Vol. 68 June 1, 2012 ECMO or Elmo for your child?

June 1, 2012

Nellie is a girl, a twin born 2 weeks prematurely in our pediatric practice. She weighed a beautiful 4 lbs. 10 oz at birth and was very healthly. At her two-month well baby visit she and her brother were clearly thriving in a loving, attentive family. She got her routine DTaP immunization (Diptheria/Tetanus/Pertussis) then. Thirty seven days later she came back to our office after vomiting three times the night before. Both twins were a bit fussy. We determined that the vomiting actually followed and was associated with several coughing spells. Her exam was normal, her lungs were clear, and she did not appear sick in any way.

The next day she returned to the office with difficulty breathing, had signs of pnemonia in her right lung, and was immediately admitted to our community hospital. Overnight in the hospital she developed pneumonia in the other lung and began to drop the oxygen level in her blood. She was transferred to a children’s hospital because she  now required a ventilator to be able to breathe.  The very next day she suffered almost complete cardiac-respiratory  collapse. Her lungs would not work at all. That is when they put her on the ECMO machine (Extra Corporeal Membrane Oxygenator, aka the “artificial lung”). Like a heart bypass machine the ECMO takes blood from the patient, circulates it through membranes with oxygen, and returns the oxygenated blood to the patient. Without that oxygen,of course, the brain and other vital organs begin to die. Her lungs had failed from an infection with pertussis, whooping cough.

Vaccinations nearly wiped out whooping cough more than 30 years ago, but it has made a vengeful comeback in California, Washington, and other states.

Cases of pertussis declined rapidly in the 1940s. The all-time low was in 1976, with only 75 cases reported in the United States. Since the early 1980s, there has been an increase in reported cases of whooping cough.

Why this resurgence?

Vaccination rates are decreasing as more parents refuse to have their children immunized against a number of preventable diseases.

But, that is not the whole story. Most of the new cases in California are in infants under two months of age, too young to be fully immunized (like Nellie). We also know that even with a full series of three to four pertussis immunizations only 85% of the children develop a level of immunity high enough to protect them. There is also recent speculation that the new pertussis cases are caused by a more virulent, mutant strain of the bacteria that can cause whooping cough even in those receiving our current vaccine. Studies have been launched to test that hypothesis.

One thing is clear. “Herd immunity”, protection of an individual infant by immunizing all the surrounding children in the community, is not enough for pertussis. Some states have refined the herd (community-wide) immunity  concept with a more focussed family-wide immunity concept, “cocooning”. Cocooning seeks to reimmunize for pertussis any adult caretakers of the infant, including the pregnant mother and all other adults surrounding the infant. The objective is too avoid any exposure of the infant to the pertussis germ in the first six months of life, or until the pertussis vaccination series can be completed. The easiest thing for adults to do is to get a Tdap (Tetanus/diptheria/pertussis) instead of their next regular tetanus booster—the Td shot – that is recommended for adults every 10 years.

THE OTHER EASIEST THING TO DO IS MAKE SURE YOUR CHILD OR GRANDCHILD GETS IMMUNIZED AGAINST PERTUSSIS STARTING AT TWO MONTHS OF AGE.

Currently there are 17 preventable diseases for which we give immunizations in the first two years of life. In 1980 we only had 7 vaccines. Those 7 vaccines contained over 3000 proteins (aka “foreign protein” by anti-vaccine advocates). In 2012 our more purified vaccines, including acellular pertussis vaccine (the “ap” of Tdap) with only 2 proteins, contain a total of  less than 200 proteins in all 17 vaccines.

Ellie was on ECMO for three weeks. Every attempt to remove her from the artificial lung resulted in a dramatic drop in blood oxygen and ECMO treatment was continued. Her kidneys , heart, and lungs were stressed to the failing point. Finally, her lungs began to recover from the pertussis infection. Yesterday they put her twin in the ICU bassinet with her, and her vital signs calmed right down and became even more stable. The two looked like they just “chilled out together” as twins do. Today she will have her breathing tube removed. We antiicpate that she will breathe on her own and continue to improve. We all wonder how her brain fared during all this stress. We shall see.  Some of us wonder what all this intensive care cost?

Make sure you do everything you can so your children to get to know Elmo rather than ECMO.

Let them have their immunizations!


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