RSV Infections in Babies: Symptoms, Treatment, Prevention – PediaCast 592

Podcast: Download

Subscribe: RSS

Show Notes

Description

Dr Bill Long and Dr Pablo Sanchez visit the studio as we consider RSV infections in babies and young children. We explore the seasonality of these infections, along with their symptoms, treatment, and prevention. We hope you can join us!

Topics

Respiratory Syncytial Virus (RSV)
Bronchiolitis

Guests

Dr Bill Long
Pediatrician, Pediatric Associates of Central Ohio
Administrative Medical Director, Nationwide Children’s

Dr Pablo Sanchez
Neonatology and Infectious Diseases
Nationwide Children’s Hospital

Links

RSV: How to Protect Your Child
RSV: A Common Respiratory Virus in Infants and Young Children
RSV and Bronchiolitis: What Do I Need to Know?
RSV: When It’s More Than Just a Cold
RSV Immunizations: Two Ways to Protect Babies
RSV in Infants and Young Children
RSV Vaccine Guidance for Pregnant Women

Episode Transcript

[Dr Mike Patrick]
This episode of PediaCast is brought to you by Nationwide Children's Hospital. 

[Music]

[Dr Mike Patrick]
Hello everyone and welcome to another episode of PediaCast. We are a pediatric podcast for moms and dads.

This is Dr. Mike, coming to you from the campus of the Nationwide Children's Hospital. We're in Columbus, Ohio. It's episode 592.

We're calling this one RSV infections in babies, symptoms, treatment, and prevention. And it's an important episode. Generally, we do an episode I feel like almost every fall on RSV because it is such an important thing for parents to consider.

It's a viral infection caused by respiratory syncytial virus. But that's why we call it RSV because respiratory syncytial virus is a lot of words and RSV is a little bit easier to say. But it is a viral infection and just a little bit of a spoiler, the symptoms can be very severe even in healthy babies who have no underlying medical conditions.

The treatment, there's not a lot of options available other than supportive care and you know it's severe symptoms for a long time. And the exciting thing that we're going to talk about today really is prevention because up until just a few short years ago we really did not have a great way to prevent RSV infection in all babies, and we do now and it's safe and it works really well. So, we're going to talk about it all about RSV and with a real highlight on prevention.

Historically, RSV has been the number one infectious cause of hospitalizations for young babies across the entire globe. I think we are making a dent in that as babies get protected against RSV, whether that's through immunization that the mother gets during pregnancy or if it's monoclonal antibodies that the baby gets. We are reducing the number of hospitalizations for RSV due to these efforts.

But we still see too many, you know, too many young babies with very severe disease that could have been prevented and that's why it's such an important thing for us to talk about. So today we're going to cover RSV in detail including its seasonality, again its symptoms, treatment, and most importantly its prevention. Of course, in our usual PediaCast fashion we have a couple of terrific guests joining us in the studio to discuss the topic.

Dr. Bill Long is a pediatrician here in Central Ohio with Pediatric Associates of Central Ohio. He also serves as administrative medical director at Nationwide Children's Hospital. And we have Dr. Pablo Sanchez. He is a neonatologist and infectious disease specialist also at Nationwide Children's Hospital. I do want to remind you the information presented in every episode of our program is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals.

If you're concerned about your child's health, be sure to call your health care provider. Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement, which you can find at pediacast.org. So, let's take a quick break. We'll get Dr. Bill Long and Dr. Pablo Sanchez settled into the studio and then we will be back to talk about RSV infections in babies and young children. It's coming up right after this. 

[Music]

[Dr Mike Patrick]
Dr. Bill Long is a pediatrician at Pediatric Associates of Central Ohio and an administrative medical director at Nationwide Children's Hospital. Dr. Pablo Sanchez is a neonatologist and infectious disease specialist at Nationwide Children's and a professor of pediatrics at the Ohio State University College of Medicine. Both have a passion for preventing RSV infection in babies and young children and treating infants and supporting families impacted by RSV and bronchiolitis. That is what they are here to talk about, the symptoms, treatment and prevention of RSV infections in babies.

Before we dive into our topic, let's pause and offer a warm PediaCast welcome to our guests, Dr. Bill Long and Dr. Pablo Sanchez. Thank you both so much for stopping by the studio today. 

