New High Risk Child RSV Prevention Guidelines

Today the American Academy of Pediatrics published a new policy statement, Updated Guidance for Palivizumab Prophylaxis Among Infants and Young Children at Increased Risk of Hospitalization for Respiratory Syncytial Virus Infection.

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This very long title is basically the roadmap that physicians should follow when deciding which infants and young children would benefit from a vaccine to prevent the virus commonly known as RSV (Respiratory Syncytial Virus). RSV is a very common virus, affecting nearly all children by 2 years of age. Reinfection seasonally (late fall to early spring) is also common. It typically causes common cold symptoms and ear infections, but in infants it can lead to bronchiolitis, a condition where there is wheezing and difficulty breathing. Most people who are infected can be treated with home therapies, but some infants require hospitalization for oxygen or iv fluids. The majority of hospitalizations occur during an infant's first year of life and are among otherwise healthy, term babies, not premature or otherwise at risk babies. This is likely due to the fact that parents of at risk infants tend to be much more cautious and aware of infection prevention and tend to avoid situations that could increase risks, such as daycare. It would be impractical for most working parents to stay home with their children the first winter, and the overall risk of hospitalization of a healthy baby is still very low despite the use of daycare. The virus is spread through close contact with others who have the virus and it can live on contaminated surfaces for several hours. Unfortunately since it only produces mild symptoms in older children and adults and can be spread before symptoms develop, caution must be taken throughout the cold and flu season to avoid spreading germs.

The palivizumab vaccine is commonly called Synagis. It has been used since 1998 to prevent RSV infection in at risk children ~ those whose lungs are underdeveloped due to prematurity, those with significant heart defects, and other risk factors. Due to cost and needs analysis, it has never been recommended for routine use in otherwise healthy children. When deciding which children will benefit from the vaccine, experts review its effectiveness, drug resistance, and cost analysis.

We are fortunate to live in a country that has high quality medical care for premature and sick infants. Preterm babies tend to be much healthier than they were in years past due to advances in medical care. The rate of hospitalization for RSV illness has declined over the years in both those who did and did not get the palivizumab vaccine.

Research now shows not only that palivizumab prophylaxis has a limited effect on hospitalizations for RSV, but also no measurable effect on mortality and only a minimal effect on wheezing. Due to these new findings, the new recommendations limit the use of palivizumab compared to years past. I am sure there are infants that were born last season whose parents anticipated they would get the vaccine again this season, but with the new guidelines they will not be eligible. While this might cause anxiety among parents, it is based on good data that they wouldn't benefit from it. And remember that RSV is only one of the many viruses that cause significant illness in at risk babies, so the primary preventions of infection control are important regardless of whether or not an infant gets this vaccine.

New guidelines recommend the use of palivizumab in

• infants born before 29 weeks gestation and in the first year of life (previously 32 weeks)
• infants with significant congenital heart disease in the first year of life (previously 2 years)
• infants with a compromised immune system under 24 months of age (similar to previous recommendations)
• infants with chronic lung disease or who require at least 28 days of oxygen after birth and in the first year of life. If they continue to have need for oxygen, diuretics, or corticosteroids, they may qualify the second year of life.
• infants with neuromuscular diseases that affect the ability to clear the airway in the first year of life (previously 2 years)
• Alaskan Native and Native American populations may have expanded uses 

For those infants who qualify, they can receive up to 5 monthly doses during the RSV season. If they are born later in the season, they may require fewer doses. If a child has a hospitalization for RSV despite the vaccine, they stop future doses of palivizumab. 

It is still important for all infants, especially those born preterm, to use infection prevention strategies, such as 

• use breast milk whenever possible
• frequent hand washing
• clean toys regularly
• immunize household members against influenza, pertussis, measles, and other recommended vaccines
• limit contact with ill people 
• avoid smoke exposure
• avoid large crowds during the first winter season
• limit use of large daycare centers during the first winter season

Remember that even infants who are getting palivizumab vaccine prevention are still at risk for other illnesses, so it is important to use the above precautions in them as well. For treatments of cough and cold symptoms, please visit Cough and Colds.