Respiratory syncytial virus immunoprophylaxis in high-risk infants with heart disease

An epidemiological investigation of high-risk infants for Respiratory Syncytial Virus infections: a retrospective cohort study

BACKGROUND

Respiratory Syncytial Virus (RSV) infections may lead to severe consequences in infants born preterm with breathing problems (such as bronchopulmonary dysplasia (BPD) and respiratory distress syndrome (RDS)) or congenital heart diseases (CHD). Since studies investigating the influence of different gestational age (WGA) and concomitant specific comorbidities on the burden of RSV infections are scarce, the present study aimed to better characterize these high-risk populations in the Italian context.

METHODS

This retrospective, longitudinal and record-linkage cohort study involved infants born between 2017 and 2019 in Lazio Region (Italy) and is based on data extracted from administrative databases. Each infant was exclusively included in one of the following cohorts: (1) BPD-RDS (WGA ≤35 with or without CHD) or (2) CHD (without BPD and/or RDS) or (3) Preterm (WGA ≤35 without BPD (and/or RDS) or CHD). Each cohort was followed for 12 months from birth. Information related to sociodemographic at birth, and RSV and Undetermined Respiratory Agents (URA) hospitalizations and drug consumption at follow-up were retrieved and described.

RESULTS

A total of 8,196 infants were selected and classified as 1,084 BPD-RDS, 3,286 CHD and 3,826 Preterm. More than 30% of the BPD-RDS cohort was composed by early preterm infants (WGA ≤ 29) in contrast to the Preterm cohort predominantly constitute by moderate preterm infants (98.2%), while CHD infants were primarily born at term (83.9%). At follow-up, despite the cohorts showed similar proportions of RSV hospitalizations, in BPD-RDS cohort hospitalizations were more frequently severe compared to those occurred in the Preterm cohort (p<0.01), in the BPD-RDS cohort was also found the highest proportion of URA hospitalizations (p<0.0001). In addition, BPD-RDS infants, compared to those of the remaining cohorts, received more frequently prophylaxis with palivizumab (p<0.0001) and were more frequently treated with adrenergics inhalants, and glucocorticoids for systemic use.

CONCLUSIONS

The assessment of the study clinical outcomes highlighted that, the demographic and clinical characteristics at birth of the study cohorts influence their level of vulnerability to RSV and URA infections. As such, continuous monitoring of these populations is necessary in order to ensure a timely organization of health care system able to respond to their needs in the future.

Prophylaxis protects infants with congenital heart disease from severe forms of RSV infection: an Italian observational retrospective study : Palivizumab prophylaxis in children with congenital heart disease

BACKGROUND

In children with congenital heart disease (CHD) respiratory syncytial virus (RSV) infection may have a severe course, with increased risk of morbidity and mortality, requiring hospital admission and intensive care. The aim of the present study was to evaluate the effect of prophylaxis with palivizumab in preventing RSV-associated hospitalization in infants with CHD.

METHODS

We carried out an observational, retrospective study in a paediatric cardiology division at a secondary-care centre in Italy, extracting from the database children with CHD who, from November 2004 to March 2022, matched the criteria for palivizumab prophylaxis, to evaluate the hospitalization rate in CHD patients with and without palivizumab prophylaxis and their RSV-related hospitalization characteristics compared with a group of children without CHD and no other underlying clinical conditions (control group, CG), hospitalized for RSV infection.

RESULTS

One hundred twenty-eight children with CHD were enrolled in the study, mainly (71.9%) with increased pulmonary flow, and received palivizumab prophylaxis. Twenty-seven received hospital care for bronchiolitis. Almost all CHD patients hospitalized for bronchiolitis (26 out of 27) received partial prophylaxis (≤ 3 doses). CHD patients with bronchiolitis stay longer in the hospital than control (14.4 ± 21.7 days vs 6.2 ± 2.3 days) some of which require intensive care (n = 4).

CONCLUSIONS

Our study provides evidence of the efficacy of palivizumab in protecting patients with hemodynamically significant CHD under the age of 2 years from RSV disease and its life-threatening complications. Reducing hospitalisation rate, morbidity, and mortality in this category of patients, passive immune prophylaxis with palivizumab may impact healthcare resource availability and utilisation.

