How Long Does Immunity Last After Routine Childhood Immunization with Pertussis Vaccine?

Patient Presentation
A 2.5 month-old male came to clinic with persistent cough of 2 weeks duration.
He started with a runny nose and then began coughing. The cough has been getting worse especially in the past 2-3 days where he is now having post-tussive emesis of his feeds.
Since last night his parents have noticed more rapid breathing and he is slower feeding also. They have not noticed any apnea, color changes, tracheal tugging or intercostal retractions. They state that “his belly keeps going up and down more though.”The coughing seems to be all the time and not in groups of coughs.
He has not had a fever, rash, or diarrhea. He did have sneezing intermittently.
The past medical history showed that he was born full-term and went home on time. He has not had his two month health maintenance visit.
The social history showed that he lives with his parents, two preschool age siblings who are immunized, and a high-school age cousin who was immunized in 2004. The cousin has been coughing for about 4 weeks and there is known pertussis in his high school.
The pertinent physical exam shows a tachypneic infant with a respiratory rate of 70 breaths/minute. He is afebrile, his oxygen saturation is 89% on room air and decreases with coughing episodes.
He has moderate subcostal retractions and minor nasal flaring and tracheal tugging. He is not cyanotic and is well-perfused.
HEENT shows no rhinorrhea. Lung examination has no rubs, rales or rhonchi. He seems to have generalized decreased breath sounds.
The rest of his examination was normal.
The differential diagnosis of his respiratory distress includes pertussis, pneumonia, sepsis, late onset perinatally acquired infections, and various viral syndromes.
It was less likely that this is congenital abnormality because of the onset and lack of previous symptoms.
The patient’s clinical course was that he was admitted to the hospital with a diagnosis of presumed pertussis.
The laboratory evaluation showed a white blood cell count of 10.3 with 70% lymphocytes.
Blood cultures, and a nasal swab for respiratory pathogens including pertussis antigen detection were sent.
The radiologic evaluation was normal.
He was given supplemental oxygen and monitored for apnea. He was also given occasional albuterol for respiratory distress and wheezing which gave some relief.
His cousin also had a nasal swab sent for pertussis antigen detection and was begun on azithromycin for presumed pertussis. He had received Td for his 11-12 year vaccinations but as 5 years had not elapsed since that time and he was not in contact with other high risk individuals, he was not re-immunized with Tdap that was currently available.
His family members were given antibiotics as well to treat unrecognized disease and to limit transmission. Public health was contacted for community disease management once pertussis was confirmed.
On day 2 of admission, the pertussis antigen testing was positive and the other cultures remained negative throughout the admission.
He slowly weaned off of his oxygen by day 4 and he had no apneic episodes in the hospital.
He received his 2 month vaccinations including DTaP prior to leaving the hospital.

Figure 56 – PA and lateral radiographs of the chest show the heart size and pulmonary vasculature to be unremarkable and the lungs to be clear from infiltrates and effusions. There is no evidence of the classic “shaggy heart” appearance of interstial infiltrates classically described in pertussis pneumonia.

Discussion
Bordetella pertussis is pleomorphic gram-negative bacillus that is transmitted by aerosolized droplets between humans which are the only known host.
The incubation period is from 5-21 days with an average of 7-10 days. It is most contagious during the catarrhal stage and first 2 weeks of cough. .
Isolation is for 5 days after treatment is started or until 3 weeks after cough has started that has not received treatment.
It occurs cyclically within communities with 3-5 year cycling but because of travel may occur in any community at any time.

The catarrhal stage occurs from the beginning of symptoms up to 2-3 weeks of coughing and has symptoms of rhinorrhea, low grade fever, cough, sore throat, headache and fatigue.
The paroxysmal stage occurs from after the catarrhal stage to weeks later and has progressive proxysmalcough that may be preceeded by an inspiratory whoop. Emesis is common.
Infants often do not have the whoop sound and may have apnea, gagging or gasping. The whooping sound may or may not be present at any age.
The convalescent stage occurs from weeks to months and has a gradual improvement of symptoms. Duration of classic pertussis is 6-10 weeks.

