Rehospitalization because of respiratory syncytial virus infection in premature infants younger than 33 weeks of gestation: a prospective study. IRIS Study Group

Maternal Risk Factors for Respiratory Syncytial Virus Lower Respiratory Tract Infection in Otherwise Healthy Preterm and Term Infants: A Systematic Review and Meta-analysis

BACKGROUND/OBJECTIVE

To date, there is no published, formal assessment of all maternal risk factors for respiratory syncytial virus lower respiratory tract infection (RSV-LRTI) in infants. A systematic literature review and meta-analysis were undertaken to ascertain: What maternal risk factors are associated with an increased risk of RSV-LRTI in infants?

METHODS

The systematic literature review used explicit methods to identify, select and analyze relevant data. PubMed, Embase and the Cochrane Library were searched (November 2022) using terms regarding: (1) RSV/LRTI; (2) risk factors; (3) pregnant/postpartum population. Bayesian meta-analysis compared RSV hospitalization (RSVH) risk in infants born to mothers with or without certain risk factors.

RESULTS

A total of 2353 citations were assessed and 20 were included in the final review (10 individual studies; 10 pooled analyses). In 10 studies examining infants (<1 year) without comorbidities (primary outcome), 10 maternal risk factors were associated with RSV-LRTI/RSVH in multivariate analyses. Meta-analysis revealed smoking while pregnant increased infant RSVH risk by 2.01 (95% credible interval: 1.52-2.64) times, while breast-feeding was protective (0.73, 95% credible interval: 0.58-0.90). Risk scoring tools have reported that maternal risk factors contribute between 9% and 21% of an infant's total risk score for RSVH.

CONCLUSIONS

A greater understanding of maternal risk factors and their relative contribution to infant RSV-LRTI will enable more accurate assessments of the impact of preventive strategies.

Morbidities and rehospitalizations during the first year of life in moderate and late preterm infants: more similarities than differences?

BACKGROUND

The aim was to compare neonatal morbidities in moderate and late preterm infants and to analyze rates and causes for rehospitalizations during the first year of life.

METHODS

Prospective follow-up of a group of moderate and late preterm infants at a tertiary care hospital.

RESULTS

The study population comprised 215 infants (58% males; 60% singletons; 99 moderate and 116 late preterm infants) with a median gestational age of 34 weeks and birth weight of 2100 grams; 20% of them were small for gestational age. Moderate preterm infants more often had a diagnosis of mild respiratory distress syndrome (26% vs. 13%, P<0.01) and feeding problems with longer need for nasogastric tube feeding (median 9.5 vs. 4.2 days, P<0.01) and parenteral nutrition (3.5 vs. 2.7 days, P<0.01), and longer duration of stay at either NICU (10.6 vs. 3.7 days; P<0.01) or hospital (13 vs. 11 days; P<0.01). Fifty-two infants (24.3%) were hospitalized at 67 occasions without differences regarding readmission rates and causes between groups. Median age at readmission was 3 months, median stay 4 days. The most common diagnosis was respiratory illness (43.3%).

CONCLUSIONS

Moderate preterm infants had more neonatal morbidities diagnosed, but the same rehospitalization rates than late preterm infants.

Does Duration Off Respiratory Support Prior to Discharge from NICU Predict Hospital Readmission among Extremely Low Gestational Age Neonates?

OBJECTIVE

Our objective was to determine if the duration off respiratory support prior to discharge home from the neonatal intensive care unit (NICU) would impact hospital readmission rates among extremely low gestational age neonates (ELGAN).

STUDY DESIGN

In this retrospective chart review, we examined readmission rates for ELGAN admitted to the Montefiore-Weiler NICU between 2013 and 2015.

RESULTS

Of 140 infants born at <29 weeks' gestational age, 30 (21%) of these infants were subsequently readmitted within 90 days, primarily for respiratory complaints. Readmitted infants were born at an earlier gestational age (median = 26 weeks; interquartile range [IQR]: 24-27 weeks) compared to infants who did not require readmission (median = 27 weeks; IQR: 25-28 weeks), p = 0.03. Birth weights were smaller among infants who required readmission, 800 ± 248 g compared to 910 ± 214 g (p = 0.02). Infants with Hispanic ethnicity and those discharged during the spring season were likely to be readmitted. Duration off respiratory support prior to discharge did not predict 90-day readmission rates. Lower gestational age and birth weight were associated with higher rates of readmissions after NICU discharge.

CONCLUSION

Duration off and invasiveness of respiratory support prior to discharge did not predict risk of 90-day readmission nor did discharge during months with traditionally higher prevalence of respiratory viruses.

Predictors of home oxygen duration in chronic neonatal lung disease

AIMS

In infants with chronic neonatal lung disease (CNLD), we aimed to identify predictors of home oxygen duration, predictors of discharge oxygen flow rates, and the association of oxygen flow rates with respiratory outcomes.

METHODS

Infants with CNLD requiring home oxygen in 2016 and 2017 were retrospectively reviewed. Hazard ratios (HR) were estimated from Cox proportional hazards regression models in the cohort. A multinomial logistic regression model examined the effects of maternal and infant variables on discharge oxygen flow rates. Kruskal-Wallis test with univariate linear regression and Fisher's exact test with binomial univariate logistic regression were used to examine associations between oxygen flow groups and post-discharge clinical variables.

RESULTS

One hundred and forty-nine infants were included. Median corrected gestational age (CGA) at oxygen cessation was 6.8 months (interquartile range, 4.4) with 87.2% of infants weaned by 12 months CGA. Shorter initial neonatal intensive care unit (NICU) stay predicted faster oxygen weaning at 9 months (HR, 0.99; 95% confidence interval [CI], 0.98-1.00, p = .02) and 12 months (HR, 0.99; 95% CI, 0.98-1.00, p = .02). Infants with hypercarbia at discharge or discharged from NICU at higher CGA had higher odds of requiring ≥ 200 ml/min relative to ≤ 125 ml/min oxygen. Infants discharged with > 250 ml/min oxygen were more likely to have a respiratory-related admission before 2 years chronological age.

CONCLUSION

Shorter initial NICU stay was the best predictor of earlier home oxygen cessation. At NICU discharge, infants with hypercarbia or a higher CGA may require more home oxygen and experience more respiratory-related hospital admission in the first 2 years of chronological age.

Risk factors for re-hospitalization following neonatal discharge of extremely preterm infants in Canada

OBJECTIVE

Survivors of extremely preterm birth are at risk of re-hospitalization but risk factors in the Canadian population are unknown. Our objective is to identify neonatal, sociodemographic, and geographic characteristics that predict re-hospitalization in Canadian extremely preterm neonates.

METHODS

This is a retrospective analysis of a prospective observational cohort study that included preterm infants born 22 to 28 weeks' gestational age from April 1, 2009 to September 30, 2011 and seen at 18 to 24 months corrected gestational age in a Canadian Neonatal Follow-Up Network clinic. Characteristics of infants re-hospitalized versus not re-hospitalized are compared. The potential neonatal, sociodemographic, and geographic factors with significant association in the univariate analysis are included in a multivariate model.

RESULTS

From a total of 2,275 preterm infants born at 22 to 28 weeks gestation included, 838 (36.8%) were re-hospitalized at least once. There were significant disparities between Canadian provincial regions, ranging from 25.9% to 49.4%. In the multivariate logistic regression analysis, factors associated with an increased risk for re-hospitalization were region of residence, male sex, bronchopulmonary dysplasia, necrotizing enterocolitis, prolonged neonatal intensive care unit (NICU) stay, ethnicity, Indigenous ethnicity, and sibling(s) in the home.

CONCLUSION

Various neonatal, sociodemographic, and geographic factors predict re-hospitalization of extremely preterm infants born in Canada. The risk factors of re-hospitalization provide insights to help health care leaders explore potential preventative approaches to improve child health and reduce health care system costs.

Respiratory Syncytial Virus-Associated Acute Lower Respiratory Infections in Children With Bronchopulmonary Dysplasia: Systematic Review and Meta-Analysis

BACKGROUND

Respiratory syncytial virus (RSV) is among the most important causes of acute lower respiratory tract infection (ALRI) in young children. We assessed the severity of RSV-ALRI in children less than 5 years old with bronchopulmonary dysplasia (BPD).

METHODS

We searched for studies using EMBASE, Global Health, and MEDLINE. We assessed hospitalization risk, intensive care unit (ICU) admission, need for oxygen supplementation and mechanical ventilation, and in-hospital case fatality (hCFR) among children with BPD compared with those without (non-BPD). We compared the (1) length of hospital stay (LOS) and (2) duration of oxygen supplementation and mechanical ventilation between the groups.

