Unless you’re really into World War II history or you have been keeping up on the latest individuals to be beatified by the Catholic Church, you may not have heard of Stanislawa Lecysynska.
She didn’t attempt to assassinate anyone. She didn’t win any battles. She didn’t blow up any munitions factories or bridges. She didn’t find out any crucial bits of military intelligence. She never even wrote a book about her experiences. In fact, she rarely talked of her time as a midwife in Auschwitz.
But that’s OK. Because a lot of the mothers who knew her have told us about her- and even a couple of the babies she saved.
The Midwife of Auschwitz
Stanislawa Lecysynska was a midwife in Poland before the war. She was imprisoned in Auschwitz when she was suspected of collaborating with the Resistance. When the camp officers found out she was a midwife, they put her in charge of delivering babies for pregnant prisoners and killing the newborns. She delivered over 3,000 babies during her time in Auschwitz, but she refused to kill any of them- even when the infamous Dr. Mengele threatened to kill her for refusing to comply.
By all accounts, Stanislawa was a woman of great hope and compassion. All the pregnant women in the camp called her “Mother” because she gave the best care she could to every mother and baby- Jewish or Christian. Women described her as going hours without sleep to attend to laboring mothers and doing everything she could to keep babies alive for as long as possible. She had a deep conviction that if a baby was born alive, it was meant to live.
She delivered babies in the most hellish environment imaginable- and yet she never stopped caring for her mothers and babies. Some accounts describe the German doctors of being incredulous that she never lost a mother or baby to labor complications- despite the abysmal resources she had to deal with. It’s little wonder that she has been beatified by the Catholic Church (the first step towards sainthood).
Saving Babies Through Breastfeeding
Infant formula was not available in concentration camps. Mothers who weren’t able to make enough milk turned to other prisoners who were lactating to feed their babies. One of these babies, Barbara Puc, lived out the first two years of her life in Auschwitz. When her mother was unable to breastfeed her, another woman who had just lost her baby offered to wet-nurse baby Barbara, saving her life. One Auschwitz inmate, Maria Saloman described how Stanislawa found two women to wet nurse her baby who ended up living to adulthood.
Kazimera Bogdanska was unable to breastfeed her little girl at first, but Stanislawa encouraged her to keep putting the baby to the empty breast in hopes that it would eventually stimulate lactation. When the camp was liberated, Kazimera was able to see a doctor who encouraged her to follow the midwife’s advice.
“Mother [Stanislawa Lecysynska] was right,” says Kazimera, “How lucky I was that I believed her. When liberty came in January 1945 and I was taken to a real hospital (since I had typhoid fever) the doctor allowed me to continue to give my child my breast devoid of milk. After some time milk returned. My daughter began to gain weight. . . . She started to become round and rosy cheeked. . . . Mother’s wisdom and faith saved my only child.”
I just think it’s beautiful advice for any mother who is struggling with breastfeeding. Even when you feel like nothing is happening, even if you have to supplement or get donor milk for a time, keep putting the baby to the breast. It might stimulate the glands.
The answer is yes… and no… and maybe under certain conditions…
In no particular order, here are some of the most commonly questioned substances and the verdict on each one:
Obviously, no one should smoke. Ever. But there are certain risks associated with breastfeeding and smoking. Heavy smokers (20+ cigarettes a day) increase the likelihood of passing nicotine to the baby. The half-life of nicotine (the amount of time it takes for it to be eliminated from the body) is 95 minutes, so even smoking before a feeding can pass nicotine to the baby. Smoking increases the risk of SIDS and respiratory problems for the baby. Studies have found that breastfed babies of smokers were more likely to have episodes of colicky crying and fussiness than breastfed babies of non-smokers.
Also, smoking and breastfeeding is associated with early weaning, lowered milk production, and inhibition of the milk ejection (“let-down”) reflex. And it lowers prolactin levels- crucial to milk production. According to Thomas Hale, Ph D, author of Mother’s Milk and Medications (the go-to book when you have questions about how stuff in your milk affects your baby), smoking cessation aids are generally less hazardous to the baby than continued smoking.
Alcohol (in Moderation)
Drinking occasionally is fine if you’re breastfeeding. The Mayo Clinic is pretty stiff on the subject and their article generally discourages drinking and breastfeeding. And truthfully, not drinking while you are breastfeeding eliminates any chance of alcohol being passed to the baby.