Complications include encephalopathy (0.5%), incontinence, pneumonia (22%), rib fractures, seizures (2%), syncope, sleep disturbance, and death. Particularly in infants < 2 months there is a 1% risk of death. This is markedly decreased after 2 months.
Diagnostic testing is available for pertussis by culturing on special culture mediums. Unfortunately this takes 10-14 days for results. DNA polymerase chain reaction testing or IgG antibody testing is also available.

Prolonged cough can also be seen with Mycoplasma pneumoniae, Chlamydia trachomatis, Chlamydophila pneumoniae, Bordetella bronchiseptica, Bordetella parapertussis, Bordetella holmseii , adenovirus, respiratory syncytial virus and some other respiratory viruses.

Infants less than 6 months are often hospitalized because of the risk of apnea. The infants also need to have their ability to self-rescue after the paroxysms of cough, and ability to remain hydrated.
Antibiotics if given during the catarrhal phase may improve the disease. After the paroxysmal stage, they are used to prevent the spread of the organism but have no effect on the disease.
Persons who are unimmunized or underimmunized should receive vaccination as soon as possible.
Penicillins and cephalosporins are not effective against pertussis.
Recommended treatment or prophylaxis is with erythromycin, azithromycin or clarithromycin. Trimethoprim-sulfa is used as an alternative.
Because of the risk of idiopathic hypertrophic pyloric stenosis associated with erythromycin, azithromycin is the preferred drug for infants < 6 months.

Learning Point
It is highly infectious with ~80% of household contacts acquiring infection regardless of immunization status.
Infection itself nor immunization provides life-long immunity. Immunity after receiving early childhood immunization (e.g. infant, preschool, kindergarten) wanes after ~ 10 years.

Tdap became available for persons 11-64 years of age since the spring of 2005.
Boosterix® by GlaxoSmithKline Biologicals is recommended for routine immunization for ages 11-18 years (preferrably at the 11-12 year vaccines).
Adacel® by Sanofi Pasteur is recommended for routine immunization for one dose in persons ages 11-64 years.

Questions for Further Discussion
1. What are the differences in the side effect profile for accelular or whole-cell pertussis vaccine?
2. What other diseases besides pertussis should be reported to the Department of Public Health?

Related Cases

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

Information prescriptions for patients can be found at MedlinePlus for these topics: Whooping Cough and Immunization.

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

To view images related to this topic check Google Images.

American Academy of Pediatrics. Pertussis, In Pickering LD, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2006;498-520.

Centers for Disease Control. Guidelines for the Control of Pertussis Outbreaks.
Available from the Internet at http://www.cdc.gov/vaccines/pubs/pertussis-guide/guide.htm (rev. 2006, cited 11/16/07).

Altunaiji S, Kukuruzovic R, Curtis N, Massie J. Antibiotics for whooping cough (pertussis).Cochrane Database Syst Rev. 2007 Jul 18;(3):CD004404.
Available from the Internet at http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004404/frame.html (rev. 7/18/2007, cited 11/16/2007).

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.

  • 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.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

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

    Date
    December 31, 2007

  • How Can We Improve Patient Safety?