[Dr Bill Long]
Thanks, Mike. It's great to be here.

[Dr Pablo Sanchez]
Thank you, Dr. Mike. It's a pleasure to be here today because as we all know, we can prevent serious RSV disease.

This is great as the season is starting.

[Dr Mike Patrick]
Yeah, it's really an important topic because as you say, RSV infections are preventable. It can also be really serious. And so, we want to prevent this in as many kids as possible.

Dr. Long, let's start with just a definition of RSV and why is this particular organism such a concern for infants and young children?

[Dr Bill Long]
Well, RSV is a common viral respiratory infection that affects people of all ages. But in young infants and even in toddlers who have other medical conditions, it can be much more severe, much more serious. And that severe disease can lead to hospitalization, often in an intensive care setting, and really puts kids at risk for some long-term morbidities as well.

[Dr Mike Patrick]
Yeah. And what are the typical symptoms of RSV infection in babies? What should parents be on the lookout for in their kids?

[Dr Bill Long]
So, RSV usually starts out with cold symptoms and a cough. It may start just like any other cold, lots of nasal congestion, mucus or snot. Cough is usually dry, maybe a fever.

But in babies and even toddlers, infection often gets into the lungs, and it causes something we call bronchiolitis. That's different from bronchitis in that it affects the smaller airways in the lung. And when babies get this bronchiolitis, you may notice some other things.

They may have a harder time breathing. They may breathe faster. You may hear a wheezing sound when they breathe out.

You may see, in more severe cases, nostrils flaring out and their belly moving up and down with breathing or something we call retractions, which looks like the skin over the ribs and the neck kind of pulling in. Very small babies can even have periods of apnea, which means they actually stop breathing for several seconds. And this is a little scary.

Well, actually, a lot scary because sometimes an illness can progress very quickly, just like from cold symptoms within a few hours to be this respiratory distress that I described. While not all cases progress to severe ones, almost always in bronchiolitis, when the worst is over, the cough persists for weeks at a time.

[Dr Mike Patrick]
Yeah, and I think we don't want to downplay just how serious this can be in some kids, in particular those who are premature or they have a history of other chronic illnesses like heart disease, asthma, those sorts of things. It can be even worse. But on the other hand, a lot of kids, it's just like a regular cold and it's hard to predict, except for those risk factors, who is going to have a mild case and who's going to have a very severe case.

And so, we really just want to prevent it in everyone, wouldn't you say?

[Dr Pablo Sanchez]
I just want to say that the majority, the vast majority of babies and infants who are hospitalized with RSV are otherwise healthy and well. We can talk about all the risk factors that you mentioned, which are true. However, the biggest risk factor is a normally healthy baby, less than eight months of age, who is experiencing their first RSV infection.

And the younger they are, the higher the risk that they're going to end up hospitalized, requiring respiratory support. So really what we need to focus is not on risk factors, but just the fact that every baby who is less than eight months of age can have a severe RSV infection leading to hospitalization. And actually, RSV infection in infancy is the number one cause of hospitalization.

And on a global scale, it is secondary only to malaria for deaths in the first five years of age. So, it's a huge, huge burden and huge, huge medical problem that we can effectively prevent.

[Dr Mike Patrick]
Yeah, yeah. And we certainly do want to prevent that. And that's why we're talking about it today.

And again, this is, you know, all babies. This can happen to anyone. And as Dr. Sanchez said, you know, the majority of babies who are in the hospital with RSV infections, you know, are otherwise healthy and don't have any underlying problems, medical conditions. And so, every baby out there really is at risk. So, Dr. Sanchez, when does RSV season typically occur? I know, you know, for a lot of things, you know, we see hand, foot, mouth disease a lot in the summer.

We see the flu in the wintertime. What about RSV season? When do we usually see it?

And then how does that seasonality affect our efforts at preventing RSV?

[Dr Pablo Sanchez]
As RSV traditionally has a known seasonality, it generally starts around November, late October, beginning of November. And then at least in Ohio and in the northern climates, it generally ends by the end of March. So, there's an established seasonality that we have seen for years.

Now, that changed during the pandemic when, as we all know, there was no RSV at all as we quarantined and did all the infection prevention strategies. But we are heading back to a normal season. We saw that last year, a little bit early last year, starting by the mid to late September.