However, research shows that 1-2 drinks generally doesn’t pose any risk to the baby. Thomas Hale says that mothers can return to breastfeeding after ingesting alcohol as soon as they feel neurologically normal. Many health professionals recommend keeping alcohol intake to 1-2 drinks a week while breastfeeding.
What about “pump and dump”? You can pump after drinking, but it won’t take the
alcohol content out of the milk any faster. However, if you’re away from your baby for a few hours and need to keep your milk supply up or relieve engorgement, by all means pump it and dump it. (FYI, Jane the Virgin didn’t need to drag her whole electric breast pump with for a night on the town with her best friend. She could have taken a small hand pump or even hand expressed milk to maintain supply and relieve engorgement.)
Here is my big post on marijuana and pregnancy for those of you who didn’t catch the controversy the first time around. Don’t use marijuana while pregnant and don’t use it while you’re breastfeeding either. Here’s why…
Marijuana smoke contains the same chemicals as tobacco smoke with the same risks to lung health for both the mother and baby. (American Lung Association, 2015). Any chemicals that the mother takes in through smoking marijuana are passed to the baby, just like smoking tobacco products. THC also passes to the baby during breastfeeding and it stays in the body longer than many substances. THC is stored in body fat, which means it actually stays in your body (and your baby’s body) for much longer than alcohol. Because THC stays in the body for long periods of time, you can’t consume marijuana and then breastfeed after a couple of hours and not pass THC to your baby. So “pump and dump” won’t work.
What about edibles and vaping? No and no. Edibles and vape pens still contain THC and that THC will pass to your baby. And while some research shows that vape pens result in lower tar, some of the newest research suggests that there might be a chemical trade-off in the form of toxic ammonia levels in the lungs from vaping. The effects of THC from marijuana edibles will actually last longer than the effects of THC from smoking marijuana.
Caffeine (In Moderation)
Don’t over-do it on the Starbucks or energy drinks, but other than that a couple of cups of coffee or cola are usually OK. (Chocolate is A-OK.) The amount of caffeine that ends up in a mother’s breastmilk is 1% of what she actually consumes. Babies younger than six months may take up to 80 hours to process caffeine, but in small amounts that’s usually OK. By about six months, babies can usually process caffeine in about 2-3 hours. It’s important to factor all caffeine sources into your caffeine consumption equation, so remember that even some OTC medications can contain caffeine. And if your baby seems especially fussy, alert or wakeful, consider that he might be a little more caffeine sensitive.
The majority of medications are actually safe for breastfeeding. Most doctors do not get information about medications and breastfeeding from actual research on a particular drug and lactation, but from package inserts of a book called The Physician’s Desk Reference. Both of theses resources come from pharmaceutical companies and may include out of date and/or incomplete information or disclaimers meant to cover the manufacturer’s collective @$$. One of the big medical treatments that is incompatible is chemotherapy because it uses radiopharmaceuticals. Sudafed can cause a drop in supply for some women, though it’s not generally harmful to the baby.
But other than that, pain relievers, anti-depressants, anti-anxiety drugs, cough medicines and many other types of medications are actually safe to take while breastfeeding. I do advise all expectant mothers to understand their options for pain medications that might be used during or after labor so they can make a choice that will cause fewer breastfeeding difficulties. (That’s why I included a section on it all my breastfeeding classes.)
Make sure to check out any supplements you are thinking about taking. Certain herbs can decrease milk supply or pass to the baby in harmful amounts, though culinary herbs and some herbal teas like chamomile are usually fine. Large amounts of certain candies, teas, cough drops, etc. might cause a drop in supply for some moms, but everyone is different.
Dairy/wheat/soy/peanuts/other potential allergens
If your baby isn’t displaying any signs of gastrointestinal upset or colic symptoms related to certain foods, you don’t need to avoid any foods. It might be a good idea to be cautious and avoid certain foods if there is a family history of food allergies on either parent’s side though. If your baby seems to be especially fussy, at different intervals, it might be time to keep a food diary and see if there is any pattern related to certain potentially allergenic foods. What about peanuts? Well, the latest information seems to indicate that exposure to peanuts through breastmilk may actually decrease the risk of peanut allergies. So go ahead and have that peanut butter cup. =)
Hardly a week goes by that I don’t find someone asking about vitamin K prophylaxis. Most people have heard that newborns are just naturally deficient in vitamin K and without vitamin K supplementation their baby will get seriously ill. Of course, this is another one of those stories full of a few half-truths and many outright lies. This video was quite the merry chase of research as I dug around in a 100 year old medical journals and an 80 year old doctoral thesis to find out how a condition called hemorrhagic disease of the newborn came to be known as vitamin K deficient bleeding and how breastfeeding relates to it.