    Patient Presentation
    A 3-week-old premature male neonate was transferred because of a medication overdose.
    The neonate had been admitted locally after a septic work-up because of a fever to 38.5° Centigrade.
    He was initially treated with ampicillin and cefotaxime but the coverage was expanded 12 hours later to include vancomycin because of a high rate of methicillin-resistant staphylococcus aureus (MRSA) in the local community and hospital.
    After the vancomycin infusion was completed 36 hours after admission, he was noted to be extremely flushed, sleepy and fussy, and it was determined that he had received 12 times the appropriate amount of vancomycin for his weight.
    His parents reported that the antibiotic infusion bag was labeled with another patient’s name.
    Laboratory studies were drawn while awaiting the transport team, which showed a vancomycin level of 242 mcg/ml and blood urea nitrogen of 8.0 mg/dl and creatinine of 0.6 mg/dl.
    The past medical history revealed a 35.5 week premature infant who needed some supplemental oxygen for 12 hours for tachypnea that resolved. He had no difficulties feeding and was discharged at 3 days of life.
    He was followed closely and regained his birth weight by 10 days of age.
    The family history was negative for any kidney disease or hearing problems.
    The pertinent physical exam on arrival showed normal vital signs. His weight was 3.2 kilograms (50%) and length and head circumferences were 50-75%.
    He was alert with very flushed skin. He had a 1 cm lesion on right foot where an IV had infiltrated and now appeared to be healing.
    The work-up included monitoring of electrolytes which were all normal.
    Vancomycin levels were 105.9 mcg/dl on admission and were < 5 mcg/dl at 36 hours after the overdose.
    The blood urea nitrogen was 7 mg/dl on discharge and never was higher than 11 mg/dl.
    The creatinine slowly decreased and was 0.3 mg/dl at discharge.
    Blood, urine and cerebrospinal fluid cultures locally all remained negative.
    A hearing test on day 3 of admission was negative.
    The diagnosis of fever in a neonate with vancomycin overdose was made.
    The patient’s clinical course improved over the 6 total days of admission, and he was discharged to followup with his local healthcare provider and audiology in 4-6 weeks for repeated testing.
    The local hospital was evaluating their medication administration system to find out why their system had failed and how they could effect change and respond to this critical incident.

    Discussion
    Vancomycin is an antibiotic that has known ototoxicity and nephrotoxicity. “Red man syndrome” of severe flushing can be seen with rapid administration of the drug.
    Vancomycin should be used for treatment of serious infections known to be caused by beta-lactam-resistant gram-positive organisms (like MRSA), in patients with serious allergy to beta-lactam antibiotics, antimicrobial-associated colitis (e.g. Clostridium difficile) that is severe and potentially life-threatening or fails to respond to metronidazole, endocarditis prophylaxis for certain high-risk patients, and for anti-microbial prophylaxis in major surgical procedures involving implantation of prosthetic materials or devices at institutions with a high rate of MRSA.
    Vancomycin is also indicated for febrile, neutropenic patients (like a neonate) in an institution with a high prevalence of MRSA such as the local hospital in this case.

    Vancomycin levels need to be checked during administration. A peak level of 25-40 mg/L and a trough of 5-10 mg/L are usually recommended. For central nervous system infections a higher peak (>35 mg/L) is recommended.
    Peak and trough measurements are usually done around the time of the third vancomycin dosing.
    As neonates have changing nephrogenic function, dosing is based upon patient weight and post-natal age.

    Learning Point
    Patient safety is an important issue for everyone. Errors of commission and omission occur inside hospitals and clinics and have been well-outlined by studies from the Institute of Medicine.
    Errors occur because human beings have limitations, medicine is a highly complex system that changes continually, and because the barriers that are put into place to stop or mitigate an error fail for some reason.
    For hospitalized children, medication errors are some of the most common errors and often they occur in infants and adolescents.

    Systems to improve patient safety need approaches that include improving the overall system, improving human factors (i.e. limiting their limitations) and developing a safety culture.

    Ideas for improved patient safety through systems:

    • Computer physician order entry (CPOE) – helps assure proper drug and dosage is ordered, transcription errors and errors because of poor handwriting are decreased or eliminated, CPOE can also “force” use of standard dosing and medications.
    • Computerized clinical decision support systems – helps assure drug is being used for the proper indication or reason, checks the drug ordered against allergies and other medications to make sure all drugs administered are compatible.
    • Barcode scanning of patients and medicine – helps assure that the proper medication is being given to the proper patient at the proper time.
    • Smart medication infusion pumps – only allows a certain volume of medication over a prescribed rate, i.e. is pre-set .
    • Streamline and simplify the process so opportunity for errors are decreased – fewer, simpler steps makes the process less likely to have an error.
    • Standardize medications – use the same medication, e.g. have available only 1 concentration of an intravenous medication and not multiple ones so the wrong dilution is used inadvertently.