But this year so far, we have not seen any significant RSV hospitalizations. We've had a couple, we've had a few. But it's generally November to the end of March.

[Dr Mike Patrick]
Really, our prevention efforts need to start now because we are heading into RSV season here pretty shortly. And we want any immunizations that we give for RSV, we want those to be working and ready when the virus does hit the community. So, this is definitely an important time to be talking about this.

Why is it, Dr. Sanchez, that so many healthy babies then end up hospitalized with RSV? Like, what is it about this particular virus that makes it so severe for otherwise healthy kids, especially as we compare it to other upper respiratory viruses out there?

[Dr Pablo Sanchez]
Yeah, I think that, as Dr. Long had said, RSV causes a lot of secretions that plug up the airways and really doesn't allow the baby to breathe effectively. And so, the most common reason that they're admitted is because their oxygen levels in their blood goes low and they require oxygen. And many of them then, because of the increased work of breathing, they require respiratory support that can be anywhere from just nasal cannula to high flow nasal cannula to CPAP, CYPAP, and even intubation in the most severe cases.

And some of them may be even leading to ECMO. So, it's really a plugging of the airway from the copious secretions that this infection results in.

[Dr Mike Patrick]
So compared to other viruses, RSV really does cause lots of mucus in the nose and down in the lungs as well. And we know that babies like to breathe through their nose, and even when they're feeding, you know, they're breathing through their nose. And if there's a lot of mucus there, that can cause quite a bit of distress because they can't move air through all that mucus.

And so, keeping their nose clean and sucked out the mucus out of there is certainly one strategy for helping, but you can't really suck it out of the lungs when it's plugging the lungs down there. And that really is a problem for a lot of these kids. Dr. Long, you know, when I was training, and I'm sure when you were training, you know, a few decades ago, you know, we thought that maybe this was similar to asthma. You know, we would hear these babies making a lot of noise when they breathe. You might hear some wheezing. And so, we now know it's really more the mucus and not necessarily airway inflammation.

That's, that's, I mean, that may be playing a role, but that mucus is really the big thing. And that's not there usually with asthma. So, can you just describe a little bit about how the treatment of RSV has changed over the years?

And I think this is important because, you know, a lot of new parents get their medical information, like from grandparents and folks who may have seen RSV and bronchiolitis treated differently in the past. And so, then they question, hey, what are they doing? Do they not know what they're doing?

Can you just describe how that has changed over the years in terms of treating RSV and bronchiolitis?

[Dr Bill Long]
Yeah, absolutely. I mean, I've been treating this since the 1990s. And you said over the years, we tried anything we had available for wheezing because we thought it was like asthma.

There was no evidence for us to back up a lot of these treatments, but we're driven by a desire to do something, anything for these patients. So, we tried those medicines. We tried for asthma.

Those medicines included oral steroids, like prednisone, even oral liquid asthma medicines, those bronchodilators that relax the smooth muscles in the lung airways. Then we tried aerosol treatments. We tried the bronchodilator aerosols.

We tried saltwater aerosols. And to be honest, you know, there were times when you give an aerosol in the office and the baby seemed to get a little bit better. And we thought, oh, this is working right.

We were clearing out some mucus, but we probably weren't doing much more than that. But I had shelves of aerosol machines in my office to give out to families every RSV season. I mean, if you were a millennial baby who had bronchiolitis, you got the SERPs and maybe the nebulizer aerosol treatments.

If you were a Gen Z baby who had bronchiolitis, your parents probably still have a nebulizer aerosol machine in their closet somewhere from when you were a baby. I mean, those were the standard treatments. But over the years, as more studies were done, we found out that none of these treatments changed the course of bronchiolitis.

And that clinical impression of improvement after an aerosol was again, probably due to clearing out some mucus, but the mucus kept coming back. And now the treatment is mainly supportive. And that, as both you and Dr. Sanchez mentioned, that's getting that mucus out of the upper airways. That's what we do in at home and in the best, we can make sure your child stays hydrated as well. Because with all that mucus, they don't want to eat. They don't want to drink.

And there are no over-the-counter medications, no cough or cold medicines that would recommend or would even reduce the symptoms of RSV. And as Dr. Sanchez said before, these young infants that have more severe disease, the oxygen is just not getting to where it needs to go. So, their oxygen levels go down, or they get really tired from breathing so hard for so long.

