I new that when I posted the note on the rubella immunization in the low
birth weight infant that it would stir some controversy.  I further realized
it when Jack, sent me his response directly to me (he didn't want me to miss
it).

Part of the fun of this medium is that we get to consult with one another
about a topic we all enjoy,  but we should all recognize, that one of the
problems of this medium,  is that "homogenized thinking is often dangerous",
and we need to remember this.

I do not subscribe to the philosophy that we should "damn the torpedoes,
full speed ahead, breastfeed, breastfeed, breastfeed". This is simply not
logical (Spock ?) and I know you probably think me a heretic.  This
philosophy inevitably suggests that the infant is the one who has to accept
the risk for our ignorance.    It is simply a fact that there are times and
situations (rarely) that breastfeeding is not safe for the infant,  and you
simply have to accept this.

Three times in the last year, I have received calls from concerned
physicians who were evaluating sick infants whose mothers were taking one or
another medication while breastfeeding.  In at least one of these cases, it
was an AAP approved drug (propranolol),  and in each of these cases it was
patently obvious (to me and the physician) it was a drug related phenomenon.
In three other situations, I received calls from moms who had withdrawn
themselves from Prozac (and wanted to report it to someone), because of side
effects in their infants (agitation, tremulousness, colic, etc).

In the case of the rubella vaccine it was too late,  the mom had already
received the vaccine,  the neonatologist was on the phone with me concerned
with the survival of the infant, and secondly, the effect of the
vaccination.   I also had four academic neonatologists (with 60 years of
collective experience) with whom I was consulting and whose opinion I dearly
respect.

After reading the case of the "hospitalized infant(13 day old) with a
history of a rash that had begun on the face, and spread to the shoulders,
trunk, and extremities",  I still believe we opted for the safest course for
this infant.

One of the first lessons one learns in academic medicine, is that the "curb
side referral" is the most dangerous act you can commit.   At least in this
case, I had the doctor on the phone and heard the concern in his voice. And
I think I did the responsible thing in collecting four incredibly brilliant
neonatologists to discuss this unique case.

(Curb side referrals are something that really concern me when I get calls
 from all over the world... the fact that I don't really have a "hands on
feeling", and each one of us needs to remember this before we second-guess
the physician when we get that call late at night).

We can all disagree, and actually I really love it when we do,  but at least
in bringing up this case, I hope we all learned that maybe, just maybe,
there are extenuating circumstances that may just change our normal
behavior.  Perhaps, we should change our standard of care of injecting all
rubella-negative postpartum women with vaccine before we think,  with a new
standard that suggests we evaluate the infant and mom first, and then inject
the mom accordingly.

PS.  I sent this directly to Jack!

Regards

Tom Hale, Ph.D.