John Monaco, M.D.
As I write this, a 2 week old infant lays in our pediatric ICU with life threatening meningitis. In this particular case, the disease is caused by a bacteria known as Group B Strep. We know that some mothers are colonized with the organism (they have the bacteria but no signs of infection) and we now understand that it is possible that babies become infected by contacting the organism while passing through the birth canal. For this reason, mothers in labor are tested for the presence of the organism, and if it is found, they are given antibiotics to prevent passage of the bacteria to the newborn. This approach has been largely successful, and as a result, the incidence of Group B Strep infections in newborns has decreased. Occasionally, however, we still see cases. And when they occur, they can be devastating.
Our patient, Kayley, was one such case. Except for the fact that her mother was only 17, the pregnancy and labor were unremarkable. Kayley's mother was found to be one of those mothers colonized with the bacteria, and she received several doses of IV antibiotics prior to delivery. This should have prevented Kayley from becoming infected but, in this case, it did not. Kayley acquired what is referred to as a "late onset" infection with this organism. In other words, she did not demonstrate symptoms in the early hours of her life. It wasn't until she was about 10 days old that she began acting differently.
She was more irritable and not interested in feeding as aggressively as she had been. When she spiked a fever to 103ƒ F, Kayley's grandmother insisted that they take the child to the pediatrician. The child's doctor took one look at her and realized that there was something terribly wrong. She was brought to our hospital immediately, where a spinal tap was performed to examine the spinal fluid for the presence of infection. The fluid that dripped back from the tiny needle carefully placed between the vertebral bodies in Kaytley's lower back confirmed the diagnosis immediately. It looked like pus. And once the lab examined the cerebrospinal fluid, they found it to be filled with white blood cells and bacteria. The bacteria turned out to be Group B Strep.
We knew from experience that the family needed to be prepared for the worst. This infection can sometimes be overwhelming at times, claiming life inside of 48 hours at times. If not fatal, it can be extremely damaging, leading to seizures and severe brain damage. It is possible, however, that if antibiotics are started soon enough, care is diligent, and the infection is relatively mild, the child can experience full recovery. We had to prepare the family for the full spectrum of possible outcomes. In this case, we had to prepare a 17 year old mother, who was about to get hit full force with very adult life issues.
It so happens that I have a teenage daughter, not far from Kayley's mom's age. At this age, she is barely responsible enough to keep her room in order, or to remember what book she must take to school on a given day. But she has an active social life, going places with boys who I see as predators intent on only one thing: stealing my little girl's innocence. The thought of her dealing with issues Kayley's Mom was about to face was incomprehensible. Yet, it is physiologically and socially possible that she could find herself in exactly the same boat, with only a very few bad decisions and poor judgments.
I tried not to make these comparisons as I spoke to Kayley's Mom. She was a mother now, no matter what her age, and it was plain to see by her attentiveness to Kayley, that she loved this child very much. She deserved to know everything we could tell her about Kayley's situation. In a way, she had declared herself an adult and it was incumbent upon us to treat her as one.
As it turned out, Kayley had a very rough course. Within 24 hours, she developed severe seizures requiring two medicines at high dosages to control them. By the third day, her nervous system infection became so severe that she could no longer breathe on her own and required a ventilator. With each bit of worsening news that we delivered to Kayley's mother, after a couple of questions of clarification, she would invariable ask, "Do you think she is going to be OK?"
Quite frankly, we would hedge, because we really didn't know. Unsatisfied with our answers, she would typically look down at Kayley, breaking eye contact with us, and say, "I think she's going to be fine." I must admit, there were a couple of times when I, myself, was reassured by the confidence of this quite remarkable 17 year old mother. Clearly, I harbored very ominous feelings about Kayley's outlook; feelings I'm sure Kayley's mother sensed.
Yet there remained a sense of peace around her. And she brought that peace to her critically ill child's bedside as she sat vigil, day and night. She never cried that I saw, and never became frustrated or angry with the staff as is so often the case with parents of very sick children overcome with fear and frustration. She simply sat there for hours, occasionally standing to stroke Kayley's hair, and mumble unintelligible affirmations in her earä encouragement no doubtä very private utterings of a mother and her brand new daughter already in crisis.
The night before my on-call period was about to end, when I would be turning Kayley's care over to one of my partners, she had another crisis. Suddenly, after a fairly uneventful day, she began coughing severely, breathing fast, and requiring increasing amounts of oxygen. I was concerned that she might be going into respiratory failure again. We hovered at her bedside, suctioning out her lungs, giving respiratory treatments, applying oxygen, hoping to save her from the ventilator. Her mother stood there, at my side, the entire time. I tried not to show the anxiety I felt. She didn't have to hide her fearä she had none. She kept stroking Kayley's head, and talking to her while we did all the things we felt we had to do to save her.
I thought for a moment of my own teenage daughter, who can barely stand the site of blood from a skinned knee, contrasted to the incredible bravery of this brand new 17-year-old mother. It occurred to me, at that moment, that there are certain times when maturity cannot be measured by chronologic age alone.
By the time I left the PICU the next morning, Kayley was indeed better. She had weathered the storm of the night before and her mother, who I know had had very little sleep, looked radiant. She looked up at me and smiled as I walked into the unit. She had placed a little pink bow in her tiny daughter's curly mop of hair. Kayley opened her eyes for the first time I had seen.
Her mother said to me, "Watch this!" as she place a pacifier in Kayley's mouth, and she sucked it vigorously for the first time since she had gotten sick. For the first time I felt there was a chance that Kayley would survive, and perhaps even thrive. And I knew it wasn't all because of the medical care she had received. Much of the credit had to go to her teenage mother.
John E. Monaco, M.D., is board certified in both Pediatrics and Pediatric Critical Care. He lives and works in Tampa, Florida.
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