And that's why they end up in the hospital. They need help. Keeping their oxygen levels up and need help with breathing.

[Dr Mike Patrick]
Yeah. And this typically is a pretty long disease where, you know, it's not like over in three or four days, like a stomach virus might be with vomiting and diarrhea. It really is prolonged.

The worst symptoms are usually as we get close to being a weekend. So, you know, four days or so, and then another week after that, it just lingers. And then, as you had mentioned, the cough can be there for a few weeks, even after that.

And there's not a lot we can do. There's no real good antiviral medication for it. There's no, you know, just sucking out the airway is about it.

And so, it does become more and more important just to prevent this from happening in the first place so that families don't have to suffer through this. And it's not just the babies that suffer, too. You know, parents may miss work.

Other, you know, that really disrupts things that can be an issue, especially like for a single parent. So just lots of reasons to want to prevent this from happening in the first place. So, Dr. Sanchez, what is new in RSV prevention?

Because there are some new things that can really make a big difference for babies and families not having to go through this in the first place.

[Dr Pablo Sanchez]
Absolutely. These are exciting times for RSV prevention. There's been a maternal vaccine that has been recommended for pregnant women from September to January, from 32 to 36 weeks of pregnancy.

And then the baby can, if the mother did not receive the vaccine or received it less than two weeks before delivery, the baby can receive one of two long-acting monoclonal antibodies. One of them is Nirsevimab and the other one is Clesrovimab that was recently approved and recommended by CDC and by the American Academy of Pediatrics. So, we are in times where we can really effectively prevent the majority of the severe RSV disease.

None of these actually prevent the infection. However, what we want to do is ameliorate the disease in these infants and high-risk children. Because, as you mentioned, it's not just the acute illness.

RSV has also been associated with later development of asthma, chronic cough and asthma. And there are data now coming out that these preventive strategies may also decrease asthma later in childhood. So, we really, these are exciting times, and we really need to get these immunizations out to the public so that we can make a difference in their lives.

Yeah, yeah, absolutely.

[Dr Mike Patrick]
Can you explain how the maternal RSV vaccine works? How is it that giving mom a vaccine during pregnancy can help prevent this infection in their babies?

[Dr Pablo Sanchez]
Yes. So, the goal of the maternal vaccine is not so much to prevent RSV in the mother. Which it can help.

But RSV right now we don't feel is a significant infection during pregnancy. It does not cause more severe disease in pregnancy, somewhat like COVID can. However, the mother, within the next two weeks after the administration of the vaccine, could develop antibodies.

These antibodies cross the placenta, get into the fetal circulation, and therefore protects the baby against severe RSV disease up to six months of age.

[Dr Mike Patrick]
Okay, so mom gets the vaccine, she makes antibodies against RSV, those cross the placenta into the baby's body and then they're there for a few months protecting the baby against severe RSV disease. As you mentioned, your baby might still get a little cold, but they're going to make a lot less mucus and it's going to be less likely that they're going to end up in the hospital or in an intensive care unit or even dead from RSV if they have those protective antibodies on board. And now if mom didn't get the RSV vaccine, then you mentioned that we can just give the babies the antibodies directly.

Why would we do that instead of giving the baby a vaccine?

[Dr Pablo Sanchez]
Well, there is no vaccine that's approved for babies. The vaccine is for mothers and actually the RSV vaccine now, there's two of them that can be given to the elderly, 75 years of age and older. So, everybody 75 years of age and older should be vaccinated.

It has an efficacy and effectiveness. It reduces severe RSV disease in the elderly by about 70 to 80 percent. And then 18 years of age and less than 75 for other individuals with risk factors for more severe RSV disease.

But there is no vaccine currently that can be given to infants and young children against RSV. We rely on monoclonal antibodies. So, the same antibodies that we produce against the RSV infection has been manufactured in the laboratory and has been made, has been formulated to last at least 150 days.

So, one shot, one intramuscular administration of this medication can protect the baby and the young child for the entire RSV season, which is typically about five months. So, we've made a lot of progress. There's two of them.

There's the Nirsevimab that we've had now, this would be the third season, and Clesrovimab that was approved by and recommended by CDC at the end of June. And now, and it's FDA approved as well. And so now we can give one of the two for the first season.

