Vol. 4 Issue 20
Parents find help for babies with respiratory infections at a special clinic at Boston Medical Center.
It's 8 a.m. on a Tuesday morning, and during the next 4 hours the Respiratory Syncytial Virus Prevention (RSVP) program at Boston Medical Center (BMC) will be bustling with families bringing their babies in for physical assessments, parenting education and monthly prophylaxis.
For the past 4 years, BMC has run the RSVP clinic to educate new parents about how to safeguard their babies from respiratory illnesses during the RSV season, which typically lasts from October through April.
Approximately 60 infants are referred to the RSVP clinic by primary care providers (PCPs), cardiologists and the NICU staff at BMC during the RSV season each year.
Nationwide, up to 125,000 children younger than age 1 are hospitalized each year due to RSV-related illnesses, which can be fatal in some cases.1,2
What Is RSV?
RSV is the most common cause of lower respiratory tract infections and viral death in children younger than 5 years old, and the No. 1 reason for hospitalization of children younger than 1 year old.3,4
Although most children contract RSV by the age of 2, premature infants are at a greater risk for severe disease complications because of their underdeveloped lung capacity and immature immune systems.5 Children with chronic lung conditions, congenital heart disease or neuromuscular disorders are also at increased risk for acquiring RSV.
RSV usually presents in two clinical categories upper respiratory infections (URI) and lower respiratory infections (LRI).
RSV-related URIs are generally mild. Symptoms include fussiness, low-grade fever and nasal congestion with a persistent, wet, non-productive cough.
RSV-related LRIs, such as bronchiolitis and pneumonia, typically strike the youngest patients. Symptoms such as irritability, poor feeding and wheezing can start moderately, but progress rapidly, resulting in respiratory distress. Lethargy, tachypnea, nasal flaring and intercostal retractions with hypoxemia usually require immediate medical attention. Nasal washing for rapid antigen testing or viral cultures are used to test for RSV. Occasionally, chest X-rays and pulse oximetry are performed as well.
Treating RSV Symptoms
The treatment used for RSV symptoms depends on the severity of the illness.
Most children remain at home with supportive care adequate oral hydration, cool mist humidifier, isolation and plenty of TLC. Giving antihistamines or cough suppressants to children remains controversial, especially with premature infants.
When hospitalization is necessary, IV hydration, a cool mist tent, bronchodilator nebulizer treatments and oxygen supplementation are usually indicated. Severe hypoxemia and respiratory distress can lead to intensive-care monitoring and mechanical ventilation.
The goal of the RSVP clinic is to prevent RSV symptoms from escalating to the point where the child needs to be hospitalized, which is very difficult for the entire family emotionally and financially.
In fact, the economic impact of RSV nationwide is immense. From 1997-2000, for example, RSV-related ED visits were estimated to cost $202 million.6 Total hospitalization charges related to RSV over the same 4 years was calculated at more than $2.6 billion.6
Fortunately, about 97 percent of patients who use BMC's RSVP clinic services have health insurance. For those families who don't, BMC offers resource programs to assist them in applying for health insurance.
Standards of Care
The standard of care for infants at high risk for developing RSV is prophylaxis with a monthly injection of a humanized monoclonal antibody specific to RSV. The medication maintains protection and may reduce the severity of symptoms should RSV infection occur.
Prior to the approval of the humanized monoclonal antibody in 1998, premature babies and infants younger than age 2 who were born less than 35 weeks gestation received a 4-hour IV infused prophylaxis. The length of the procedure, poor vein access and fluid imbalances posed many problems and often the patient did not receive the entire dose.
All premature infants born at 32 weeks gestation or less who are still younger than 12 months of age at the onset of RSV season, receive monthly injections of the RSV prophylaxis. Infants born 33-35 weeks gestation must have at least two additional risk factors in order to receive prophylaxis during RSV season. Factors such as daycare attendance, school-aged siblings and exposure to environmental pollutants like tobacco smoke, increase the likelihood for these children to contract RSV.
Other children who should be considered for RSV prophylaxis are those 24 months old or younger and born with congenital airway abnormalities, significant cardiac disease or severe neuromuscular disease.
Infants enrolled in the RSVP clinic receive monthly prophylaxis for RSV and to follow up on infectious disease issues that were identified prenatally or during their initial stay in the NICU. Recommendations for follow up diagnostic tests or blood labs are often suggested to PCPs.