RESULTS

Twenty-nine studies fulfilled our inclusion criteria. The case definition for BPD varied substantially in the included studies. Risks were higher among children with BPD compared with non-BPD: RSV hospitalization (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.7-4.2; P < .001), ICU admission (OR, 2.9; 95% CI, 2.3-3.5; P < .001), need for oxygen supplementation (OR, 4.2; 95% CI, .5-33.7; P = .175) and mechanical ventilation (OR, 8.2; 95% CI, 7.6-8.9; P < .001), and hCFR (OR, 12.8; 95% CI, 9.4-17.3; P < .001). Median LOS (range) was 7.2 days (4-23) (BPD) compared with 2.5 days (1-30) (non-BPD). Median duration of oxygen supplementation (range) was 5.5 days (0-21) (BPD) compared with 2.0 days (0-26) (non-BPD). The duration of mechanical ventilation was more often longer (>6 days) in those with BPD compared with non-BPD (OR, 11.9; 95% CI, 1.4-100; P = .02).

CONCLUSIONS

The risk of severe RSV disease is considerably higher among children with BPD. There is an urgent need to establish standardized BPD case definitions, review the RSV prophylaxis guidelines, and encourage more specific studies on RSV infection in BPD patients, including vaccine development and RSV-specific treatment.

Effectiveness of Palivizumab Against Respiratory Syncytial Virus Hospitalization Among Preterm Infants in a Setting With Year-Round Circulation

BACKGROUND

The year-round respiratory syncytial virus (RSV) circulation in tropical regions leads to different transmission patterns and burden of disease among infants born very preterm.

METHODS

We conducted a retrospective cohort study to estimate the effectiveness of palivizumab in preventing RSV hospitalization at 6 and 12 months after discharge, among infants born at <32 weeks' gestation in our tropical setting.

RESULTS

A total of 109 infants (26.3%) received palivizumab at discharge, of 415 who were eligible. All patients received ≥4 doses, with 105 infants (96.3%) completing 5 doses. Within 1 year after discharge, there were 35 RSV-associated admissions (3 [2.8%] in the palivizumab vs 32 [10.5%] in the nonpalivizumab group; P = .02). After adjustment for confounders, the effectiveness of palivizumab against RSV hospitalization was estimated to be 90% (95% confidence interval, 10%-99%) up to 6 months after discharge. The median time to RSV hospitalization was shorter in the nonpalivizumab than in the palivizumab group (median [range], 155 [15-358] vs 287 [145-359] days, respectively; P = .11). Five infants (14.3%), all from the nonpalivizumab group, required admission to the intensive care unit.

CONCLUSIONS

In our setting with year-round RSV circulation, palivizumab prophylaxis was effective in reducing RSV hospitalization among high-risk preterm infants of <32 weeks' gestation within the initial 6 months after discharge.

Bronchopulmonary dysplasia: A review of the pulmonary sequelae in the post-surfactant era

We describe the respiratory complications of bronchopulmonary dysplasia (BPD) in childhood and adolescence. The pathophysiology of bronchopulmonary dysplasia has evolved in the era of modern neonatal intensive care. In this review, we aim to summarise the contemporary evidence base and describe the common respiratory morbidities related to BPD including; home oxygen therapy, rehospitalisation, asthma and exercise limitation.

Risk factors associated with paediatric unplanned hospital readmissions: a systematic review

OBJECTIVE

To synthesise evidence on risk factors associated with paediatric unplanned hospital readmissions (UHRs).

DESIGN

Systematic review.

DATA SOURCE

CINAHL, EMBASE (Ovid) and MEDLINE from 2000 to 2017.

ELIGIBILITY CRITERIA

Studies published in English with full-text access and focused on paediatric All-cause, Surgical procedure and General medical condition related UHRs were included.

DATA EXTRACTION AND SYNTHESIS

Characteristics of the included studies, examined variables and the statistically significant risk factors were extracted. Two reviewers independently assessed study quality based on six domains of potential bias. Pooling of extracted risk factors was not permitted due to heterogeneity of the included studies. Data were synthesised using content analysis and presented in narrative form.

RESULTS

Thirty-six significant risk factors were extracted from the 44 included studies and presented under three health condition groupings. For All-cause UHRs, ethnicity, comorbidity and type of health insurance were the most frequently cited factors. For Surgical procedure related UHRs, specific surgical procedures, comorbidity, length of stay (LOS), age, the American Society of Anaesthesiologists class, postoperative complications, duration of procedure, type of health insurance and illness severity were cited more frequently. The four most cited risk factors associated with General medical condition related UHRs were comorbidity, age, health service usage prior to the index admission and LOS.

CONCLUSIONS

This systematic review acknowledges the complexity of readmission risk prediction in paediatric populations. This review identified four risk factors across all three health condition groupings, namely comorbidity; public health insurance; longer LOS and patients<12 months or between 13-18 years. The identification of risk factors, however, depended on the variables examined by each of the included studies. Consideration should be taken into account when generalising reported risk factors to other institutions. This review highlights the need to develop a standardised set of measures to capture key hospital discharge variables that predict unplanned readmission among paediatric patients.

Burden, Etiology, and Risk Factors of Respiratory Virus Infections Among Symptomatic Preterm Infants in the Tropics: A Retrospective Single-Center Cohort Study

Background

The burden of respiratory viral infections (RVIs) among preterm infants in the first few years of life, especially those living in the tropics with year-long transmissions of respiratory viruses, remains unknown. We aimed to describe the clinical epidemiology and associated risk factors for RVIs among symptomatic preterm infants ≤32 weeks up to 2 years of life.

Methods

We performed a data linkage analysis of clinical and hospital laboratory databases for preterm infants born at KK Women's and Children's Hospital, Singapore, from 2005 to 2015. RVI episodes during initial admission and subsequent hospital readmissions were included.

Results

Of 1854 infants in the study, 270 (14.5%) infants were diagnosed with at least 1 RVI. A total of 285 (85.3%) episodes were diagnosed postdischarge, with the highest risk for RVIs being from 3 to 5 months of age. The incidence of RVI in this population was 116 per 1000 infant-years and respiratory syncytial virus was the main overall causative pathogen. Infants with RVIs were more likely to be born at ≤27 weeks' gestational age (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.2-2.3), to have received postnatal steroids (OR, 1.5; 95% CI, 1.0-2.1), and to be diagnosed with bronchopulmonary dysplasia (OR, 1.7; 95% CI, 1.2-2.4).

Conclusions

The burden of RVIs is high in preterm infants in the tropics, affecting >1 of 10 infants born at ≤32 weeks' gestation before 2 years of age. Respiratory syncytial virus was the main causative pathogen identified. Risk factors for RVI included extremely low gestational age, receipt of postnatal steroids, and bronchopulmonary dysplasia.

Seasonal peaks and risk factors of respiratory syncytial virus infections related hospitalization of preterm infants in Taiwan

Objectives

To assess the nationwide seasonal peaks, risk factors, and utilization of medical resources of respiratory syncytial virus-associated hospitalization (RSVH) in preterm infants in Taiwan.

Study design

A Taiwan nationwide birth cohort was extracted from the Birth Certificate Application Database during 2007–2009 and prospectively linked to the National Health Insurance database. We evaluated the seasonal peaks and risk factors (gestational age [GA], chronologic age [CA], and bronchopulmonary dysplasia [BPD]) associated with the RSVH of preterm infants. The length of hospital stays (LOS), care in intensive care unit (ICU), and use of mechanical ventilation (MV) were also analyzed.

Results

There is a total duration of 9 months of RSVH season in Taiwan, three seasonal peaks and two seasonal peaks of RSVH in preterm infants with BPD and without BPD, respectively. Preterm infants had significantly higher RSVH rate than term infants (2.6% vs 0.9%, p<0.0001). Preterm infants born at 29–35 weeks of gestational age (wGA) with BPD had significantly higher RSVH rate than those without BPD (p<0.0001). Preterm infants without BPD born at < 32 wGA had higher RSVH rate than those born at 33–35 wGA (p<0.0001). Overall, 56.4% of RSVH occurred within 9 months of CA. Preterm infants with BPD had significantly higher ICU admission rate within 18 months of CA (p<0.0001), MV usage within 12 months of CA (p<0.0001) and LOS within 18 months of CA (p<0.001) than those without BPD. RSVH occurred within 6 months of CA was significantly associated with higher ICU admission rate (p<0.0001), MV usage (p = 0.0002) and longer LOS (p<0.001) in preterm infants without BPD.

Conclusions

There is a total duration of 9 months of RSVH season in Taiwan. Preterm < 32 wGA, BPD, and CA within 6 months were risk factors of RSVH which also contribute to higher utilization of medical resources.

Respiratory syncytial virus associated hospitalizations in children with congenital diaphragmatic hernia

BACKGROUND

To evaluate the risk of RSV infection in infants and children with congenital diaphragmatic hernia (CDH) over two consecutive RSV seasons.

