Patient Presentation
A 2-month-old male came to clinic for his health maintenance examination. The mother is concerned about some episodes where he turns red in the face and shakes. There is no body stiffening or eye changes. The episodes last only a few seconds. The mother blows in his face and he gasps or make another sound terminating the episodes.
They are not associated with feeding and occur at different times of the day without warning. They have occured at least 10 times in the past two weeks. His mother reports that he is otherwise well.
The past medical history shows the infant was born full-term, and was appropriate for gestational age with no prenatal or perinatal complications. He went home with his mother at 48 hours of life and has been gaining appropriate weight.
The family history reveals an older sibling who died as an infant because of possible sepsis.
The review of systems is negative.
The pertinent physical exam shows a weight of 4.72 kg (25%), head circumference of 38 cm (25%), length 50 cm (50%), heart rate = 140, respirations = 36, and blood pressure = 90/55. He was alert and in no distress. His anterior fontanelle is open, soft and flat. Eyes show a red reflex bilaterally. His heart has a regular rate and rhythm without murmur. Lungs are clear with no flaring retracting or grunting. Neurological examination shows normal tone and strength. His cranial nerves III-IV are intact. He has normal deep tendon reflexes, Moro reflex, palmar grasp and blink reflexes are present.
Dermatological examination is normal. The rest of the physical examination was normal.
The work-up included a consultation with neonatology who recommended monitoring the child in the hospital to observe these episodes. No episodes occurred after 30 hours of monitoring and the infant was discharged to home on an apnea monitor until a sleep study could be performed.
The sleep study revealed a diagnosis of obstructive sleep apnea which is being further evaluated at this time.

Discussion
Sleep studies or Polysomography (PSG) continously record multiple physical parameters of sleep and respiration. Sleep is monitored by electroencephalogram, electrooculogram and electromyogram.
Respiration is monitored by nasal and oral airflow, respiratory effort (by movement electrodes on the body), oxygen satuation and carbon dioxide.
An electrocardiogram is also often used along with monitors for body position and snoring volume and the patient may be monitored by a video camera.
There is little night to night variability in pediatric patients so one night is usually sufficient for diagnosis. Almost any age patient can be accomodated.

The PSG evaluates sleep architecture (REM and non-REM sleep) and sleep quality and disturbances can be identified.
Central or obstructive respiratory events are also identified. Central apnea is the absense of oranosal airflow with no respiratory effort. Central apnea is found in all normal children but last less than 20 seconds.
Obstructive apnea is cessation of oronasal airflow with continued respirtory effort. These are rare in children. Hypopnea is a 50% of more decrease in the amplitude of the oronasal airflow with respiratory effort. Hypopneas are common in children.
Apneic events can also be mixed and are common in younger children.

Learning Point
Indications for sleep studies include:

• Obstructive sleep apnea (OSA) – To diagnose OSA is the most common reason for PSG. OSA is recurrent events of partial or complete upper airway obstruction during sleep which disrupts normal ventilation and sleep patterns.
  Untreated OSA can cause growth failure, pulmonary hypertension and cor pulmonale, and learning and behavior problems including problems with attention and memory.
  Primary snoring is children who snore but have no sleep or respiratory abnormalities. History and physical examination are poor at discriminating between primary snoring and OSA. Screening pulse oximetry is predictive of OSA if it is positive (positive predictive value of 97%) but is not good if it is negative (negative predictive value of 47%).
  As PSG is often only available in larger medical centers, oximetry can be a useful screening test. While not excluding OSA, a negative test may reassure the family and pediatrician that the child is unlikely to have severe OSA while waiting a full PSG.
  Children at risk for OSA include upper airway abnormalities (e.g Pierre-Robin Sequence), genetic/metabolic problems (e.g. Down Syndrome), neurological syndromes (e.g. cerebral palsy, Prader-Willi syndrome) and obesity. OSA can be treated with nocturnal ventilation or surgery.

• Neuromuscular disease – With the combination of respiratory muscle weakness, impaired central ventilatory control and decreased upper airway tone, children with neuromuscular disease are at risk for central and obstructive sleep apnea.
  Symptoms of nocturnal respiratory failure include: daytime sleepiness or behavioral changes, morning headache, fatigue, difficulty sleeping, and needing frequent repositioning in the night. Treatment is nocturnal ventilation.

