In a recently released issue of Pediatrics, Drs. Andrea Beckhaus and Jose Castro-Rodriguez (10.1542/peds.2018-0225) report on their meta-analysis of studies that evaluated RSV (respiratory syncytial virus) -associated mortality and morbidity among children with Down Syndrome, as compared to children without Down Syndrome. As the authors note, Down Syndrome is the most common chromosomal disorder worldwide, and RSV is a major cause of lower respiratory tract infections (LRIs), so any increased risk associated with Down Syndrome in RSV infection has meaningful implications for patient and family burden, and for resource expenditure. Primary outcomes included hospital admission and death, and secondary outcomes included all the morbidities associated with LRIs, including length of hospital stay, intensive care unit admission and other markers of respiratory support. Although the number of studies meeting inclusion criteria was just 12, the studies included 3,662 children with Down Syndrome and over one million without.
Any pediatrician or parent who has cared for a child with Down Syndrome will not be surprised to learn that morbidity and mortality due to RSV infection are significantly increased among those with Down Syndrome, compared to those without. The magnitude of the difference is much greater than I expected, and holds up across all outcomes examined. How can we use this information?
First of all, pediatricians can use this data to provide evidence-based and realistic anticipatory guidance to parents whose children have Down Syndrome. Since the main impact of RSV-associated morbidity and mortality falls in the first two years of life, parents may not yet have had the life experience with their child to expect the extent of the challenges that RSV infection brings, and may worry that their child’s course is uniquely downhill. Certainly evaluation for co-morbidities of Down Syndrome, described by the authors and others, such as airway malacia and sleep apnea, are not precluded by good anticipatory guidance! But parents may be comforted that they are not alone, and that their child is following an expected course even when it is a rough one.
Secondly, the authors make the excellent point that their data provides strong support for the AAP to consider a recommendation for Palivizumab prophylaxis of young children with Down Syndrome. Palivizumab, known more readily by its brand name Synagis™, is the monoclonal antibody injection given monthly through high-risk seasons that lowers risk of RSV infection, and has potential to meaningfully reduce disease burden for children with Down Syndrome. A formal AAP recommendation would be likely to impact insurance coverage for children with Down Syndrome for this immunization, which is essentially otherwise unaffordable. It will be interesting to see if this journal article leads to a new recommendation and a practice change!
