Pediatric Respiratory Syncytial Virus Hospitalizations and Respiratory Support After the COVID-19 Pandemic

Abstract

Importance: After the COVID-19 pandemic, there was a surge of pediatric respiratory syncytial virus (RSV) infections, but national data on hospitalization and intensive care unit use and advanced respiratory support modalities have not been reported.

Objective: To analyze demographics, respiratory support modes, and clinical outcomes of children with RSV infections at tertiary pediatric hospitals from 2017 to 2023.

Design, setting, and participants: This cross-sectional study evaluated children from 48 freestanding US children's hospitals registered in the Pediatric Health Information System (PHIS) database. Patients 5 years or younger with RSV from July 1, 2017, to June 30, 2023, were included. Each season was defined from July 1 to June 30. Prepandemic RSV seasons included 2017 to 2018, 2018 to 2019, and 2019 to 2020. The postpandemic season was delineated as 2022 to 2023.

Exposure: Hospital presentation with RSV infection.

Main outcomes and measures: Data on emergency department presentations, hospital or intensive care unit admission and length of stay, demographics, respiratory support use, mortality, and cardiopulmonary resuscitation were analyzed. Postpandemic season data were compared with prepandemic seasonal averages.

Results: A total of 288 816 children aged 5 years or younger (median [IQR] age, 8.9 [3.3-21.5] months; 159 348 [55.2%] male) presented to 48 US children's hospitals with RSV from July 1, 2017, to June 30, 2023. Respiratory syncytial virus hospital presentations increased from 39 698 before the COVID-19 pandemic to 94 347 after the pandemic (P < .001), with 86.7% more hospitalizations than before the pandemic (50 619 vs 27 114; P < .001). In 2022 to 2023, children were older (median [IQR] age, 11.3 [4.1-26.6] months vs 6.8 [2.6-16.8] months; P < .001) and had fewer comorbidities (17.6% vs 21.8% of hospitalized patients; P < .001) than during prepandemic seasons. Advanced respiratory support use increased 70.1% in 2022 to 2023 (9094 vs 5340; P < .001), and children requiring high-flow nasal cannula (HFNC) or noninvasive ventilation (NIV) were older than during prepandemic seasons (median [IQR] age for HFNC, 6.9 [2.7-16.0] months vs 4.6 [2.0-11.7] months; for NIV, 6.0 [2.1-16.5] months vs 4.3 [1.9-11.9] months). Comorbid conditions were less frequent after the pandemic across all respiratory support modalities (HFNC, 14.9% vs 19.1%, NIV, 22.0% vs 28.5%, invasive mechanical ventilation, 30.5% vs 38.0%; P < .001).

Conclusions and relevance: This cross-sectional study identified a postpandemic pediatric RSV surge that resulted in markedly increased hospital volumes and advanced respiratory support needs in older children with fewer comorbidities than prepandemic seasons. These clinical trends may inform novel vaccine allocation to reduce the overall burden during future RSV seasons.

Figure 1.. Hospital Presentations, Hospital- and Intensive Care Unit (ICU)–Days, and Patient Age by Respiratory Syncytial Virus (RSV) Season

The x-axis denotes RSV seasons, defined as July 1 to June 30. Boxes indicate IQRs, with the horizontal line indicating the mean, and error bars indicate minimum and maximum values.

Figure 2.. Hospital and Intensive Care Unit (ICU) Admissions and Length of Stay by Respiratory Syncytial Virus (RSV) Season

The x-axis denotes RSV seasons, defined as July 1 to June 30. ED indicates emergency department.

Figure 3.. Respiratory Support Mode Use by Respiratory Syncytial Virus (RSV) Season

Total number and proportional respiratory support requirements for patients receiving high-flow nasal cannula (HFNC) (A), noninvasive ventilation (NIV) (B), invasive mechanical ventilation (IMV) (C), high-frequency ventilation (HFV) (D), extracorporeal membrane oxygenation (ECMO) (E), and inhaled nitric oxide (iNO) (F). The x-axis denotes RSV seasons, defined as July 1 to June 30. Bars (left y-axis) indicate the proportion of total hospitalized patients requiring the respective respiratory support mode. Circles with connecting line (right y-axis) indicate the total number of patients requiring the respective respiratory support mode. Each panel has a different y-axis scale to show trends.

Figure 4.. Respiratory Support–Days, Age, and Comorbidities by Respiratory Syncytial Virus (RSV) Season

A, Total support-days for high-flow nasal cannula (HFNC), noninvasive ventilation (NIV), and invasive mechanical ventilation (IMV) are shown for each RSV season. The x-axis denotes RSV seasons, defined as July 1 to June 30. B, Age for HFNC, NIV, and IMV inpatient populations during prepandemic vs postpandemic seasons are shown. Boxes indicate IQRs, with the horizontal line indicating the mean, and error bars indicate minimum and maximum values. C, Proportions of patients with comorbid conditions for each respiratory support type for prepandemic vs postpandemic inpatient populations are shown.