• Central hypoventilation – is defined as normal ventilation while awake and hypoventilation while asleep. It is due to inadequate central respiratory control and can be congenital or acquired. Treatment is nocturnal ventilation.
• Monitoring nocturnal ventilation needs – Children requiring nocturnal ventilation need annual reassessment because of growth or possible disease progression.
• Excessive daytime sleepiness and narcolepsy – Excessive daytime sleepiness can be caused by sleep disruption, insufficient sleep, brain lesions, depression and drugs. Narcolepsy is a problem of REM sleep regulation with excessive daytime sleepiness as its primary symptoms. Narcolepsy also has sudden muscular weakness (i.e. cataplexy) as a major symptom.
• Parasomnias are disruptive sleep behaviors that occur in healthy children and generally disappear by adolescence. Common parasomnias include sleep walking, night terrors and confusional arousal. These are due to impaired arousal from deep sleep.
• Otherwise unexplained episodic disorders.

Questions for Further Discussion
1. What is the normal sleep pattern for infants?
2. What is the differential diagnosis of episodic disorders in infants?

Related Cases

Disease
Sleep Apnea
Sleep Disorders

Symptom/Presentation
Health Maintenance and Disease Prevention
Sleep Disturbance

Specialty
Allergy / Pulmonary Diseases
Developmental Disabilities
Neonatology
Otolaryngology

Age
Infant

ACGME Competencies Highlighted by Case

Patient Care
1. When interacting with patients and their families, the health care professional communicates effecively 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.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused case 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.

Interpersonal and Communication Skills
18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.

Systems Based Practice
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.

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 Pediatric Common Questions, Quick Answers for this topic: Childhood Sleep Apnea.

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

Davey MJ. Investigation of Sleep Disorders. J. Paediatr. Child Health. 2005:41:16-20.

Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:333-34, 417-420.

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

Date
November 21, 2005

Patient Presentation
The mother of a 2.5-year-old male calls because her son bit another child at daycare today and the bitten child’s family is threatening to call the state agency to have her son taken out of the daycare and to have the daycare closed down.
The daycare provider is not worried about the incident but had to contact the mother because of the possible state agency action. The mother states that her son bit the same child last week also. Both incidents were witnessed by the childcare provider who says that the children were arguing over a toy and the childcare provider could not get to the children to intervene in time.
The son has bitten his younger brother in the recent past, again because of a toy.
The past medical history reveals normal development and growth of the boy.
The diagnosis of normal toddler behavior was made. The physician discussed that biting is a common, normal behavior for toddlers that can be caused by a number of factors including frustration and the inability to use language or other means to solve the problem.
The mother was told to monitor the behavior as this appeared to be a new behavior. She was told to try to prevent these situations by offering a variety of toys and to try to intervene early if a potential conflict is developing. She was also instructed to try to remain calm and model other forms of conflict management such as using words or ignoring.
She was told that these methods would not work right away but overtime would help show her son other ways to help solve problems.

Discussion
Occasional acts of anger, aggression or biting, especially during temper tantrums, are a normal part of toddler and preschooler behavior. These children do not have the self-control to express their anger in a less dangerous manner. Most children only bite when they are angry and provoked.
Being tired, hungry, and overstressed often heightens the frustrustration and anger. Some children can bite because of extreme emotions that they cannot control (i.e. they are so happy to see someone that they bite them).
Most children can be distracted or consoled and often quickly forget their anger. Concerning symptoms include:

• Biting occurs daily for more than 3-6 months
• Frequent rages where the child attacks others, animals or himself
• Preschoolers who lash out for no apparent reason or who feel no remorse or empathy for the other child
• Concern by an adult that the child will seriously injury himself or another child
• A child is barred from play by neighbors or school

Parents should be instructed to supervise their children and not interfere in minor disagreements as this allows the children to try to solve the conflict on their own. Parents must intervene when there is a physical threat which continues.
Parents should also be told reprimand the child immediately for breaking important rules (e.g. no hitting, biting, running into the street) as the child so the child will understand what he has done wrong. Modeling and teaching other non-violent forms of conflict resolution including saying “NO” in a firm voice, ignoring, walking away, or asking a grown-up for help are good methods. Praising the child for using these non-violent strategies also reinforces these preferred behaviors.

Mammalian bites occur in 1-5 millon cases annually. Most mammalian bites are due to dogs (80-90%), cats (5-10%), and humans (2-3%).

