Day: October 11, 2004

Which Infants Need RSV Prophylaxis?

Patient Presentation
A 62-day-old female infant born at 29 2/7 weeks gestation comes to the outpatient clinic for a weight check after discharge 5 days ago in July. Her weight is up 56 grams on 24 calories/ounce premie formula. Her past medical history was complicated by intubation for 1 week and nasal canula oxygen for another 3 weeks. She had no apnea and bradycardia including when placed into a car seat prior to discharge. She also had neonatal jaundice that resolved within 1 week. Her hearing screening and head ultrasound were normal. Her retinal exam reveals vascularization that is normal to zone 3 but needs to be followed at least once more by ophthalmology. The pertinent physical findings reveal a normal, healthy, almost term infant. Her mother asks if she is a candidate for Respiratory Syncytial Virus (RSV) prophylaxis.

Discussion
Once discharged, the services and procedures needed for comprehensive premature infant follow-up are varied because of individual differences in gestation age at birth, weight, medical conditions and hospital course. Healthcare providers should review the patient’s chart to see if the following common tests and procedures were considered, completed or planned:

  • Universal metabolic screening
  • Universal hearing screening
  • Retinopathy of Prematurity (ROP) ophthalmologic exam
  • Developmental assessment
  • Head ultrasound for possible intracranial bleeding
  • Echocardiogram for possible patient ductus arteriosis
  • Nutritional assessment and plan
  • Immunizations
  • Car seat screening for apnea

Many other tests and procedures may have been evaluated or need to be evaluated depending on the individual circumstances.

RSV can cause pneumonia and bronchiolitis in infants and the morbidity and mortality can be especially high in premature infants. Prophylactic medication is available and should be given to those susceptible. Because of the medication cost, delivery methods and individual infant risk, guidelines are generally used to determine which medication should be given. Currently at the Children’s Hospital of Iowa, infants with chronic lung disease less than 1 year of age receive RespiGamTM (RSV immunoglobulin) monthly by IV infusion. The RespiGam should be started at the onset of RSV season and continued until the end of the season. SynagisTM is a monoclonal antibody. It is given as an intramuscular injection. Infants less than 2 years of age on home oxygen therapy or who have stopped therapy within 2 months of RSV season should be considered for Synagis. Also any infant who was born less than 28 weeks gestation and is less than 6 months of age during RSV season should be considered for monthly Synagis to begin at the onset of RSV season and continued until the end of the season. Infants born at or before 32 weeks gestation discharged during RSV season also should be given one injection prior to discharge. Other infants may be considered for RespiGam or Synagis depending on their individual circumstances.

Learning Point
This patient was not a candidate for prophylactic RSV medication according to these current guidelines because of gestation and chronological age. She was also not on home oxygen and it is not RSV season. These guidelines may change and need to be reviewed at least yearly. This patient had appropriate screening evaluations done during her hospital stay and during this visit she was given her 2-month immunizations. In the future she would be changed to standard formula once she reaches 40 weeks corrected gestation and will not need the additional nutritional supplementation offered in premature infant formulas. She will also be changed to 20 calories/ounce formula when she has continued appropriate weight gain.

Questions for Further Discussion
1. What is the therapy for premature and other infants with RSV who are hospitalized?
2. What is the categorization of ROP?
3. How does oxygen therapy relate to ROP and Bronchopulmonary Dysplasia (BPD)?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for this topic: Respiratory Syncytial Virus (RSV).

Iowa Neonatology Handbook. University of Iowa. Available from the Internet at: http://www.vh.org/pediatric/provider/pediatrics/iowaneonatologyhandbook/index.html (rev. 12/04, Cited 8/30/04)

Sherman MP, Steinfeld MB, Phillips AF, Shoemaker CT. Follow-up of the NICU Patient. Available from the Internet at: http://www.emedicine.com/ped/topic2600.htm (rev. 2/02, cited 8/30/04)

American Academy of Pediatrics Committee on the Fetus and Newborn. “Hospital Discharge of the High-Risk Neonate – Proposed Guidelines,” Available from the Internet at: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;102/2/411 (rev. 1998, cited 9/16/04)

Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa

Date
October 11, 2004