SECOND CHANCE AT LIFE AFTER WHOOPING COUGH

Tiny Bryanna beats the odds, but her harrowing case illustrates whooping cough's grave danger for infants

Family shares story to highlight grave risks of respiratory illness
2013-06-08T00:00:00Z 2014-07-30T17:16:24Z Tiny Bryanna beats the odds, but her harrowing case illustrates whooping cough's grave danger for infantsStephanie Innes Arizona Daily Star Arizona Daily Star
June 08, 2013 12:00 am  • 

Tiny Bryanna Robles was in respiratory failure from whooping cough and her parents were agonizing over a controversial, high-risk and last-ditch intervention.

"I didn't want her to suffer more," said her father, Gilbert Robles, 25.

"Were we killing her?" said her mother, 22-year-old Jessica Contreras.

Doctors at Diamond Children's medical center in Tucson met for several hours looking over Bryanna's medical charts before deciding to offer the family a treatment that is used only for the most desperate cases. Extracorporeal membrane oxygenation (ECMO), which would act as an external lung and heart for the dark-eyed Tucson infant, has numerous serious risks, including stroke, cardiac arrest and devastating neurological effects.

"I did not think that she was going to make it," said Dr. Michele Munkwitz, a pediatric critical-care physician at Diamond Children's, which is part of the University of Arizona Health Network. "It's really hard as a physician not to take away a family's hope but also to be very realistic about the risks of what we are doing to their baby and what to expect."

Once a baby is hospitalized for whooping cough, the odds are against them. The odds get even worse for babies who are treated with the external heart and lung machine.

Bryanna surprised everyone by pulling through. She spent two weeks on the external lung and heart, another couple of weeks recovering in the intensive care unit, and is expected to go home Monday.

Her family hopes that by sharing Bryanna's story they can educate the public about the grave danger of whooping cough to infants like Bryanna who are too young to be vaccinated.

Indeed, at a time when community immunity to whooping cough is waning, pediatric infectious disease expert Dr. Sean P. Elliott says Bryanna serves as a reminder of the damage that whooping cough can cause to otherwise healthy babies.

Bryanna was a healthy 6-pound, 9-ounce baby when she was born March 31. No one knows how she contracted the whooping cough, which is formally called pertussis.

But cases of whooping cough in Arizona increased by more than 400 percent between 2007 and 2012, state data show.

Last year, the Arizona Department of Health Services recorded 1,130 confirmed and probable cases. Federal data show 18 deaths from whooping cough nationwide last year, including one in Arizona. Most of the deaths occurred in infants too young to be immunized.

Vaccinations decline

The spike is due to various factors, including an increasing number of parents who are not vaccinating their children against the highly contagious disease, Elliott said.

A lack of awareness that adults should be getting a pertussis "booster" shot is another contributing factor, he said. While adults don't typically get sick from whooping cough, they can get infected and pass the disease along to babies and people with compromised immune systems.

"It is a vaccine-preventable illness," said Elliott, a professor of pediatrics at the University of Arizona.

A switch during the 1990s from what's called a "whole cell" pertussis vaccine to a more purified "acellular" version appears to be causing the childhood pertussis vaccine to wear off faster than in the past. The change was made to reduce side effects. That's why Elliott says it's so important for both adults and adolescents to get a pertussis booster, known as Tdap, which stands for tetanus, diphtheria and pertussis.

"We have more young adults, adolescents, middle schoolers in the community at risk for pertussis," Elliott said. "So, countrywide and in Tucson, we are seeing more pertussis across the board."

The number of adults who have received the federally recommended whooping-cough booster remains low. Elliott says it's recommended that women in their second or third trimester of pregnancy be offered the Tdap, but a lack of awareness remains a problem.

Vaccination doesn't give 100 percent protection, but studies show people who are not vaccinated against whooping cough are 22 times more likely to get it than people who are. Before pertussis vaccines became widely available in the 1940s, about 200,000 U.S. children got sick with it each year and about 9,000 died.

The last resort

Bryanna was admitted to Diamond Children's on April 24 and immediately placed on a ventilator. Three days later, her white-cell count was dangerously high, and her fingers and toes were turning purple. An ultrasound of her heart showed severe pulmonary hypertension. The progression of the disease indicated death very soon, Munkwitz said. The last option was the ECMO machine, which helps the heart and lungs to rest and get better. But it was not an easy call.

"Some people would say that if there is a chance that you can save someone's life that you should always do everything, but sometimes in what we do we can cause some other problems," Munkwitz said. "If they get a brain bleed or a clot, they can be neurologically devastated. Even if they make it through the ECMO, they may never walk, talk or interact again. But it's the last thing we have to offer."

After a difficult discussion and a lot of prayer, Bryanna's parents told Munkwitz to hook their only child up to the machine. They didn't want to have any "what ifs," Contreras said.

Bryanna briefly became worse. Her chest X-ray was completely whited out, meaning there was no air in the lungs. Her prognosis remained grim.

"They kept throwing bombs at us, but none of them went off," said Bryanna's grandfather Richard Robles. "God had her in his arms, and he gave her back to us."

The controversial treatment ended up saving Bryanna's life. The blood vessels in her lungs recovered circulation, and, in spite of all the inflammation from the whooping cough, her white-cell count did not go back up.

The mood in Bryanna's hospital room was celebratory on Thursday. The family was buoyed by news of Bryanna's discharge. They were now eager to share her story.

Bryanna's mother said her health-care provider never talked to her about the Tdap booster when she was pregnant. Bryanna illustrates why vaccinations are so important, she said.

"She is so young, but she already has a purpose."

On StarNet: For a video showing what whooping cough looks and sounds like, go to azstarnet.com/video

By the numbers

Probable and confirmed cases of whooping cough in Arizona

2013* 493

2012 1,130

2011 867

2010 546

2009 277

2008 218

2007 210

*through May 31

Source: Arizona Department of Health Services

Vaccines

The shots that prevent whooping cough are the DTap (diphtheria, tetanus and pertussis) in infants and children and Tdap (tetanus, diphtheria and pertussis) in preteens and adults.

• Pertussis vaccines are recommended for people of all ages. Infants and children should get five doses of DTap for maximum protection. A dose is given at 2, 4 and 6 months, at 15 through 18 months, and again at 4 through 6 years. A booster dose of Tdap is given to preteens at 11 or 12 years of age.

• Any adolescents or adults who didn't get Tdap as a preteen should get one dose. Getting Tdap is especially important for pregnant women and others who care for infants.

Contact reporter Stephanie Innes at sinnes@azstarnet.com or 573-4134.

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