Introduction
It is likely that you’ve heard about a child who has had Respiratory Syncytial Virus (RSV) from a friend, a family member, or perhaps you’ve even had your own personal experience with it. But, you may not realize how common it actually is! Did you know that almost all children get RSV at least once before they are two years old? For healthy children, it is likely to present just like a typical cold or virus, but for some children, they become very ill with RSV.
Infants who are more at risk of developing the severe symptoms of RSV, receive a series of Synagis injections during the peak RSV season. Synagis is a a humanized RSV antibody that has been approved by the FDA that provides passive immunity against RSV. Infants born prematurely, or those diagnosed with bronchopulmonary dysplasia (BPD), or children with hemodynamically significant congenital heart disease (CHD) are considered high-risk patients who may be eligible to receive Synagis.
The typical RSV season is from November to April. Since that season is upon us, we reviewed RSV, how it gets transmitted, what the typical symptoms are, and when parents should contact their provider. We also review Synagis, what exactly it is, the current inclusion criteria so you know if your infant will be likely to receive it, how often it should be given, the length of treatment, and signs and symptoms parents should watch for that may be indicative of an allergic reaction.
Keep reading or start listening as I know you will learn something new!
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Episode 39
Respiratory Syncytial Virus
What is it?
October is RSV Awareness Month and because we are now approaching the peak season, I think it’s important to review RSV! Respiratory Syncytial Virus, or RSV was initially discovered in 1956 and subsequently has been recognized as one of the most common causes of childhood illness. It is a large, enveloped, nonsegmented, negative-strand RNA paramyxovirus. What does all of that mean? Basically, it is a virus that causes respiratory illness and it typically involves the nose, throat, and lungs.
Humans are the only source of infection and RSV is spread by respiratory secretions. Droplets can actually survive on environmental surfaces for hours and for 30 minutes or more on our hands. For children, their initial infection typically occurs during their first year of life, although reinfection throughout their lifetime is common.
RSV is the leading cause of bronchiolitis, pneumonia, and severe lower respiratory tract disease in children less than 2 years of age, especially in preterm or immunocompromised infants. According to the Centers for Disease Control and Prevention (CDC), one to two out of every 100 children younger than 6 months of age with RSV infection may need to be hospitalized. Per Gomella et al., RSV is associated with up to 120,000 pediatric hospitalizations each year in the United States or 1-3% of children in the first 12 months of life. The hospitalization rates are highest amongst children that are less than 6 months old at 2% and premature infants less than a year old at 6.4%. Children that require hospitalization may require oxygen, intubation, and/or mechanical ventilation for respiratory support. Most children improve with supportive care and are discharged within a few days, but for other children, the course is more severe and can be fatal at times.
Seasonal Variations
As I mentioned, the peak season for RSV is typically in the late fall and runs through the early spring months with the highest activity in February. But, regional variation exists in different parts of the country. Some communities in the southern part of the United States, like in Florida, tend to experience the earliest onset of RSV and may see cases as early as July.
Following the masking and social-distancing guidelines in March of 2020 in attempts to prevent the spread of the novel coronavirus, the number of RSV infections in the United States dramatically decreased. RSV cases remained low through the traditional 2020-2021 fall-winter season, but after safety measures relaxed, there was a noted increase in the number of cases in the spring of 2021. The number of cases at that time were more similar to a typical fall-winter season, yet continued throughout the spring, summer, and fall as well.
The atypical, interseasonal spike also correlated with an increase in emergency department visits and hospitalizations for infants and children. At that time, the American Academy of Pediatrics (AAP), recognized the importance of flexible approaches in management of RSV including early initiation of Synagis prior to the typical fall onset. The CDC also released a health advisory at that time recommending broader RSV testing in patients who presented with acute respiratory symptoms. The CDC continues to monitor RSV activity in the United States in collaboration with state and county health departments as well as commercial and clinical laboratories.
Risk Factors
There are risk factors that place certain infants and children at an increased risk of developing severe RSV. The main risk factors include infants less than 6 months of age, premature infants born prior to 35 weeks’ gestation, infants with an underlying lung disease like BPD, infants less than 2 years of age with heart disease, infants with school-aged siblings, infants who attend daycare, infants who have a family history of asthma, infants with regular exposure to secondhand smoke or air pollution, multiple birth babies, male children, immunocompromised patients, infants who did not receive any breastmilk or those who received less than a month of breastmilk, and infants who share a bedroom with others. Additionally, the risk is increased with peak RSV season immunodeficiency (from fall to the end of spring), high altitude also increases the risk of RSV hospitalizations and children with Down syndrome or those with neuromuscular disorders who have difficulty swallowing or clearing mucus are also at an increased risk for severe RSV disease.
Pathophysiology
As I mentioned, RSV is transmitted by direct or close contact with contaminated secretions. The inoculation of the virus occurs in the nasopharyngeal or ocular mucus membranes after contact with the virus-containing secretions. The virus actually replicates in the nasopharynx and spreads to the small bronchiolar epithelium or tissues. Next, the virus extends into the alveolar cells in the lungs.