    Ideas for improved patient safety through human factors:

      • Limit prolonged work hours – fatigue and sleep deprivation are known causes of increased errors so methods to limit total hours worked and protect sleep are important
      • Protect sleep recovery periods
      • Employ strategic napping and judicious use of caffeine
      • Improve communications through decreased patient handoffs, decrease cross-coverage of patients by healthcare providers (i.e. increase continuity of healthcare providers and the patient)
      • Improve communications through improved information transfer during handoffs and feedback – e.g. use a computerized sign-out program to assure all pertinent information is communicated verbally and in written form

      Ideas for improved patient safety through developing a safety culture:

      • Develop methods for error reporting that is non-punitive
      • Develop methods for anonymous error reporting to a central registry
      • Conduct audits of patient safety with non-punitive feedback given to healthcare providers and the institution
      • Analysis by the institution of critical incidents that occur, along with the authority of the analyzing body to change the system to improve it
      • Educate healthcare personnel and the public

      Questions for Further Discussion
      1. What patient safety efforts are ongoing in your own institution?
      2. How can you report a patient safety problem in your own institution?

      Related Cases

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

    Information prescriptions for patients can be found at MedlinePlus for these topics: Drug Safety and Poisoning.

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

    To view images related to this topic check Google Images.

    Committee on Quality of Health Care in America.
    To Err is Human. Institute of Medicine, National Academy Press.
    Washington, D.C..
    Available from the Internet at http://www.nap.edu/catalog.php?record_id=9728#toc (rev. 11/1/1999, cited 11/12/07).

    Committee on Quality of Health Care in America.
    Crossing the Quality Chasm:
    A New Health System for the 21st Century. Institute of Medicine, National Academy Press.
    Washington, D.C..
    Available from the Internet at http://www.nap.edu/catalog.php?record_id=10027#toc (rev. 3/1/2001, cited 11/12/07).

    Committee on Quality of Health Care in America.
    Patient Safety:
    Achieving a New Standard for Care. Institute of Medicine, National Academy Press.
    Washington, D.C..
    Available from the Internet at http://www.nap.edu/catalog.php?record_id=10863#toc (rev. 11/20/2003, cited 11/12/07).

    Robertson J, Shilkofski N. The Harriet Lane Handbook. 17th. Edit. Mosby Publications: St. Louis. 2005:996-997.

    Committee on Quality of Health Care in America.
    Preventing Medication Errors: Quality Chasm Series. Institute of Medicine, National Academy Press.
    Washington, D.C..
    Available from the Internet at http://www.nap.edu/catalog.php?record_id=11623#toc (rev. 7/20/2006, cited 11/12/07).

    American Academy of Pediatrics. Appropriate Use of Antimicrobial Agents, In Pickering LD, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2006;740-741.

    Morriss, FW. Patient Safety in Pediatrics. Presentation at the Department of Pediatrics’ Societal, Professional and Ethical Issues Conference. University of Iowa Children’s Hospital, 11/8/2007.

    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.
    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.

  • 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.

  • 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.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

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

    Date
    December 17, 2007

  • Which Vaccines Contain Preservatives?

