Why do you worry about RSV in the Intensive Care Unit?

Dr. Kiefer: I am a Neonatal Intensive Care Unit (NICU) physician, which means that I care for premature and often for-term babies who are born with heart or lung disease. Respiratory syncytial virus, or RSV for short, can cause a severe infection in babies.

Babies have small airways, so viruses that cause a little runny nose for adults can make it hard for babies to breathe and eat. RSV causes changes in the cells that line the airway, which first make it hard for the body to clear mucus. Clumps of these infected cells can slough off and block small airways. This is also how RSV moves deeper into the lung of infants, usually one-to-three days after the infection starts. This means that we really don’t want any preemie or baby who is still in the NICU to get RSV.

RSV is still a big problem for NICU graduates in their first one-to-two years at home.

Dr. Casey: As a physician in the Pediatric Intensive Care Unit (PICU), I help care for any severely ill child that requires admission to the hospital from age 2 days to 18 years old. While RSV is often limited to the symptoms of the common cold in older children and adults, infections can be much more dangerous in small children, as Dr. Kiefer noted.

According to the Centers for Disease Control and Prevention, two or three of every 100 infants under 6 months old require hospitalization for RSV each year. In some of those children, RSV causes such severe difficulty in that they require a breathing tube and a ventilator for up to a week in the PICU.

Unfortunately, severe RSV infections requiring PICU admission are so common during parts of the winter that RSV infections account for over half of our admissions to the PICU on many days.

What can families do to try to avoid a severe RSV infection?

Dr. Kiefer: We used to only be able to tell families to wash their hands often during cold and flu season, and the tiniest preemies (< 29 weeks gestation at birth) could get a monthly antibody called palivizumab (Synagis) through their primary care doctor to try to prevent severe RSV infections.

Handwashing and avoiding people who are sick is still good advice, especially if your child is a recent NICU graduate. There are newer options for families to prevent RSV infection that don’t require so many trips to the doctor.

First, pregnant mothers can receive the RSV vaccine. If mothers receive the vaccine two weeks or more before their baby is born, important antibodies against RSV have enough time to pass to the baby through the placenta. These antibodies can help protect baby, especially in the first 6 months of age after delivery.

Second, there is a new antibody treatment that only requires one shot during the RSV season. This is called nirsevimab (Beyfortus) and can help stop RSV from getting into the body’s cells and causing infection.

Dr. Casey: I agree that it’s very important for NICU graduates, but getting RSV protection through maternal vaccination or nirsevimab is recommended for all children under 8 months of age this RSV season.

Although NICU graduates and those with other medical conditions, such are congenital heart disease, are at highest risk for severe infection, the majority of children hospitalized with RSV each year are previously healthy children. Unfortunately, RSV infection has the potential to cause severe infection in any infant.

Do these new RSV prevention options actually work?

Dr. Kiefer: Yes! If mothers receive the RSV vaccine toward the end of their pregnancy (32-36 weeks), it can decrease the chance of their baby having a RSV infection requiring doctor’s visits or a hospital stay by over 80 percent in the first 3 months of age.

Dr. Casey: Absolutely. One dose of nirsevimab protects an infant from RSV for five months or more, which is the length of the typical RSV season. In some studies, nirsevimab has been shown to lower the risk of a young child being admitted to hospital by over 90 percent during the RSV season. While we’re always prepared to treat children whenever needed, as pediatricians, we are just as passionate about preventing severe illness whenever possible.

What if my child is older than 8 months of age? Could they still be eligible for the RSV antibody?

Dr. Kiefer: Some kids up to 19 months of age are eligible for nirsevimab antibody if they are at a higher risk of having a severe RSV infection. Some NICU graduates are in this category!

For example, if your child needed oxygen, diuretics, or chronic steroids for chronic lung disease of prematurity in the six months before the start of RSV season, then talk to your child’s doctor about getting nirsevimab for this RSV season.

Dr. Casey: Children up to 19 months old that are either severely immunocompromised or have cystic fibrosis with severe lung disease also qualify for treatment with nirsevimab.

What if I can’t get access to these RSV preventive treatments?

Dr. Kiefer: Last year, we did see shortages of nirsevimab. We don’t expect any shortages of RSV vaccine for mothers, so getting the vaccine in pregnancy is a great option to protect your baby from RSV. If your child is high risk (NICU graduate), you may still be able to get monthly palivizumab shots. The monthly shots are still effective in preventing RSV; they just require more trips to the doctor’s office.

Dr. Casey: If a child is started on monthly palivizumab shots due to a temporary shortage of nirsevimab, they are still eligible to receive nirsevimab when it becomes available to complete coverage for the rest of the RSV season.

What’s the overall “ICU view” of RSV?

Dr. Kiefer: In the NICU, we really want to see pregnant moms get the RSV vaccine at the end of pregnancy, because it protects their baby. If your baby needs NICU care, we hope to get them home safely and as soon as possible. Avoiding RSV infection is a great way to do that. If mom wasn’t able to get the RSV vaccine at least two weeks before delivery, we want NICU graduates to see their primary care doctor and ask about the preventive RSV antibody, nirsevimab, as soon as possible in the RSV season.

Dr. Casey: RSV infections cause 57,000-80,000 hospitalizations per year in children under 5. One in five of those hospitalized children requires care in an intensive care unit. In the PICU, we see first-hand how stressful those hospitalizations are for families. I am excited that for the first time there are such widely available and effective options for the prevention of severe RSV disease in infants. I would strongly recommend that all pregnant mothers and caregivers of newborns discuss these new options for RSV prevention with their medical team.

For more information on RSV, or to schedule an appointment with your doctor to discuss RSV prevention options visit WVUKids.com or call 1-855-WVU-CARE.