The second season for those, for those children who are at high risk, those who have bronchopulmonary dysplasia, those who are severely immunocompromised, or those who have more severe, you know, cystic fibrosis, those infants in the second season should only get Nirsevimab currently, because Clesrovimab has not yet been studied in a second season.

[Dr Mike Patrick]
Okay. Now, when we have something new come out, a lot of times parents have concerns about safety. We hear this more and more that folks, you know, see things that aren't necessarily true online.

There's a lot of myths and misinformation, and not just amongst the general public, even at the highest levels of government, we're seeing that now, where things are being said that aren't really evidence-based. So, what, Dr. Sanchez, what do you say to parents who may be questioning the safety of giving their babies the monoclonal antibodies to protect them against RSV?

[Dr Pablo Sanchez]
So certainly, Nirsevimab, as well as Clesrovimab, has been shown to be safe. The side effects that have been seen has been maybe a low-grade fever, or maybe a little bit of local reaction, because both of them are intramuscular injections, but no significant anaphylaxis, you know, like allergic reaction, nothing, you know, certainly no deaths associated with the administration either. So really, both of these products have been shown to be very safe, and so very highly recommended.

This would be the third season that we are giving Nirsevimab. It is being given on a global scale. Spain has done a fantastic job of immunizing infants less than six months of age.

Chile also has a countrywide experience, and so the safety has been well-documented post-licensure on a global scale.

[Dr Mike Patrick]
And as we think about any intervention in medicine, we always want to look at the risks versus the benefits. And so, with that safety profile, but also knowing that RSV is the leading cause of hospitalization in babies, you know, the benefit of receiving the monoclonal antibody for RSV prevention is going to be far, far, far greater than any risk that there might be, given what we know about it, correct? Absolutely.

Absolutely.

[Dr Pablo Sanchez]
The benefits far, far, far outweigh any potential risk to the point that every single human, every single country in the world wants to administer these medications, either the vaccine or the monoclonal antibodies, to mothers and or babies. It's been a global effort. And in the United States, we really need to make sure that all eligible infants and high-risk children are immunized to protect them against the RSV.

[Dr Mike Patrick]
You had mentioned that the vaccine in elderly folks, it reduces hospitalizations by over 80 percent. Is that also what we're seeing in terms of the reduction in hospitalization in babies who receive the monoclonal antibody or whose mother received the vaccine?

[Dr Pablo Sanchez]
Absolutely. On a global scale, including the United States, we are seeing reductions that are from 60 to 90 percent reduction in RSV hospitalizations and even more with reductions in RSV disease requiring intensive care. So, the effectiveness of these monoclonal antibodies has mirrored the studies that were for efficacy.

So, in other words, the initial studies compared these monoclonal antibodies to a placebo, normal saline, and they followed these children for safety as well as for efficacy. And this is in a very controlled fashion. And now that we're giving it to so many infants and young children, we're seeing this similar effectiveness as we were seeing in the controlled placebo-controlled studies.

So, really, it's been it's been a huge, huge success.

[Dr Mike Patrick]
Yeah. So, it would really encourage parents if your pediatrician or your family doctor, nurse practitioner, whoever you see for your child's health care, if they don't mention the RSV shot, please bring it up at your visit. And if you don't have a visit scheduled, you know, in the next couple of months, call their office and ask about it and really advocate for your child to get an RSV shot to prevent this from happening.

[Dr Pablo Sanchez]
Absolutely. We want this administered right before and during the RSV season, but we want to administer it today. We would like every single baby born during the RSV season to receive it during their birth hospitalization before leaving the hospital.

We certainly do that in neonatal intensive care units here in Columbus, but for the normal newborn, we have we have not been able to get it into these hospitals. But it's important, very important, that when they see their pediatrician in the ensuing two, three, five days after they go home from the well-baby nursery, it is very important that they receive the monoclonal antibody at that visit. We do not want them, the monoclonal antibodies to be delayed when they get their routine two-month vaccines, because that's two months that this baby could be exposed to RSV, infected.

And we know that young infants that age will have a very severe RSV infection. So, we want to give it yesterday, not today.

[Dr Mike Patrick]
Yes, yes. So, call your call your doctors today and find out if this is something that your baby needs. And the reason I say if your baby needs, because this sounds a little bit challenging.

And Dr. Long, I want to talk about this from primary care perspective. An individual baby, the mom may or may not have had the RSV vaccine, which will make a difference in whether you give the monoclonal antibody to the baby. And the baby may or may not have had an RSV immunization or let's just call it the shot because it's not really a vaccine.

But they might have gotten that in the newborn nursery, or they might not have. So, I would imagine this has been sort of challenging to figure out which babies are not protected in one way or another since there's multiple routes. Has that been your experience?

[Dr Bill Long]
I think the biggest challenge is many families still don't know about any of the options. In the past week, I've seen multiple babies who are eligible for the RSV prevention. And only about 25 percent of the families knew about it beforehand.

Many families that aren't expecting it need time to think about it. But as Pablo said, we have a really short window in which to give this treatment. We want to give it yesterday.

And that short window and the need for more information is a challenge for those infants who are eligible. But they don't have a visit coming up until later in the RSV season. And getting those patients back in before that two-month visit or the four-month visit or the six-month visit, that can be difficult.

Some families don't have the capability to receive text or email messages, and it's hard to contact them. And then when they're available, there's the challenge of having enough nursing staff in the office to bring those babies back in.

[Dr Mike Patrick]
How have you found parents when you tell them about this? Are they pretty receptive to their baby receiving it? Or is this something you have to sort of convince them of the importance?

[Dr Bill Long]
Great question. I think that most of the time when someone hears about something that's new, they need time to think about it. They want to absorb what you said.

But fortunately, if you have a good relationship with the family and they know you and they will, whatever you recommend, they will do. So that's helpful. But I mean, there are some vaccine-hesitant or immunization-hesitant families out there.

And so, yeah, it sometimes takes some time. But that's why you have to start early. And that's why I think and agree with Dr. Sanchez that the decision ideally is made well before the baby's born that the family knows what they want to do.

[Dr Pablo Sanchez]
I agree with that. And I think that RSV prevention should be discussed not just at the OB office, but also at the prenatal pediatrician office. Just like we discussed the importance of breastfeeding, the importance of vaccines, the importance of whatever, well, baby care, you know, vitamin K.

But I think that prenatal visit, both at the OBs as well as at the pediatrician or family practitioner, they need to hear about RSV prevention because that is something that we want to give as soon as possible. I will say that it's interesting. The parents who've had children and infants with RSV are all into it because they know the severity.

They know the problem, the pain that having a sick child is and sick infant. But you're right. There's a lot of people, a lot of parents who've never even heard of RSV, particularly first-time parents.

And we really need a media campaign to make people aware and educate parents because it's something that, as we've talked about, is serious and it can be prevented. And we just need to make people aware. So, at every single time that we can educate a person, we need to do that.

[Dr Mike Patrick]
Yeah, so very important. One other thing I wanted to bring up, Dr. Sanchez, I want to get your opinion on this. For babies who do come into a pediatric office or an urgent care or an emergency department with the symptoms of bronchiolitis, which is the disease that RSV causes when there's a lot of mucus present, we know that there are other viruses that can also cause bronchiolitis.

So, bronchiolitis is a clinical condition that can be caused by several viruses. It's just that RSV is the most common and usually tends to be more severe than when there are other causes of it. And so, a lot of parents, when they hear, oh, your baby has bronchiolitis, they may want an RSV test.

Is it important, especially in the outpatient setting, should we be testing for RSV or should we just be treating bronchiolitis since knowing if it's RSV or a different virus doesn't really make a difference in terms of the course of the disease? What are your thoughts on that?

[Dr Pablo Sanchez]
I very much, as an infectious disease specialist, I very much want to know which virus it is. I will say that respiratory viruses traditionally, excluding the pandemic, have a very seasonal pattern. So, in November, December, we start seeing and testing hospitalized children for the viruses and we start seeing a lot of RSV.

So, chances are that an infant, young child in the ambulatory care setting, in the pediatrician office, if we're seeing a lot of that virus in the community, that's likely what they have. But that's not always the case. And as you mentioned, there's a lot of other respiratory viruses, including influenza, which is treatable.

So, I'm very much a proponent of testing. We need to know what they have. It also will help us define the course because we know RSV will get worse over the first four to five days.

