobin and hematocrit are late indicators of ID and IDA though. The American Academy of Pediatrics recommends universal screening using hemoglobin concentrations and risk factor assessment.

    Hemoglobin is well standardized and probably the most widely used measurement for screening and initial treatment indicators for ID or IDA. Hemoglobin concentrations are affected by measurement of red cell mass and plasma volume. The normative value changes based on age, elevation above sea level, ethnicity, gender, pregnancy status, and even some changes that are seasonal. Because the hemoglobin is affected by the plasma volume, capillary sampling methods can affect the results. Capillary samples must have the finger or heel pricked and spontaneously flowing blood used for the sample.

    Hematocrit is a measurement of packed cell volume and is a commonly performed test. It is simple to perform and there is widespread availability of the necessary equipment but it has no advantage compared to haemoglobin measurement.

    There are other tests can be used to help determine ID and IDA. Serum ferritin is considered the most specific test correlating with relative total body iron stores. Erythrocytes protoprophyrin is the precursor to heme. It is affected by lead poisoning, infections, and other forms of anemia. It is a good test once ferritin levels drop below the cut-off values indicating inadequate tissue supply. ID causes an increase in transferrin and total iron-binding capacity levels and in transferrin saturation but there is great diurnal variation and therefore these are often not used independently. Mean corpuscular volume and mean corpuscular hemoglobin are the two most sensitive red blood cell indices.

    Questions for Further Discussion
    1. What is the recommended daily allowance of iron for infants and children?
    2. What testing can/should be done at follow-up after treatment for suspected IDA?
    3. What are the advantages of Hemocue® for determining hemoglobin concentration?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Anemia and Iron.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    World Health Organizaton. Iron deficiency anaemia: assessment, prevention and control. A guide for programme managers Available from the Internet at http://apps.who.int/iris/bitstream/10665/66914/1/WHO_NHD_01.3.pdf
    (rev. 2001, cited 10/6/14).

    Lynch S. Indicators of the iron status of populations: red blood cell parameters from the World Health Organization. Assessing the iron status of populations. 2nd Edition including Literature Reviews. Available from the Internet at http://www.who.int/nutrition/publications/micronutrients/anaemia_iron_deficiency/9789241596107_annex1.pdf?ua=1 (rev. 2007, cited 10/6/14).

    Eden AN, Sandoval C. Iron deficiency in infants and toddlers in the United States. Pediatr Hematol Oncol. 2012 Nov;29(8):704-9.

    Thompson J, Biggs BA, Pasricha SR.
    Effects of daily iron supplementation in 2- to 5-year-old children: systematic review and meta-analysis. Pediatrics. 2013 Apr;131(4):739-53.

    Baker RD, Greer FR. The Committee on Nutrition
    Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0-3 Years of Age)
    Pediatrics. 2014:126(5);1040 -1050 .

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
    16. Learning of students and other health care professionals is facilitated.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • Is This Bursitis?

    Patient Presentation
    A 16-year-old male came to clinic as 5 hours earlier while in school he noted that his right elbow was swollen. He watched it for about an hour and thought that it was enlarging so he saw the school nurse. The nurse was concerned and called his parents who took him to a local urgent care center. Over that time, the elbow continued to swell. The family was not happy with the care provided at the urgent care center so they brought him to the pediatric clinic. He denied any trauma, pain or decreased motion. He denied any recent insect bites, minor scratches or pruritis. The past medical history showed a healthy male. The review of systems was negative for fever, rash, sore throat, cough, upper respiratory tract infection symptoms, genitourinary symptoms, emesis, diarrhea, nausea or headache.

    The pertinent physical exam showed a healthy male with normal vital signs and he was afebrile. His elbow was markedly swollen posteriorly with no external landmarks visible. There was a 5 cm difference in size greater than the left. He had swelling that was located 2-3 cm above the palpated olecranon process and 5 cm below it. The swelling had increased from those marked by the school nurse (2 cm distally and 1 cm proximally) and the urgent care center (1 cm distally and 1/2 cm proximally). There was a faint pink area of 2 cm centered over the olecranon process. He had full range of motion without pain in the entire extremity. Pulses were normal. The patient complained of some tingling over the swollen area. There was no discernable temperature difference between the affected and unaffected areas. Palpation of the boney areas and also the muscle groups themselves did not produce pain. His skin examination showed mild acne of the face and back, but none on the arms and a detailed examination of the arm was negative for any skin changes.