METHODS

Retrospective, single-center cohort study from southern Austria including infants with CDH born between 1993 and 2012. Infants were retrieved by searching via ICD-10 codes Q79.0 and Q79.1 and by using a local electronic database. Children were followed over 2 years of life including at least two consecutive RSV seasons (November to April). We also defined a group of hypothetical RSV infections with the following criteria: 70% of the admissions due to a respiratory infection (diagnosis of bronchiolitis and/or LRI score ≥3) during the RSV seasons over the first 2 years of life, when no test for RSV was performed.

RESULTS

Twenty-nine of 45 infants with CDH comprised the study population (6 were lost to follow-up and 10 died) of whom 9 (31%) exhibited 17 hospitalizations due to respiratory illness. Two hospitalized infants (6.9% of the study population) tested RSV positive, one during the first and the other during the second RSV season. Nine of 29 infants (31%) had documentation of palivizumab prophylaxis, none (0%) had proven RSV hospitalization compared to 1 of 20 (5%) without prophylaxis during the first RSV season (p = 0.256). Including the hypothetical cases, we calculated 0 of 9 (0%) in the palivizumab group and 4 of 20 (20%) in the group without prophylaxis (p = 0.079).

CONCLUSIONS

We found a moderate rate of proven RSV hospitalizations in infants with CDH, and palivizumab prophylaxis led to a non-significant reduction of proven and hypothesized RSV hospitalizations.

Effects of a transition home program on preterm infant emergency room visits within 90 days of discharge

OBJECTIVE

To evaluate effects of a transition home program (THP) and risk factors on emergency room (ER) use within 90 days of discharge for preterm (PT) infants <37 weeks gestation.

STUDY DESIGN

This is a prospective 3-year cohort study of 804 mothers and 954 PT infants. Mothers received enhanced neonatal intensive care unit transition support services until 90 days postdischarge. Regression models were run to identify the effects of THP implementation year and risk factors on ER visits.

RESULTS

Of the 954 infants, 181 (19%) had ER visits and 83/181 (46%) had an admission. In regression analysis, THP year 3 vs year 1 and human milk at discharge were associated with decreased risk of ER visits, whereas increased odds was associated with non-English speaking, maternal mental health disorders and bronchopulmonary dysplasia.

CONCLUSION

Enhanced THP services were associated with a 33% decreased risk of all ER visits by year 3. Social and environmental risk factors contribute to preventable ER visits.

Respiratory syncytial virus associated hospitalizations in preterm infants of 29 to 32 weeks gestational age using a risk score tool for palivizumab prophylaxis

To evaluate the efficacy of palivizumab in infants of 29 to 32 weeks of gestational age (GA) based on a risk score tool developed for Austria. Retrospective single-center cohort study including all preterm infants of 29 (+0) to 32 (+6) weeks of GA born between 2004 and 2012 at a tertiary care university hospital. Data on RSV-related hospitalizations over the first 2 years of life were analyzed and compared between those having received palivizumab and those without. The study population was comprised of 789 of 816 screened infants, of whom 262 (33%) had received palivizumab and 527 (67%) had not. Nine of 107 rehospitalizations (8.4%) in the palivizumab group compared to 32 of 156 rehospitalizations (20.5%) in the group without prophylaxis were tested RSV-positive (p = 0.004; OR 0.356 [CI 90% 0.184-0.689]). Proven and calculated RSV hospitalization rate was 3.1% (8/262) in the palivizumab group and 5.9% (31/527) in the group without (p = 0.042; OR 0.504 [CI 90% 0.259-0.981]). Increasing number of risk factors (up to three) increased the RSV hospitalization rate in infants with (6.1%) and without (9.0%) prophylaxis. RSV-associated hospitalizations did not differ between groups with regard to length of stay, severity of infection, age at hospitalization, demand of supplemental oxygen, need for mechanical ventilation, and admission rate to the ICU. A risk score tool developed for infants of 29 to 32 weeks of gestational age led to a reduction of RSV-associated hospitalizations without influencing the severity of disease.

Respiratory syncytial virus hospitalizations in infants of 28 weeks gestational age and less in the palivizumab era

OBJECTIVE

To obtain data on respiratory syncytial virus (RSV) associated hospitalization rates in preterm infants of 28 weeks gestational age and less in the era of palivizumab prophylaxis.

METHODS

Retrospective single-center cohort study including all preterm infants up to 28 weeks+6days gestational age and born between 2004 and 2012 at a tertiary care university hospital. Data on RSV related hospitalizations over the first two years of life covering at least two RSV seasons (November-April) were analyzed.

RESULTS

Ninety-one of 287 (32%) infants were hospitalized due to respiratory illness, and a total of 17 infants (5.9%) tested RSV positive during the first 2 years of life. Fourteen infants (4.9%) were hospitalized during the first RSV season. RSV hospitalization rate in infants with BPD was 4.5% (2/44) compared to 4.9% (12/243) without BPD. Palivizumab prophylaxis was documented in 74.6% of the infants. Infants with RSV compared to other respiratory tract infection were of younger age (6.8 vs. 9.1 months; p=0.049), had longer hospital stays (median 11 vs. 5 days; p=0.043) and more severe respiratory illness (median LRI score 3 vs. 2; p=0.043).

CONCLUSIONS

Despite palivizumab prophylaxis the burden of RSV disease and all cause respiratory illness was still remarkable in this vulnerable preterm population and mainly limited to the first season.

First versus second year respiratory syncytial virus prophylaxis in chronic lung disease (2005-2015)

Children aged <2 years with chronic lung disease (CLD) have a 10-fold higher risk for respiratory syncytial virus-positive hospitalization (RSVH) compared to healthy term infants. Based on the updated position statements, we compared respiratory-related illness hospitalization (RIH) and RSVH risks in CLD children who received palivizumab during the first year (FY) versus second year (SY) of life in the Canadian Registry of Palivizumab (CARESS). Demographic data were collected at enrolment and RIH events recorded monthly from 2005 to 2015. Eight hundred forty-seven FY and 450 SY children with CLD were identified. SY children had a lower gestational age (27 versus 29 weeks) and required more days of respiratory support (64 versus 43), oxygen therapy (108 versus 55), and length of stay (118 versus 73) during the neonatal course compared to FY children; all p < 0.0005. RIH rates were 12.2 (FY) and 18.2 (SY), and RSVH rates were 2.3 (FY) and 3.9 (SY). Cox regression showed similar hazards for both RIH (hazard ratio 0.9, 95% CI 0.6-1.6, p = 0.812) and RSVH (hazard ratio 1.1, 95% CI 0.4-2.9, p = 0.920).

CONCLUSIONS

SY and FY children had similar risks for RIH and RSVH. The findings imply that SY children with CLD are correctly selected for palivizumab based on neonatal illness severity and merit prophylaxis. What is Known: • Children with chronic lung disease have a 10-fold higher risk for RSV-positive hospitalization in comparison to healthy term infants and commonly receive palivizumab prophylaxis as a preventative measure against serious RSV-related lower respiratory tract infections. • The American Academy of Pediatrics [ 2 ] and the Canadian Paediatric Society [ 30 ] have recently modified their recommendations for RSV prophylaxis in children with chronic lung disease, limiting palivizumab to either those <32 weeks gestation or those in the first year of life who are oxygen dependent or require medical therapy for the treatment of their condition. What is New: • Children with chronic lung disease receiving an additional course of palivizumab in their second year of life were determined to be at similar risk for both respiratory illness-related hospitalization and RSV-positive hospitalization as palivizumab-naïve children enrolled in the first year of life in the Canadian Registry for palivizumab (CARESS). • CARESS physicians are correctly identifying high-risk children with chronic lung disease in their second year of life, whom they believe will benefit from an additional year of palivizumab prophylaxis, based on neonatal illness severity.

Impact of a Transition Home Program on Rehospitalization Rates of Preterm Infants

OBJECTIVES

To evaluate the effects of a transition home program on 90-day rehospitalization rates of preterm (PT) infants born at <37 weeks gestational age implemented over 3 years for infants with Medicaid and private insurance, and to identify the impact of social/environmental and medical risk factors on rehospitalization.

STUDY DESIGN

In this prospective cohort study of 954 early, moderate, and late PT infants, all families received comprehensive transition home services provided by social workers and family resource specialists (trained peers) working with the medical team. Rehospitalization data were obtained from a statewide database and parent reports. Group comparisons were made by insurance type. Regression models were run to identify factors associated with rehospitalization and duration of rehospitalization.