Viral Respiratory Infection, a Risk in Pediatric Cardiac Surgery: A Propensity-Matched Analysis

OBJECTIVES

1) To describe the postoperative course and outcomes of cardiac surgery in children with perioperative viral respiratory infection, 2) to evaluate optimal surgical timing for preoperative viral respiratory infection patients, and 3) to define risk stratification.

DESIGN

Retrospective study of children undergoing cardiac surgery. Children were tested using a multiplex polymerase chain reaction (respiratory virus polymerase chain reaction) panel capturing seven respiratory viruses. Respiratory virus polymerase chain reaction testing was routinely performed in patients under 2 years old. Those with negative results yet highly suspected of viral respiratory infection after surgeries would be tested again.

SETTING

A pediatric cardiac surgical ICU of pediatric cardiac surgery department at Fuwai Hospital.

PATIENTS

Children admitted between January 1, 2014, and December 31, 2016, to perform respiratory virus polymerase chain reaction testing and cardiac surgery were included.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 2,831 patients had respiratory virus polymerase chain reaction testing, and viruses were detected in 91 patients (3.2%), including 35 preoperative and 56 postoperative. Of the 35 preoperative viral respiratory infection patients, there were 29 viral respiratory infection-resolved (patients for whom surgery was postponed until resolution of viral respiratory infection symptoms and negative respiratory virus polymerase chain reaction) and six viral respiratory infection-unresolved (who underwent cardiac surgery before resolution of symptoms and clearance of carriage) patients. Furthermore, there were seven deaths, including one in the preoperative viral respiratory infection-unresolved group and six in the postoperative viral respiratory infection group. A propensity score matching was performed to correct the selection bias and identify the comparable patient groups. Compared to their matched nonviral respiratory infection patients, viral respiratory infection-resolved patients had similar duration of mechanical ventilation and length of stay, while viral respiratory infection-unresolved patients had longer durations of postoperative mechanical ventilation (p = 0.033), PICU (p = 0.028) and hospital length of stay (p = 0.010), and postoperative viral respiratory infection patients had significantly greater duration of postoperative recovery (p < 0.001) and higher mortality (p < 0.001). Earlier diagnosis of postoperative viral respiratory infection was associated with longer mechanical ventilation duration (r = 0.422; p < 0.001). Palliative cardiac surgery was the only variable significantly associated with mortality in multivariate analysis (odds ratio, 12.0; 95% CI, 1.6-87.5; p = 0.014).

CONCLUSIONS

The preoperative-unresolved and postoperative viral respiratory infection were associated with prolonged postoperative recovery, increased severity, and mortality in children with cardiac surgeries. Our results suggested the optimal surgical timing may be after the resolution of viral respiratory infection symptoms and carriage unless the perceived benefits of early surgery outweigh the risk of death, prolonged ventilation, and PICU length of stay. Palliative surgeries were associated with increasing mortality.

Mortality in children hospitalised with respiratory syncytial virus infection in Singapore

INTRODUCTION

This study aimed to investigate the trend and seasonality of infection due to respiratory syncytial virus (RSV) at KK Women's and Children's Hospital (KKH) in Singapore and to examine the risk factors for mortality among children with RSV infection requiring admission to the paediatric intensive care unit (PICU).

METHODS

A retrospective study was conducted at KKH on children with RSV infections who were admitted to the PICU between January 2004 and December 2010. The medical records of children who died from RSV infections were reviewed. Linear regression was performed to determine the risk factors of RSV mortality.

RESULTS

RSV infection was documented in 5,785 children during the study period, occurring throughout the year, with a small increase in prevalence between the months of June and August annually. Among 85 (1.5%) of 5,785 children who were admitted to the PICU for RSV infection, 74 (1.3%) survived and there were 11 (0.2%) deaths. Multivariate logistic regression analysis showed that significant haemodynamically significant cardiac disease (odds ratio [OR] 12.2, 95% confidence interval [CI] 0.9-16.7, p = 0.05), immunodeficiency (OR 71.4, 95% CI 8.2-500, p < 0.001) and metabolic disease (OR 71.4, 95% CI 4.3-1,000, p = 0.003) were independent risk factors for mortality in RSV infections. Prematurity increased the risk of admission to the PICU but was not significantly associated with mortality.

CONCLUSION

Children with haemodynamically significant cardiac disease, immunodeficiency and metabolic disease were at higher risk of death after hospitalisation for RSV-related illnesses. These children should be considered for palivizumab prophylaxis.

Respiratory syncytial virus prophylaxis and the "special population"

Bronchiolitis is the most frequent airway infection in the first 2 years of life, and the respiratory syncytial virus (RSV) is the most frequently responsible virus. In selected high-risk groups, RSV may cause severe respiratory disease leading to hospitalization, need for mechanical ventilation, and even death. These high-risk groups include children with congenital heart disease, infants with neuromuscular impairment, cystic fibrosis, Down Syndrome, immunodeficiency syndromes and others specific conditions. In these high-risk populations defined in literature as "special population", a 3- to 10-fold increase in the rate of RSV hospitalization has been observed, justifying RSV specific prophylaxis with palivizumab, a monoclonal antibody that binds a viral glycoprotein epitope and blocks the link between RSV and target cell. Evidence of safety and efficacy of RSV prophylaxis in these populations is lacking. Given the low incidence of these conditions, randomized clinical trials are not feasible. The purpose of this paper is to give an update from the literature of various conditions at higher risk to develop severe RSV infection, and to offer an overview of the efficacy of palivizumab in preventing RSV infection in these specific populations.

Respiratory virus prophylaxis in congenital heart disease

Respiratory syncytial virus (RSV) is the leading cause of acute lower respiratory tract infections and causes up to 200,000 infant deaths a year worldwide. The average rate of hospitalization for severe RSV infection is 5 per 1000 children, and the rate is three-times higher in those with congenital heart disease (CHD). Palivizumab, a monoclonal antibody, reduces hospitalization rates and intensive care admissions. It is used prophylactically and is administered as monthly doses during the RSV season. Hemodynamically unstable CHD is the most susceptible CHD to a severe episode of RSV infection. This review explores current evidence surrounding therapies, patterns of infection and identifies groups which may still be vulnerable to severe RSV infection.

CHD and respiratory syncytial virus: global expert exchange recommendations

BACKGROUND

Palivizumab is the standard immunoprophylaxis against serious disease due to respiratory syncytial virus infection. Current evidence-based prophylaxis guidelines may not address certain children with CHD within specific high-risk groups or clinical/management settings.

METHODS

An international steering committee of clinicians with expertise in paediatric heart disease identified key questions concerning palivizumab administration; in collaboration with an additional international expert faculty, evidence-based recommendations were formulated using a quasi-Delphi consensus methodology.

RESULTS

Palivizumab prophylaxis was recommended for children with the following conditions: <2 years with unoperated haemodynamically significant CHD, who are cyanotic, who have pulmonary hypertension, or symptomatic airway abnormalities; <1 year with cardiomyopathies requiring treatment; in the 1st year of life with surgically operated CHD with haemodynamically significant residual problems or aged 1-2 years up to 6 months postoperatively; and on heart transplant waiting lists or in their 1st year after heart transplant. Unanimous consensus was not reached for use of immunoprophylaxis in children with asymptomatic CHD and other co-morbid factors such as arrhythmias, Down syndrome, or immunodeficiency, or during a nosocomial outbreak. Challenges to effective immunoprophylaxis included the following: multidisciplinary variations in identifying candidates with CHD and prophylaxis compliance; limited awareness of severe disease risks/burden; and limited knowledge of respiratory syncytial virus seasonal patterns in subtropical/tropical regions.

CONCLUSION

Evidence-based immunoprophylaxis recommendations were formulated for subgroups of children with CHD, but more data are needed to guide use in tropical/subtropical countries and in children with certain co-morbidities.

Comparing First- and Second-year Palivizumab Prophylaxis in Patients With Hemodynamically Significant Congenital Heart Disease in the CARESS Database (2005-2015)

BACKGROUND

Respiratory syncytial virus hospitalization (RSVH) rates in children <2 years of age with hemodynamically significant congenital heart disease (HSCHD) are 2- to 4-fold higher compared with healthy term infants. Pediatric recommendations differ as to whether palivizumab is beneficial beyond 1 year of age. The objective of this study was to determine whether differences exist in respiratory-related illness hospitalization (RIH) and RSVH in HSCHD infants receiving palivizumab during the first year versus second year of life in the Canadian Registry of Palivizumab.