RSV symptoms typically appear 2 to 8 days after contact. According to the CDC, people infected with RSV are usually contagious for 3 to 8 days, although in very young infants or those who have a weakened immune system, they may be contagious for as long as four weeks, even if they are not actively showing symptoms.
RSV Syptoms
As I mentioned, the virus typically begins in the nasopharynx which results in congestion and a runny nose. Within the first 2 to 5 days, it may progress to the lower respiratory tract and progress to a cough, labored breathing, and wheezing. Lethargy, or a lack of energy, irritability, and decreased appetite with poor feeding are commonly present in infants as well. A fever of 100.4 or higher may be present, but does not always occur with RSV. Apnea or pauses in breathing, is the presenting symptom in approximately 20% of infants hospitalized with RSV. Sadly, it is the apneic episodes that may be the cause of sudden, unexpected deaths.
Fortunately, most children recover from RSV at home with supportive care. But, for some children, their symptoms may progressively worsen. It is important for parents to pay close attention and to call their child’s provider if their child’s breathing becomes fast, their nostrils begin to flare, they have head bobbing with their breathing, grunting with their breathing, wheezing or an increased work of breathing, and absolutely if they notice that their child is having apneic episodes, or pauses in their breathing.
How to identify increased work of breathing
As a parent, if you’re unsure how to identify if your child has increased work of breathing, here are some things to look for: as I previously stated, look for their head to bob up and down with their breathing, look at your child’s ribs and watch to see if there is any additional pulling through or underneath their ribs. Also, you can look up at their neck area and see if the skin is getting pulled in with their breathing.
If your child displays any of the aforementioned symptoms or they become dehydrated and have fewer than 1 wet diaper every 8 hours, they are becoming apneic and have pauses in their breathing, they become gray or blue around their mouth, on their tongue, or their skin, or if they have a significant decrease in their activity or alertness, please call your Pediatrician or 911 right away.
How is RSV diagnosed?
You may be wondering how the medical professionals will know whether your child has RSV versus a common cold. Well, there are a couple of laboratory tests that are available to confirm an RSV infection. A rapid diagnosis is made by PCR testing of respiratory secretions. Additionally, a viral culture can be done, but it may take 1 to 5 days to get the results.
Management and Supportive Care
Now, if your child is diagnosed with RSV and stable enough to remain at home, it is recommended to use supportive care as you would with any other cold or virus. Consider gentle suctioning as needed with the use of normal saline and a cool-mist humidifier to help break up the mucus. It is important to ensure your child remains hydrated. It is likely that they will not eat as much and may feed more slowly due to their difficulty breathing. Consider suctioning your baby’s nose prior to the feeding to assist with breathing. To assist with any fevers, you can give your child Tylenol or if they are older than 6 months, Ibuprofen is an option.
If your child requires hospitalization, treatment is mostly supportive with hydration, supplemental oxygen, nasal continuous positive airway pressure otherwise known as CPAP or mechanical ventilation if needed.
Prevention
One of the key components of RSV is prevention. Palivizumab or Synagis is a monoclonal antibody recommended by the AAP to be administered to high-risk infants and young children. Synagis is a humanized RSV antibody that has been approved by the FDA. It is given intramuscularly in children younger than 2 years of age and provides passive immunity against RSV by binding the RSV envelope fusion protein on the surface of the virus and blocking critical steps in the membrane fusion process. Synagis also prevents cell-to-cell fusion of RSV-infected cells.
The dose of Synagis is 15 mg/kg and the AAP recommends 5 consecutive monthly doses starting in October or November and given every 28-30 days during the RSV season. With 5 consecutive doses, it provides serum levels associated with protection for 6 months through the length of the typical RSV season. It is very important to stay on the schedule your infant is started on. The Synagis company put together a really nice graph or calendar so parents can clearly see when their infants next dose is due for both the 28-day and 30-day dosing schedule.
Synagis Criteria
Synagis is not given to every infant, only those who are at high risk for severe RSV disease. The inclusion criteria per the AAP guidance includes:
- Infants with a gestational age less than 29 weeks, who are less than 12 months of age at the onset of the RSV season and preterm infants born between 29 to 35 weeks who have additional qualifying conditions.