RESULTS

In bivariable analyses, Medicaid was associated with more infants hospitalized, more than 1 hospitalization, and more days of hospitalization. Early PT infants had more rehospitalizations by 90 days than moderate (P = .05) or late PT infants (P = .01). In regression modeling, year 3 of the transition home program vs year 1 was associated with a lower risk for rehospitalization by 90 days (OR, 0.57; 95% CI, 0.36-0.93; P = .03). Medicaid (P = .04), non-English-speaking (P = .02), multiple pregnancies (P = .05), and bronchopulmonary dysplasia (P = .001) were associated with increased risk. Both bronchopulmonary dysplasia and Medicaid were associated with increased days of rehospitalization in adjusted analyses. The major cause of rehospitalization was respiratory illness (61%).

CONCLUSIONS

Transition home prevention strategies must be directed at both social/environmental and medical risk factors to decrease the risk of rehospitalization.

Defining the Risk and Associated Morbidity and Mortality of Severe Respiratory Syncytial Virus Infection Among Infants with Chronic Lung Disease

INTRODUCTION

The REGAL (RSV evidence-a geographical archive of the literature) series provide a comprehensive review of the published evidence in the field of respiratory syncytial virus (RSV) in Western countries over the last 20 years. This third publication covers the risk and burden of RSV infection in infants with chronic lung disease (CLD), formerly called bronchopulmonary dysplasia (BPD).

METHODS

A systematic review was undertaken of publications between January 1, 1995 and December 31, 2015 across PubMed, Embase, The Cochrane Library, and Clinicaltrials.gov. Studies reporting data for hospital visits/admissions for RSV infection among infants with CLD/BPD who were not prophylaxed, as well as studies reporting RSV-associated morbidity, mortality, and healthcare costs, were included. Burdens of disease data were compared with preterm infants without CLD/BPD, other high-risk groups and term infants. Study quality and strength of evidence (SOE) were graded using recognized criteria.

RESULTS

A total of 1837 studies were identified and 39 were included. CLD/BPD is a significant independent risk factor for RSV hospitalization [RSVH (odds ratio 2.2-7.2); high SOE]. Infants and young children with CLD/BPD had high RSVH rates which were generally similar in Europe, the United States, and Canada, mostly varying between 12 and 21%. Infants with CLD also had a longer length of hospital stay than other high-risk groups and term infants (high SOE). On average, infants spent 4-11 days in hospital (moderate SOE). Once hospitalized for RSV, affected children were at risk for a more severe course of disease than children with no RSVH (moderate SOE).

CONCLUSION

Severe RSV infection in infants and young children with CLD/BPD poses a significant health burden in Western countries. Further studies focussing on the burden of RSV infection in this well-recognized population at high risk for severe disease are needed to help improve outcomes and plan allocation of healthcare resources.

FUNDING

AbbVie.

Defining the Risk and Associated Morbidity and Mortality of Severe Respiratory Syncytial Virus Infection Among Preterm Infants Without Chronic Lung Disease or Congenital Heart Disease

INTRODUCTION

The REGAL (RSV Evidence-a Geographical Archive of the Literature) series provide a comprehensive review of the published evidence in the field of respiratory syncytial virus (RSV) in Western countries over the last 20 years. This second publication covers the risk and burden of RSV infection in preterm infants born at <37 weeks' gestational age (wGA) without chronic lung disease or congenital heart disease.

METHODS

A systematic review was undertaken for articles published between January 1, 1995 and December 31, 2015. Studies reporting data for hospital visits/admissions for RSV infection among preterm infants as well as studies reporting RSV-associated morbidity, mortality, and risk factors were included. Study quality and strength of evidence (SOE) were graded using recognized criteria.

RESULTS

2469 studies were identified of which 85 were included. Preterm infants, particularly those born at lower wGA, tended to have higher RSV hospitalization (RSVH) rates compared with otherwise healthy term infants (high SOE). RSVH rates ranged from ~5 per 1000 children to >100 per 1000 children with the highest rates shown in the lowest gestational age infants (high SOE). Independent risk factors associated with RSVH include: proximity of birth to the RSV season, living with school-age siblings, smoking of mother during pregnancy or infant exposure to environmental smoking, reduced breast feeding, male sex, and familial atopy (asthma) (high SOE). Predictive models can identify 32/33-35 wGA infants at risk of RSVH (high SOE).

CONCLUSION

RSV infection remains a major burden on Western healthcare systems and is associated with significant morbidity. Further studies focusing on the prevalence and burden of RSV in different gestational age cohorts, the changing risk of RSVH during the first year of life, and on RSV-related mortality in preterm infants are needed to determine the true burden of disease.

FUNDING

AbbVie.

Respiratory Syncytial Virus Hospitalizations in Healthy Preterm Infants: Systematic Review

BACKGROUND

Studies have explored the risk for and impact of respiratory syncytial virus (RSV) infection requiring hospitalization among healthy preterm infants born at 29-35 weeks of gestational age not given RSV immunoprophylaxis. We performed a systematic review and qualitative synthesis of these studies.

METHODS

Two experienced reviewers used prespecified inclusion/exclusion criteria to screen titles/abstracts and full-text studies using MEDLINE, Embase, BIOSIS and Cochrane Library (January 1, 1985, to November 6, 2014). We abstracted data on risk factors for RSV hospitalization, incidence and short- and long-term outcomes of RSV hospitalization. Using standard procedures, we assessed study risk of bias and graded strength of evidence (SOE).

RESULTS

We identified 4754 records and reviewed 27. Important risk factors for RSV hospitalization included young age during the RSV season, having school-age siblings and day-care attendance, with odds ratios >2.5 in at least one study (high SOE). Incidence rates for RSV hospitalizations ranged from 2.3% to 10% (low SOE). Length of hospital stays ranged from 3.8 to 6.1 days (low SOE). Recurrent wheezing rates ranged from 20.7% to 42.8% 1 to 2 years after RSV hospitalization (low SOE).

CONCLUSIONS

Young chronological age and some environmental risk factors are important clinical indicators of an increased risk of RSV hospitalization in healthy preterm infants 32 to 35 weeks of gestational age. SOE was low for estimates of incidence of RSV hospitalizations, in-hospital resource use and recurrent wheezing in this population. Studies were inconsistent in study characteristics, including weeks of gestational age, age during RSV season and control for confounding factors.

Risk factors associated with RSV hospitalisation in the first 2 years of life, among different subgroups of children in NSW: a whole-of-population-based cohort study

BACKGROUND

Data on risk factors for respiratory syncytial virus (RSV)-associated hospitalisation in Australian children may be informative for preventive measures.

METHODS

A whole-of-population-based study was conducted to identify comparable risk factors for RSV hospitalisation in different subgroups of children aged <2 years in New South Wales. The cohort was divided into Indigenous children and high-risk and standard risk non-Indigenous children. Data on risk factors were obtained from the Perinatal Data Collection. RSV hospitalisations were ascertained from the Admitted Patient Data Collection. Adjusted HRs were calculated for each subgroup. Population-attributable risk associated with risk factors was estimated.

RESULTS

Four factors were associated with increased risk of RSV hospitalisation: maternal smoking during pregnancy, male sex, multiparity and birth during the first half of the RSV season. Increase in relative socioeconomic advantage was associated with decreased risk of hospitalisation. Among high and standard risk non-Indigenous children, the hazard was approximately double for children born to multiparous women compared to those born to primiparous women and among Indigenous children the hazard was approximately double among those born during the first half of the RSV season. Maternal smoking during pregnancy was associated with a 26-45% increased risk across subgroups and accounted for 17% (95% CI 9.3% to 24%) of RSV hospitalisations in Indigenous children, 5% (95% CI 2.5% to 8%) in high-risk and 6% (95% 5% to 7%) in standard risk non-Indigenous children.

DISCUSSION

Promoting avoidance of smoking during pregnancy may help in lowering the disease burden, with Indigenous children likely to benefit most.

Relative frequency, Possible Risk Factors, Viral Codetection Rates, and Seasonality of Respiratory Syncytial Virus Among Children With Lower Respiratory Tract Infection in Northeastern Brazil

Few studies, each limited to a single major city, have investigated the prevalence and seasonal patterns of different viruses among children with low respiratory tract infections (LRTI) in Northeastern Brazil. The aim of this study was to determine the frequency of respiratory syncytial virus (RSV) and of 7 other viruses in children for LRTI in 4 capitals from this region, and investigate their association with several risk factors, including meteorological data. From April 2012 to March 2013, 507 children, aged up to 24 months and hospitalized with LRTI in one of the participating centers at Aracajú, Salvador, Recife, and Maceió, had a sample of nasopharyngeal aspirate collected and analyzed for the following viruses by reverse-transcription polymerase chain reaction followed by hybridization on low-density microarrays: RSV, influenza, parainfluenza, adenovirus, rhinovirus, metapneumovirus, bocavirus, and coronavirus. The result was positive in 66.5% of cases, RSV was the most common virus (40.2%). Except for rhinovirus (17%), all other virus had frequency rates lower than 6%. Viral coinfections were detected in 13.8% of samples. Possible related risk factors for RSV infection were low age upon entry, attendance of daycare, low gestational age, and low educational level of the father. The relative frequency of viral infections was associated with increasing temperature and decreasing humidity separately, but the results also suggested both associated with increased frequency of RSV. Some of these findings differ from those reported for other regions in Brazil and may be used to guide policies that address LRTI.