    The diagnosis of olecranon bursitis that was septic or aseptic, developing cellulitis or much less likely septic arthritis were considered. Fracture, tendonitis or ligamentous injuries appeared remote because of no history of trauma and no pain. The radiologic evaluation of plain radiographs were normal. His laboratory evaluation included a normal complete blood count with a white blood cell count of 3.6 x 1000/mm2 and no left shift. His erythrocyte sedimentation rate was 2 mm/hr and C-reactive protein was < 0.5 mg/dl. The patient’s clinical course while in the clinic showed that he continued to have increased spreading of the swelling and also more developing erythema of the area directly over the olecranon process. He also said that he was now having a little bit of pain in the general area. An orthopaedist was consulted because of the concern for developing septic bursitis vs cellulitis who saw the patient within the hour. Examination at that time showed no continued progression of the general area of swelling or the smaller area of erythema. The patient also denied any pain at that time. The orthopaedist felt that this was aseptic olecranon bursitis and the patient was to use a protective brace, non-steroidal anti-inflammatory medication and to monitor for any significant changes. Over the next several days the swelling began to resolve.

    Discussion
    Bursa are the body’s bumper pads for tendons. They are a small synovial fluid-filled sac that lies between tendon and a bone or skin. There are more than 150 of them in the body. With bursitis there can be thickening and proliferation of the synovial lining, bursal adhesions, chalky deposits and villus formation. Trauma, repetitive stress, infection and autoimmune usually are the reasons for bursitis but idiopathic etiology also occurs. The differential diagnosis includes infection, arthritis, tendonitis, tendon or ligament injury, fracture or neoplasm. The usual signs and symptoms are localized pain and tenderness over a bursa, and if the bursa is superficial edema can be seen. Other specific signs and symptoms occur because of location. Bursitis is described as septic or aseptic and acute vs. chronic. Recurrence is common in certain locations such as the olecranon.

    Learning Point
    Olecranon bursitis (OB) is sometimes called “student’s elbow” or “miner’s elbow” because of the association with these occupations and the obvious repetitive stress to the elbow that can occur. The incidence is not known but it is more common in males aged 30-60 years. Septic OB is more often caused by common skin pathogens of Staphylococcus aureus and Staphylococcus epidermidis (90%) and Streptococcus (9%). Aseptic OB is caused by idiopathic, trauma or crystal-inducing disease processes such as gout.

    The olecranon bursa forms after age 7. It is superficial and covers the dorsal olecranon extending from the distal triceps insertion to the proximal subcutaneous ulnar border. If acutely distended this bursa can be 6-7 cm long and 2.5 cm wide.

    OB has a unilateral posterior swelling over the olecranon process which may be painless or painful and symptoms are quite variable. Septic OB is less common (only 20% of cases) and usually has more pain and tenderness than aseptic bursitis but both can have cellulitic components and be indistinguishable. For example, erythema is seen in 63-100% of septic OB and 25% of aseptic OB. Pain also does not distinguish between septic and aseptic OB. Septic arthritis of the elbow is usually distinguished from OB because of increased pain with flexion. The flexion decreases the joint space and therefore increases the pain because the joint space fluid is under increased pressure during flexion.

    Evaluation may include radiographs (plain or magnetic resonance imaging), metabolic evaluation and possibly aseptic aspiration of the bursa. Treatment is most commonly conservative with joint protection to decrease trauma, non-steroidal anti-inflammatory drugs, and occasional aspiration for drainage. Unfortunately joints that are aspirated often have recurrence. Septic bursitis is treated with anti-bacterial drugs for the common pathogens. For chronic OB, conservative treatment is offered, but additional corticosteroid injections or various surgical procedures are sometimes undertaken.

    Questions for Further Discussion
    1. How does prepatellar bursitis present?
    2. How does retrocalcaneal bursitis present?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Bursitis and Elbow Injuries and Disorders.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Stewart NJ, Manzanares JB, Morrey BF. Surgical treatment of aseptic olecranon bursitis. J Shoulder Elbow Surg. 1997 Jan-Feb;6(1):49-54.

    Aaron DL, Patel A, Kayiaros S, Calfee R.
    Four common types of bursitis: diagnosis and management. J Am Acad Orthop Surg. 2011 Jun;19(6):359-67.

    Del Buono A, Franceschi F, Palumbo A, Denaro V, Maffulli N. Diagnosis and management of olecranon bursitis. Surgeon. 2012 Oct;10(5):297-300.

    Maffulli A, Longo UG, Denaro V. Bursitis. ePocrates.
    Available from the Internet at https://online.epocrates.com/noFrame/showPage?method=diseases&MonographId=523&ActiveSectionId=52 (rev. 4/24/14, cited 10/3/14).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Immunizations Can Pregnant and Postpartum Women Receive?

