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AAP updates interim guidance on preventing severe RSV, handling surge of patients

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The AAP is recommending pediatricians consider giving high-risk infants and children in some areas more than five consecutive monthly doses of palivizumab to protect them from respiratory syncytial virus (RSV).

The updated interim guidance comes during another unusual RSV season and is accompanied by updated recommendations on handling a surge in patient volume.

“It appears that the circulation of (RSV) came earlier than is usual, and the number of cases is more than is typical,” said Mary T. Caserta, M.D., FAAP, a member of the AAP Committee on Infectious Diseases who led creation of the interim guidance. “There’s been a dramatic increase in the number of cases and the number of hospitalizations.”

Clinicians in some areas may have started giving palivizumab this summer, which means the six months of protection from the recommended five doses could be close to running out. Under the updated guidance, extra monthly doses of the humanized monoclonal antibody could be given if RSV activity remains high in a patient’s region. Clinicians can monitor regional RSV trends through local specialists and public health officials as well as the Centers for Disease Control and Prevention’s (CDC’s) National Respiratory and Enteric Virus Surveillance System.

“If places started early, they have to be able to continue dosing because right now it doesn’t appear this is going to end any day soon,” Dr. Caserta said.

There are only a few small studies on giving more than five doses of palivizumab but no evidence of increased safety concerns.

Children eligible for palivizumab include infants born at less than 29 weeks’ gestation, infants with chronic lung disease of prematurity, infants with certain types of hemodynamically significant congenital heart disease, infants and young children with certain immunodeficiency states, and infants with pulmonary abnormalities or neuromuscular conditions that impair ability to clear secretions from the upper airway.

RSV can cause severe lower respiratory tract disease such as bronchiolitis or pneumonia. Infants younger than 6 months are at highest risk for severe disease, especially during their first fall and winter. A typical RSV season runs from fall through spring with a peak in February, but the last several seasons during the COVID pandemic haven’t followed that pattern.

About 58,000 children under age 5 years are hospitalized each year due to RSV, and 100 to 500 die from the virus, according to the CDC. Early symptoms in infants and young children include a runny nose, decreased appetite, cough and wheezing. Infants under 6 months may show signs of irritability, decreased activity, decreased appetite and apnea. Some children may have RSV without a fever.

The surge of RSV along with other respiratory viruses, a continuing mental health crisis and workforce shortages have led to significant hospital capacity issues. The AAP has updated its interim guidance on caring for patients during a surge in volume that addresses equipment, space, staff and structure in different types of settings. The guidance calls for enhancing capabilities and capacity for emergency readiness and raises awareness that children with special health care needs may be impacted disproportionately during surge events.

In addition, the AAP and Children’s Hospital Association have asked federal officials to declare a public health emergency to address the current surge. The emergency declarations they requested in a letter to President Joe Biden and U.S. Department of Health and Human Services Secretary Xavier Becerra, J.D., would provide flexibility in how hospitals share resources, use space, move patients and manage workforce shortages.

“Pediatricians are rising to this challenge once again but we need federal action to allow the flexibilities and resources to support this care,” AAP CEO/Executive Vice President Mark Del Monte J.D., said in a statement.




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