Prematurity and the burden of influenza and respiratory syncytial virus disease

BACKGROUND

Respiratory morbidity of former preterm infants and especially those with bronchopulmonary dysplasia (BPD) is high during infancy and early childhood.

DATA SOURCES

We performed a review based on a literature search including EMBASE, MEDLINE, and CINAHL databases to identify all relevant papers published in the English and German literature on influenza and respiratory syncytial virus infection associated with preterm infant, prematurity, and BPD between 1980 and 2014.

RESULTS

Recurrent respiratory symptoms remain common at preschool age, school age and even into young adulthood. Acute viral respiratory tract infections due to different pathogens cause significant morbidity and necessitate rehospitalizations during the first years of life. Influenza virus infection plays a minor role compared to respiratory syncytial virus (RSV) associated respiratory tract infection during infancy and early childhood. Nevertheless, particular morbidity to both viruses is high.

CONCLUSIONS

The particular burden of both viral diseases in preterm infants is dominated by RSV and its associated rehospitalizations during the first two years of life. Prophylactic measures include vaccination against influenza virus of family members and caregivers and active immunization starting at the age of 6 months, and monthly injections of palivizumab during the cold season to avoid severe RSV disease and its sequelae.

Risk of respiratory syncytial virus infection in preterm infants: reviewing the need for prevention

Premature infants are at substantial risk for a spectrum of morbidities that are gestational age dependent. Respiratory syncytial virus (RSV) infection is most common in the first two years of life with the highest burden in children aged <6 months. Preterm infants ≤35 weeks' gestation are handicapped by incomplete immunological and pulmonary maturation and immature premorbid lung function with the added risk of bronchopulmonary dysplasia. Superimposed RSV infection incites marked neutrophilic airway inflammation and innate immunological responses that further compromise normal airway modeling. This review addresses the epidemiology and burden of RSV disease, focusing on the preterm population. Risk factors that determine RSV-disease severity and hospitalization and the impact on healthcare resource utilization and potential long-term respiratory sequelae are discussed. The importance of disease prevention and the evidence-based rationale for prophylaxis with palivizumab is explored, while awaiting the development of a universal vaccine.

Use of Medical Resources by Preterm Infants Born at Less than 33 Weeks' Gestation Following Discharge from the Neonatal Intensive Care Unit in Korea

This study was aimed to provide data on the use of medical resources by preterm infants following discharge from the neonatal intensive care unit (NICU). The cohort included preterm infants (n=2,351) born at 22-32 weeks' gestation who were discharged from the NICUs of 44 Korean hospitals between April 2009 to March 2010. Mean duration of post-discharge follow-up was 425±237 days. After discharge from the NICU, 94.5% of total infants visited a pediatric outpatient clinic (11.5±9.8 mean visits), 42.9% visited a pediatric clinic for respiratory problems irregularly (4.9±6.6 mean visits), and 31.1% utilized emergency center at least once. Among all visits to the emergency center, 24.7% resulted in readmission and 50.8% of those visits were due to respiratory problems. At least one episode of readmission was required by 33.6% (788/2,346) of total infants, and 18.4% (431/2,346) of total infants were readmitted with respiratory problems at least once. Among all infants readmitted for respiratory problems, 16.2% (70/341) were diagnosed with respiratory syncytial virus infection which accounted for 30.3% of viral etiologies confirmed by laboratory testing. Infants born at <30 weeks' gestation had more frequent total readmission and respiratory readmission than those ≥30 weeks' gestation (2±1.7 vs. 1.7±1.2, P=0.009, 1.8±1.2 vs. 1.5±1.1, 0.027, respectively). Overall, use of medical resources is common, and respiratory problems are the leading cause of use of medical resources. Total readmissions and respiratory readmissions are more frequent in more immature infants.

Respiratory Syncytial Virus Related Readmission in Preterm Infants Less than 34 weeks' Gestation Following Discharge from a Neonatal Intensive Care Unit in Korea

This study was done to evaluate respiratory syncytial virus (RSV) related readmission (RRR) and risk factors of RRR in preterm infants < 34 weeks gestational age (GA) within 1 yr following discharge from the neonatal intensive care unit (NICU). Infants (n = 1,140) who were born and admitted to the NICUs of 46 hospitals in Korea from April to September 2012, and followed up for > 1 yr after discharge from the NICU, were enrolled. The average GA and birth weight of the infants was 30(+5) ± 2(+5) weeks and 1,502 ± 474 g, respectively. The RRR rate of enrolled infants was 8.4% (96/1,140), and RSV accounted for 58.2% of respiratory readmissions of infants who had laboratory tests confirming etiological viruses. Living with elder siblings (odd ratio [OR], 2.68; 95% confidence interval [CI], 1.68-4.28; P < 0.001), and bronchopulmonary dysplasia (BPD) (OR, 2.95; 95% CI, 1.44-6.04; P = 0.003, BPD vs. none) increased the risk of RRR. Palivizumab prophylaxis (OR, 0.06; 95% CI, 0.03-0.13; P < 0.001) decreased the risk of RRR. The risk of RRR of infants of 32-33 weeks' gestation was lower than that of infants < 26 weeks' gestation (OR, 0.11; 95% CI, 0.02-0.53; P = 0.006). This was a nationwide study that evaluated the rate and associated risk factors of RRR in Korean preterm infants. Preterm infants with BPD or living with siblings should be supervised, and administration of palivizumab to prevent RRR should be considered.

Heliox inhalation therapy for bronchiolitis in infants

BACKGROUND

Bronchiolitis is the leading cause of hospitalisation among infants in high-income countries. Acute viral bronchiolitis is associated with airway obstruction and turbulent gas flow. Heliox, a mixture of oxygen and the inert gas helium, may improve gas flow through high-resistance airways and decrease the work of breathing. In this review, we selected trials that objectively assessed the effect of the addition of heliox to standard medical care for acute bronchiolitis.

OBJECTIVES

To assess heliox inhalation therapy in addition to standard medical care for acute bronchiolitis in infants with respiratory distress, as measured by clinical endpoints (in particular the rate of endotracheal intubation, the rate of emergency department discharge, the length of treatment for respiratory distress) and pulmonary function testing (mainly clinical respiratory scores).

SEARCH METHODS

We searched CENTRAL (2015, Issue 2), MEDLINE (1966 to March week 3, 2015), EMBASE (1974 to March 2015), LILACS (1982 to March 2015) and the National Institutes of Health (NIH) website (May 2009).

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs of heliox in infants with acute bronchiolitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality.

MAIN RESULTS

We included seven trials involving 447 infants younger than two years with respiratory distress secondary to viral bronchiolitis. All children were recruited from a paediatric intensive care unit (PICU; 378 infants), except in one trial (emergency department; 69 infants). All children were younger than two (under nine months in two trials and under three months in one trial). Positive tests for respiratory syncytial virus (RSV) were required for inclusion in five trials. The two other trials were carried out in the bronchiolitis seasons. Seven different protocols were used for inhalation therapy with heliox.When heliox was used in the PICU, we observed no significant reduction in the rate of intubation: risk ratio (RR) 2.73 (95% confidence interval (CI) 0.96 to 7.75, four trials, 408 infants, low quality evidence). When heliox inhalation was used in the emergency department, we observed no increase in the rate of discharge: RR 0.51 (95% CI 0.17 to 1.55, one trial, 69 infants, moderate quality evidence).There was no decrease in the length of treatment for respiratory distress: mean difference (MD) -0.19 days (95% CI -0.56 to 0.19, two trials, 320 infants, moderate quality evidence). However, in the subgroup of infants who were started on nasal continuous positive airway pressure (nCPAP) right from the start, because of severe respiratory distress, heliox therapy reduced the length of treatment: MD -0.76 days (95% CI -1.45 to -0.08, one trial, 21 infants, low quality evidence). No adverse events related to heliox inhalation were reported.We found that infants treated with heliox inhalation had a significantly lower mean clinical respiratory score in the first hour after starting treatment when compared to those treated with air or oxygen inhalation: MD -1.04 (95% CI -1.60 to -0.48, four trials, 138 infants, moderate quality evidence). This outcome had statistical heterogeneity, which remained even after removing the study using a standard high-concentration reservoir mask. Several factors may explain this heterogeneity, including first the limited number of patients in each trial, and the wide differences in the baseline severity of disease between studies, with the modified Wood Clinical Asthma Score (m-WCAS) in infants treated with heliox ranging from less than two to more than seven.