    Patient Presentation
    A 4-day-old male came to clinic for his followup newborn appointment. He was a full-term male, born by vaginal delivery without complications. His mother was a 26 year old female, G1P1, who had no prenatal or natal complications and received obstetrical care throughout her pregnancy. He was breastfeeding every 2-3 hours for 10-15 minutes and was having many wet diapers. He was stooling 4-5 times/day and the stools were starting to transition. His mother had received Tdap during pregnancy and his father received it in the nursery, but influenza vaccine was not available at the hospital. The pertinent physical exam revealed a vigorous infant, with a decrease in weight of 6% and other vital signs were normal. He was mildly jaundiced on the face but not the body. His examination was otherwise normal.

    The diagnosis of a healthy male infant was made. The pediatrician’s office in a multispeciality group practice had just begun vaccinating patients for seasonal influenza and recommended that the parents also receive it. The parents were concerned because the mother was breastfeeding. He said that it was recommended for all those around an infant to be vaccinated to provide “cocooning” and also because the mother was postpartum and at higher risk. The mother was still hesitant, so the pediatrician contacted her obstetrical group that was also in the same building. They confirmed that they did recommend influenza vaccine and had also just starting vaccinating patients. The obstetrical office offered to have the family come upstairs and they would vaccinate both parents.

    Discussion
    Pregnant, postpartum and breastfeeding women along with their infants are at higher risk for infectious diseases. Pregnant women have altered immune, cardiac and respiratory systems that contribute to the increased risk. It is thought that postpartum immunological recovery can be up to 1 year. For the infant, breastfeeding provides some immunity to infectious diseases. Cocooning, where others in close contact are immunized against common infectious diseases is also another strategy to help infants who are not yet old enough to be vaccinated.

    Recent guidelines for treatment of influenza with antiviral medications note that:
    “Pregnant women are at higher risk for severe complications and death from influenza. Changes in the immune, respiratory, and cardiovascular systems that occur during pregnancy result in pregnant women being more severely affected by certain pathogens, including influenza.

    Postpartum women, who are in transition to normal immune, cardiac, and respiratory function, should be considered to be at increased risk of influenza-related complications up to 2 weeks postpartum (including following pregnancy loss).”

    Learning Point
    Vaccines recommended for pregnant (prenatal) women include:

    • Inactivated influenza
    • Td/Tdap – There is no minimum interval between receipt of Tdap and of the last Td booster and women should receive this with each pregnancy.

    Others include Hepatitis B for some women. For other inactivated virus vaccines, pregnancy is considered a precaution and risks/benefits should be weighed. Vaccines not recommended during pregnancy are live attenuated influenza, MMR, Varicella (including Zoster), and Smallpox. These are not recommended because of theoretical risks of live virus vaccines with the exception of smallpox which has been shown to have a small increased risk of fetal vaccinia.

    In the initial postpartum time period (ie before discharge from hospital after birth) the following are recommended for women at risk or without immunity and include:

    • Human papilloma virus
    • Influenza
    • Rubella
    • Tdap
    • Varicella

    Close contacts should receive any vaccinations they may need because of risk or lack of immunity with the exception that Smallpox vaccine should not be given because of the small risk of fetal vaccinia.
    Tdap and influenza vaccine are high priorities for close contacts.

    For breastfeeding women, smallpox vaccination is contraindicated and yellow fever should be avoided.

    Questions for Further Discussion
    1. What are the recommendations for treatment or prophylaxis for influenza in high risk populations?
    2. What immunization recommendations are there for pregnant women and teenagers who are traveling to foreign countries?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Immunization and Infections and Pregnancy.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Groer MW, Davis MW, Smith K, Casey K, Kramer V, Bukovsky E. Immunity, inflammation and infection in post-partum breast and formula feeders. Am J Reprod Immunol. 2005 Oct;54(4):222-31.

    New York State Department of Health. Vaccinating Women of Reproductive Age Recommendations and Guidelines.
    Available from the Internet at https://www.health.ny.gov/prevention/immunization/vaccinating_women_of_reproductive_age_guidelines.htm (rev. 1/13, cited 9/30/14).

    Centers for Disease Control. Guidelines for Vaccinating Pregnant Women.
    Available from the Internet at http://www.cdc.gov/vaccines/pubs/preg-guide.htm (rev. 3/14/14, cited 9/30/14).

    Centers for Disease Control. Recommendations for Obstetric Health Care Providers Related to Use of Antiviral Medications in the Treatment and Prevention of Influenza.
    Available from the Internet at http://www.cdc.gov/flu/professionals/antivirals/avrec_ob.htm (rev. 9/4/14, cited 9/30/14).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital