JAMA Pediatrics: Children with RSV post-pandemic needed more support.

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In the wake of the COVID-19 pandemic, pediatric hospitals in the United States saw a marked increase in respiratory syncytial virus (RSV) cases among children. This cross-sectional study documented a substantial increase from 39,698 cases before the pandemic to 94,347 cases afterward (P < .001). Hospital admissions also saw a notable surge, rising 86.7% from 27,114 to 50,619 cases (P < .001).

Regarding treatment, the study found a significant increase in the use of advanced respiratory support methods after the pandemic. The adoption of high-flow nasal cannula (HFNC) and noninvasive ventilation (NIV) rose by 70.1%. Children needing these treatments were notably older compared to previous seasons (median ages: HFNC 6.9 vs 4.6 months; NIV 6.0 vs 4.3 months, P < .001). There was a decrease in the prevalence of comorbid conditions among children requiring respiratory support across all studied modalities (HFNC, NIV, and invasive mechanical ventilation; P < .001).

“This is the largest US database study to date examining pediatric RSV infection focused on use of advanced respiratory support modes and clinical metrics of disease severity before and after the COVID-19 pandemic. Although a lower proportion required hospitalization or ICU admission than typical RSV seasons, the strain on pediatric hospital systems was apparent in the 50% increase in total hospital-days and 25% increase in ICU-days during the 2022 to 2023 postpandemic season in this analysis,” according to the investigators.¹

Conducted from July 2017 to June 2023, researchers analyzed data from the Pediatric Health Information System database covering 48 freestanding US children’s hospitals. Over this period, 288,816 children aged 5 years or younger were hospitalized with RSV. After the pandemic, older median ages were observed during the 2022-2023 season compared to before (11.3 vs 6.8 months, P < .001). There was a decrease in the proportion of children with comorbidities post-pandemic, indicating a trend towards a healthier cohort requiring hospitalization.

According to the investigators, “21.6% of children across seasons required advanced respiratory support, the increase during the 2022 to 2023 post-pandemic season was largely driven by increases in the use of noninvasive support with HFNC and NIV. In this cohort, the number of patients supported with HFNC and total HFNC-days nearly doubled in 2022 to 2023, whereas the proportions of children requiring IMV and total IMV-days were stable from prepandemic data.”¹

This study has limitations, it includes data from 48 pediatric hospitals in the PHIS database, which may not fully represent the whole US pediatric population. The dataset predominantly features large university medical centers, potentially overlooking perspectives from smaller hospitals and children’s facilities integrated within adult settings. Additionally, reliance on ICD-10 codes for RSV diagnosis may overestimate or underestimate infections due to inconsistent testing practices. Lack of data on viral and bacterial coinfections, potential impacts of increased viral respiratory testing availability post-pandemic on case numbers, and variations in hospital practices regarding respiratory support modes for RSV. Reporting of HFNC use across hospitals is limited, and small sample sizes for rare respiratory support modes constrain analysis. Challenges in accurately identifying patients needing only supplemental oxygen and changes in resource allocation during infectious disease surges further complicate drawing definitive conclusions.

These findings suggest potential implications for vaccine distribution strategies to mitigate future RSV season challenges.

Similarly, data from another large cohort indicate shifts in the seasonal timing of RSV and bronchiolitis infections since the COVID-19 pandemic, especially in hospitalizations among older children with RSV. However, some of these changes may be influenced by increased testing practices overall. This underscores the necessity for new prevention strategies in this vulnerable pediatric population.

An investigator from this study noted, “an overall shift in RSV seasonality toward a summer season in 2021. Although seasonal timing began to shift back to a more typical pattern (eg, occurring in colder months) in 2022 to early 2023, the number of cases in children younger than 5 years was higher overall during this season.”²

Learn more: RSV Rountable Series—a collaborative effort with our sister brands, Contemporary Pediatrics, and Contemporary OB/GYN—physicians with various areas of expertise weigh in on what they are seeing at their institutions in terms of RSV infection rates.

References

1. Winthrop ZA, Perez JM, Staffa SJ, McManus ML, Duvall MG. Pediatric Respiratory Syncytial Virus Hospitalizations and Respiratory Support After the COVID-19 Pandemic. JAMA Netw Open. 2024;7(6):e2416852. doi:10.1001/jamanetworkopen.2024.16852

2. Hoffman, M. Earlier RSV Seasonal Peaks Point to Need for Prevention in Older Children. Contagion. Published April 23, 2024. Accessed June 18, 2024. https://www.contagionlive.com/view/earlier-rsv-seasonal-peaks-need-prevention-older-children

3. Rha B, Curns AT, Lively JY, et al. Respiratory syncytial virus-associated hospitalizations among young children: 2015-2016. Pediatrics. 2020;146(1):e20193611. doi:10.1542/peds.2019-3611