AUTHORS' CONCLUSIONS

Current evidence suggests that the addition of heliox therapy may significantly reduce a clinical score evaluating respiratory distress in the first hour after starting treatment in infants with acute RSV bronchiolitis. We noticed this beneficial effect regardless of which heliox inhalation protocol was used. Nevertheless, there was no reduction in the rate of intubation, in the rate of emergency department discharge, or in the length of treatment for respiratory distress. Heliox could reduce the length of treatment in infants requiring CPAP for severe respiratory distress. Further studies with homogeneous logistics in their heliox application are needed. Inclusion criteria must include a clinical severity score that reflects severe respiratory distress to avoid inclusion of children with mild bronchiolitis who may not benefit from heliox inhalation. Such studies would provide the necessary information as to the appropriate place for heliox in the therapeutic schedule for severe bronchiolitis.

Association of Gestational Age at Birth with Reasons for Subsequent Hospitalisation: 18 Years of Follow-Up in a Western Australian Population Study

Background

Preterm infants are at a higher risk of hospitalisation following discharge from the hospital after birth. The reasons for rehospitalisation and the association with gestational age are not well understood.

Methods

This was a retrospective birth cohort study of all live, singleton infants born in Western Australia between 1^st January 1980 and 31^st December 2010, followed to 18 years of age. Risks of rehospitalisation following birth discharge by principal diagnoses were compared for gestational age categories (<32, 32–33, 34–36, 37–38 weeks) and term births (39–41weeks). Causes of hospitalisations at various gestational age categories were identified using ICD-based discharge diagnostic codes.

Results

Risk of rehospitalisation was inversely correlated with gestational age. Growth-related concerns were the main causes for rehospitalisation in the neonatal period (<1 month of age) for all gestational ages. Infection was the most common reason for hospitalisation from 29 days to 1 year of age, and up to 5 years of age. Injury-related hospitalisations increased in prevalence from 5 years to 18 years of age. Risk of rehospitalisation was higher for all preterm infants for most causes.

Conclusions

The highest risks of rehospitalisation were for infection related causes for most GA categories. Compared with full term born infants, those born at shorter GA remain vulnerable to subsequent hospitalisation for a variety of causes up until 18 years of age.

Preterm cord blood CD4⁺ T cells exhibit increased IL-6 production in chorioamnionitis and decreased CD4⁺ T cells in bronchopulmonary dysplasia

BACKGROUND

Chorioamnionitis (CA) is associated with premature delivery and bronchopulmonary dysplasia (BPD). We hypothesize that preterm infants exposed to CA have reduced suppressive regulatory T cells (Treg) and increased non-regulatory T cell pro-inflammatory cytokines, increasing risk for BPD.

OBJECTIVE

To evaluate cord blood CD4(+) T cell regulatory phenotype and pro-inflammatory cytokine production in CA and BPD groups.

STUDY DESIGN

Cord blood mononuclear cells from infants (GA ⩽32 weeks), with or without placental histological evidence of CA (hChorio), were analyzed by flow cytometry. Clinical information was collected by retrospective chart review. Numbers of putative Treg (CD4(+)FoxP3(+)CD25(+)CD127Dim), CD4(+) non-Tregs, and CD4(+) T cell intracellular cytokine content following in vitro stimulation were compared with CA status and oxygen requirement at 36weeks postmenstrual age.

RESULT

Absolute Treg numbers were not different in CA and non-CA exposed samples. However, the infants who developed BPD had a significant decrease in Treg and non-regulatory T cell numbers. Greater IL-6 production was observed in hCA group.

CONCLUSION

A pro-inflammatory CD4(+) T cell status is noted in CA and BPD but the later disease is also associated with decrease in Tregs, suggesting that the development of BPD is marked by distinct inflammatory changes from those of CA exposed infants.

Clinical characteristics and risk factors of severe respiratory syncytial virus-associated acute lower respiratory tract infections in hospitalized infants

BACKGROUND

To investigate the clinical characteristics and analyze risk factors for severe respiratory syncytial virus (RSV) infection in hospitalized infants with acute lower respiratory tract infections (ALRIs).

METHODS

A retrospective review of the medical records of infants with RSV-associated ALRIs between March 1st, 2011 and February 29th, 2012 was conducted. Subjects were followed up over the phone or by outpatient visit six and twelve months after discharge.

RESULTS

Among 913 RSV-associated ALRIs infants, 288 (31.5%) had severe infections, which accounted for 4.2% of hospitalized children. The hospital RSV mortality rate was 1.0%. The proportions of cases with tachypnea, apnea, cyanosis, and fine rales were significantly higher in the severe ALRIs group (all P<0.001). Multivariate logistic regression showed that low-birth-weight [1.698 (1.028-2.805)], age less than 3 months old [3.385 (2.174-5.271)], congenital heart disease [1.667 (1.149-2.418)], bronchopulmonary dysplasia [8.505 (1.731-41.780)], and airway abnormalities [2.246 (1.008-5.005)] were independent risk factors for severe ALRIs. The incidence of bronchitis, pneumonia and readmission in the severe group was significantly higher than that of the non-severe group during the one-year follow-up (all P<0.001).

CONCLUSIONS

Younger age, low birth weight and underlying disease are associated with severe RSVassociated ALRIs. Furthermore, severe RSV infections may be associated with a higher frequency of subsequent bronchitis, pneumonia and re-hospitalization in the following year.

Prolonged seasonality of respiratory syncytial virus infection among preterm infants in a subtropical climate

Objective

There is limited epidemiological data on the seasonality of respiratory syncytial virus (RSV) infection in subtropical climates, such as in Taiwan. This study aimed to assess RSV seasonality among children ≤24 months of age in Taiwan. We also assessed factors (gestational age [GA], chronologic age [CA], and bronchopulmonary dysplasia [BPD]) associated with RSV-associated hospitalization in preterm infants to confirm the appropriateness of the novel Taiwanese RSV prophylactic policy.

Study Design

From January 2000 to August 2010, 3572 children aged ≤24-months were admitted to Taipei Mackay Memorial Hospital due to RSV infection. The monthly RSV-associated hospitalization rate among children aged ≤24 months was retrospectively reviewed. Among these children, 378 were born preterm. The associations between GA, CA, and BPD and the incidence of RSV-associated hospitalization in the preterm infants were assessed.

Results

In children aged ≤24 months, the monthly distribution of RSV-associated hospitalization rates revealed a prolonged RSV season with a duration of 10 months. Infants with GAs ≤32 weeks and those who had BPD had the highest rates of RSV hospitalization (P<0.001). Preterm infants were most vulnerable to RSV infection within CA 9 months.

Conclusions

Given that Taiwan has a prolonged (10-month) RSV season, the American Academy of Pediatrics' recommendations for RSV prophylaxis are not directly applicable. The current Taiwanese guidelines for RSV prophylaxis, which specify palivizumab injection (a total six doses until CA 8–9 months) for preterm infants (those born before 28^6/7 weeks GA or before 35^6/7 weeks GA with BPD), are appropriate. This prophylaxis strategy may be applicable to other countries/regions with subtropical climates.

Updated guidance for palivizumab prophylaxis among infants and young children at increased risk of hospitalization for respiratory syncytial virus infection

Guidance from the American Academy of Pediatrics (AAP) for the use of palivizumab prophylaxis against respiratory syncytial virus (RSV) was first published in a policy statement in 1998. Guidance initially was based on the result from a single randomized, placebo-controlled clinical trial conducted in 1996-1997 describing an overall reduction in RSV hospitalization rate from 10.6% among placebo recipients to 4.8% among children who received prophylaxis. The results of a second randomized, placebo-controlled trial of children with hemodynamically significant heart disease were published in 2003 and revealed a reduction in RSV hospitalization rate from 9.7% in control subjects to 5.3% among prophylaxis recipients. Because no additional controlled trials regarding efficacy were published, AAP guidance has been updated periodically to reflect the most recent literature regarding children at greatest risk of severe disease. Since the last update in 2012, new data have become available regarding the seasonality of RSV circulation, palivizumab pharmacokinetics, the changing incidence of bronchiolitis hospitalizations, the effects of gestational age and other risk factors on RSV hospitalization rates, the mortality of children hospitalized with RSV infection, and the effect of prophylaxis on wheezing and palivizumab-resistant RSV isolates. These data enable further refinement of AAP guidance to most clearly focus on those children at greatest risk.

