Management and Treatment of RSV in Pediatric Patients
Acute Treatment of RSV Infection
RSV treatment is entirely supportive—there is no antiviral therapy or specific medication that treats established RSV disease. 1, 2 Palivizumab is FDA-approved only for prevention, not treatment, and should never be used to treat active RSV infection. 2
Supportive Care Measures
- Provide supplemental oxygen for hypoxemia 1
- Ensure adequate hydration (oral or intravenous fluids as needed) 1
- Use nasal suctioning to clear secretions 1
- Monitor respiratory status closely for deterioration 1
Infection Control in Healthcare Settings
- Hand decontamination before and after patient contact is the single most important preventive measure 1
- Use alcohol-based hand rubs preferentially over soap and water 1
- Cohort RSV-positive patients together and restrict healthcare personnel caring for infected patients from caring for uninfected high-risk patients 3
- Restrict healthcare workers with upper respiratory symptoms from caring for high-risk patients 3
Prevention with Palivizumab Prophylaxis
Palivizumab (15 mg/kg IM monthly for maximum 5 doses during RSV season) is the only available immunoprophylaxis for preventing severe RSV disease in high-risk pediatric populations. 1, 4, 2
Primary Indications for Palivizumab
Infants born before 29 weeks, 0 days' gestation who are younger than 12 months at RSV season start should receive prophylaxis. 1, 4
Infants and children younger than 24 months with chronic lung disease (bronchopulmonary dysplasia) requiring medical therapy (supplemental oxygen, bronchodilators, diuretics, or corticosteroids) within 6 months before RSV season should receive prophylaxis. 1, 4, 2
Children younger than 24 months with hemodynamically significant congenital heart disease should receive prophylaxis, specifically: 1, 4, 2
- Infants receiving medication for congestive heart failure 1
- Infants with moderate to severe pulmonary hypertension 1
- Infants with cyanotic heart disease 1
Dosing Protocol
Administer 15 mg/kg intramuscularly every 30 days throughout RSV season (typically November through March), with a maximum of 5 doses. 1, 4, 2
- Give the first dose before RSV season begins 2
- Continue monthly dosing even if breakthrough RSV infection occurs 3
- Administer an additional 15 mg/kg dose after cardiopulmonary bypass surgery (serum levels decrease by 58% after bypass) 1, 3, 2
- Inject preferably in the anterolateral thigh; avoid gluteal muscle due to sciatic nerve risk 2
- Divide volumes exceeding 1 mL into separate injection sites 2
Special Populations Where Prophylaxis MAY Be Considered
Profoundly immunocompromised children younger than 24 months during RSV season may be considered for prophylaxis. 1, 4
Children younger than 2 years undergoing cardiac transplantation during RSV season may be considered for prophylaxis. 1, 4
Infants with cystic fibrosis demonstrating clinical evidence of chronic lung disease AND/OR nutritional compromise in the first year may be considered for prophylaxis. 1, 4
Populations That Should NOT Receive Palivizumab
Do not give palivizumab to infants with hemodynamically insignificant heart disease (secundum atrial septal defect, small ventricular septal defect, mild pulmonic stenosis, uncomplicated aortic stenosis, mild coarctation, patent ductus arteriosus). 1, 3
Do not routinely give palivizumab to children with Down syndrome unless they have qualifying heart disease, chronic lung disease, airway clearance issues, or prematurity (<29 weeks). 1
Do not routinely give palivizumab to infants with cystic fibrosis unless other qualifying conditions exist. 1, 3
Critical Pitfalls to Avoid
Never use palivizumab to treat established RSV infection—it has no therapeutic benefit and is FDA-approved only for prevention. 4, 2
Discontinue palivizumab after breakthrough RSV hospitalization—the likelihood of a second RSV hospitalization in the same season is extremely low (<0.5%). 1
Do not withhold routine childhood immunizations—palivizumab does not interfere with standard vaccines. 4, 3
Do not continue prophylaxis beyond 5 doses or beyond the RSV season. 1
Remember to give an additional dose after cardiac bypass surgery, as bypass significantly reduces palivizumab serum concentrations. 1, 3, 2
General Preventive Measures for All High-Risk Infants
Keep high-risk infants away from crowds and restrict group childcare participation during RSV season whenever feasible. 1, 3
Ensure meticulous hand hygiene for all caregivers and family members. 1, 3
Eliminate all tobacco smoke exposure—never expose infants to secondhand smoke. 1, 3
Administer influenza vaccine to all eligible infants (≥6 months) and their contacts. 1
Evidence on Palivizumab Effectiveness
Palivizumab reduces RSV hospitalization by 55% in premature infants and those with chronic lung disease, and by 45% in infants with hemodynamically significant congenital heart disease. 3, 5, 2, 6
However, palivizumab has not been shown to reduce mortality from RSV infection or decrease recurrent wheezing after RSV infection. 1, 3, 5 The 2014 AAP policy narrowed eligibility criteria for moderate-to-late preterm infants (29-34 weeks), which was followed by increased RSV hospitalization rates in this population. 7, 8