Here it is on Vimeo.
And here it is on YouTube.
Last year, two babies in Arizona developed Legionnaires’ Disease after their mothers labored in birthing pools. Since then, I’ve seen parenting magazines and websites decrying water birth as dangerous and Legionnaires’ Disease as just one more piece of “proof”.
These claims are not informed by current research or by the American Congress of Obstetricians and Gynecologists’ stance on water immersion during labor.
So, the second video in the “Let Me Level With You” series is dedicated to setting the record straight on Legionnaires’ Disease and water birth.
Feel free to share this video any time someone posts misinformation about this subject on social media. Enjoy!
I’ve often felt like much of the public health information parents get is filtered. When I was first advised about vitamin D supplementation for newborns, our son’s doctor at the NICU said that because our baby was exclusively breastfed he would get rickets if he wasn’t supplemented. Well, that was an extremely oversimplified and misleading statement that does not reflect the high degree of variability for vitamin D levels, breastfeeding and sunlight exposure.
This is the first in a new series of videos to help parents get a better idea of the research behind the recommendations. I want to bridge the gap between the research and the information that parents get from medical and public health professionals, thus the title “Let Me Level With You”. All videos in this series will use scholarly references, so the information you get will be the most up-to-date.
So without further ado, here is “Let Me Level With You About Vitamin D and Breastfeeding”…
Sickle cell disease made the news earlier this year when rapper Prodigy died from complications related to SCD this past June at the age of 42. It’s actually very common among African-Americans with 1 in 13 being carriers for the disease and 1 in 365 having sickle cell disease. There are other ethnic groups that are frequently affected as well. In some parts of Central India and eastern Saudi Arabia, as much as 40% of the population carries the sickle cell trait or is affected by sickle cell disease. People with Mediterranean and Central American heritage have higher rates as well. (People with Mediterranean heritage often have a variety of SCD known as thalassemia.) Because of the high number of people with Sub-Saharan African ancestry in the Caribbean and parts of South America, sickle cell trait is more common there as well.
For a long time, sickle cell disease was treated as a fatal children’s disease because children who were born with it frequently died very young. But in the last 3o years, advances in medications and treatment have led to longer lifespans for people with sickle cell disease- resulting in more women of childbearing age with the disease. While there are more specialists going into pediatric care for SCD, there are fewer care providers who are confident or knowledgeable about treating adults.
This gap between pediatric care and adult care is more of a problem as we have more children living to adulthood with birth defects and genetic conditions. I feel a similar frustration with CJ’s care. I feel like specialists are often thinking mostly of the “here and now” instead of the impact on his life as he grows to adulthood. To me, it kind of feels like that part in Dark Knight where the Joker says, “I’m like a dog chasing a car. I wouldn’t know what to do with one if I caught it.” As we have more children with disabling and genetic conditions living longer, our healthcare professionals are going to have to raise the bar beyond “Your child is still alive”. (But I digress…)
Sickle cell disease testing has only only been widely implemented since 1986 and universal testing only started in the 2000’s. The American Society of Hematology estimates that as many as 30% of infants with SCD may be lost to follow-up. So the current situation is that many women of childbearing age who are at risk may not know that they have SCD or that they are carriers for the disease. We also have a growing population of immigrants from areas where SCT is common who may not have had genetic testing available to them and may not know their sickle cell status.
If you want the whole ten page paper I wrote on this in all it’s APA cited glory with recommendations for public health strategies, you can find it here. (A little light reading before bedtime anyone?)
How SCD causes pregnancy complications
Most of us have red blood cells that are round shaped, but people with sickle cell disease have red blood cells that are shaped like a crescent or sickle. This causes the red blood cells to become stiff and sticky and clump together. When the blood cells clump together, it cuts off oxygen to the body’s tissues and organs causing pain and organ damage. Sickle cell trait (SCT) can cause all kinds of problems, but it also seems to give carriers a level of protection against malaria that other people don’t have. Scientists think it may have evolved as a way to protect people living in malaria prone areas from the disease.
Sickle cell disease impacts many of the body’s systems, it can cause many different types of complications for a pregnant woman and her baby:
- Infections- UTI’s, but also kidney and lung infections
Heart enlargement and heart failure from anemia
- Severe anemia for baby
- Intrauterine growth restriction (IUGR)
Low birth weight (less than 5.5 pounds).
