Aimee Henry, Marty Hanna, Vincent McLarnon, Colm Darby, Rachel Hearst, Shilpa Shah
Here’s a story that’s never been told before. Or has it? We’ll let you be the judge of that. Before you start, we would like to point out that the patient and family in this piece are fictional but the events have been inspired by real life situations we have all faced.
Sadie was born early at 28 weeks. Small and frail, she was in NICU for a number of weeks; Ventilation, CPAP, TPN, antibiotics, the works. Her mom and dad, Mandy and Tom, always by her side, viewed her through the transplant walls of the incubator, hoping and praying. They wanted to
protect her but felt helpless. Mandy expressed breast milk everyday for tube feeding. She knew this would offer her immunity and protect her. They watched her grow, and started to get excited about her coming home.
2, 3 and 4 month vaccinations
At 8 weeks old (36 weeks corrected), Sadie was bigger and stronger, managing all her feeds without a tube and breathing without any support. Mandy knew she would be getting home soon. That’s when Colm, the advanced neonatal nurse practitioner approached her to get consent for Sadie’s first set of immunisations.
“What?” said Mandy “Are you sure? Isn’t she too small? Couldn’t we wait until she is 8 weeks from her due date? She should have immunity because I breast feed her, isn’t it?” All these questions came rushing, as did tears. She was naturally scared.
Colm wanted to understand Mandy’s concerns so took time to sit and listen, and then offered information. Here is a summary of what he shared with her.
Preterm babies are recommended to receive their immunisation at the chronological rather than corrected age to prevent delays. This is because preterm infants have a higher incidence and severity of disease from vaccine preventable diseases. Prematurity is independently associated with a higher risk of severe pertussis and invasive pneumococcal diseases. Premature babies have a higher risk of complications and hospitalization following rotavirus compared to term infants. Also, the late trimester placental transfer of passive immunity is missed, which makes them even more vulnerable.
Immunisation has been associated with an increased risk of apnoea in preterm infants. Also, extremely preterm infants immunised in hospital may require increased respiratory support (oxygen or non-invasive respiratory support) after their first immunisation. It is therefore recommended that the cardiorespiratory function of hospitalised preterm infants be monitored for 24-48 hours post immunisation. If there is a history of apnoea following immunisation, consideration must be given to administering future immunisations under medical supervision including after discharge from hospital.
Breast milk is obviously best for the baby and it offers immunity. This immunity however is passive, and does not confer specific or adequate protection for vaccine preventable infections. So it’s really important to get all vaccines and continue breastfeeding, if possible.
Mandy was satisfied with this and gave her consent. Sadie tolerated her vaccines very well and was discharged after 48 hours. At 3 months and 4 months old, further immunisations were completed at the GP surgery as per the UK immunisations schedule.
Sadie’s overall growth, development and health remained well. Her neonatologist was pleased with her. At 8 months old Sadie was diagnosed with mild egg allergy after a few episodes of urticaria, but she never had symptoms of anaphylaxis. She also had an episode of viral triggered wheeze when she was 12 months old but did not need admission to hospital.
12 and 13 month vaccinations
At 13 months old, Sadie had a fever and was brought by her dad Tom to the paediatric short stay unit. Here they met Vincent, the advanced paediatric nurse practitioner.
Vincent examined Sadie and diagnosed her with an ear infection. By way of history, he checked whether her immunisations were up to date.
Her dad said, “Well, she’s had all her baby vaccines but she’s not had her MMR yet. I’ve read a lot about it causing autism. My nephew has autism and I know how hard it is for him and family. I really don’t want to take any chances. I want to do the best for her. She’s been through so much already”
Vincent asked Tom a bit more about his thoughts on the subject, and spent time reassuring him by deconstructing some of the myths about the MMR vaccine.
When children are given two doses of the MMR vaccine, they develop high levels of immunity. Measles, mumps and rubella are diseases with some nasty potential complications that are best avoided, and vaccination is the best way to protect children from them.
There are various factors that have lead parents to believe in an association between the MMR vaccine and autism, a major one being misinformation within the media. Controversy first came about in 1998 when a now retracted, fraudulent case study involving 12 children suggested an association between the MMR vaccine and the onset of autism. This was extensively reported in the media causing parental concern and vaccine hesitancy which has never gone away. Over recent years researchers have investigated the relationship between MMR and autism and found no evidence to suggest that the MMR vaccine causes or increases the risk of autism. These studies include a combined total of almost 1.5 million children.
Vincent also recommended the MMR as a combined vaccine opposed to three separate injections. He also suggested an online NHS resource for further reading.
Tom was happy with the verbal and written information. He rearranged the appointment with primary care and Sadie received her 13-month vaccines as per schedule.
Time has a way of passing. Sadie continued to grow and develop well. Her wheeze however persisted, and she was diagnosed with childhood asthma at 3 years old. She was started on salbutamol and a preventer inhaler. She also remained on an egg free diet. At her next visit to the allergy clinic, she met Marty, a paediatric registrar. He recommended Sadie should get the live attenuated flu vaccine, which is given intranasally. Since she was a preschool child it would be given by the GP.
“But doctor” said Mandy, “Sadie has egg allergy. How can she have the flu vaccine? Doesn’t it contain eggs? Will she not get an allergic reaction? I want to protect her but I’m scared of her having this vaccine”
Marty sat down with Mandy to chat through her worries. He explained the following.
The influenza vaccines available in the UK include inactivated influenza vaccine and live attenuated influenza vaccine (LAIV).
Inactivated influenza vaccines are egg-free or have a very low ovalbumin content and studies show they may be used safely in individuals with egg allergy.
The Joint Committee for vaccination and immunisation (JCVI) has advised that children with an egg allergy – including those with previous anaphylaxis to egg – can be safely vaccinated with LAIV in any setting (including primary care and schools). The only exception is for children who have required admission to intensive care for a previous severe anaphylaxis to egg, for whom no data is available; such children are best given LAIV in the hospital setting.
LAIV remains the preferred vaccine for this group – and the intranasal route is less likely to cause systemic reactions.
Marty directed Mandy to an online resource created by the Vaccine Knowledge Project on flu vaccine – it includes a patient testimonial well worth listening to.
Mandy was satisfied and arranged for Sadie to have her flu vaccine.
The story does not end here – but we will leave you for now. Part 2 focuses on Sadie as a teenager. Until then we leave you with the words of wisdom from A/P Margie Danchin – listen here to her podcast on vaccine hesitancy.
Authors: Aimee Henry (ST1 Paediatrics), Marty Hanna (ST5 Paediatrics), Vincent McLarnon (Advanced paediatric nurse practitioner), Colm Darby (Advanced neonatal nurse practitioner), Rachel Hearst (GPST2) & Shilpa Shah (Paediatric Consultant)
Craigavon Hospital, Southern Health & Social Care Trust, Northern Ireland