Age: 0.01
Sex: M
Vaccine: HEP, RV5
Symptoms: Nasal congestion, Occult blood negative, Opisthotonus, Pain, Rash maculo-papular
Clinical narrative: Information has been received a physician assistant via pediatric medical records concerning a 3 week old white male who's mother on 29-OCT-2007 was vaccinated with GARDASIL (MSD WAES # 0808USA00985).  On 01-SEP-2008 the baby was vaccinated with RECOMBIVAX HB.  On 23-SEP-2008 the patient was presented in the physician's office for a follow-up visit for reflux esophagitis.  Mom was suspicious of reflux, makes regurgitative movement with his mouth, cries 8 - 10 minutes into his feeds, arches back and cries, cries, cries when laid supine, but sleeps for 3 hours straight when in a car seat.  Gaining 2 oz/day.  Was 10 oz above birth weight at 2 weeks.  Previously seen at outside MD.  The baby was exclusively breast fed.  Tried pacifier, worked for 10 minutes then would spit it out and cry, not satisfying him.  The only thing that satisfies him was putting him to the breast.  Feedings were 10-12 times/day for 30 to 45 minutes at a time.  The baby has a maculopapular rash on the neck and trunk; appearance was consistent with neonatal acne.  The assessment was physiologic GER plus overfeeding.  Reviewed limiting breast feeds to 7 minutes (since demonstrated reflux symptoms consistently at 8-10 minutes, positioned HOB up.  May recheck weight gain PRN for reassurance that shorter breast feeds are adequate.  Mom intended on starting meds, encouraged to try 1/2 tsp of MYLANTA about 15 minutes before feeding 2-3 times daily, discontinue if not helping.  Return if symptoms worsening or no improvement with above changes.  The plan was reassurance was given.  On 30-SEP-2008 the patient was a 4 week old male who was presented with a complaint of follow-up.  Since last seen, makes gulping sounds even when not eating, does the arching/stiffening within a few minutes of starting feeds.  Past several days has been eating every hour if mom tries to keep him off, will scream/cry the entire hour.  Parents were concerned that he was having acid pain in between feeds.  The baby started having congestion and snoring when sleeping sounds like a deep purr.  When mom was away for a bit he was given MBM in bottle, always wants to eat an hour later, no difference with the formula.  The principal diagnosis was esophageal reflux.  The assessment was frequent regurgitative movements, witnesses in the office.  Relieved of screaming/apparent pain only when actively swallowing, gaining weight well.  Trail of ZANTAC).  Continue GER precautions.  If no resolution in pain after week, will switch to PRILOSEC, mom was agreeable.  On 08-OCT-2008 the patient was 5 weeks old.  For the first few days, went for stretches of 3 hours without having to eat, was doing really well at night to 4 hours, but last day had been bad.  Took 5 oz bottle feed while mom was away.  Mom weighted on home scale 11 pounds.  Still arching and fussing for the most part better, except 2 days ago.  Mom recalled that she had drank a lot of milk that day.  Mom tried eliminating milk after that, noted he had another bad night last night, so felt that it did not make a difference.  The physician discussed a differential diagnosis with mom of fussiness with GI symptoms apparent either GERD or lactose intolerance or protein allergy.  If lactose intolerance, should notice improvement in fussiness by now.  If protein allergy, then inflammatory reaction in intestinal lining may still be present to cause discomfort.  After a long discussion with mom, decided to increase ZANTAC, have her go back to drinking milk, eating dairy and will check stool gualacs on 3 separate specimens.  Mom was to pick up hemoccult cards X 3 from another office and send them back.  If gualacs were negative, will switch to PREVACID.  If gualacs were positive, need to initiate elimination diet for mom, would start with cow's milk/soy products.  Mom agreed.  The assessment was frequent regurgitative movements, witnessed in office.  Relieved of screaming/apparent pain only when actively swallowing, gaining weight well.  Continue GER precautions.  Consider switching to PREVACID or PRILOSEC if no relief with ZANTAC.  The baby was also diagnosed with fussy infant.  On 10-OCT-2008 the baby had occult blood feces screen performed and the results were negative.  The assessment for esophageal reflux was frequent regurgitative/movements, witnessed in office.  Relieved of screaming/apparent pain only when actively swallowing, gaining weight well.  Trial of ZANTAC failed.  Continue GER precautions.  Switch to PREVACID.  On 17-OCT-2008 the patient was 6 weeks old.  Spoke with mom, Dad is HepBSag positive and the mom is negative.  The mother spoke with a health care professional and said the baby is fine and does not need HBIG and wanted to know the physicians thoughts.  The physician agrees that reviewed that if she was negative, its unlikely that the baby would have been exposed in utero but can always check titers on him after age 6 months when he is likely to have made his own immunoglobulins to things.  Mom will consider.  The PREVACID seems to be working well.  The baby has been sleeping up to 5 hours usually 3 hours and no longer overfeeding, not fussy.  Giving the PREVACID, crushed and dipping his moist nipple into it to give him each dose.  On 29-OCT-2008 the patient was 8 weeks old male who was presented with a complaint of well child visit.  The child is in for a follow-up 2 month well child visit.  Parents have routine questions without major concerns and first child.  Nutrition: breast fed.  There are no feeding difficulties (occasionally does still hit at mom and arch back, but significantly more comfortable overall since started PREVACID.  Feedings/day 7.  On 29-OCT-2008 the baby was vaccinated with PENTACEL (lot # C3181AA) 0.5 mL IM in the right thigh, PREVNAR (D05881) 0.5 mL in the right thigh IM, ROTATEQ (MSD) (lot # 661687/0968X) 2 mL orally and ENGERIX-B (AHBVB659BA) 0.5 mL in the left thigh IM.  Follow-up in 2 months or as needed.  On 17-NOV-2008 the baby was 11 weeks old.  Baby had cough for 5 days, on GER meds, dry and he is congested as well.  Happy no fever, eating fine, rare cough, most first AM, no gagging, no daycare, no exposures.  There were no findings on exam.  Pediatrics medical records were received and reviewed and the following experience was identified:  gastrooesophageal reflux disease, acne infantile and irritability.  Additional information is not expected.