Mammals can inflect a broad spectrum of injuries including scratches, abrasions, contusions, punctures, and lacerations, or combinations of these injuries. Complications occur such as cellulitis, deep compartment syndrome, tendinitis, osteomyelitis and septic arthritis.

Dog bites frequently occur with large family dogs. Half of the bites are unprovoked. They occur in males > females often in the upper extremities, but children < 5 years old often have head and neck injuries. The rate of infection is 15-20%.

Cat bites occur in household provoked cats. They occur in females > males, mainly in the upper extremities and have a rate of infection of 50%. Puncture wounds are common.

Human bites are a leading cause of injuries in daycare centers. They appear as semi-circular, erythematous or bruised areas often over the face, upper extremities or trunk. The intercanine distance for a child bite is < 2.5 cm. If it is > 3 cm then the bite is likely from an adult and child abuse must be considered.
Humans bites also often occur when an open mouth and teeth strike a clenched fist.

The organisms that complicate dog and cat bites include: Pasteurella species, Staphylococcus aureus, streptococci, anaerobes, Capnocytophagea species, Moraxella species, Corynebacterium species, and Neisseria species. Cat bites have an especially high rate of Pasteurella multocida contaminating its wounds (50%).

The organisms that complicate humans bites include: streptococci, Staphylococcus aureus, Eikenella corrodens, and anaerobes.

Learning Point
Treatment for mammalian bites includes:

• Cleaning the wound – Sponge away obvious debris and then irrigate with copious amounts of normal saline by high pressure syringe irrigation. Puncture wounds should not be irrigated because of the potential to actually drive the organisms deeper into the wound.
• Wound culture – should be done if there are early signs of infection, an immuncompromised patient or if an animal bite is more than 8 hours old.
• Operative debridement of devitalized tissue is important. Bites to the hand should be considered for debridement. Cranial bites may need radiographs to look for free air in the skull.
• Wound closure – is indicated for non-puncture bite wounds less than 8 hours old. Immobilization may be necessary for large wounds.
• Vaccination for Tetanus, Rabies and Hepatitis B should be evaluated. HIV risk should be also evaluated and treated by CDC guidelines for non-occupational exposure to HIV ( see also PediatricEducation.org Case from 2/14/05). Intact or nonintact skin or percutaneous contact with saliva is usually considered a negligible risk for HIV transmission.
• All significant wounds should be rechecked in 24-48 hours.
• Antibiotic prophylaxis should be initiated for all human bites and for all but the most trivial dog or cat bites. Indications include moderate to severe bite wounds especially if crush injury or edema is present, puncture wounds, an immunocompromised patient or bites in the following locations: face, hand, foot, genitalita.
  First line oral antibiotic for dogs/cat/human bites is amoxicillin/clavulante for non-penicillin allergic patients.

Questions for Further Discussion
1. Should antimocrobial or antiinfective solutions be added to the saline solution for irrigation?
2. What are the potential complications of rodent bites?
3. What is the preferred antibiotic treatment for penicillin-allergic patients?

Related Cases

Disease
Bites and Stings
Child Behavior Disorders
Child Daycare

Symptom/Presentation
Behavior Problems
Bites

Specialty
Emergency Medicine
Infectious Diseases
Psychiatry and Psychology
School

Age
Toddler

ACGME Competencies Highlighted by Case

Patient Care
1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
4. Patient management plans are developed and carried out.

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
17. A therapeutic and ethically sound relationship with patients is created and sustained.

Systems Based Practice
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

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

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

Fleisher GR, Ludwig S. Synopsis of Pediatric Emergency Medicine. Williams and Wilkins. Baltimore, MD. 1996:473-475.

American Academy of Pediatrics. Bite Wounds, In Pickering LD, ed. Red Book: 2003 Report of the Committee on Infectious Diseases. 26th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2003;182-186.

Shelov, Steven P. Caring for Your Baby and Young Child Birth to Age 5. Bantam Books. New York, NY. 1997:495-497.

