Age: 1.17
Sex: M
Vaccine: MMR
Symptoms: Hearing impaired, Nasopharyngitis, Otitis media, Pharyngitis, Pyrexia
Clinical narrative: Information has been received regarding a case in litigation concerning a 14 month old male with no family history who was delivered as a fresh still birth, with IUGR following severe type II dips on the CTG. Placental function was poor and this meant he was less able to cope with an asphyxial insult. He was ventilated for 4 days and his main problem was severe hypoxic ischemic encephalopathy, with resistant convulsions. He had large frontal and left temporal parietal ischaemia areas and a small right intraventricular hemorrhage. The child also has a past medical history of cario-respiratory arrest at birth (fully resusitated0, meconium aspiration, severe birth asphyxia/hypoxia ischaemic encephalopathy, left cerebral hemorrhage and ischaemia in left frontal and left temporal parietal areas, hypoglycemia, renal insufficiency, and natal tooth lower incisor removed on 11/5/94. Although he was feeding well on discharge on 11/15/94, he was given a guarded neurodevelopmental prognosis to his parents. They were aware of difficulty of predicting his long term outcome at that stage. It has since been noted that the parents feel that the child's behavior has been difficult from birth. On 6/27/95, the child was vaccinated with a dose of MMR (lot # 610165/1671W). On 7/5/95, the child experienced status epilepticus, also reported as grand mal fit. On 10/30/95, the child experienced a febrile convulsion. On 7/2/96, it was also reported that the child had two febrile seizures, one lasting 20 minutes in July 1995 and a second fit in November 1995 lasting 10 minutes. No further fits were reported at that time. On 7/2/96, at 2 years and 2 months of age, the child visited a speech therapist, arranged as the child's speech had seemed delayed when he was seen for his review at 2 years old. The child attended with his mother and grandmother who were concerned about his speech, as this did not seem to be progressing. He was vocalizing a lot and producing about 6 words car, mum, dad, dog, and he said bye bye once. He tended to indicate his needs by gesturing or going to fetch an object and became very angry if he could not make an adult understand him. His understanding was thought to be good in that he would fetch familiar objects on request or select pictures in one of his story books. There were not concerns about his hearing, although it was noted that he had frequent colds over the winter months and his father also suffered from a conductive hearing loss in childhood. Assessment was carried out by informal observation of the child's play with a variety of toys. The child's attention was focused on the task of his own choice and he tended to quickly remove from one activity to another. In his non-verbal play, he was functioning like a little boy of around 18 months. He enjoyed putting objects in and out of containers; he stacked 3 bricks and produced some circular scribble, but was unable to copy a straight line. He preferred to use his right hand for play and had an accurate reach and fine pincer grip. He enjoyed teddy play and with prompting fed teddy or dolly and on one occasion put a telephone to dolly's ear. He looked with interest at pictures of Ladybirds, but did not name any, and enjoyed turning the pages and looking at the pictures in one of his own story books. The child appeared delayed to between the 12 and 15 month level in his communication skills. He demonstrated good situational understanding and clearly indicated to his mother when he wanted some crisps or something to drink. He recognized the names of familiar people and gave a toy to this nannie on request, but did not seem to recognize the names of familiar objects such as dolly or teddy. At the end of the session he readily waved bye bye and also echoed the word bye. In summary, the child was noted to be a picture of generalized delay in his play, but is having particular difficulties with his communication skills, which is aggravated by his immature attention control. The child's mother wondered whether the child's delay was associated with his illness at birth. In general, developmental delay due to brain damage at birth is usually linked with motor impairment and the child has shown no evidence of difficulties with his movements. The consultant pediatrician indicated that it may be necessary to ascertain whether the child's language problem could be linked in any way with his left-sided cerebral hemorrhage and associated EEG change. The consultant pediatrician noted that it would be worth while carrying out some investigations with blood and urine tests including chromosome studies and an MRI scan of his brain. She also thought necessary to arrange a repeat hearing test in the Audiology Unit, although his parents have no concerns about his hearing. His vision has been monitored by the Orthoptist who passed it as normal in October 1995, but plan to review him again at 3.5 years. The speech and language therapist has arranged to see the child for a batch of speech and language therapy sessions to give ideas to develop his play and language skills. Blood test will be arranged following one of the speech therapy sessions. On 2/2/00, the consultant pediatrician met with the parents of the child to discuss their concerns about their child's behavior. They were concerned about a recent school report, where the child was described as becoming over-excited during playtimes, and holding on to children very tightly. He also finds it difficult to talk about abstract things and finds it easier to talk about objects he can see or hold. He often draws very good pictures, but then will scribble all over them, obliterating them, saying his name repeatedly. He also has difficulties following a conversation, will often talk about a series of totally unrelated subjects, barely stopping for breath. The staff sometimes find it difficult to make eye contact with him. The child's parents have noted some of the same behaviors in the home setting, and one particular instance, when he was away at a friend's house. His mother arrived to find him in an overexcited state, flushed and rushing backwards and forwards, then he grabbed a child much younger than himself, and hurled the child across the room. She was naturally very shocked. They also noted difficulties having conversations with the child. He has sometimes a very repetitive way of scribbling all over his drawings, or repeating the same comment over and over again. He also memorizes sequences from his videos and repeats them back verbatim. He very much enjoys the Power Ranger videos, and particularly the sections of fighting, which he acts out to himself. The child's parents indicated that they feel his behavior  has been difficult from birth. Initially, he was a crying baby, and then moved into a phase of having temper tantrums. Now his behavior has become aggressive and over-excited. The child does not appear to know when or how to stop. The child's parents are, however, quite clear that his difficult behaviors only occur in certain specific situations. His behavior is fine in clearly structured setting, particularly with close adult input, but deteriorates markedly in free play settings with other children, when the situation is less structured. The parents were anxious to know whether their child's behavioral problems were due to his cerebral damage at birth, his unilateral hearing loss, whether they were linked with his anti-convulsant medication, carbamazepine, or whether their style of upbringing, with some relatives having a strict approach, and others a more relaxed approach to behavioral limits, had contributed to the problem. The consultant pediatrician indicated that it was impossible to ascertain the precisse cause of the child's behaviors, but difficulties controlling behavior, were more likely to occur in children who have sustained cerebral damage at birth, and in those with epilepsy, or specific learning difficulties. The physician felt that the child's carbamazepine medication is an unlikely cause, but it is impossible to rule out. The child does, however, need to continue on a regular anti-convulsant to prevent prolonged seizures, which might cause further brain damage. It was also noted that on 3/18/98, the child experienced status epilepticus. Upon internal review, the status epilepticus, the febrile convulstion, and the communication disorder were considered to be other important medical events (OMIC). Information was received on 9/16/03 which pertained to events that occurred 3 years following vaccination with MMR  on 6/27/95. This information contained the following adverse experiences: acute non-suppurant otitis media (12/12/95 and 2/9/96), vomiting (7/96), acute pharyngitis )8/19/96), acute conjunctivitis (11/11/96, 11/21/96, and 12/13/96), acute tonsillitis (2/10/97 and 5/6/97), acute nasopharyngitis (3/20/97), hearing difficulty (11/6/97), adenoidectomy (12/3/97), cough (1/29/98), pyrexia (3/4/98), and acute sinusitis (4/15/98). Additional information is expected. All available medical records will be provided upon request.