METHODS

The Canadian Registry of Palivizumab is a prospective database of infants who received ≥1 dose of palivizumab in 32 hospitals from 2005 to 2015. Demographic data were collected at enrollment and RIH events recorded monthly. Infants <24 months of age with HSCHD were recruited.

RESULTS

Of 1909 HSCHD infants, 1380 (72.3%) in the first year (mean age, 4.2 months) and 529 (27.7%) in the second year of life (mean age, 17.8 months) received prophylaxis. Baseline demographics for day-care attendance, multiple births, enrollment age and weight differed between the groups (all P < 0.05). Additionally, second year infants had a more complicated neonatal course, with significantly longer length of stay (51.2 vs. 24.9 days) compared with those in the first year. The RIH and RSVH rates in the first year were 11.2% and 2.3% and in the second year were 10.6% and 1.7%. Cox regression analysis showed similar hazard for RIH [hazard ratio, 1.9; 95% confidence interval: 0.7-4.6; P = 0.18] and RSVH [hazard ratio, 2.0; 95% confidence interval: 0.2-16.5; P = 0.52].

CONCLUSIONS

Infants in the first and second year of life had a similar RSVH hazard. These findings suggest that infants in the second year with HSCHD, who remain unstable, are equally at risk for RSVH and merit prophylaxis.

Incidence of Respiratory Disease During the First Two Years of Life in Children with Hemodynamically Significant Congenital Heart Disease in Italy: A Retrospective Study

Children affected by hemodynamically significant congenital heart disease (HSCHD) experience severe respiratory complications that can increase the frequency of hospitalizations. The aim of the SINERGY study was to describe the incidence of respiratory diseases and to collect information on active and passive immunoprophylaxis in the first 2 years of life. In this retrospective, multicenter, and epidemiologic study, children with HSCHD were enrolled across 11 Italian sites. Children born between December 31, 2007, and December 31, 2012, were observed during their first 2 years of life. Data were collected through hospital database searches and parent interviews. Four hundred twenty children were enrolled: 51.7 % were female, 79.5 % were born full-term (≥37 weeks), and 77.6 % weighed >2500 g at birth. The most frequent heart defects were ventricular septal defect (23.1 %) and coarctation of the aorta (14.3 %). The incidence of respiratory diseases was 63.1 %. Frequent respiratory diseases not requiring hospitalization were upper respiratory tract infections (76.4 %), acute bronchitis (43.3 %), and influenza (22.1 %), while those requiring hospitalization were bronchitis and bronchiolitis (8.3 % each one). While active immunoprophylaxis was applied with wide compliance (diphtheria/pertussis/tetanus, 99.5 %; Haemophilus influenzae type b, 72.5 %; pneumococcus, 79.9 %; meningococcus, 77.4 %), only 54 % of children received respiratory syncytial virus (RSV) passive prophylaxis (palivizumab). Of the 35 hospitalizations due to bronchiolitis, 27 (77.1 %) did not receive prophylaxis against RSV, compared with 8 (22.9 %) who received prophylaxis (P < 0.0001). Children with HSCHD are at major risk of respiratory diseases. Passive immunoprophylaxis can help to prevent hospitalizations for bronchiolitis.

Consensus conference on the appropriateness of palivizumab prophylaxis in respiratory syncytial virus disease