It peaks around day five. And we know that although we don't have any specific therapy, there are other respiratory viruses that may have therapies. Plus, I think it's important to know what we can do.

Now, having had one RSV infection in that same season, that baby can still receive Nirsevimab or Clesrovimab following that infection as well, because there are repeated infections with RSV in the same season. So that does not preclude the infant from receiving Clesrovimab or Nirsevimab following an RSV infection.

[Dr Mike Patrick]
So, when you recommend testing for what virus it is, there's also a cost associated with that. There are rapid RSV tests and then there are ones that are a little bit more sophisticated that don't come back right away and that also cost a lot more money. In terms of the rapid RSV test, is that a pretty sensitive and specific test?

Is that a good one? Or do you recommend the PCR test, which is the more sophisticated one that takes longer to do? What are your thoughts there?

[Dr Pablo Sanchez]
Well, the PCR is the best, and it doesn't take longer because it only takes a few hours. We know that same day. Certainly, in the pretreatment offices, the antigen tests can be, you know, you'll know right away.

I think it depends on when you're doing the test and what is the prevalence of the infection in the community. Because if you're doing a rapid test in the summer where there's very little to no RSV, most of those tests can be false positives. Whereas if you're doing it during the time that you're seeing a lot of RSV, the positive test is likely to be real.

So, I think that you have to use it judiciously and know when to use it and what the results may be. But obviously, if you really want the best optimal answer in a child or in an infant or child who is quite ill, it's best to do the PCR because that will take you to a variety of different viruses and bacteria that could be causing their respiratory distress.

[Dr Mike Patrick]
The only reason I'm spending this much time on it is because it seems like each year more and more parents ask about this. You know, just four or five years ago, like people didn't, RSV wasn't really on anyone's radar unless you were a pediatrician. And so, we knew about it, you know, from, you know, decades ago.

But a lot of parents are just really learning about this for the first time. And so, you know, when their baby has a bad cold, they want to know, is it RSV? So, there's the parent pressure to know what's causing my baby to be ill.

But there's also the medical system pressure of, well, let's only do tests if it's going to change what we do. Or, you know, think about the cost of testing every baby with a cold, because that's a pretty big cost. So, I mean, there's all of these issues that make it difficult from the provider standpoint, because you want to do the right thing, but you also want to answer the parents' questions.

So, Dr. Long, how has that played out in your practice in terms of RSV testing?

[Dr Bill Long]
Well, so I think there's a greater demand for testing, not only from what you said, people want to know if it's RSV, but, you know, since the COVID pandemic, you know, there's been kind of a culture of testing, you know, anyway. So, you know, I want to know if it's COVID, I want to know if it's flu. And we've changed our testing platform in our office to be able to do the COVID, the flu, the RSV, the strep, and all the same platform.

And that's a highly accurate test. So, yeah, there's an increased demand. And sometimes if it's a younger baby and parents want to know, yeah, we will test.

If it's an older child and there's no other smaller babies in the home, we won't test. It's just kind of shared decision making. But I do think, yes, you're right, there is increased demand to know, I don't say demand, but at least a desire to know what's going on.

And like Dr. Sanchez, at the beginning of the season, we're testing everyone, we want to see if it's there, right? So, we can tell people, hey, RSV is here. And for those who may be a little bit hesitant about getting the monoclonal antibodies, put a little sense of urgency to say, hey, we're in the season now, we can't wait to help your baby prevent this.

[Dr Mike Patrick]
Yeah, absolutely. So, wrapping up, Dr. Sanchez, what is your take-home message here? As a neonatologist and an infectious disease expert, what is your take-home message for parents as this RSV season approaches?

[Dr Pablo Sanchez]
First of all, protect your infants and high-risk children against RSV. We, in the young infants, we can also prevent the exposure. A baby who has just been born in the first few months of age should not be, people who are sick with any cold should not be visiting and should not be with the baby.

But aside from the routine precautions from any infection that somebody else may have and may transmit to the baby or to the high-risk child, we have ways of preventing severe RSV disease. So pregnant women should talk to their obstetricians at 32 to 36 weeks to get vaccinated. If not, then every single baby, every single infant should receive either Nirsevimab or Clesrovimab if they're less than eight months of age, meaning that they're going through their first RSV season.