In special instances, certain children will receive prophylaxis for 2 seasons, or until the age of 2, based on the specific risk factors and medical history of the patient.
During the 2003-2004 season, the RSVP clinic at BMC prophylaxed only a few patients for a second season. For instance, one child was born at 24 weeks in December 2002, went home in March 2003, received prophylaxis for 2 months and was referred back to the RSVP program in October because she was still younger than 1 year old at the onset of RSV season.
Other children do not fit the criteria for a second-season prophylaxis, however, such as one referred to the clinic whom was born with only one lung. This patient did receive second-season prophylaxis, however, but only because of a strong recommendation from an infectious disease specialist.
There are additional factors to remember with cardiac patients on prophylaxis as well. If the child requires surgery using cardiopulmonary bypass, for example, the serum concentration levels of the RSV prophylaxis decrease by 58 percent during the operation. In one case involving a 4-month-old infant with trisomy 21 being admitted to an outside hospital for cardiac surgery, for instance, the patient would not have received the prophylaxis postoperatively if the RSVP staff at BMC had not alerted the attending cardiac team.
Respiratory virus education and prevention is foremost on the RSVP nursing team's agenda with each patient visit to the BMC clinic.
Many parents are young, single and have never heard of RSV. We teach them what wheezing sounds like, educate them about the warning signs of RSV and most importantly, when to seek help. Additionally, newborn care is discussed, parenting skills assessed and any feeding concerns parents may have are addressed.
Besides RSV, the staff addresses the possible need for influenza vaccines, which may have been overlooked by many medical providers, but are now recommended by the AAP for all children younger than 24 months old. Growth parameters are closely monitored each month by RSVP clinicians and any concerns RSV-related or not are communicated to PCPs. Last year, the clinic admitted three preemies to the hospital at BMC because of their failure to thrive. None had RSV.
Even if an infant enrolled in the program is diagnosed with RSV, monthly prophylaxis continues due to the high incidence of re-infection and the possibility of more than one strain of RSV circulating.
Benefits of RSVP Clinic
The greatest benefit of the RSVP clinic is the personalized care we provide to patients. Staff members provide additional monitoring of the babies through specialized care and monthly physical exams, while their working relationship with PCPs is mutually beneficial.
By the end of the season, in April, we are exhausted. But we have grown close to these families and have watched their babies surpass milestones. We look forward to when babies graduate from the program.
In fact, the most gratifying part of working at the clinic is when a mother brings a preemie and RSVP alum, who is now a thriving 4-year-old, back to BMC for a visit with the clinic staff. We're always so proud that we've played a role in the child's health.
1. Shay, D.K., Holman, R.C., Newman, R.D., et al. (1999). Bronchiolitis-associated hospitalizations among U.S. children, 1980-1996. Journal of the American Medical Association, 282, 1440-1446.
2. Shay, D.K., Holman, R.C., Roosevelt, G.E., et al. (2001). Bronchiolitis-associated mortality and estimates of respiratory syncytial virus associated deaths among U.S. children, 1979-1997. Journal of Infectious Diseases, 183(1), 16-22.
3. Committee on Infectious Disease and Committee on Fetus and Newborn. (1998). Preventions of respiratory syncytial virus infections: Indications for the use of palivizumab and update on the use of RSV-IGIV. Pediatrics, 102(5), 1211-1216.
4. Leader, S., & Kohlhase, K. (2002). Respiratory syncytial virus-coded pediatric hospitalizations, 1997 to 1999. Pediatric Infectious Disease Journal, 21(7), 629-632.
5. Glezen, W.P., Taber, L.H., Frank, A.L., et al. (1986). Risk of primary infection and reinfection with respiratory syncytial virus. American Journal of Diseases in Children, 140(6), 543.
6. Leader, S., & Kohlhase, K. (2003). Recent trends in severe respiratory syncytial virus among U.S. infants, 1997 to 2000. Journal of Pediatrics, 123, s127-s132.
Barbara Damon-Marinaccio is a primary nurse practitioner of pediatric infectious disease at Boston Medical Center. She specializes in pediatric and adolescent HIV and provides education to families with infants at high risk of acquiring RSV.