    Patient Presentation
    A 3-year-old female came to clinic for her health supervision visit. The resident physician noted that the preschooler was due for her second Hepatitis A and Influenza vaccines.
    Her mother said, “I know that most of the thimerosal has been taken out of the vaccines, but do they still have preservatives in them?” The resident stated that he wasn’t sure but would find out for the mother before ordering the vaccines.
    When discussing the healthy child with his attending physician, the resident said that he wasn’t sure where to find the preservative information.
    The attending physician offered several suggestions including checking the American Academy of Pediatrics RedBook®, looking at the package inserts that the nursing staff kept easily available where they prepared the vaccines, and also looking at the U.S. Food and Drug Administration’s website.
    Together the resident and attending physician looked up information about thimerosal and also the other preservatives in currently licensed vaccines.
    The Hepatitis A vaccine (Havrix®) contained 2-phenoxyethanol but the Influenza vaccine (FluMist®) did not. Both did not contain thimerosal.
    The diagnosis of a healthy preschooler was confirmed by the attending physician. During the discussion about the preservatives, the mother decided to have her daughter receive both vaccines.

    Discussion
    Preservatives in vaccines and other biological products are used to prevent growth or kill microorganisms especially bacteria and fungi that could accidentally contaminate the product prior to administration.
    While preservatives can decrease the risk of contamination, especially in multi-dose vials, they cannot completely eliminate the risk.

    Thimerosal has been used as a preservative for many years and is approximately 50% mercury by weight. It is metabolized into ethyl mercury and thiosalicylate. Ethyl mercury is an organomercurial that is related, but distinctive from, methylmercury.
    Methylmercury is a known neurotoxin and most exposure comes through food.

    Because of potential concerns about thimerosal as a preservative, especially neurocognitive concerns, manufacturers have decreased or eliminated thimerosal as a preservative in many vaccines and other biological agents.
    The Institute of Medicine Immunization Safety Review Committee issued a report in 2004 which concluded that the evidence “??? favors rejection of a causal relationship between thimerosal-containing vaccines and autism, and that hypotheses generated to date concerning a biological mechanism for such causality are theoretical only. The committee also stated “???that the benefits of vaccination are proven and the hypothesis of susceptible populations is presently speculative, and that widespread rejection of vaccines would lead to increase in incidence of serious infectious diseases like measles, whooping cough and Hib bacterial meningitis.”

    Learning Point
    Preservatives used in vaccines licensed in the U.S.

    • 2- Phenoxyethanol
      • DTaP – Infranix by GlaxoSmithKline Biologicals
      • Hepatitis A – Havrix by GlaxoSmithKline Biologicals
      • Hepatitis A/Hepatitis B – Twinrix by GlaxoSmithKline Biologicals
    • 2 -Phenoxyethanol and formaldehyde
      • DTaP – Daptacel by Sanofi Pasteur, Ltd
    • Inactivated Poliovirus – IPOL by Sanofi Pasteur, SA
    • Benzethonium chloride (Phemerol)
      • Anthrax – Biothrax by BioPort Corporation
    • Phenol
      • Pneumococcal Polysaccaride – Pneumovax 23 by Merck and Co., Inc.
      • Typhoid Vi Polysaccaride – Typhim Vi by Sanofi Pasteur, SA
    • Thimerosal
      • DT
      • Td – several manufacturers
      • TT – several manufacturers
      • Influenza – several manufacturers


    Thimerosal-free vaccines
    for vaccines routinely recommended for children under 6 years of age

    • DTaP
      • Infanrix by GlaxoSmithKline Biologicals, thimerosal free since 9/29/2000
      • Daptacel by Sanofi Pasteur, Ltd, never contained thimerosal
    • DTaP-HepB-IPV – Pediarix by GlaxoSmithKline Biologicals, thimerosal free since 1/29/2007
    • Hepatitis B
      • Recombivax HB by Merck and Co, Inc., thimerosal free since 8/27/99
      • Engerix B by GlaxoSmithKline Biologicals, thimerosal free since 1/30/2007
    • Haemophilus influenza type b conjugate (HIB)
      • ActHIB by Sanofi Pasteur, SA, never contained thimerosal
      • OmniHIB by GlaxoSmithKline Biologicals, never contained thimerosal
      • PedvaxHIB by Merck and Co, Inc., thimerosal free since 8/99
      • HibTITER (single dose) by Wyeth Pharmaceutical Inc., never contained thimerosal
    • Hib/Hepatitis B combination – Comvax by Merck and Co, Inc., never contained thimerosal
    • Inactivated Poliovirus – IPOL by Sanofi Pasteur, SA, never contained thimerosal
    • Influenza (inactivated)- Fluzone by Sanofi Pasteur, inc, thimerosal free since 12/23/2004
    • Influenza (live) – FluMist by MedImmune Vaccines, Inc., never contained thimerosal
    • Measles-Mumps-Rubella – M-M-R-II by Merck and Co, Inc., never contained thimerosal
    • Pneumococcal conjugate – Prevnar by Wyeth Pharmaceutical Inc., never contained thimerosal
    • Rotavirus – Rotateq by Merck and Co, Inc., never contained thimerosal
    • Varicella – Varivax by Merck and Co, Inc., never contained thimerosal