And if the pediatrician, the healthcare professional who's caring for the infant does not know at the time that they're seeing that child whether or not the mother received the vaccine, it's best to go ahead and give them the protection that the infant merits. And then in those who are eight to 19 months of age with certain risk factors, they also should receive Nirsevimab. And so, I can only just completely urge and really, I don't know, I just want to get this medication into my babies so we can protect them, please.

[Dr Mike Patrick]
Yeah. And having seen a lot of severe RSV disease in your career, Dr. Sanchez, your passion for this is obvious. And it's because you care about babies and you know how bad RSV infections can get.

And we can prevent them, at least severe RSV infections. Your baby might still get a little cold from RSV, but they're not going to end up or it's going to be less likely that they'll end up in the hospital or an intensive care unit or on a ventilator or ECMO with RSV.

[Dr Pablo Sanchez]
No, it's tragic. It's tragic in today's world, even in the past two years, it's tragic to see an infant hospitalized who was eligible for this monoclonal antibody and is having severe respiratory distress. We're sending them over to the pediatric intensive care unit.

They may end up intubated. It's tragic and it hurts. And please, please, Terrence, do it for them.

Yes, yes, absolutely.

[Dr Mike Patrick]
Well, this has been a great conversation. We are going to have a lot of resources in the show notes over at pediacast.org. It's episode 592.

So, if you want to learn more about RSV, we have references from Nationwide Children's Hospital. We have some blog posts with some great information about RSV and its prevention. We also have resources from the American Academy of Pediatrics and the Centers for Disease Control and Prevention.

So be sure to check out the show notes over at pediacast.org for more info on RSV. And again, all of us really urge parents out there to make sure that your babies are protected against RSV, whether that be from a vaccine that mom got when she was pregnant or from the monoclonal antibodies that babies can get at the beginning of the RSV season. So, it's really, really important.

And this is the time of the year to do it because we are heading into RSV season. So once again, Dr. Bill Long, Pediatrician with Pediatric Associates of Central Ohio and Administrative Medical Director at Nationwide Children's and Dr. Pablo Sanchez, Neonatologist and Infectious Disease Expert at Nationwide Children's. Thank you both so much for stopping by today.

[Dr Pablo Sanchez]
Thank you.

[Dr Bill Long]
Thanks, Mike. Thanks for giving us a chance to talk about this exciting and great time where we can prevent RSV disease in kids.

[Music]

[Dr Mike Patrick]
We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. We really appreciate your support. Also, thanks again to our guests this week, Dr. Bill Long, Pediatrician with Pediatric Associates of Central Ohio and Administrative Medical Director at Nationwide Children's. Also, thanks to Dr. Pablo Sanchez, Neonatologist and Infectious Disease Expert at Nationwide Children's. Don't forget, you can find us wherever podcasts are found. We're in the Apple Podcast app, Spotify, iHeartRadio, Amazon Music, Audible, YouTube, and most other podcast apps for iOS and Android.

Our landing site is pediacast.org. You'll find our entire archive of past programs there. Show notes for each of the episodes and our terms of use agreement.

Also, a handy contact page if you would like to suggest a future topic for the program. Reviews are helpful wherever you get your podcasts. We always appreciate when you share your thoughts about the show.

And we love connecting with you on social media. You'll find us on Facebook, Instagram, Threads, LinkedIn, X, and BlueSky. Simply search for PediaCast.

Also, don't forget, we have another podcast for any pediatric providers who are in the crowd. We turn the science up a couple notches and offer free continuing medical education credit for those who listen. It's called PediaCast CME.

And that credit is actually category one credit for physicians, of course, but also nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists. And since Nationwide Children's is jointly accredited by all of those professional organizations, it's likely we offer the credits you need to fulfill your state's continuing medical education requirements. Shows and details are available at the landing site for that program, pediacastcme.org.

You can also listen wherever podcasts are found. Simply search for PediaCast CME. An additional podcast that I host, this one is a faculty development podcast from the Center for Faculty Advancement, Mentoring, and Engagement at The Ohio State University College of Medicine.

If you are a teacher in academic medicine or a faculty member in any of the health sciences, then this is a podcast for you. And you can find FAMEcast at famecast.org and wherever podcasts are found by searching for FAMEcast. Thanks again for stopping by.

And until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long, everybody.

[Music]