Are You Ready for RSV?

November 3, 2023

Transcript

Dr. Angela Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, home to The Kid Experts, where the complex is our every day. We bring you intriguing stories and relevant pediatric health care information as we partner with you in the care of your patients. Our guests, data, ideas, and practical tips will surprise, challenge, and perhaps change how you care for kids.

Welcome to Talking Pediatrics. I’m your host Dr. Angela Kade Goepferd. Every year in this country, RSV leads to approximately 2.1 million outpatient visits among kids younger than five and up to 80,000 hospitalizations. Coming off what many of us felt like was a particularly brutal RSV season last year, many of us in pediatrics are feeling a little bit wary heading into this winter. There have also been some recent changes to RSV vaccination that we need to be aware of this year. Joining us today to help us better understand RSV and what we need to do as primary care clinicians is Dr. Brian Carroll, pediatric pulmonologist with Children’s Respiratory & Critical Care Specialists here in Minneapolis. Brian, thanks for joining us today.

Dr. Brian Carroll: Yeah. Thanks so much for having me.

Dr. Angela Kade Goepferd: So you’re relatively new to CRCCS and I’m just meeting you today for the first time. I’d love to learn a little bit more about you, how you ended up here, and why pulmonology.

Dr. Brian Carroll: I think maybe a lot of other pediatric pulmonologists I work with and I’ve met, had asthma and I was younger and had my own pediatric pulmonologist who was just great and really introduced me to medicine and not just healed me as a person, but also got me interested in a future career. When I was 10 I had my bad asthma attack and intubated in the local pediatric ICU and he was there and walked with me on that journey all the way up to high school and college. And yeah, I never really deviated through med school or training too much and here I’m today.

Dr. Angela Kade Goepferd: Can you just give us a little reminder of why we’re so worried about RSV, particularly in infants and younger kids?

Dr. Brian Carroll: Being a pediatric pulmonologist, we see so many different viruses and so many kids who either come into the clinic or the primary care clinic or the emergency room with bronchiolitis and we just know RSV is a little more virulent than other ones. It really has that tropism for the lower airways and so it tends to gum up and block up those small breathing tubes and little ones. And yeah, as you stated in your introduction, just the burden of disease I think, and the health care system is huge and obviously it leads to some problems down the road medically for a slew of these kids too.

Dr. Angela Kade Goepferd: And which kids in your mind are kind of the most vulnerable when it comes to hospitalization, or really ones that we should have our flags up for when they come in?

Dr. Brian Carroll: If you look at the whole population of kids who get sick enough maybe to come into the ER or the clinic with RSV, certainly most of those are otherwise previously healthy kids who are term and have no other medical problems, but certainly the sort of kids that we would see in the pulmonary clinic, and obviously you’re seeing in the primary care clinic too, they tend to be the kids that have other underlying medical conditions, so asthma being the most common one. Kids who have maybe other neurodevelopmental problems and have some difficulty coughing out secretions, those sorts of things. You don’t just have to be a little baby to get sick enough with RSV to get them into the hospital, you can be older too. And so probably those kids that have primary lung problems, cystic fibrosis, asthma, bronchopulmonary dysplasia, those would be the top ones. But really any kid who has difficulty coughing or moving as other children would be high on my list of suspicion.

Dr. Angela Kade Goepferd: This last season of RSV, I feel like RSV just came at us with a vengeance a little bit and I was seeing kids who maybe didn’t fit that bill who were a little more sick. But in general, is there sort of an age cutoff at which you think, “Okay, kids whose bodies are big enough, airways are big enough, are generally older than about this age tend to do okay.” Or what do you think about there?

Dr. Brian Carroll: Yeah, I mean like you said, this last year was so strange and I’m assuming this is kind of a reset after the pandemic and masking requirements going away and we’re trying to reset that viral season and some lost immunity for older kids too. So I do hope things are kind of getting back to normal for this year maybe. But yeah, certainly age two to three is when we in our pulmonary clinic tend to think about, “Hey, if you’re having an RSV infection that’s lingering, symptoms aren’t seeming to kind of go away in the normal amount of time.” That seems a little strange.

Dr. Angela Kade Goepferd: Sure.

Dr. Brian Carroll: Is there something different about you? Do you have early asthma, something else? Yeah.

Dr. Angela Kade Goepferd: So one of the things that we’re always thinking about particularly in outpatient pediatrics is like you said there are many viruses that cause bronchiolitis. When do we need to test? When is it important to understand if this is RSV or do we just treat it as bronchiolitis and we don’t care?

Dr. Brian Carroll: And I think the new kind of paradigm shift in the last five to 10 years is to try to be agnostic to which virus it is. There’s some older data that we think about a lot in pulmonary that’s been kind of bopped around that suggests that if you get an RSV infection your risk of wheezing in the future is higher. There’s been some newer studies that kind of not necessarily debunk that but are controversial and would suggest that maybe it’s not necessarily which virus you get, it’s just if you get a bad enough virus in early life to land you in a hospital, then you’re more likely to wheeze. So in general, when I’m talking to primary care physicians and taking outside calls, I’m not usually recommending a viral panel unless things aren’t making sense. We’ve had a child who’s had symptoms or a fever for a month and hey, can we put our finger in something. But yeah, usually I’m pretty agnostic to which virus it is.

Dr. Angela Kade Goepferd: Yeah, I mean I think with the new bronchiolitis guidelines, and we’ll talk a little bit about inpatient management here in a second, it seems to me that in the outpatient setting, you just treat the patient that’s in front of you and treat the bronchiolitis and it would probably only be when a kid is sick enough to make it to the ER inpatient setting that we would consider testing. Would you endorse that?

Dr. Brian Carroll: I agree. Yeah. I think it makes a lot of sense when I see patients who have been to the ER recently and we have our rapid panels. And if we have RSV that pops up, then it’s kind of like, “Okay, good. We were wondering is there something else going on here? Was this an early pneumonia?” But now we have something maybe help us to take a step back and just monitor because as you mentioned for these kids, so much of it is symptomatic care. And fluids and suctioning and rest.

Dr. Angela Kade Goepferd: And what are those warning signs or things that you think would be the tipping point for managing a kid outpatient versus sending them into the ER?

Dr. Brian Carroll: Even when I talk to families, I always talk about that normal timeline of RSV knowing that it’s something like a 10-day illness. And so if we’re just only on day two to three of symptoms and we’re already in a clinic and we’re maybe borderline oxygen and borderline vital signs and there’s some different sorts of alarm bells going off, I think those are the patients that probably warrant either a follow-up the next day in clinic or a low threshold to go to the urgent care or the ER because we know that around day four to five that those symptoms can worsen. And so if a patient comes to see us and we’re already five to six days into it and things are stabilizing, then we just cross our fingers and say, “Hey, we should get through this.” But if it’s early on and they’re already kind of starting to do some funny business, those are the kids I tend to worry about more.

Dr. Angela Kade Goepferd: From my days in primary care and doing hospital medicine, the kids that I worried about the most were the young kids who were experiencing apnea. Those still kind of the higher risk.

Dr. Brian Carroll: Absolutely. And not even the kids who have other medical problems and are born prematurely, we know that there’s those increase in those neurotransmitters that happen with RSV and happen in those kids. That’s a definite sign to more monitoring is warranted.

Dr. Angela Kade Goepferd: So let’s talk a little bit about management of RSV. I think the most dramatic shift has been on the inpatient side. What should we know or what do you want to make sure people are aware of when it comes to management of RSV, particularly in the inpatient setting?

Dr. Brian Carroll: I think our hospitalist colleagues here do such an amazing job that to be honest, in pulmonary we don’t hear about most of the kids with RSV come in and that’s how it should be. It’s like we are a tertiary medical center and most kids with RSV need our support and within a few days, hopefully they get better and go home and never have any lingering symptoms. Tend to think the kids who aren’t making sense, they’re getting sicker after that normal sort of window in the first five days, the week and a half into this RSV and they’re getting sicker. Those are the kids that I think are of interest and more into a little broader thinking.

And then certainly the kids who maybe have had other sorts of lingering symptoms beforehand with other viruses and this RSV was maybe the first time they’d been in the hospital. I think we in pulmonary probably would like to see those kids, even if it’s their “first hospitalization.” If they’ve coughed and they’ve had questionable sort of wheezing and exertional problems in the past. I think that first RSV can be a time for us to meet the family and just talk about trajectory, not that we necessarily start meds, but kind of where is this going, I think.

