A clinical prediction rule can help stratify young children at risk for hospitalization from respiratory syncytial virus infection
Article Outline
Rietveld E, Vergouwe Y, Steyerberg EW, Huysman MW, de Groot R, Moll H. Hospitalization for respiratory syncytial virus infection in young children: Development of a clinical prediction rule. Pediatr Infect Disease J 2006;25-201-7.
Question Among children at risk for respiratory syncytial virus (RSV), is there a valid clinical prediction rule that can predict which children are likely to be hospitalized (and thus could be candidates for passive immunization with a RSV-specific immunoglobulin)?
Design Retrospective cohort study.
Setting 29 hospitals in the southwestern part of the Netherlands.
Participants 140,661 at-risk children (2,469 who were hospitalized) born between January 1, 1996 and December 31, 1998.
Intervention Children hospitalized for proven RSV infection were compared with children not hospitalized for RSV infection. The monthly risk was estimated with a logistic regression model including five clinical predictors (sex, gestational age, birth weight, presence of bronchopulmonary dysplasia [BPD], and age) and the mean seasonal monthly pattern of RSV infections.
Outcomes Monthly risk of hospitalization for RSV infection. The authors compared the predictive performance of the prediction rule with the guidelines of the American Academy of Pediatrics (AAP).
Results All predictors were statistically significant, with age and the seasonal monthly RSV pattern having the strongest effects. The clinical prediction rule that included these predictors could better discriminate between high and low risk children than the AAP guidelines and would potentially reduce the number of immunizations by 20%.
Conclusions The prediction rule reliably estimates individual monthly risks of hospitalization for RSV infection in the population studied. It provides an improved index for passive immunization, but further validation in other populations is required.
Comment RSV infections result in up to 90,000 infant hospitalizations during the winter months in the United States. Mortality is largely confined to infants with congenital heart disease or immune deficiency.1 The AAP currently recommends administration of RSV-specific immunoglobin to high-risk infants, at a cost of $4500 to $5000 for a 5-month course.1 The risk of hospitalization as a result of RSV is about 12% among infants with prematurity or presence of BPD. Passive immunization cuts this risk and that of intensive care unit admission approximately in half.2 Rietveld et al’s prediction instrument appears to offer a more accurate prediction of RSV-related hospitalization risk than achievable using the AAP criteria, and it might allow for a more efficient selection of infants who are likely to benefit from passive immunization. Their derivation study predates the clinical availability of RSV-specific immunoglobins. Because of current routine use of these agents, a prospective validation of their instrument would require an informed consent protocol and caretakers willing to forgo the intervention despite the AAP recommendations. Reitveld’s instrument calculates a monthly and seasonal risk of admission on the basis of sex, birth weight, gestational age, and presence or absence of BPD, assuming the peak RSV season to be November through January, and it may be accessed as an online spreadsheet at http://www2.eur.nl/fgg/mgz/software.html#rsv. Practitioners might consider using it to counsel caretakers of infants otherwise falling under AAP guidelines but who are reluctant for financial or other reasons to comply. Systematic use of the instrument will require the determination of an appropriate admission risk threshold for revised recommendations. Cost effectiveness analysis of this issue has heretofore proved problematic.1
References
PII: S0022-3476(06)00557-9
doi:10.1016/j.jpeds.2006.06.011
© 2006 Mosby, Inc. All rights reserved.
