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.

photo source: Shutterstock

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.

My Child's Cough and Breathing Sounds Like...

Parents often bring in kids with a cough but can't describe what it sounds like. I sometimes get to hear it if they cough, but Murphy's Law also says that a child who coughs often throughout the night and frequently during the day will have a 15 minute period of no cough at the exact time the doctor is in the exam room.

photo source: Shutterstock

In all seriousness -- coughs, regardless of the source -- are usually worse at night, which means your  doctor won't usually get to hear the worst of it.

I often wish there was one place I could refer parents to so they could see what various coughs sound like, so I decided to put a list together. The internet is ripe with videos now, but I have spent many hours watching videos that weren't very helpful in order to find these. I'm sure I missed some of the best ones, so if you have one that you really like, please post in the comments below.

My next blog will be on how to treat cough and colds.

Regardless of how the cough sounds, if you are worried about your child's breathing or the sound of the cough, bring your child in to be seen.

Disclaimer: I have no ties to any of the videos below and am not responsible for any of the opinions or errors within them. Some are professionally done and others are videos parents uploaded. Some have advertisements which I do not necessarily endorse.

Croup

The initial seconds of this baby with croup stridor video show the typical croupy cough. At about 0:55 it shows the stridor that many kids with croup have. Stridor is a whistling sound as the baby breathes in (often confused with wheezing, which happens when you breathe out). It is common in croup and is caused by the swelling near the voice box. (Older kids and adults who get the same viruses that cause croup in younger kids often get laryngitis from the swelling near the voice box in a larger neck.)

This ER physician of TheEDExitVideo spends the first couple of minutes discussing what causes croup. At 2:27 sounds of stridor in an otherwise happy looking baby are shown. At 3:44 is a picture showing intercostal retractions (also seen with wheezing or other types of respiratory distress).

Dry Cough

Dry cough can be from an irritation in the throat, asthma, acid reflux, or any common cold. It can also come from a habit cough (often seen after an illness and goes away with sleep only to return when awake).

Laryngomalacia

Laryngomalacia wasn't on my original list because it isn't from a virus or bacteria causing illness, but it is a cause of noisy breathing in infants. It is caused by floppy tissues near the voice box (i.e. larynx). Linden's Laryngomalacia - 3 Months shows this breathing. It is often worst when baby is excited or fussy.

For more information on this (even a video of a scope into the airway), check out Children's Hospital of Philidelphia's Laryngomalacia page. 

Pneumonia

The cough with pneumonia can sound like a wet cough or dry cough, so no specific videos are for this cause of cough. The clues to pneumonia include a fever with cough, difficulty breathing between coughs, shallow breathing, shortness of breath with brief exertion, pain in the chest, rapid breathing, or vomiting after cough. Pneumonia can be caused from viruses and bacteria and can range in severity. Walking pneumonia generally means that the person is not sick enough to require hospitalization. Some pneumonias lead to severe difficulty breathing and require oxygen support.

Wet Cough

Wet cough can be from pneumonia or bronchitis, but also from postnasal drip with a common cold or allergies.

When kids "cough stuff up" it is usually the postnasal drip being coughed up, not mucus from the lungs coming up. The same is true if they "cough up blood". This blood is usually from a bloody nose draining into the throat, not from lung tissue. (Note: bloody mucus can be from more serious causes and if your child has no signs of blood in the nose or is otherwise ill, he should be properly assessed by a physician.) 

Wheezing

Wheezing is typical in asthma (and bronchiolitis). Many parents mistake the upper airway congestion sound that many kids make with postnasal drip as wheezing. Wheezing can sound like a whistle as a child breathes out. Ethan's wheezing shows a baby with noisy breathing without distress. This Wheezing - Lung Sounds Collection video has the sounds one would hear with a stethoscope, but if you put your ear against your child's back (without a shirt) you might be able to hear them. If you don't hear wheezing, but your child is struggling to breathe, it does not mean there is no wheezing! Treat like you would if you hear the wheeze.

Asthma

Asthma Attack in a child starts with information on asthma, then at 1:50 video of what retractions look like. 

Asthma attack shows the typical short breathing in phase with long exhale seen with an asthma attack. Also you can see the airway pulling in at the neck (retractions).

Bronchiolitis, often simply called RSV, but caused by many viruses

Bronchiolitis Cough, 3.5 months old shows a baby with a wet sounding cough, typical of bronchiolitis. 

Bronchiolitis is a video from the ER physician Dr Oller. He reviews causes of bronchiolitis, how it's spread, and how it affects the body. At 1:40 he discusses the natural progression of the simple cold into bronchiolitis. At 3:04 there is a picture of how we collect a nasal swab to help with diagnose of any viral illness.

Sick with Bronchilitis shows an infant with suprasternal retractions (sucking in at the base of the neck) and the typical cough associated with bronchiolitis. The man erroneously says "croupy", see below for croup.