Dr. Angela Kade Goepferd: One thing that from my perspective as someone who’s done a lot of hospital-based medicine, I’ve seen a dramatic shift in how we do the inpatient management of kids with RSV. When I used to be a pediatric hospitalist, we would keep an oxygen monitor on kids, it would stay on them through sleep. They could keep their saturations up and then they could go home, which resulted in really prolonged hospitalizations for several kids. That’s changed now. Can you talk a little bit about how we’re changing how we monitor kids with RSV in the hospital?

Dr. Brian Carroll: Yeah. There’s been a paradigm shift in the last eight to 10 years, I think with both monitoring and treatment. From the monitoring perspective, absolutely. I think judicious use of the pulse oximeter is important. Certainly in pulmonary clinic, we have lots of families who use different sorts of home oximeters, the Owlet and other sorts of things, and we just know that there’s a natural kind of ebb and flow to oxygen saturations overnight. And so what’s clinically significant, what isn’t. Most patients who have gotten off of respiratory support have reassuring vital signs are feeding. Usually we’re watching them for a few hours on the pulse oximeter and then they just come off and we watch them clinically what parents will be doing at home.

Dr. Angela Kade Goepferd: Right. One other sort of tricky point is around the use of any kind of bronchodilator with kids with RSV, and I think for a while there was some mixed use and the data really suggests not, but could you talk a little bit about if there are any treatments, inpatient or outpatient that are worth considering or not?

Dr. Brian Carroll: The studies are pretty clear for the general population children who don’t have comorbidities like bronchopulmonary dysplasia, right, the vast majority of them don’t seem to respond to mucolytic therapy like the hypertonic saline. They don’t seem to respond to albuterol. Steroids are not usually indicated. It’s really that bedrock of supportive management.

I think here at Children’s we have the right sort of balance, which is kids who are in distress have very significant wheezing, that seems out of proportion to what our clinicians are used to with RSV, trying an albuterol treatment can be helpful. I think it can be difficult on the front end when a child comes in sick to get all that sort of back history of, “Oh actually, hey, maybe there were some symptoms before this.” And that’s where we in pulmonary or the hospitalist team will get a better sense of that. But I think not fully restricting it, but just realizing that probably the best thing for most of these patients is supportive care.

Dr. Angela Kade Goepferd: Right. Just a lot of suctioning.

Dr. Brian Carroll: Exactly.

Dr. Angela Kade Goepferd: Which is gross, but what they often need, right?

Dr. Brian Carroll: Right.

Dr. Angela Kade Goepferd: Let’s move over into RSV vaccination. We used to really give RSV vaccine to a very prescribed subset of patients, and that’s all shifted this year. Can you walk us through sort of what’s new with RSV vaccination?

Dr. Brian Carroll: Absolutely. I think this is one of the most exciting things that happen to pediatric pulmonary medicine in really a long time because it kind of touches almost every kid. We know that by the age of three or four, almost every single child has been exposed to RSV. And so there’s just this huge proportion of kids that get sick, whether they come into the hospital or not, they get really sick. So I think the biggest changes, as you said before, SYNAGIS was only given to a small proportion of kids and it was quite expensive and onerous, monthly shots for five months. We now have nirsevimab, which I’m still learning how to say, which is also called Beyfortus. That was a new shot that was approved by the FDA here this summer and is now on our routine vaccine schedule.

Dr. Angela Kade Goepferd: Okay.

Dr. Brian Carroll: One of the first things I tell families and other providers is it’s not a vaccine in the sense of kind of being a recombinant vaccine like the COVID shot. It is an antibody, a monoclonal antibody, which I think has been helpful for some parents to hear that too. And it works kind of just like SYNAGIS, goes to that glycoprotein that helps the RSV to bind to our respiratory cells blocks its activity and it’s one shot and it can be given to anybody eight months and younger and ideally as soon as possible. So there’s some question of whether these children would get it still in the mother-baby ward, just like they get other hep B shots, or is it something we do at the first newborn visit. But really within the first week of life, if we’re in that sort of RSV range of October to late spring, every single child eight months and younger should get this one-time shot.