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

Date
November 14, 2005

A 2 month old male came to clinic for his health maintenance examination. His parents state that he is a very fussy baby. He cries at all different times of the day that does not consistently respond to feeding, rocking, bundling, swinging, massaging, being left alone, baths or riding in a car or stroller.
Most days, he cries during the day and evening . Generally, from midnight to 5-6 am he sleeps well except to feed. He sleeps well at other times once he is asleep, but he can be hard to settle to sleep. The episodes can last from 5 minutes to > 1 hour in length. He is breastfeeding exclusively and has a small amount of effortless spitting up after feeds.
He has normal bowel movements and urination. He is currently smiling and making cooing noises.
The past medical history reveals an episode of premature contractions at 23 weeks gestation. He was full-term with an otherwise unremarkable prenatal and natal history. The crying spells began on the first day of life.
The review of systems is negative.
The pertinent physical exam shows the child to be 50% for weight, 25% for height and head circumference. His examination is unremarkable.
The clinical diagnosis of colic was made and the parents were reassured that over time that his crying would improve. In addition to discussing the usual natural history of colic, they were offered other ideas for calming the child such as using a white noise or motion generator.
They were also counseled about the normal feelings of frustration, anger and resentment that many parents feel towards a child who is difficult to console.
They were told to take regular breaks from the baby, and to just put the child down in a safe place and walk away if they felt they might hurt the baby. They were told to call the clinic if they had any concerns.
Over the next few months, the patient’s clinical course showed a consolidation in his crying with fewer but more intense episodes. These episodes sometimes occurred when he was tired and generally were in the afternoon and evening. The crying would last 20-60 minutes. Often he could be calmed by being placed upright against his parents chest with them swinging their upper body forcefully back and forth in a rhythmic motion while walking/marching and singing certain songs.
These episodes decreased dramatically by 12 months of age. At 3 years of age, this child wants to be consoled in a similar manner when he is crying from a temper tantrum or other emotional event by having his parents walk with him upright in their arms. He is otherwise developmentally normal and said to be very well-mannered by his daycare providers.

Discussion
Colic is often defined by Wessel’s rule of threes: crying 3 or more hours/per day, 3 or more days per week, for 3 weeks or more. Colic is a diagnosis of exclusion based upon through history and physical examination in a healthy growing child being fed properly. It usually starts at 41-42 weeks gestation, stops around 3-4 months and has no predictable long-term outcomes such as behavioral, tempermental or psychological problems. There are generally two patterns:

• A hyperirritable baby who cries at all times of the day in response to unidentifiable or ambiguous stimuli
• A paroxysmal fussy baby who has a crying period in the early evening. The child is easily consoled at other times of the day.

The crying is often associated with motor behaviors and facial expressions such as legs over the abdomen, clenched fists, or pain facies. There may also be gastrointestinal symptoms such as distention, gas or regurgitation. The inability to soothe is also characteristic and the episodes appear to stop and start without reason.

Normal amounts of crying changes with the infant’s age, averaging: 2 weeks old = 1 hour and 45 minutes, 6 weeks old = 2 hours and 45 minutes, and at 12 weeks of age = less than 1 hour.
There are many theories of colic’s etiology but none have been proven conclusively. These include gastrointestinal problems (i.e. cow’s milk intolerance, lactose intolerance, abnormal feeding practices, immature gastointestinal tract), hormones causing enterospasm (i.e. serotonin, motilin, progesterone), temperment and parent handling.

Important history questions to ask:

• When does the crying occur?
• How long does it last?
• What do you do when your baby cries?
• What does the cry sound like?
• What and how do you feed your baby?
• How does it make you feel when your baby cries?
• How is it affecting your family?
• What do you think is causing the crying?

The physical examination needs to rule out medical problems that can cause pain or discomfort and also helps to reassure the family that the baby is healthy. This is especially important in a hyperirritable baby.

• Head – hydrocephalous, hemorrhage
• Eyes – corneal abrasion, glaucoma
• Ears – otitis media
• Mouth – oral herpes
• Abdomen – diarrhea, constipation, gastroesophgel reflux, anal fissures
• Cardiac – supraventricular tachycardia
• Genitourinary – posterior urethral valves, hernia, urinary tract infection
• Skeletal – fracture, tourniquet on toe/finger
• Miscellaneous – drug withdrawal such as narcotics, genetic syndromes

Learning Point
As the etiology of colic is usually not clear several suggestions are given to parents for treatment of colic. No treatment works for all infants and each suggestion works for about 30% of infants.
Additionally, one of the most important treatments is parental support. This includes informing the family what is known about colic’s etiology and time course, and empathizing with parental feelings.
Many parents feel guilty that they have done or not done something to cause colic.
Many parents will not say that their child causes them to feel angry or resentful. Acknowledging to the parents that these feelings are normal and that all parents have these feelings at some time about their colicky infant can be helpful.
As well as acknowledging that the parents are not bad people for having those feelings. It is also helpful to discuss what they can do when they have feelings of resentment or anger towards the child such as telling them to place the child in a safe place and walk away for a short time.
Even if the parents does not feel angry or resentful, taking short breaks can help the parents overall coping with the situation.
If a parent states that he/she feels that they will harm the child and cannot cope with the situation, then this information needs to be taken seriously and hospitalization may be necessary to provide respite, and social/psychological support. Close follow-up with the family also allows further discussion
and reassurance and support to the family.