Respiratory syncytial virus infection represents a clinical burden among young children under 24 months. Palivizumab is the only drug licensed in Italy for the prevention of serious lower respiratory tract disease requiring hospitalization caused by respiratory syncytial virus in children at high risk. However recommendations for palivizumab prophylaxis are heterogeneous. Not all the published documents agree about the clinical indications of palivizumab; this could lead to different clinical practices and concerns about the appropriateness of prophylaxis. These issues and the lack of evidence about palivizumab prophylaxis efficacy in specific medical conditions brought on the idea of a consensus conference on the current recommendations for the management and prevention of bronchiolitis, in order to share useful indications. The goal was to perform a review of the evidence regarding the efficacy and the safety of palivizumab and give recommendations in order to harmonize its use. A structured and validated method to conduct the consensus process was adopted. The consensus conference recommends palivizumab prophylaxis in infants born before 29 weeks and younger than 12 months at the start of the epidemic season. According to evidence from literature and experts' opinion, palivizumab prophylaxis is not recommended in preterm infants of gestational age ≥29 weeks, without co-morbidity (i.e., cardiac, bronchopulmonary diseases). The experts identified some clinical rare conditions for which the decision of prophylaxis should be entrusted to the specialists. The evaluation of the appropriateness of palivizumab prophylaxis in the single patient should be documented by the specialists. Pediatr Pulmonol. 2016;51:1088-1096. © 2016 Wiley Periodicals, Inc.

Retrospective Multicenter Study of Respiratory Syncytial Virus Prophylaxis in Korean Children with Congenital Heart Diseases

BACKGROUND AND OBJECTIVES

We conducted a review of current data on respiratory syncytial virus (RSV) prophylaxis with palivizumab, in Korean children with congenital heart diseases (CHD). In 2009, the Korean guideline for RSV prophylaxis had established up to five shots monthly per RSV season, only for children <1 year of age with hemodynamic significance CHD (HS-CHD).

SUBJECTS AND METHODS

During the RSV seasons in 2009-2015, we performed a retrospective review of data for 466 infants with CHD, examined at six centers in Korea.

RESULTS

Infants received an average of 3.7±1.9 (range, 1-10) injections during the RSV season. Fifty-seven HS-CHD patients (12.2%) were hospitalized with breakthrough RSV bronchiolitis, with a recurrence in three patients, one year after the initial check-up. Among patients with simple CHD, only five (1.1%) patients received one additional dose postoperatively, as per the limitations set by the Korean guideline. Among the 30 deaths (6.4%), five (1.1%) were attributed to RSV infection; three to simple CHD, one to Tetralogy of Fallot, and one to hypertrophic cardiomyopathy (HCM). Of the three HCM patients that exceeded guidelines for RSV prophylaxis, two (66.6%) were hospitalized, and one died of RSV infection (33.3%).

CONCLUSION

In accordance to the Korean guideline, minimal injections of palivizumab were administered to patients having HS-CHD <one year of age during the RSV season; the risk of RSV infection remains significant among children with simple CHD, cardiomyopathy, and children above the age of one year with HS-CHD.

Respiratory Tract Infection and Risk of Hospitalization in Children with Congenital Heart Defects During Season and Off-Season: A Swedish National Study

Respiratory tract infections (RTI) are common among young children, and congenital heart defect (CHD) is a risk factor for severe illness and hospitalization. This study aims to assess the relative risk of hospitalization due to RTI in winter and summer seasons for different types of CHD. All children born in Sweden and under the age of two, in 2006-2011, were included. Heart defects were grouped according to type. Hospitalization rates for respiratory syncytial virus (RSV) infection and RTI in general were retrieved from the national inpatient registry. The relative risk of hospitalization was calculated by comparing each subgroup to other types of CHD and otherwise healthy children. The relative risk of hospitalization was increased for all CHD subgroups, and there was a greater increase in risk in summer for the most severe CHD. This included RSV infection, as well as RTI in general. The risk of hospitalization due to RTI is greater for CHD children. Prophylactic treatment with palivizumab, given to prevent severe RSV illness, is only recommended during winter. We argue that information to healthcare staff and parents should include how the risk of severe infectious respiratory tract illnesses, RSV and others, is present all year round for children with CHD.

Efficacy of palivizumab prophylaxis among infants with congenital heart disease: A case control study

BACKGROUND

Palivizumab prophylaxis for RSV has been consistently reported to reduce the risk of hospital admissions related to RSV infection in children with symptomatic cardiac disease. This study was designed to investigate the efficacy of palivizumab prophylaxis among infants with congenital heart disease (CHD) in Turkey.

METHODS

A total of 91 infants with CHD who received palivizumab prophylaxis and 96 infants with CHD without prophylaxis (0-12 months:52; 12-24 months:44) were included in this single-center retrospective case control study. Data on patient characteristics, household environment, and LRTIs were evaluated.

RESULTS

In patients without prophylaxis, the rate of overall lower respiratory tract infections (LRTIs) (P < 0.001), complicated LRTIs (P = 0.006), LRTI-related hospitalization (P < 0.001) and ICU admission (P = 0.008) were significantly higher than control patients. Weight <10th percentile (odds ratio (OR) 5.78, 95% confidence interval (CI):1.37; 24.4, P < 0.001) and concomitant chromosome abnormality (OR 4.01, 95% CI:1.01;16.45, P < 0.001) in patients with prophylaxis, while presence of a sibling <11 years of age (OR 3.38, 95% CI: 1.21; 9.46, P < 0.001) and congestive heart failure (OR 8.63, 95% CI: 2.81; 26.6, P < 0.001) in the control group were the significant correlates of LRTI-related hospitalization.

CONCLUSION

Our findings revealed significantly lower rate of overall and complicated LRTIs, LRTI-related hospitalization and ICU admissions in infants with CHD via palivizumab prophylaxis.

Effectiveness of Palivizumab in Preventing RSV Hospitalization in High Risk Children: A Real-World Perspective

Infection with respiratory syncytial virus (RSV) is one of the major causes globally of childhood respiratory morbidity and hospitalization. Palivizumab, a humanized monoclonal antibody, has been recommended for high risk infants to prevent severe RSV-associated respiratory illness. This recommendation is based on evidence of efficacy when used under clinical trial conditions. However the real-world effectiveness of palivizumab outside of clinical trials among different patient populations is not well established. We performed a systematic review focusing on postlicensure observational studies of the protective effect of palivizumab prophylaxis for reducing RSV-associated hospitalizations in infants and children at high risk of severe infection. We searched studies published in English between 1 January 1999 and August 2013 and identified 420 articles, of which 20 met the inclusion criteria. This review supports the recommended use of palivizumab for reducing RSV-associated hospitalization rates in premature infants born at gestational age < 33 weeks and in children with chronic lung and heart diseases. Data are limited to allow commenting on the protective effect of palivizumab among other high risk children, including those with Down syndrome, cystic fibrosis, and haematological malignancy, indicating further research is warranted in these groups.

Evaluating national guidelines for the prophylactic treatment of respiratory syncytial virus in children with congenital heart disease

AIM

This is the first study to evaluate compliance with the 2003 Swedish national guidelines for prophylactic treatment of respiratory syncytial virus (RSV) in children with congenital heart disease (CHD). We estimated the relative risk (RR) of children with CHD being hospitalised with a RSV infection, studied the extent to which RSV prophylactic treatment with palivizumab corresponded to the guidelines and determined the morbidity of children with CHD who developed RSV infection despite prophylaxis.

METHODS

This national observational study comprised prospectively registered data on 219 children with CHD treated with palivizumab, medical records on RSV cases and information on hospitalisation rates of children with CHD and RSV infection.

RESULTS

The calculated RR of children with CHD being hospitalised with RSV infection was 2.06 (95% CI 1.6-2.6; p < 0.0001) compared with children without CHD. Approximately half of the patients (49%) born before the RSV season and 25% born during the RSV season did not start treatment as recommended by the guidelines.

CONCLUSION

Having CHD increased the rate and estimated RR of children being hospitalised with RSV infection. The guidelines were not followed for about half of the children born before a RSV season and a quarter of the children born during a RSV season and need updating.