- Infants with Chronic Lung Disease of Prematurity who are less than 12 months of age at the onset of the RSV season or those with CLD who are less than 24 months of age at the onset of the RSV season and still require supplemental oxygen, chronic systemic corticosteroid therapy, or diuretic therapy within 6 months of the RSV season onset
- Infants with hemodynamically significant Congenital Heart Disease who are less than 12 months of age and meet specific criteria at the onset of the RSV season
- Infants undergoing cardio-pulmonary bypass during the RSV season who are less than 24 months of age at the onset of the RSV season
- Infants with anatomic Pulmonary Abnormalities and Neuromuscular Disorders that impair the ability to clear secretions from the upper airway who are less than 12 months of age at the onset of the RSV season
- Infants who will be profoundly immunocompromised during the RSV season who are less than 24 months of age at the onset of the RSV season
- Infants with Cystic Fibrosis and clinical evidence of either CLD of prematurity or nutritional compromise who are less than 12 months of age at the onset of the RSV season
- Infants with Cystic Fibrosis who have either CLD, nutritional compromise, and either manifestations of severe lung disease or weight for length less than the 10th percentile who are less than 24 months of age at the onset of the RSV season
- For Alaska Native and Other American Indian Infants, a medical director consultation is required. For Alaska Native infants, their prophylaxis eligibility may differ from the remainder of the United States and for American Indian infants, special consideration may be prudent for Navajo and White Mountain Apache infants in the first year of life
Now it is important to remember that Synagis is not a vaccine so it does not fully prevent or treat RSV. Children can still get severe RSV disease despite receiving Synagis. But, even if your child develops an RSV infection while receiving Synagis, they should continue to receive the monthly doses throughout the RSV season to minimize their risk of getting it again.
Synagis Side Effects
Although Synagis does help protect children from RSV, it is important to mention that there are possible side effects including a severe rash, hives, or itchy skin, swelling of the lips, tongue, throat or face, difficult, rapid, or irregular breathing, bluish color of the skin, lips, or under fingernails, muscle weakness or floppiness, and or unresponsiveness. Please tell your child’s healthcare provider about any side effects that your child experiences or call 911 if there is a life-threatening side-effect. Also, please report suspected adverse reactions by calling 1-866-773-5274.
Lastly, as we enter into RSV season, I think it’s also important to review some basic preventative measures we can all take, but that are especially important if you have a baby at risk for developing severe RSV disease.
- Wash your hands often and teach your children to wash their hands
- Keep your hands away from your face
- Avoid close contact with people who are sick
- Cover your coughs and sneezes
- Clean and disinfect surfaces
- Stay home when you are sick
- Limit your baby’s exposure to crowds and other children
- Feed your baby breastmilk (due to all of its’ unique antibodies)
The future of RSV
Although there is not a vaccine for RSV, scientists are working to develop one as well as medications to help treat RSV. But, in the meantime, I think it is essential for parents of high risk children to be aware of the risk of RSV, ask your infant’s provider if they qualify for Synagis, follow the schedule closely for their Synagis injections, and remember to take preventive measures, especially during the peak RSV season.
Closing
I hope you enjoyed this review of RSV. As I mentioned, RSV is very common in children and adults. But, many children do end up hospitalized due to their symptoms, so it is important to be able to identify the severe symptoms and to know when to call your child’s provider. If your child has risk factors that place them at an increased risk for severe RSV disease, please ask your baby’s Neonatologist or Pediatrician if they will qualify for Synagis so they can be more protected. If your child begins the Synagis series, please make sure you continue to follow the schedule closely and complete all 5 doses so they are more protected during peak RSV season.
Prevention is key with RSV and most of it goes back to the basics of good handwashing, covering your mouth, proper disinfecting, and especially keeping your child away from public places or other children if they are immunocompromised or have risk factors for severe RSV disease.
References
Eichenwald, E. Hansen, A., Martin, C., & Stark, A. (2017). Cloherty and Stark’s Manual of Neonatal Care, Eight Edition. Wolters Kluwer.
Gomella, T., Eyal, F., & Bany-Mohammed, F. (2020). Gomella’s Neonatology: Management, Procedures, On-Call Problems, Diseases, and Drugs, Eight Edition. McGraw-Hill.
Jones, A. (2022, October 12). RSV: When It’s More Than Just a Cold. Healthy Children. https://www.healthychildren.org/English/health-issues/conditions/chest-lungs/Pages/RSV-When-Its-More-Than-Just-a-Cold.aspx
Palivizumab (Synagis) Criteria for Respiratory Syncytial Virus (RSV) Infection. (2022, February). Magellan Provider. Retrieved October 1, 2022 https://specialtydrug.magellanprovider.com/media/135369/synagis_criteria_feb-2022.pdf
RSV in Infants and Young Children. (2020, December 18). Centers for Disease Control and Prevention. Retrieved October 1, 2022 from https://www.cdc.gov/rsv/high-risk/infants-young-children.html
Synagis (Palivizumab) 2021-2022 Authorization Guidelines. (2021). Buckeye Health Plan. Retrieved on October 1, 2022 from https://www.buckeyehealthplan.com/content/dam/centene/Buckeye/WebsitePDFs/Pharmacy/RSVSeason/Synagis%202021-2022%20Auth%20Guidelines%20508.pdf
Updated Guidance: Use of Palivizumab Prophylaxis to Prevent Hospitalization From Severe Respiratory Syncytial Virus Infection During the 2022-2023 RSV Season. (2022, August 26). American Academy of Pediatrics. Retrieved on October 1, 2022 fromhttps://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/interim-guidance-for-use-of-palivizumab-prophylaxis-to-prevent-hospitalization/
What is Synagis? (2022). Synagis. Retrieved October 1, 2022 from https://www.synagis.com/what-is-synagis.html#isiSec