A novel six consecutive monthly doses of palivizumab prophylaxis protocol for the prevention of respiratory syncytial virus infection in high-risk preterm infants in Taiwan

BACKGROUND

Respiratory syncytial virus (RSV) circulates year round in Taiwan. A novel six consecutive monthly doses of palivizumab for RSV prevention protocol has been approved for high risk preterm infants since December 2010. This study aimed to determine the clinical effectiveness and safety of this novel protocol for the prevention of RSV infection.

METHODS

From April 2011 to March 2013, we enrolled infants born at ≤28 weeks gestation and infants born at ≤35 weeks gestation with chronic lung disease (CLD) who received palivizumab prophylaxis as study group and followed up for 12 months. Historic control, those who were born and followed up between July 2000 and June 2008, were retrieved for propensity score matching. Primary endpoint was RSV-related hospitalization, and secondary endpoints included the length of hospital stay and intensive care unit (ICU) care.

RESULTS

We enrolled 127 infants (108 infants born at ≤28 weeks and 19 infants born at 29-35 weeks with CLD). They completed 6-dose palivizumab as scheduled. Among the study group, the RSV-related hospitalizations were 2 (1.6%) within 6 months and 5 (3.9%) within 12 months after discharge. We matched 127 infants in the control group with 127 infants in the study group by propensity score matching. The reduction of RSV-related hospitalization rates were 86% (10.2% vs 1.6%, p = 0.002) within 6 months after discharge and 78% (15.7% vs 3.9%, p = 0.004) within 12 months after discharge. Compared to the control group, the rate of ICU care significantly decreased from 7.1% to 0.8% (p = 0.024) within 6 months after discharge and from 7.9% to 0.8% (p = 0.014) within 12 months after discharge. Adverse events were recorded in 6.4% injections.

CONCLUSIONS

Six monthly intramuscular administration of palivizumab is effective for prevention of RSV hospitalization in regions with no single seasonal peak of RSV infection such as Taiwan.

At-risk characteristics for hospital admissions and ED visits

PURPOSE

The purpose of this study was to explore the factors associated with hospital utilization among infants and young children with complex chronic conditions (CCC).

DESIGN AND METHODS

A descriptive, retrospective study was conducted with 216 medical records of children with CCC.

RESULTS

Greater complexity, younger age, living with siblings, use of public insurance or self-pay, use of more than one type of insurance, and presence of conditions affecting certain body systems were associated with increased hospital and emergency department (ED) utilization.

PRACTICE IMPLICATIONS

Nurses must have a heightened awareness of these at-risk characteristics to prevent avoidable hospital admissions and ED visits.

Long-term growth and general health for the tiniest or most immature infants

Given the improving survival rates of extremely preterm (EP, gestational age <28 weeks) infants, there is a need to understand their general growth and health outcomes not only in childhood, but also into adulthood. EP children are shorter and lighter compared with term children at term-equivalent age; with time, the weight disadvantage diminishes but the height disadvantage remains relatively unchanged. EP children and young adults also have higher rates of reported health concerns, medical conditions and visual impairment. Hospital readmissions are higher in early childhood, mostly attributed to respiratory illness. Individuals born EP have reduced bone health and are at increased risk for metabolic disorders. Increased rates of conditions such as diabetes or pathological fractures are not reported in the literature, although follow-up studies so far have only tracked EP individuals into young adulthood. Consequently, health care utilization and costs are increased in EP children and young adults. A thorough knowledge of the health risks related to EP birth is essential in planning surveillance and intervention strategies to optimize their health and wellbeing. Despite the increased risk of health problems, EP young adults generally report their quality of life to be similar to that reported in their term counterparts.

A cost-effectiveness analysis of respiratory syncytial virus (RSV) prophylaxis in infants in the United Kingdom

BACKGROUND

Respiratory syncytial virus (RSV) is a common cause of respiratory infection that is highly prevalent in infants. Severe cases of RSV infection require hospitalisation; this is most likely to occur in infant populations at high risk. The study assesses the cost-effectiveness of palivizumab versus no prophylaxis in infants at high risk of hospitalisation with RSV in the United Kingdom (UK).

METHODS

A decision tree model was developed to reflect the clinical pathway of infants at high risk of severe RSV infection who receive either prophylaxis with palivizumab or no prophylaxis. The main outcome was the incremental cost-effectiveness ratio (ICER). One-way and probabilistic sensitivity analyses were performed to assess the degree of uncertainty surrounding the results. A threshold analysis considered the impact of clinical and environmental risk factors on the cost-effectiveness in the subgroup of preterm infants 33-35 weeks gestational age (wGA).

RESULTS

Prophylaxis with palivizumab compared with no prophylaxis is associated with the following ICERs; £33,216 for infants with congenital heart disease; £19,168 for infants with chronic lung disease; £3,845 for preterm infants < 29 wGA; £30,205 for preterm infants 29-32 wGA; and £99,056 for preterm infants 33-35 wGA. One-way sensitivity analysis suggests that these results are highly sensitive to the input data. Threshold analysis in the preterm 33-35 wGA subgroup demonstrates that an adjusted RSV-hospitalisation baseline risk of 17.94% or higher would result in an ICER below the £30,000 per quality-adjusted life-year threshold.

DISCUSSION

Palivizumab is cost-effective compared to no prophylaxis in the United Kingdom in many of the subgroups considered, showing that palivizumab would be a cost-effective use of National Health Service resources.

Hospital readmissions and repeat emergency department visits among children with medical complexity: an integrative review

Children with medical complexity (CMC) have chronic conditions, intense healthcare needs, and high healthcare utilization. Proposed changes in the healthcare environment initiated by the Affordable Care Act have led to efforts toward preventing hospital readmissions. The purpose of this integrative review is to explore the current empirical literature and examine how hospital readmissions and repeat emergency department visits have been studied among CMC. A computer database search and ancestry search were conducted, resulting in a sample of 26 studies. The results of the integrative review are presented along with gaps in the literature and implications for nursing practice and research.

Should respiratory care in preterm infants include prophylaxis against respiratory syncytial virus infection? The case in favour

Respiratory syncytial virus (RSV) is the most significant cause of acute respiratory tract infections (RTI) in infants and young children throughout the world. Preterm infants are at increased risk for severe RSV lower respiratory tract infection due to small lung volumes, a reduced lung surface area, small airways and an increased air space wall thickness. Additionally, the airways of preterm infants have been ventilated mechanically and suctioned and potentially damaged by many microtraumas with disruption of endothelial surfaces enabling pathogens to invade more easily. The immune system of preterm infants is immature resulting in low antibody titers (incomplete transplacental transfer of maternal antibodies) and a reduced cellular immunity with reduced viral clearance. Rehospitalization rates of preterm compared to term infants due to RSV infection are increased as are total morbidity and mortality associated with RSV disease. Palivizumab effectively reduces RSV related rehospitalisation in this high-risk population.

Effects of parental and household smoking on the risk of respiratory syncytial virus (RSV) hospitalisation in late-preterm infants and the potential impact of RSV prophylaxis

OBJECTIVE

To assess the impact of household smoking and palivizumab prophylaxis on the risk of respiratory syncytial virus (RSV) hospitalisation in late-preterm (32-35 weeks' gestational age) infants.

METHODS

Familial smoking and other RSV risk factor data from the FLIP, FLIP-2 and IMpact studies and datasets from France, Germany and Italy, together with palivizumab prophylaxis data from the FLIP-2 and IMpact studies, were analysed using cross-correlation and Bayesian meta-analytical modelling employing Markov Chain Monte Carlo sampling.

RESULTS

There were 2.35 times (95% confidence interval [CI] 1.37-4.02) as many hospitalisations amongst infants from smoking compared with those from non-smoking families. Among non-prophylaxed infants, there were 2.53 times (95% CI 1.27-4.94) as many RSV hospitalisations from smoking than from non-smoking families and that excess hospitalisation was reduced to 1.03 times (95% CI 0.38-2.99) amongst prophylaxed infants. Familial smoking correlates significantly (p < 0.01) with other RSV risk factors: positive correlation with number of school-age siblings, history of family atopy, family wheeze and gestational age; negative correlation with birth weight and breast feeding.

CONCLUSIONS

Late-preterm infants from smoking families appear to be at heightened risk for severe RSV infection requiring hospitalisation of which the risk may be reduced with RSV prophylaxis.

The risk of mortality among young children hospitalized for severe respiratory syncytial virus infection

Respiratory syncytial virus (RSV) lower respiratory tract infection (LRTI) is the leading cause of childhood morbidity. Although also an important cause of childhood mortality worldwide, the impact of key risk factors has not been established. A systematic review of 34 articles reporting case fatality rates in young children hospitalized for severe RSV LRTI, according to the presence of underlying RSV risk factors, was conducted. The weighted mean case fatality rate was 1.2% (range, 0-8.3%; median, 0%; n = 10) among preterm infants; 5.2% (range, 2.0-37.0%; median, 5.9%; n = 7) among children with CHD; and 4.1% (range, 0-10.5%; median, 7.0%; n = 6) among children with BPD. Case fatality estimates among children not at high risk (n = 6) ranged from 0% to 1.5% (weighted mean, 0.2%; median, 0.0%). Fatality during hospitalization for severe RSV LRTI is rare among children not at high risk, but occurs more commonly among children at higher risk of RSV LRTI.