Respiratory syncytial virus--a comprehensive review

Respiratory syncytial virus (RSV) is amongst the most important pathogenic infections of childhood and is associated with significant morbidity and mortality. Although there have been extensive studies of epidemiology, clinical manifestations, diagnostic techniques, animal models and the immunobiology of infection, there is not yet a convincing and safe vaccine available. The major histopathologic characteristics of RSV infection are acute bronchiolitis, mucosal and submucosal edema, and luminal occlusion by cellular debris of sloughed epithelial cells mixed with macrophages, strands of fibrin, and some mucin. There is a single RSV serotype with two major antigenic subgroups, A and B. Strains of both subtypes often co-circulate, but usually one subtype predominates. In temperate climates, RSV infections reflect a distinct seasonality with onset in late fall or early winter. It is believed that most children will experience at least one RSV infection by the age of 2 years. There are several key animal models of RSV. These include a model in mice and, more importantly, a bovine model; the latter reflects distinct similarity to the human disease. Importantly, the prevalence of asthma is significantly higher amongst children who are hospitalized with RSV in infancy or early childhood. However, there have been only limited investigations of candidate genes that have the potential to explain this increase in susceptibility. An atopic predisposition appears to predispose to subsequent development of asthma and it is likely that subsequent development of asthma is secondary to the pathogenic inflammatory response involving cytokines, chemokines and their cognate receptors. Numerous approaches to the development of RSV vaccines are being evaluated, as are the use of newer antiviral agents to mitigate disease. There is also significant attention being placed on the potential impact of co-infection and defining the natural history of RSV. Clearly, more research is required to define the relationships between RSV bronchiolitis, other viral induced inflammatory responses, and asthma.

Estimating intracardiac and extracardiac shunting in the setting of complex congenital heart disease

Complex congenital heart disease (CHD) is associated with significant morbidity worldwide. Managing hypoxemia in these populations can be difficult, particularly in the setting of cyanotic CHD. However, the presence of additional extracardiac shunts secondary to acute respiratory disease can be very challenging to manage. Before understanding how to deal with hypoxemia in patients with dual shunts, one needs to understand the physiology and diagnosis related to the individual shunts and apply this knowledge to the patient as a whole.

Respiratory syncytial virus prophylaxis in children with cardiac disease: a retrospective single-centre study

OBJECTIVES

To examine the characteristics of congenital heart disease patients hospitalised with respiratory syncytial virus infection after prophylaxis and determine the associated comorbidities and the incidence of breakthrough respiratory syncytial virus infections.

STUDY DESIGN

This is a retrospective, single-centre study that was conducted over a period of 7 years. Respiratory syncytial virus infection was identified by classification codes and confirmed by virological tests. Data on baseline demographics, cardiac anomalies, other underlying disease, criteria for hospitalisation, type of respiratory illness and management, complications, and palivizumab prophylaxis were analysed by standard descriptive methods and comparative statistics.

RESULTS

A total of 30 patients were enrolled. The majority were ≤ 2 years (n = 24). The mean admission age was 15.1 months (standard deviation = 18.3). In all, 90% were acyanotic, 40% had haemodynamically significant disease, and 60% had ≥ 1 underlying medical illness. Patients were admitted with: respiratory distress (86.7%), hypoxaemia (66.7%), fever (60%), inability to maintain oral intake (36.7%), and apnoea (16.7%). More than 50% required mechanical ventilation and intensive care with a median stay of 11 days (range: 1-43); the length of hospital stay for all children was 10 days (range: 1-65). Complications included: concurrent bacterial sepsis (20%), electrolyte abnormalities (16.7%), and worsening pulmonary hypertension (13.3%). Of 10 infants ≤ 2 years with haemodynamically significant heart disease, four had received prophylaxis. There was one death, which was attributed to respiratory syncytial virus infection.

CONCLUSIONS

Overall, 185 infants ≤ 2 years with haemodynamically significant cardiac disease received prophylaxis. In all, six qualifying infants missed immunisation and were hospitalised. Breakthrough respiratory syncytial virus infections occurred in 2.2%, demonstrating good efficacy of palivizumab in this population compared with the original, multi-centre, randomised trial.

Prevention and prophylaxis of respiratory syncytial virus in pediatric cardiology: a UK perspective

ABSTRACT: 

Respiratory syncytial virus (RSV) is a common infection, causing bronchiolitis in over 70% of infants each year and almost all children by the age of 2. It is the leading cause of acute lower respiratory tract infections and admissions to hospital worldwide. Previously healthy infants may have a prolonged cough or wheezing following RSV infection but up to 20% of those with congenital cardiac disease will be hospitalized and have significant morbidity and mortality. For this reason, it is generally recommended that many such infants should receive prophylaxis against RSV infection with palivizumab. This paper reviews the current state of knowledge about RSV affecting children with congenital heart disease from the perspective of those living in the UK and the current protection offered to such children. We also discuss the plans for the future of protection against RSV.