RSV and Infant Treatment shows the best treatment for babies with RSV (or any bronchitis): suctioning. Some babies need this deep suctioning in the doctor's office or hospital. Others can get by with nasal aspirating at home. (Note, the next blog will be about treatments, but I have to say here that the bulb syringe is fairly useless for this.)

Whooping Cough

Pertussis - Whooping Cough: A Family's Story is an informational video on pertussis with the classic whooping cough in a child and pictures of a newborn with pertussis.


Silence the Sounds of Pertussis - Whooping Cough is a commercial for vaccinating, but it starts with the typical whooping cough sound.


Pertussis (whooping cough) shows a young infant with a cough from pertussis. Young infants do not always whoop, they stop breathing.

8 Year Old With Pertussis (Whooping Cough) shows a typical cough for an older child. Her positioning in front of the toilet shows that these kids often vomit from the force of the cough. The 2nd video from this same girl shows how normal and healthy kids can appear between episodes.

Sick, Sick, and More Sick.

Photo source: Shutterstock

It isn't news that we are experiencing a rough winter as far as illnesses go. Flu is all over the news. Schools have high rates of absenteeism. You hear coughs wherever you are in public places.

A few nuggets of information that might help you treat your family this sick season:

Fever

Fever is a symptom of illness and makes us feel achey and miserable, but the number on the thermometer does not necessarily correlate with the diagnosis or treatment needed. Look at your child. If they are happy with a fever, over 3 months and immunized, let it run its course. If they complain of pain (or if your immunized infant over 2-3 months is fussy) give a pain reliever/fever reducer. Push fluids to avoid dehydration. Treat other symptoms as needed. Don't worry if the temperature on the thermometer goes up ~ worry if your child is in severe pain, having difficulty breathing, or looks dehydrated.

Cough

Coughs do not need medicine generally. Honey (for those over 1 year) has been shown to be safer and more effective than other cough suppressants. Adding humidification to the air does wonders to loosen mucus and ease breathing.

If the cough is accompanied by rapid breathing, sucking in of the ribs or abdomen, or followed by vomiting, your child should be seen by a medical practitioner for further evaluation and treatment.

If your child has a history of asthma or other wheezing, it is okay to see if the rescue medicine (albuterol or levalbuterol) helps the cough. If not, it either is really bad wheezing that needs further evaluation or a cough. And don't forget your prevention medicine if you use it!

If your child has been exposed to whooping cough and develops a cough, please see your medical provider for evaluation and treatment.

Water's Power

Water is good for most illnesses. Increase fluids to prevent dehydration and help the body repair itself. Sips of water can help a sore throat and ease a cough. Add humidification to the air when the weather is cold and dry. Use saline to clear the mucus from the nose and open nasal passageways. Never underestimate the power of water!

Tamiflu 

Tamiflu is recommended for certain high risk people who are exposed to or sick with influenza. Prophylaxis can be given to prevent illness in children over 1 year of age who have known exposure within the past 48 hours if they meet high risk indications. Treatment of illness can be given to those over 2 weeks of age if they meet high risk criteria. There are shortages beginning this season and resistance can easily develop, so its use should be limited to those who truly need it.

High risks include: less than 2 years, lung disorders, immunologic disorders (immune compromised), chronic metabolic disease, and neuromuscular disorders.

If influenza symptoms have been present for more than 48 hours, it is not indicated unless there are special circumstances.

Tamiflu shortens the symptoms of influenza by 26 hours, about a day. It can help prevent the spread of the virus. It can have side effects, most commonly nausea and vomiting, but also more serious rashes and neurologic symptoms (confusion, delirium, and hallucinations).

Flu Vaccine

Vaccination is the best prevention against influenza. It does not make people get the flu. It is safe and indicated for everyone over 6 months of age. Thank you to all my patients who were vaccinated this year!  Although it is not 100% effective, it should lessen the risk of influenza to you.

Please don't wait to see if it will be a bad season before deciding if it's worth it to get the vaccine. Once the season has started it is less effective because it takes your body about 2 weeks to build immunity. Waiting also puts you at risk for being left out if there are shortages. Our office gave more vaccine than ever this year, but we still ran out earlier than ever this year.

If your family still needs the vaccine, check your local health department and pharmacies.  When we start vaccinating again this summer for next season, be sure to get your family vaccinated! (We will publicize availability on our website, Facebook page, and by email to those registered on our website.)

Vomiting and/or diarrhea

Vomiting and diarrhea can result from many viruses, usually NOT influenza. Treat with an electrolyte solution (such as Pedialyte, Gatorade's G2 - less sugar than regular). Give small volumes frequently. When kids get thirsty, they might gulp and then vomit, so put only 1 teaspoon in a small cup or syringe, or give a popsicle made of the electrolyte solution. Juice, carbonated lemon/lime drinks, and other high sugar drinks should be avoided.

Dairy increases stomach upset, and I generally say to avoid all milk products (except human milk) for 48 hours after the last vomiting or diarrhea. Breast milk can sometimes be tolerated, but it must be given slowly too, so often breast feeding should be stopped. Pump and give the expressed milk by the teaspoon in a syringe.