Dr. Angela Kade Goepferd: Is there anyone who should not get the vaccine in that kind of less than eight months old?

Dr. Brian Carroll: Really it’s just children who would have had known anaphylaxis or allergies to the components of the shot itself. And that’s just our standard guidance for all vaccines, but really all children eight months and younger should get it. And then children who fall into certain higher risk groups, which would be bronchopulmonary dysplasia, needing oxygen or some other support in the preceding six months, cystic fibrosis, which is obviously something I’m very interested in. Those children who have lung disease, until 19 months of age. And then children who are Native American or Alaskan natives would also get that as well.

Dr. Angela Kade Goepferd: And that’s because of a higher risk of RSV in that population?

Dr. Brian Carroll: Yeah. Higher risk of morbidity. Yep.

Dr. Angela Kade Goepferd: Okay. And so are we done doing SYNAGIS? Will certain populations still get SYNAGIS?

Dr. Brian Carroll: Yeah, the CDC is, they hedge their bets a little bit, but it really says that unless Beyfortus is not available in the community and SYNAGIS is, there’s really no reason to use SYNAGIS anymore.

Dr. Angela Kade Goepferd: Okay.

Dr. Brian Carroll: Yeah. Beyfortus is quite effective. Something like a 70 to 80% decrease in clinic visits and urgent care visits.

Dr. Angela Kade Goepferd: Wow.

Dr. Brian Carroll: And 90% decrease in pediatric ICU admissions. And so extremely effective.

Dr. Angela Kade Goepferd: Yeah. That’s great.

Dr. Brian Carroll: Keeping kids out of the hospital.

Dr. Angela Kade Goepferd: That was going to be my next question, so no, that’s really great to hear. And I know that the burden of RSV weighs pretty heavily on the mind of parents, even though most kids will be fine if they get it, they hear horror stories about kids hospitalized with RSV. So hopefully, we can get a good uptake of the vaccine this season.

Dr. Brian Carroll: Yeah.

Dr. Angela Kade Goepferd: Anything else you think it would be helpful to share with our colleagues out in the community who are taking care of kids this respiratory season?

Dr. Brian Carroll: Well, I think the biggest thing, even thinking about this shot, I always think that vaccine hesitancy was a problem before the pandemic. It became much more of a public awareness thing for physicians and everyone else during the pandemic. And I think just the way we talk about this shot is just so important. Because I think it can really totally remake childhood illnesses when we think about the things that have changed with varicella chickenpox, and that’s just not the sort of problem it was even when I was a young person. It’s like we can totally change the burden of respiratory disease in everybody. And RSV is something that really a lot of parents have at least a working understanding and like you said, a working fear of. And so I think kind of doing our best as health care providers to educate and encourage this shot, I think is extremely important.

Dr. Angela Kade Goepferd: Yeah. And I think some of the nuance that you mentioned earlier around this being monoclonal antibody, not a traditional vaccine, may be helpful for some parents who are a little more hesitant. It’s more of a preventative treatment than it is a vaccine.

Dr. Brian Carroll: Yeah, exactly. I think for some families I’ve even talked to in clinic already this year, they like the idea that it’s the same sort of idea as mother passing antibodies in the breast milk. And I think those sorts of things can be helpful for families that kind of give a sense of relief that, hey, I’m doing something extra for my child. And that’s what we know most parents want.

Dr. Angela Kade Goepferd: Well, Brian, thanks so much for joining us today. This was really great information that I think will help equip us all heading into the winter season. We’ll cross our fingers that RSV got its sort of burliness out of its system last year and will go a little bit easier on us this year. But appreciate all you do for kids and taking the time to talk to us today.

Dr. Brian Carroll: Yeah. Thanks for inviting me.

Dr. Angela Kade Goepferd: Thank you for joining us for Talking Pediatrics. Come back for a new episode with our caregivers and experts in pediatric health. Our executive producer and showrunner is Ilze Vogel. Episodes are engineered, produced, and edited by Jake Beaver. Amie Juba is our marketing representative. For more information and additional episodes, visit us at childrensmn.org/talkingpediatrics, and to rate and review our show, please go to childrensmn.org/survey.