Possible treatment options include:

• Medications
  • Antispasmotics should NOT be used as they could cause respiratory arrest
  • Herbs – mint, fennel, verbena or licorice (often given as tea)
  • Simethicone is probably harmless but itsefficacy is not proven

• Altering the sensory environment
  • Audiotape of human heart beat or white noise generator
  • SleepTight® – vibrates a bed and generates white noise simultaneously.
  • Carrying the child
  • Car seat on dishwasher or dryer – must be observed because of movement of the seat
  • Massage
  • Pacifier
  • Riding in car – not advised at night because of driver drowsiness
  • Scenery change
  • Swinging
  • Swaddling
  • Warm water bottle

• Nutrition
  • Change formula – may or may not help, may be more expensive
  • Change mother’s diet – eliminate cow’s milk, caffeine, etc.
  • Change feeding practices such as substituting a different bottle/nipple, feeding in an upright position, more frequent burping
  • Sugar water

Questions for Further Discussion
1. What are the classifications of tempermentally difficult children?
2. Is there a correlation between infants with colic and child abuse and neglect?

Related Cases

Disease
Colic
Infant and Newborn Care

Symptom/Presentation
Crying and Colic
Health Maintenance and Disease Prevention

Specialty
General Pediatrics
Psychiatry and Psychology

Age
Infant

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 Pediatric Common Questions, Quick Answers for this topic: Crying and Colic.

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

Parker S, Zuckerman B. Behavioral and Developmental Pediatrics. Little, Brown and Company, Boston, MA. 1995; 101-105.

Boychuk RB. Infant Colic. University of Hawaii Case Based Pediatrics For Medical Students and Residents.
Available from the Internet at http://www.hawaii.edu/medicine/pediatrics/pedtext/s09c01.html (rev. 4/2003, cited 9/7/05).

Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:414-417.

ACGME Competencies Highlighted by Case

Patient Care
1. When interacting with patients and their families, the health care professional communicates effecively 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.

Medical Knowledge
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.

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.

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

Date
November 7, 2005

Patient Presentation
A 10-month-old female came to clinic with a mild cough, runny nose and a fever for 2 days.
The child has recently relocated from the New Orleans area because Hurricaine Katrina had devastated their home.
She was drinking and urinating well, was playful and had no specific ill contacts.
The past medical history revealed a healthy female who had received routine health care up to 6 months of age.
Her immunizations were current.
The pertinent physical exam revealed a playful female with a normal temperature and no tachypnea. She had mild clear rhinorrhea anda small amount of fluid behind her tympanic membranes bilaterally with no injection. Her throat and lungs were normal.
The diagnosis of a viral upper respiratory illness was made. Her parents were told to give symptomatic care and to monitor symptoms. The parents asked what they should do about their child’s immunization schedule because of the hurricaine and the lack of vaccine documentation.
The parents were told that the Centers for Disease Control website had recommended that health care providers assume that patients without documentation of immunization would have had all of their vaccinations and to continue the regularly schedule vaccines at the proper time. They were offered Influenza vaccine in a few weeks when it became available.

Discussion
A humanitarian emergency generally can be described as “an acute situation affecting a large population where through disruption or displacement neither the population nors it’s government is capable of providing for all of the basic needs.”
There can be various inciting events including natural disasters (e.g. hurricanes, droughts, famines, earthquakes, etc.) or manmade disasters (e.g. terrorist attacks, bombings, nuclear explosions, civil war, etc.). The United Nations High Commission for Refugees refers to the individuals affected as “persons of concern.”These persons of concern are either refugees (people who leave and cross an international border to another country) or internally displaced persons (IDPs, people who leave their homes but do not cross an international border and enter another country).
Refugees sometimes maybe better off than IDPs because once a border is crossed then international treaties and laws often apply to their treatment. This is not true for IDPs as a sovereign government needs to accept aid for what is considered an internal problem.