Stillbirth and newborn death
One little known fact is that even women who are carriers of sickle cell trait are at risk for pregnancy complications that can result pre-term birth. Women who are carriers of the sickle cell trait are more likely to have urinary tract infections during pregnancy and a condition called pyelonephritis during pregnancy. (Pyelonephritis is a serious and potentially life-threatening condition where the kidneys develop inflammation from a bacterial infection.) With the increased risk of kidney/urinary tract infections comes an increased risk of preterm birth and even death for the mother and baby. This could be a strong contributing factor to the distressingly high rates of maternal and infant morbidity and mortality among African-American women.
What Can We Do?
If you read the above link to the CDC’s short article on the high rates of preterm birth for African-American women, you can see that they’re not talking about SCD and SCT as a possible contributing factor. The March of Dimes mentions “clotting abnormalities” as one of many possible contributing factors. Awareness about how much this could be impacting African-American women seems to be pretty low in the public health and medical fields. The relationship between pregnancy and sickle cell disease and sickle cell trait is still relatively new. But with an increasingly diverse population in the United States which includes immigrants from India, the Caribbean and the Middle East, SCD/SCT related pregnancy complications could become an even bigger problem if it’s not addressed.
There are a few things that moms who are at risk for SCD/SCT can do:
- Get tested for your sickle cell status. The blood test can be performed on adults and will tell you whether you are a carrier, have SCD or are unaffected. If other women in your family have had serious infections during pregnancy or given birth prematurely it might be an indicator that SCD/SCT runs in your family. The CDC has a short pamphlet on SCD and pregnancy that you can find here.
- Know the signs and symptoms of preeclampsia and preterm birth. Having SCD is a HUGE risk factor for preeclampsia and other hypertensive disorders of pregnancy. If you are experiencing any of the following symptoms during pregnancy and have SCD, DO NOT IGNORE IT. With symptoms like changes in vision, you should go to the emergency room immediately. Changes in vision can be a sign that the preeclampsia has progressed to a life threatening stage. I recommend reading the updated guidelines for diagnosing preeclampsia. ACOG revised their guidelines because they found that even women who weren’t displaying “classic” signs of preeclampsia like spilling protein in urine or blood pressure greater than 160/110 were still developing organ damage from hypertensive disorders of pregnancy.
- Keep a record of your blood pressure. High blood pressure in pregnancy can be a sign of preeclampsia. But the catch is that blood pressure readings can vary from person to person, so even if you have “low” blood pressure, you could still have preeclampsia. Keep a record of your blood pressure; maybe even request a copy from your doctor at each visit. With a record of your blood pressure readings, you can help the doctors and nurses at the ER better understand your condition if you ever need to go there.
- Get help! People with SCD have to strike a fine line on exercise and activity. If they do too much, it can bring on a sickle cell crisis (clotting problems and pain), but doing too little could increase problems with congestive heart failure and lung problems. Getting too cold, hot or over tired can trigger a sickle cell crisis, so get whatever help you can with housework, cooking and caring for older children both before and after the baby comes.
- Stay healthy. Eat plenty of fruits, vegetables, protein and whole grains. Drink water and cut back on soft drinks, fast food, sugar and processed food. Wash your hands to prevent viral and bacterial infections and help everyone else in the household to do the same. For exercise, listen to your body and stay as active as you can without getting too overtired.
Communities should get involved too:
- Hold awareness events- Encourage women to get screened for SCD/SCT, even they are not pregnant yet.
- Help out- In some European countries, all mothers are entitled to in-home visits from a nurse to help the mother and family adjust to the baby. They typically refer mothers to resources that might help them, watch for signs of postpartum depression or postpartum complications, and even just listen to the mother talk about her situation. Unfortunately, we don’t have that kind of option in the US, but we can provide support to expectant mothers- with and without SCD/SCT- through community groups, churches, family and friends. Visitors who help the mother by caring for older children, preparing meals or doing housework can actually be very welcome if their focus is on helping instead of just “seeing the baby”. (Got dietary restrictions? Check out this post on how neighbors, friends and family can help out with meals.)
YES!!! It’s possible!
Even if you have never given birth.
Even if you have never been pregnant.
Even if you can’t get pregnant.
You can breastfeed a baby!
How it works…
Lactation does not actually start with the mammary glands.
It starts with the pituitary gland, a pea-sized gland located at the base of the brain.
The pituitary gland produces a hormone called prolactin in response to suckling (or pumping) at the breasts. Prolactin then stimulates milk production.
How You Can Use It To Your Advantage…
You can induce lactation through pumping at any point in the adoption process- before or after your new baby comes home. The most ideal situation is that you have a specific timeframe when the baby will be coming home and you can start pumping and stockpiling a couple of months in advance. (You can keep milk in the freezer for about three months if it’s stored properly.)
However, even if you have short notice, have to travel a long distance or even if your baby is older when she arrives home, you can still get going. Older babies who have never been breastfed may take a little more patience and time to get used to breastfeeding, but it can be done. (Skin-to-skin contact can help.) Even with a later start, you can still get going and make milk.
There are herbs and medications that can be used to help the process along, but pumping is the key component. Without suckling/pumping, the body will stop producing high levels of prolactin and the milk starts to dry up. Lactation teas and cookies may help boost your supply a little, but they can’t take actually induce or sustain a milk supply.
How Much Milk Can You Make?
This is hard to predict. Most moms who induce lactation do need to partially supplement with formula. But this is where I think we as Americans need to get away from the “all-or-nothing” breastfeeding mindset. For many diseases like childhood leukemia and pre-menopausal breast cancer, any amount of breastfeeding offers some protection. Your milk also provides immune protection against particular antigens in your local environment- something that formula can’t do. For feedings where you need to supplement with formula, you can use a supplementary nursing system to help your baby feed at the breast.
Where To Go For More Info…
An awesome book on breastfeeding and adoption is Breastfeeding the Adopted Baby by Debra Stewart Peterson. Debra breastfed all three of her children who came into their family through adoption. She was a WIC breastfeeding counselor for several years too.
The La Leche League has some stories from moms on how they navigated breastfeeding through many different types of adoptions.
I have a breastfeeding class available on breastfeeding and adoption. You can find it here.
Today I am officially a milk donor. After one phone interview, two paperwork packets, a visit to the rural health clinic, a blood test, 100+ oz. of milk, and several calls to FedEx Peri Ship, my donation arrived and was accepted today.
I first started to consider becoming a milk donor during my breastfeeding educator certification when I did a handout on milk banking. I found out that the demand that milk banks receive far outstrips the supply. I’ve had a baby in the NICU and it’s hard. You want to do whatever it takes to get your baby well and take him home.
I was able to breastfeed my son exclusively, but I know that a lot of moms have trouble breastfeeding- especially after a difficult birth or emergency c-section. Donor breastmilk reduces the risk of a premature baby developing necrotizing enterocolitis, a potentially fatal disease of the intestinal tissue that affects formula fed premature babies, so while it’s still second best when compared to a mother’s own milk it can be life-saving.
I’m one of those moms that has plenty of milk. I can give another mom’s baby a fighting chance. So I called the milk bank and got started.
It’s not easy becoming a milk donor for a reputable milk bank because they are so careful to make sure that there is no risk that the receiving baby will receive milk that could be contaminated by a blood borne illness and that the donor mother and her baby are healthy enough to donate. But it was so worth it.
If you’re interested in becoming a donor, please think about it. I donated to the Mother’s Milk Bank in San Jose, California. Just call up your closest milk bank to get started. You do not need to live right by the milk bank. (I live in the rural forest 7,000 feet above sea level and several hours away from San Jose. The folks at Fed Ex make it happen!!!)
I know that the demand for donor milk is not sufficient for the supply and that a lot of moms are not able to get breast milk for their babies. This has led to more casual buying and selling of extra milk through online classifieds and Facebook groups. If you’re having difficulty breastfeeding a full-term and otherwise healthy baby, I do recommend getting help to breastfeed before you resort to buying unscreened milk.
If your milk supply has dropped or you’re no longer lactating, chances are that with the right information and help you can still breastfeed. There are several ways to drive your supply up again or even get your milk supply back if it has dried up. It’s far safer to partially breastfeed and supplement with formula for a time than use “black market” milk.
If your baby is in the NICU and you are struggling to breastfeed, come take my class. I have tons of info on how to breastfeed in the NICU, build your supply after a planned or emergency c-section and even induce lactation. Even if you need to supplement for a time, your milk is still best for your baby because your body will customize the immune enhancing factors and nutrition to meet your baby’s needs. And your freshly pumped milk can be fed to your baby straight up without pasteurization, so it is superior to donated milk.
To those moms of the babies who will get my milk, my heart goes out to you. I’ve been there. My daughter and I are happy to share with you. =)
This is a new phenomenon I’ve been hearing about. Apparently in my area, there are many doctors prescribing Zantac for breastfed babies because the baby spits up after feeding. It sounds as though some doctors and parents are concerned that spitting up after feeding means the baby has gastroesophageal reflux disease or GERD. GERD can be a big deal- but spitting up is normal. Because it’s such a misunderstood topic, I spent a whole section in my breastfeeding class dealing with it.
Now, I’ve met a few moms who have had babies with genuine GERD. Their babies were not gaining weight well, fussy all the time, arching the back, etc. For these moms and babies, a medication like Zantac can provide relief and allow the baby to take feedings without being in pain. But not all babies who spit up have GERD.
A few points to remember if you’re concerned about whether your baby has GERD:
- Breastfed babies are not at a higher risk of GERD. The actual incidence of GERD between formula fed and exclusively breastfed infants is about the same. However, breastfed babies tend to have fewer and shorter episodes of GERD.
- Happy Spitters vs. Scrawny Screamers. If your baby is spitting up but happy, gaining weight well and feeding well, it’s very unlikely that she has GERD (Happy Spitter). If your baby is frequently fussy and not gaining weight well, it’s quite possible your baby does have GERD and might need medicine to reduce the inflammation (Scrawny Screamer). Because their stomaches are so small, little babies often spit up if they get too much milk too quickly. It’s actually quite normal!
- Babies with GERD may not always spit up. “Silent reflux” is when the contents of the baby’s stomach come back up to the esophagus and are then re-swallowed- so there’s reflux but no spitting up or vomit. These babies are in pain and very fussy, but they’re not spitting up.
- An antacid is not the “first line” against GERD. Generally an antacid is only prescribed after you’ve tried sleeping and feeding changes with no success and/or the baby is not gaining weight well. (Disturbingly, the above link tells parents to thicken the baby’s feeds with cereal, a practice which is not backed up by evidence. At best, thickened feedings may be moderately helpful at reducing reflux in formula fed babies, but these thickened feeding studies have not used cereal.)
- It’s not a good idea to give babies a medication if they don’t have an actual need for it. Zantac is generally safe for babies, but like any medication it has side effects including headaches and malaise. It also means that you are changing your baby’s stomach acid ph when GERD may not be present.
- Signs of severe GERD include:
- Severe fussiness associated with feeding
- Baby taking too little or too much milk during feeding
- Arching the back
- Poor weight gain
- Breathing problems
- Weird spit up, i.e. with blood or greenish-yellowish fluids
- Trouble swallowing
- Frequent nasal congestion or sinus/ear infections
- Refusing the breast or formula feedings.
Unless your baby is at the severe GERD stage, medication for GERD is probably not necessary.
Part of me feels like I should be saying, “Sorry!!!” for bringing up this issue. No one really wants to hear about it. On the other hand, a bigger part of me thinks, “Why should I be sorry for telling people about an actual health threat that is backed up by current medical research and isn’t widely discussed? After all, it could potentially save a life.”
So I’m going to ruin your day.
Here we go…
You and your kid are at risk for pertussis.
Even if you are vaccinated…
…Even if your child is vaccinated…
…Even if that ice cream party at your kid’s class worked and everyone in your kid’s class is vaccinated…
…And even if you don’t have any symptoms…
You’re all at risk for pertussis. Or more accurately pertussis and parapertussis.
(Quick note on whooping cough and bordetella pertussis- whooping cough is the illness caused by the bacteria Bordetella pertussis. Our current vaccines are only for the bordetella pertussis strain of the bacteria, but other strains are out there like Bordetella holmesii and now Bordetella parapertussis. More parapertussis in a minute.)
If we could describe the current state of affairs for pertussis control with a Facebook relationship status, it would be: “It’s complicated”.
The CDC started noticing a rise in pertussis cases in pertussis cases back in the 1980’s. There have been a four different hypotheses for this: 1) waning immunity from vaccination or natural infection 2) evolution of the B. pertussis bacteria to escape protective immunity 3) low vaccine coverage and more recently 4) asymptomatic transmission from individuals vaccinated with the currently used acellular B. pertussis vaccines- in other words, you’re vaccinated, not showing any symptoms and still spreading the disease.
Pertussis and Waning Immunity
Waning immunity doesn’t explain the rise because waning immunity would occur mostly in older age groups as their immunity dies off. But the rise was seen across all age groups.
The Switch from DTP to DTaP
The acellular pertussis vaccine (DTaP) that is currently used is supposed to be less effective than the older whole cell pertussis vaccine (DTP) that was used until the 1990’s. But there’s a catch to the old DTP vaccine- it had a higher rate of both mild and serious adverse events. (How serious was “serious”? Long story short, multiple large case-control studies found that babies who received the DTP vaccine were more likely to develop encephalopathy- a term that is used for brain damage, disease or malfunction. And follow-up showed that ten years later that children who had experienced a serious neurologic illness after receiving DTP were more likely than children in the control group to have chronic nervous system dysfunction ten years later. If you want the long story, you can read it here- the stuff on DTP starts on page 22. This is an interesting read from a public health perspective. It’s the September 6, 1996 Weekly Morbidity and Mortality Report from the CDC. It’s interesting to kind of take a ride in a time machine and understand what the CDC was looking at around the time the DTP vaccine was removed from the American schedule.
But it still couldn’t account for many cases. For example, in 2005 there was an outbreak in Lithuania where DTP was still in use and 75.7% of the children who had laboratory confirmed pertussis were fully vaccinated with DTP.
Low Vaccine Coverage
This has received the most media attention, but is probably the least likely to account for the rise in pertussis. If you look at the CDC’s chart of reported pertussis cases between 1922 and 2015, rates of pertussis have been rising despite the widespread use of Tdap vaccines for adults. There are some places where vaccine coverage is lower, but low vaccine coverage can’t account for the resurgence of pertussis in these areas because pertussis cases have been found in vaccinated individuals and in infants who were “cocooned”. For example, Boulder, Colorado is known for having lower rates of vaccination, which made it a great case study for low vaccine coverage. An article in the Atlantic from 2002 tried to examine the pertussis resurgence from this perspective. But in the middle of his piece though, the author is confronted with a paradox and states: “Although unvaccinated children are six times as likely as vaccinated children to get whooping cough during an outbreak, about half the cases in Colorado have involved vaccinated children.” Even with low vaccine coverage, vaccinated children were not getting anywhere near the levels of expected protection.
An outbreak of pertussis in San Diego presented a similar problem. Of the 1,000 adults and children who tested positive for pertussis in 2010, over half had been vaccinated. A survey of nine other counties in California showed that between 44 and 83 percent of individuals with pertussis had been immunized.
Another example is a case from Israel in 2000 where a vaccinated 4 month old baby died of pertussis despite the parents, siblings, aunt and all the children at the siblings’ day care centers being vaccinated with DTP. The report examined 46 fully vaccinated children, five of whom tested positive for pertussis with laboratory diagnostic testing (not just basis of symptoms), Only two of those children met the World Health Organization’s diagnostic criteria for pertussis. The study concluded that even vaccinated, asymptomatic children can be carriers of pertussis.
And so we come to…
Asymptomatic transmission of pertussis
Asymptomatic means that you aren’t displaying any symptoms. Discussion of asymptomatic transmission of pertussis has mostly been in medical and epidemiology journals- though the CDC has hinted at this in their information for the public:
“If you get pertussis after getting pertussis vaccines, you are less likely to have a serious infection. Typically, your cough won’t last as many days and coughing fits, whooping, and vomiting after coughing fits won’t occur as often. When vaccinated children get pertussis, fewer have apnea (life-threatening pauses in breathing), cyanosis (blue/purplish skin coloration due to lack of oxygen), and vomiting.”
Althouse and Scaprino (2015) found that asymptomatic transmission was the best fit for the observed changes in pertussis. It explained the changes in age-specific attack rates, the increased genetic diversity within the bacteria population, the increasing incidence and the failure of the “cocooning” strategy to protect infants. They also noted that asymptomatic transmission might bias assessments of vaccine efficacy that are made only on observations and not on laboratory confirmed testing.
Adults and teens may not display the “whoop”, they may have a very long, lingering cough. Of course, the tricky part is that a long, lingering cough can be caused by many things. Estimates are that 10-30% of long, lingering coughs are pertussis– but many of these cases may not be reported, which also makes the number of pertussis cases seem deceptively low.
Bordetella Pertussis has Adapted
In 1998, Dutch researchers used to DNA sequencing and found that the protein composition of Bordetella pertussis has changed. Bordetella pertussis proteins (P.69) are an important component in vaccines. Pertussis vaccines use the P.69A type of Bordetella pertussis proteins. That worked well for a while. Within the Dutch population, P.69A was the dominant type of pertussis in circulation from about 1949 to 1980. But in 1981, two different types emerged P.69B and P.69C. Within the Dutch population, these became the predominant Bordetella pertussis proteins circulating. Though Bordetella pertussis P.69A,B, and C are 93% similar, the vaccine only protects against P.69A. Basically, the bacteria adapted to a new threat- similar to what we’ve seen with antibiotic resistant strains of bacteria.
A study from Italy had similar findings: “Molecular analysis suggests that also in Italy B. pertussis strains differ from those included in the current vaccine.”
Bacteria are not smart, but considering that they can produce a new generation in hours, they are very adaptable.
CDC has also hinted at this too:
“CDC is evaluating potential causes of increasing rates of pertussis, including changes in disease-causing bacteria types (“strains”). Unlike a foodborne illness where one strain causes an outbreak, multiple types or strains of pertussis bacteria can be found causing disease at any given time, including during outbreaks. Research is underway to determine if any of the recent genetic changes to pertussis bacteria may contribute to the increase in disease in the United States.”
Bordetella parapertussis is a species of the Bordetella bacteria that causes whooping cough as well. Pertussis vaccines do not protect against it because it is a different species of Bordetella pertussis. But the resulting illness is very similar. There is no vaccine for it. Certain antibiotics can be used for it- at least for now. Estimateas are that parapertussis accounts for anywhere between 1% and 35% of Bordetella outbreaks. California’s public health department has put together an information sheet on it here.
Now obviously, if it’s 1% that’s not an enormous threat, but if 35% of Bordetella infections are parapertussis, it could actually be extremely common. There are other strains of Bordetella too like Bordetella bronchiseptica and Bordetella holmseii
So What CAN We Do?!
Right now, we treat pertussis with antibiotics- but this isn’t exactly a “cure”. It’s not the actual infection with the bacteria that kills a person- it’s the secondary complications like pneumonia. Antibiotics can kill the bacteria bordetella pertussis, making the patient non-infectious, but antibiotics can’t actually halt the progression of the disease. Secondary conditions like uncontrollable vomiting, hypoxia, and dehydration can result from the severity of the coughing. This is why pertussis remains difficult to treat even with antibiotics. And (more bad news) antibiotic resistant strains of pertussis have recently been isolated .
EVERYONE needs to be aware of the risk of pertussis transmission and parapertussis transmission. You should always assume that you could spread a bordetella infection and please do not assume that herd immunity will protect your baby.
- Since cocooning hasn’t been effective at protecting infants, the CDC recommends that pregnant women get a Tdap shot in their third trimester with the idea that the mother will pass the antibodies through the placenta to her baby before birth. However, this will not protect against parapertussis or P.69B and C type pertussis.
- Transmission mostly occurs through contact with saliva and mucus of an infected person. Wash your hands frequently and if you have a baby make sure everyone who is contact washes their hands frequently and keeps coughs and sneezes contained (vampire cough).
- Breastfeed as much as you can. Antibodies against pertussis can be passed through breastmilk and can help give a baby further protection. Breastfeeding alone can’t protect against pertussis, but it may offer some degree protection. Though it hasn’t been studied, hypothetically speaking breastfeeding could give your baby some degree of protection against parapertussis and P.69 B,C pertussis since the mother’s body will adapt to produce antibodies to antigens in the environment. The relationship between pertussis and breastfeeding still isn’t fully understood, but it’s a good idea!
- Limit your baby’s contact with large crowds- especially in the first six months. Reduced exposure=reduced risk.
- If you think your baby may have pertussis or parapertussis, get him into the hospital right away. The further the secondary complications progress, the greater the chances of death. Earlier treatment=better chances of survival.
How Worried Should I Be???
Pertussis rates are still much, much, much lower than they were during the 1920’s and 1930’s. (Though asymptomatic cases and cases in teens and adults mean that these numbers are not a complete representation of pertussis transmission.) Parapertussis is still not a notifiable disease, so it’s hard to know exactly how many cases are out there. Definitely take adequate precautions and be aware of all forms of pertussis and parapertussis, but chronic diseases still pose the greatest threats. The CDC gets about 10,000 to 40,000 reported cases per year and about 20 deaths per year are attributed to pertussis- most in young babies. By comparison, there were about 1,685,210 new cases of cancer diagnosed in the United States in 2016 with 595,690 deaths. In 2014, 1,960 children died of cancer. Or another comparison, in 2011-2012 5,300 children and young adults under the age of 20 were diagnosed with type 2 diabetes. If you have a baby and want to understand how breastfeeding might impact pertussis (and several other diseases), please see my “Breastfeeding and Immunity” class for more info on how to protect your baby.
So this post may have been a little on the depressing side. So let’s lighten things up a bit:
Life is still good.