AAP updates guidelines on RSV immunoprophylaxis

In a recently updated guidance, the American Academy of Pediatrics (AAP) recommends that immunoprophylaxis against respiratory syncytial virus (RSV) infection be reserved for certain high-risk infants. H. Cody Meissner, MD, a member of the committee that drafted the updated guidance, reviewed the new recommendations and the basis for the changes in a session titled “RSV: the new knowledge and evolving guidance” held on Saturday, October 11. Meissner is professor of pediatrics at Tufts University School of Medicine and director, pediatric infectious disease, Tufts Medical Center, Boston.

He said that pediatric RSV infections continue to cause a large burden of disease in the United States as well as throughout the world. In the absence of a safe and effective vaccine, interest has focused on the role of immunoprophylaxis for protection against RSV lower respiratory tract disease for children in specific groups. Because the monoclonal antibody palivizumab was licensed by the US Food and Drug Administration in 1998, recommendations from the AAP have attempted to define those infants and young children who are most likely to benefit from monthly prophylaxis. 

In the past few years, new data have become available regarding the seasonality of RSV circulation; risk of RSV hospitalization as a function of gestational and chronologic age;  pharmacokinetics of palivizumab; absence of a difference in RSV hospitalization rates between African-American and white children; lower mortality rates than previously estimated among children hospitalized with RSV infection; minimal impact of prophylaxis on episodes of wheezing; and the detection of palivizumab-resistant RSV isolates among hospitalized infants who received prophylaxis. In addition, cost-analyses have demonstrated a high-cost versus limited benefit. The AAP updated its guidance in an effort to address these issues as well as to simplify recommendations for the use of palivizumab (Pediatrics. 2014;134[2]:415-420), Meissner explained. 

Because the impact of monthly prophylaxis on RSV disease is small, the AAP concluded that the use of palivizumab cannot be justified for most infants for whom RSV prophylaxis was previously recommended, Meissner further stated. Immunoprophylaxis should be limited to infants born before 29 weeks’ gestation and those with chronic illnesses such as congenital heart disease or chronic lung disease. For all infants, the AAP emphasizes the importance of minimizing the risk of RSV and other viral infections by breastfeeding and practicing good hygiene. -Karen Rosenberg