The most vulnerable individuals in humanitarian emergencies are the youngest and oldest of a population. Orphaned and unaccompanied children are even more vulnerable. Women and women-headed households often have less access to relief services. Pregnant and lactating women are also vulnerable because of their increased nutritional needs.

The appropriate emergency response must always be tailored for the disaster.
Ten essential emergency relief measures to evaluate and institute are:

• Rapid assessment of the situation and the affected population
• Provide adequate shelter and clothing
• Provide adequate food – minimun 1900 kcal/person/day
• Provide elementary sanitation and clean water 3-5 liters/person/day
• Institute diarrhea control program
• Immunize against measles and provide Vitamin A supplements
• Establish primary care medical treatment
• Establish disease surveillance and a health information system
• Organize human resources – victims themselves, community leaders, interpreters, surrogates for unaccompanied minors
• Coordinate activities with local authorities, relief organizations, government agencies, military etc.

Learning Point
The Centers for Disease Control (CDC) has issued recommendations for immunization implementation plans for IDPs of the Hurricaine Katrina and Rita disasters that occurred in the fall of 2005 (see To Learn More). Many medical records were destroyed in these disasters.

• If medical records are available and the patient has current vaccines, then the patient should continue to receive the proper vaccines on the regular schedule
• If medical records are available and the patient is missing vaccines, then the patient should receive the proper vaccines on the catch-up schedule.
• If no medical records are available, then the recommendations are based upon age:
  • <10 years – the patient is assumed to have current vaccines and should receive the proper vaccines for their age based upon the current schedule and state immunization practices. Varicella vaccine should be given unless there is a reliable history of disease.
  • 10-18 years – the patient should receive the adult formulation of diphtheria toxoids and acellular pertussis (Tdap), meningococcal conjugate vaccine (ages 11-12, and 15 years only) and Influenza vaccine if in high risk Tier 1 category.
  • > 18 years – the patient should receive adult formulation of diphtheria toxoids and acellular pertussis (Tdap) if 10 years or more since last tetanus, Pneumococcal vaccine for adults > 65 years, and Influenza vaccine if in high risk Tier 1 category.

It is important for health care providers not only to document the immunizations given, but also to document that the decision for the immunization plan was based upon the natural disaster recommendations from the CDC or other agency. This can prevent possible confusion in the future for the other health care providers who may not know of these recommendations and to prevent unnecessary vaccine duplication.
As for school requirements, the CDC has stated,”States affected by Hurricane Katrina had immunization requirements for school and daycare and it is likely that children enrolled prior to the disaster would be vaccinated appropriately. It is not necessary to repeat vaccinations for children displaced by the disaster, unless the provider has reason to believe the child was not in compliance with applicable state requirements.”

People living in crowded group conditions should be immunized for Influenza, Varicella, MMR and Hepatitis A according to the CDC guidelines.

Questions for Further Discussion
1. What are some of the mental health needs of refugees and IDPs?
2. What is the relationship between governmental agencies and non-governmental organizations in disasters?
3. What is your own role in providing help during a local diaster?

Related Cases

Disease
Childhood Immunization
Coping with Disasters
Immunization
Natural Disasters

Symptom/Presentation
Cough
Common Cold
Fever and Fever of Unknown Origin

Specialty
Emergency Medicine
General Pediatrics
Infectious Diseases
Preventive Medicine and Health Maintenance

Age
Infant

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 Pediatric Common Questions, Quick Answers for these topics: Traveling with Small Children and Colds / Upper Respiratory Infection (URI)

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

Uniformed Services University of the Health Sciences, Department of Pediatrics. Military Medical Humanitarian Assistance Course. October 2003. pp. 3-24.Available from the Internet at http://www.pedsedu.com/course_manual.htm (rev. 9/8/05, cited 10/17/05).

Centers for Disease Control. Interim Immunization Recommendations for Individuals Displaced by Hurricane Katrina.
Available from the Internet at http://www.bt.cdc.gov/disasters/hurricanes/katrina/vaccrecdisplaced.asp (cited 10/17/05).

ACGME Competencies Highlighted by Case

Patient Care
1. When interacting with patients and their families, the health care professional communicates effecively 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
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.
15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.

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
Associate Professor of Pediatrics, Children’s Hospital of Iowa

Date
October 31, 2005