Clinical and epidemiologic features of respiratory syncytial virus

Since its discovery in 1955, respiratory syncytial virus (RSV) has consistently been noted to be the single most important cause of lower respiratory tract illness in infants <1 year of age. RSV also causes repeat infections and significant disease throughout life. In addition to the young child, persons with compromised immune, pulmonary or cardiac systems, and the elderly have significant risk from infection. Though RSV causes the full spectrum of acute respiratory illnesses, it is most notably associated with signs and symptoms of increased airway resistance manifested as wheezing and, in the young child, diagnosed as bronchiolitis. In temperate climates, RSV occurs as yearly outbreaks usually between late fall and early spring lasting 3-4 months in a community. The timing of outbreaks varies between years and in the same year between regions and even between nearby communities. RSV can be a serious nosocomial pathogen in high risk individuals but nosocomial transmission that can often be prevented with meticulous attention to good infection control practices. High risk groups include the premature infants and persons of any age with compromised cardiac, pulmonary, or immune systems. Risk factors for infection include increased number of children in the household and day care center attendance. There are reasonable estimates of the sizable burden of RSV disease in infants and young children and the elderly but less data on disease in older children, the role of RSV in later reactive airway disease (see chapter by M.T. Lotz et al. , this volume), and RSV-associated mortality in developing countries. The available data on burden of disease suggests there are at least four potential target populations for a vaccine, the young infant, young children >4-6 months of age, pregnant women, and the elderly. A link between infection in the young infant and later reactive airway disease and mortality in developing countries is needed. Each target population has different vaccine safety and efficacy concerns and may warrant a different type of vaccine.

Cost-effectiveness of palivizumab in infancy

Respiratory syncytial virus is the most common cause of bronchiolitis, a lower respiratory tract infection occurring in infancy. It is responsible for several rehospitalizations, substantial morbidity and occasional deaths in the UK every year. Palivizumab is a recombinant monoclonal antibody that has been shown to reduce hospitalizations in infected infants. It is licensed for high-risk infants, primarily those born pre-term or with chronic pulmonary or cardiac conditions. Palivizumab is expensive, but several economic analyses have determined highly discrepant costs. This article reviews the limitations of the available efficacy and economic data, and highlights problems in interpretation and extrapolation. We also present the results of a cost-effectiveness analysis relevant to populations of high-risk infants in the UK.

Prolonged exclusive breastfeeding, autumn birth and increased gestational age are associated with lower risk of fever in children with hand, foot, and mouth disease

Epidemics of hand, foot, and mouth disease (HFMD) have been emerging and reemerging in recent years. This study aims to investigate whether breastfeeding and other factors may affect the profile of fever and disease course in children with HFMD. Three hundred seventy-two preschool children with HFMD were included. The demographics, environmental factors, and delivery- and feeding-associated factors in the children were obtained and their effects on the profile of fever and disease course were analyzed. Of the 372 children, 139 (37.37%) had fever during the disease course. Gender, breastfeeding pattern, birth season and gestational age were significantly different between the children with and without fever (p = 0.034, p < 0.0001, p = 0.035 and p = 0.013, respectively). After multivariate-adjusted analysis, prolonged exclusive breastfeeding (p = 0.001, OR 0.401, 95% CI 0.229-0.704), autumn birth (p = 0.007, OR 0.409, 95% CI 0.214-0.784) and higher gestational age (p = 0.029, OR 0.089, 95% CI 0.010-0.781) were protective factors for the incidence of fever.

Epidemiology of respiratory syncytial virus infection in infants born at less than thirty-five weeks of gestational age

BACKGROUND

The aims of this study were to observe the respiratory syncytial virus (RSV) hospitalization rate and to identify the risk factors for hospitalization for RSV infection among infants in Korea born at <35 weeks of gestational age and who had not previously received palivizumab.

METHODS

We conducted a study over a 2.5-year period (between April 2007 and September 2009) that included premature infants (<35 weeks of gestational age) who underwent follow-up during 1 year after discharge from the neonatal intensive care unit. Demographic information was collected for each subject at baseline, and the reasons for hospitalization were obtained during the 1-year follow-up period.

RESULTS

The study population included 1022 subjects who completed follow-up interviews. Eight hundred seventeen infants were included in analysis for RSV hospitalization. Excluded from the study were 167 subjects with chronic lung disease who had received palivizumab prophylaxis and 38 subjects who were not tested for RSV. The overall incidence of RSV hospitalization in the group that did not receive palivizumab was 4.5% (37 of 817 patients). Independent risk factors associated with RSV hospitalization were multiple gestation (P = 0.022) and longer duration of mechanical ventilation in the neonatal intensive care unit (P = 0.039).

CONCLUSION

This study showed the epidemiology and risk factors of RSV hospitalization in preterm infants in Korea. RSV infection was one of the main causes of hospitalization after discharge from the neonatal intensive care unit in patients born at <35 weeks of gestational age.

Factors associated with rehospitalizations of very low birthweight infants: impact of a transition home support and education program

OBJECTIVE

To determine the effects of a transition-home education and support program, BPD, and health insurance type on VLBW infant rehospitalizations at 3 and 7 months corrected age. It was hypothesized that the transition-home program would be associated with decreased rehospitalizations between Phase 1 and 2, and public health insurance and BPD would be associated with increased rehospitalizations.

METHODS

274 infants with birth weight <1500 g were enrolled in two successive years of a transition-home program (Phase 1-start-up) and (Phase 2-full implementation) and followed to 7 months CA.

RESULTS

The Phase 2 rehospitalization rates were lower but not statistically significant at both 3 months (20% and 15%; p=0.246), and 7 months (24% and 17%; p=0.171). Infants with public insurance had twice as many rehospitalizations by 3 months (28% versus 11%; p=0.018) in Phase 1. In regression analyses the intervention effects did not achieve significance for the cohort at 3 months (OR=0.63; CI=0.33 to 1.20) or 7 months (OR=0.61; CI=0.33 to 1.13). BPD and public insurance did not reach significance in the models whereas siblings were significantly associated with increased odds of rehospitalization. In subgroup analyses for infants on pubic health insurance the intervention significantly decreased the odds of rehospitalization between Phase 1 and 2(OR=0.43; CI=0.19 to 0.96) at 3 months.

CONCLUSIONS

Our findings suggest that a transition-home program may be beneficial to reduce the rehospitalization rate for VLBW infants, and infants on public insurance may derive greater benefit.

Systematic literature review assessing tobacco smoke exposure as a risk factor for serious respiratory syncytial virus disease among infants and young children

BACKGROUND

The role of environmental tobacco smoke (ETS) exposure as a risk factor for serious respiratory syncytial virus (RSV) disease among infants and young children has not been clearly established. This systematic review was conducted to explore the association between ETS exposure and serious RSV disease in children younger than 5 years, including infants and young children with elevated risk for serious RSV disease.

METHODS

A systematic review of English-language studies using the PubMed and EMBASE databases (1990-2009) was performed to retrieve studies that evaluated ETS as a potential risk factor for serious RSV illness. Studies assessing risk factors associated with hospitalization, emergency department visit, or physician visit due to RSV (based on laboratory confirmation of RSV or clinical diagnosis of RSV) in children under the age of 5 years were included.

RESULTS

The literature search identified 30 relevant articles, categorized by laboratory confirmation of RSV infection (n = 14), clinical diagnosis of RSV disease (n = 8), and assessment of RSV disease severity (n = 8). Across these three categories of studies, at least 1 type of ETS exposure was associated with statistically significant increases in risk in multivariate or bivariate analysis, as follows: 12 of 14 studies on risk of hospitalization or ED visit for laboratory-confirmed RSV infection; 6 of 8 studies of RSV disease based on clinical diagnosis; and 5 of the 8 studies assessing severity of RSV as shown by hospitalization rates or degree of hypoxia. Also, 7 of the 30 studies focused on populations of premature infants, and the majority (5 studies) found a significant association between ETS exposure and RSV risk in the multivariate or bivariate analyses.

CONCLUSION

We found ample evidence that ETS exposure places infants and young children at increased risk of hospitalization for RSV-attributable lower respiratory tract infection and increases the severity of illness among hospitalized children. Additional evidence is needed regarding the association of ETS exposure and outpatient RSV lower respiratory tract illness. Challenges and potential pitfalls of assessing ETS exposure in children are discussed.