    Questions for Further Discussion
    1. What other biological agents contain mercury as a preservative?

    Related Cases

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

    Information prescriptions for patients can be found at MedlinePlus for these topics: Childhood Immunization and Immunization

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

    To view images related to this topic check Google Images.

    U.S. Food and Drug Administration. Thimerosal in Vaccines.
    Available from the Internet at http://www.fda.gov/cber/vaccine/thimerosal.htm#t1 (rev. 9/6/2007, cited 11/8/2007).

    Immunization Action Coalition. Thimerosal in Vaccines.
    Available from the Internet at http://www.vaccineinformation.org/thimerosal.asp (rev. 7/6/2007, cited 11/8/2007).

    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.
    6. Information technology to support patient care decisions and patient education is used.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • 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.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
    16. Learning of students and other health care professionals is facilitated.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

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

    Date
    December 10, 2007

  • How Old Are Those Subdural Hematomas?

    Patient Presentation
    A 4-month-old female was referred to the pediatric intensive care unit after she presented with 9 days of emesis. She initially began vomiting once per day but this increased to several times per day over 3-4 days.
    She was seen by a local health care provider who admitted her locally. She improved with intravenous fluid by the next day and was discharged home.
    Three days later she began to have emesis again and her mother noticed her crossing her eyes. She was again seen by her local health care provider who noticed a large fontanelle.
    A computed tomography scan of her head revealed bilateral subdural hematomas and she was referred for neurosurgical care.
    The past medical history revealed a healthy female who was born full-term by scheduled caesarean section because her mother had had a previous caesarean section.
    She had been seen for normal health supervision visits and had her 2-month immunizations.
    The family history was positive for heart disease and cancer, but not for blood dyscrasias, skeletal abnormalities, and children or infants who died young or who had congenital abnormalities.
    The review of systems showed her to be fussier and crying more over the past 9 days also.
    The pertinent physical exam showed an alert infant with normal vital signs. Head circumference was 44 cm (> 95%).
    She was a fussy infant with bulging fontanelle that was tense. Pupils were 3-4 mm in diameter and reactive to light. Bilaterally eyes were adducted and did not appear to be able to full abduct.
    She was not able to fixate on a light. Frenulae was intact. Lungs, chest, abdomen, genitourinary and skin examinations were normal.
    Neurologically she had normal tone and strength in all extremities. All other cranial nerves were intact except the sixth nerve as noted.
    The laboratory evaluation included complete blood count, liver and pancreatic function tests, chemistries, and coagulation studies including von Willibrand factor were normal.
    She also had a urine and hair drug screen for potential substances of abuse which were normal. Urine organic acids were also normal.
    The radiologic evaluation showed bilateral chronic subdural hematomas that also had newer blood within them.
    The work-up included an ophthalmological examination and skeletal surveys (one on admission and a second skeletal survey 2 weeks later) that were normal.
    The child protection team also evaluated the child and interviewed the family. The family members could not remember any trauma, even minor incidents, that could have produced the hematomas.
    They also had no concerns about the childcare provider or family friends who had baby-sat for them.
    The diagnosis of bilateral subdural hematomas of unknown cause with increased intracranial pressure was made.
    The team also noted that under good constant supervision, which this infant needed because of her age, any significant trauma would be observed by a caretaker.
    As there is no disclosure of any incident there was a concern for non-accidental head trauma.
    The Department of Human Services was contacted when the infant was admitted and they investigated the social situation.
    Over the next two weeks, the patient was transferred to the inpatient ward and the patient’s clinical course showed that she would have episodes of increasing head circumference and anterior fontanelle tension, followed by emesis. The neurosurgeons would then aspirate the subdural fluid through the anterior fontanelle with relief of the tension and stopping of the emesis.
    The patient underwent 3 aspirations. She was discharged after 6 days when she had stable head circumference measurements, physical examinations of her fontanelle and eyes, and no emesis.
    She was discharged to foster care along with her older sibling pending further investigation by the Department of Human Services and court action.


