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.
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).”
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
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?
- Symptom/Presentation: Health Maintenance and Disease Prevention
- Specialty: Adolescent Medicine | Infectious Diseases | Neonatology | Obstetrics / Gynecology | Preventive Medicine and Health Maintenance
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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
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.
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.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
19. The health professional works effectively with others as a member or leader of a health care team or other professional group.
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.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital