Four weeks ago we were blessed with the arrival of our third child, a girl this time. Her two brothers are delighted with her so far, and in true third child style she has just slotted into our family pretty seamlessly. It is quite amazing with what ease you can slip back into the newborn routine of frequent feeds and night time wakings once you have been through it a couple of times before. The challenges come now, not in how to manage the baby’s needs (she is the actually the ‘easy’ one), but in how to manage the competing needs of multiple children of different ages and stages all at once. This seems most noticeable with the uncanny knack the older children have to time their ‘urgent’ needs such as needing their bottom wiped, right in the middle of a breastfeed! I am by no means an expert at how to do this with 3, but check in with me in a few months and hopefully we will all have survived it!
One thing I had seemingly forgotten is just how tiny and delicate babies are in the early days and weeks and how vulnerable they are to illness. As my almost 2 year old walked into my hospital room with snot pouring out his nose to greet his 1-day-old baby sister, I felt instant fear about the germs she would be exposed to so early on in her life and how best I could protect her. I certainly can’t change the fact that she lives with two little germ-factories of older brothers, nor make her grow up any quicker (nor would I want to as the squishy cuddles are just too delightful), but there are ways I can protect her from illness, particularly one of the more terrifying illnesses that a newborn can be exposed to, Whooping cough.
What is this Whooping Cough?
Many of you have heard of whooping cough, but hopefully not many will have first-hand experience of it. Whooping cough is the name of the illness caused by the bacteria Bordetella pertussis, and for this reason it is also known as pertussis. Whooping cough is a respiratory (lung) infection which causes severe coughing, usually in fits of coughs followed by a characteristic sound, a ‘whoop’, made as the child finally takes a breath. It is highly contagious and small children especially infants are particularly vulnerable to its effects.
Pertussis infections usually start with a temperature and runny nose, essentially cold-like symptoms which may be present for a few days to a week before the characteristic cough presents. Children are often not too unwell during this early phase and it can be difficult to identify their symptoms as more than the common cold. The diagnosis becomes more apparent once the cough begins, anywhere up to a week after the initial symptoms. The typical cough pattern involves coughing fits followed by the ‘whoop’ as described above. Some children may cough so hard that their face changes colour (red or blue) and it is not uncommon for a vomit to follow these coughing fits. Some small babies may not display the typical cough and may just be unwell with poor feeding, lethargy, dehydration, colour changes, choking or apnoeas (long pauses in their breathing). Older children and adults may only have a very mild illness.
If whooping cough is suspected your doctor will perform a nose or throat swab or to confirm the diagnosis. It can also be confirmed with a blood test though this is used less commonly.
So how bad is whooping cough and should I be worried?
Before I started in general practice I worked as a paediatric registrar, and have been involved in the care of multiple children admitted with whooping cough of varying severity. I still remember the sound of the 6 month old I cared for at the Royal Children’s hospital years ago stuck in coughing fits which seemed endless and the way his little face turned bright red each time as he struggled to breathe between coughing. I remember the look of horror on the faces of the parents of the 4 week old in ICU as their tiny baby was placed on a ventilator to help them breathe in the face of their overwhelming pertussis infection. And I am still distressed at seeing the 3 month old I had reviewed a day earlier with a mild temperature and runny nose and had been happy to send home, return the following day in the throes of a severe pertussis infection that saw them admitted to the high dependency unit for 2 weeks.
Make no mistake about it, whooping cough can be a devastating infection in these tiny and vulnerable children. In 2016 there were 20106 notifications of whooping cough and 445 hospital admissions with over one third of these in children under 1 year old (AIHW 2018). We continue in Australia to have outbreaks of whooping cough occur every few years, but thankfully deaths from whooping cough are now rare, though not unheard of. The average number of deaths per year from whooping cough over the last 20 years is 2, compared to almost 300 per year prior to the vaccination program commencing in 1942 (AIHW 2018). I’m sure that all would agree however that 2 deaths per year is still 2 deaths too many. Some of you will be familiar with the tragic story of 4-week-old Dana McCaffery, who died after contracting Whooping cough in 2009. Her parents have since tirelessly campaigned to ensure that no other children have to suffer in the same way as their precious Dana. You can read about their story at www.danamccaffery.com, or on the Dana McCaffery – Whooping cough Awareness Facebook page. Similarly tragic is the story of little Riley Hughes who passed away at 32 days of age from Whooping cough, and whose parents have also thrown themselves into campaigning for changes that help to protect other vulnerable children through their Light for Riley Campaign. You can read their story on the Light for Riley Facebook page, or at www.immuniseationfoundation.org.au/light-for-riley/
So how can I protect my children from whooping cough?
The answer to this is immunisation. All immunised children will receive the pertussis vaccine as a combination with diphtheria and tetanus in the DTPa vaccine. Children receive their primary course of this at 6 weeks, 4 months and 6 months of age. This is followed by a booster at 18 months, another at 4 years, and another during their high school years. Children do not begin to acquire immunity until after their 2nd dose of Pertussis containing vaccine at 4 months, and do not develop full immunity until after their 3rd dose at 6 months. This is why younger babies are particularly vulnerable to this illness. The vaccine is suspected to be about 80-90% effective after the 3rd dose, but newer evidence is suggesting that the protection from the DTPa vaccine begins to wane at about the 3 year mark post vaccine, so boosters are required to maintain effective protection.
Previously the only means we had by which to protect young babies other than trying to avoid contact with obviously sick people, was a method termed ‘cocooning’. It has been shown that infections in young babies most often come from adults and older children in frequent contact with the babies, often grandparents or siblings who may be spreading pertussis without showing obvious signs of infection. To combat this it was recommended that all people likely to be in regular contact with young babies have their immunity boosted for pertussis if it had been more than 5 years since their last vaccination. This ensures that the highly vulnerable baby is surrounded by (cocooned with) vaccinated people who are unlikely to be a source of infection. This is still recommended and I encourage this in all my patients expecting to have close contact with small babies.
More recently it has been recognised that better protection for newborns and young infants can be achieved with vaccinating pregnant women in their 3rd trimester of pregnancy. This allows the mother to form protective antibodies against the pertussis bacteria which have been shown to cross the placenta and provide valuable protection to newborn babies in those first 6 months until they have received their first few vaccinations. Thanks mostly to the Light for Riley campaign, it has now become a nationwide standard of care for all pregnant women to be offered a pertussis vaccination once they have reached 28 weeks in each and every pregnancy (no matter how close together). This is the single most important thing you can do to protect your baby in those early vulnerable days. Please discuss this with your GP or obstetrician if you are pregnant and have not yet had your booster.
So what do I do if I think my child has whooping cough?
If you believe your child may have whooping cough it is important to see a doctor to confirm the diagnosis. If your child is very young or very sick then please get them seen to immediately. If their illness is more mild then see your GP as soon as able. It is important to phone ahead and notify your doctor of your concern so that they can take precautions to prevent spreading of the infection to others in the waiting room. If whooping cough is suspected it is very important to isolate your child until the diagnosis is made. Do not send them to school, daycare or social events while awaiting swab results unless your doctor advises it is safe to do so.
If the diagnosis is suspected or confirmed your doctor may prescribe antibiotics for your child depending on their age, how sick they are, and how long they have been unwell for. Once your child has completed 5 days of appropriate antibiotics they are no longer infectious and may return to school/daycare. Pertussis also used to be known as ‘The 100 day cough’ as the cough can be persistent for 3 months or more even after the infectious period is long past. Do not be surprised if the cough lasts for many weeks, even after a completed course of antibiotics. It will eventually abate, though frustratingly there is not much that can be done to speed the process up.
Whooping cough is a notifiable disease which means that any positive results are notified to the public health department. In this way outbreaks can be identified and hopefully contained when they occur.
So now what?
If you would like to discuss a booster vaccination against whooping cough for you or your family members, particularly if you have a new baby coming into the mix, please book in with your friendly GP. With everybody’s help and vigilance we can reduce the number of cases of whooping cough even further and protect the most vulnerable members of our community from the horrors of this vaccine preventable illness.
That’s all from me for now folks.
‘Til next time.
References and Further Information
Australian Institute of health and Welfare, 2018. Vaccine Preventable diseases fact sheet series: Whooping Cough in Australia. https://www.aihw.gov.au/getmedia/303c1ab7-9b04-4544-9c5d-852c33ac87a/aihw-phe-236_WhoopingCough.pdf.aspx
Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook, Australian Government Department of Health, Canberra, 2018, https://www.immunisationhandbook.health.gov.au
Immunise Australia http://www.immunise.health.gov.au/