    Figure 55 – Axial T1 (left), T2 (center) and FLAIR (right) weighted images from an MRI scan of the brain performed without intravenous contrast obtained at the same level as the previously performed CT scan of the brain better demonstrates the large, bilateral chronic subdural hematomas with the linear focus of acute subdural hematoma in the frontal aspect of the left chronic subdural hematoma. Note the appearance of the signal intensity of the CSF in the patient’s normal subarachnoid space on the T1, T2 and FLAIR weighted images which are the same signal intensity as the CSF in the ventricular system.


    Figure 54 – Axial image of a CT scan of the brain performed without intravenous contrast shows large, bilateral, low density extraxial fluid collections that are subdural hematomas. In the frontal aspect of the left chronic subdural hematoma a linear focus of high density is seen and this represents an area of acute subdural hematoma within the chronic subdural hematoma. Another acute subdural hematoma was noted in the left posterior fossa (not pictured).

    Discussion
    Accidentally injured children are usually brought to medical attention quickly by a supervising adult who gives a history that is consistent with the extent and proposed mechanism of the child’s injury; the story generally remains the same when re-told to multiple healthcare providers over time also.
    Children who present to health care providers without a history of trauma, or with a trauma history that is not consistent with the extent of the child’s injury or proposed mechanism of injury or a history that changes during re-telling, should make a health care provider consider non-accidental trauma as a potential cause.

    Birth trauma should be considered as a potential cause of subdural hematomas. Approximately 25% of normal, vaginally delivered, term infants have the potential of developing asymptomatic acute subdural hematoma that sometimes may evolve into chronic subdural hematomas.
    This child was delivered by caesarean section and therefore this is not a possibility.

    The absence of retinal hemorrhages in this child also does not necessarily rule out non-accidental head trauma because in mild to moderate cases of non-accidental head trauma up to 50% may not have retinal hemorrhages.
    It is possible that this child was shaken or shaken and then slammed against a softer surface sometime in the past. At the time of injury, she might have had other signs of injury such as retinal hemorrhages or bruising of the skin that were not apparent when the subdural hematomas were identified.

    Fractures, especially fractures at different stages of healing, posterior rib fractures and metaphyseal fractures are more likely to be associated with non-accidental trauma.
    Incidental findings such as rib fractures can be the presentation of non-accidental trauma. A second skeletal survey was conducted to look for occult fractures that might have been missed on the original skeletal survey, which ruled out any skeletal injury in this child.

    Learning Point
    Timing of injuries may assist the health care providers treating the patient, e.g. knowing approximately when the maximum brain swelling should occur for acute head injuries.
    Timing may also assists child protection legal system professionals such as social workers, police officers, lawyers and judges. However, in some cases, especially those presenting with chronic findings, it maybe difficult to precisely time injuries exactly owing to many factors.
    Factors that can affect the imaging appearance include hemoglobin level at the time of bleeding, location of the bleeding (brain parenchymal versus extraaxial), oxygen status of hemoglobin, intracellular versus extracellular location of hemoglobin, single versus recurrent bleeding, operative intervention, and obviously time from injury to imaging, to name a few.
    Because of this, timing of subdural hematomas should be done based on utilizing imagining findings combined with taking into consideration the onset, progression and severity of clinical findings.

    There is little of reliable data for the dating of extraaxial hemorrhages such as subdural hemorrhages.
    There is data on timing of brain parenchymal hemorrhages using magnetic resonance imaging. This is often grouped according to the following information below, but note timing in only approximate.

    • Hyperacute
      • Timing – < 24 hours
      • Appearance – Oxyhemoglobin shows up hyperintense on T1 weighted images and hyperintense on T2 weighted images
    • Acute
      • Timing – < 1 week
      • Appearance – Deoxyhemoglobin shows up isointense/slightly hypointense to gray matter on T1 weighted images and hypointense to gray matter on T2 weighted images
    • Subacute
      • Timing – 1-3 weeks
      • Appearance – Methemoglobin shows up
        • Intracellular: Hyperintense on T1 weighted images from peripheral to central; hypointense on T2 weighted images
        • Extracellular: Hyperintense on both T1 and T2 weighted images
    • Chronic
      • Timing – > 3 weeks
      • Appearance – Generally hypointense on the T1 and T2 weighted images. However there may be multiple compartments with variable signals (especially if rebleeding occurs) with septation; hemosiderin deposition causes low signals

    Questions for Further Discussion
    1. What is the radiographic appearance of acute and healing fractures and what timing is associated with each stage?
    2. What legal and ethical responsibilities does a health care professional have for protecting a minor?
    3. Locally, how do the medical and legal systems work together to coordinate care and protection of a minor?

    Related Cases

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

    Information prescriptions for patients can be found at MedlinePlus for this topic: Child Abuse
    and at Pediatric Common Questions, Quick Answers for this topic: Child Abuse

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

    To view images related to this topic check Google Images.

    Kim MY, Armstron DC, Huyer D, Mian M, Levin AV, Correlation Between Retinal Abnormalities and Intracranial Abnormalities in the Shaken Baby Syndrome. Am J. Ophthalmology 2003;134:354-9.

    Pierre-Kahn V, Roche O, Dureau P, et.al. Opthalmologic Findings in Suspected Child Abuse Victims with Subdural Hematomas. Ophthalmology. 2003;110:1718-23.

    Huisman, TAGM. Intracranial Hemorrhage: Ultrasound, CT and MRI Rindings. Eur Radiol. 2005;15:434-440.

    Ghahreman A, Bhasin V, Chaseling R, Andrews B, Lang EW. Nonaccidental head Injuries in Children: A Sydney Experience. J Neurosurg. 2005:103:213-8.

    Scaletta T. Subdural Hematoma. eMedicine.
    Available from the Internet at http://www.emedicine.com/EMERG/topic560.htm (rev. 5/11/06, cited 11/5/07).

    Wager AL. Subdural Hematoma. eMedicine.
    Available from the Internet at http://www.emedicine.com/radio/topic664.htm (rev. 11/17/06, cited 11/5/07).

    Looney CB, Smith JK, Merck LH, Wolfe HM, Chescheir NC, Hamer RM, Gilmore
    JH. Intracranial hemorrhage in asymptomatic neonates: prevalence on MR
    images and relationship to obstetric and neonatal risk factors.
    Radiology. 2007 Feb;242(2):535-41.

    Internet Stroke Center. CT and MRI Criteria for Infarction and Hemorrhage.
    Available from the Internet at http://www.strokecenter.org/education/ct-mri_criteria/#hemo (cited 11/12/07).

    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.
    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.

  • 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.
    21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.

  • Systems Based Practice
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

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

    Resmiye Oral, M.D.
    Clinical Associate Professor of Pediatrics, University of Iowa Children’s Hospital

    Simon C. Kao, M.D., F.A.C.R.
    Professor of Radiology, University of Iowa Children’s Hospital

    Date
    December 3, 2007