What is RSV and who gets it?

RSV (respiratory syncytial virus) is a seasonal respiratory virus. It is a common virus — most children (~70%) are infected in the first year of life and almost all children (~97%) are infected by 2 years of age. Thereafter, recurrent infections occur throughout life — these are typically mild due to immunity that the body’s developed from the earlier infections.

Who is at risk for severe RSV infections?

RSV is the leading cause of hospitalization in infants in the United States. Two to three percent of infants are hospitalized with RSV. The risk of hospitalization is the greatest in the first months of life; risk declines with increasing age. Infants with the following medical conditions are at greatest risk of hospitalization from RSV: prematurity, congenital heart disease, chronic lung disease, and immunocompromising conditions.

When is RSV season?

The RSV season in Texas generally runs from October through March, with a peak in December or January. The peak of RSV season usually precedes the peak of flu season by 1 to 2 months. The Texas Health Department releases information about RSV cases throughout the state on their website (https://www.dshs.texas.gov/respiratory-syncytial-virus-rsv/respiratory-syncytial-virus-rsv-data) .

What are the symptoms of an RSV infection in infants and young children? What is the treatment?

RSV causes a lower respiratory infection called “bronchiolitis”. Young children with bronchiolitis will typically have mild runny nose and cough at the beginning of the illness, followed by cough and respiratory distress. They will often breathe faster than normal and have retractions; doctors will hear certain sounds with their stethoscope during the exam (wheezing, crackles).

There is no antiviral treatment for RSV bronchiolitis. Infants with RSV are helped by supporting their body while their immune system clears the virus. Frequent nasal suctioning, hydration, and monitoring the child’s breathing are the hallmark of caring for infants with bronchiolitis at home. Hospitalized infants with RSV are often given oxygen and IV hydration. Some hospitalized infants with RSV are given breathing treatments.

What is the new RSV prevention product? Is it effective? Is it safe?

Beyfortus (nirsevimab) is a new product developed after decades of research. It contains preformed antibodies that attach to a protein (the F protein) on the outside of the RSV virus. It is given as a single intramuscular shot. Ideally, it’s given shortly before the start of the RSV season to eligible infants.  It provides immediate and short-term protection (around 5 months). Beyfortus is more effective and provides longer protection than a currently available product (Synagis) that is only given to the most vulnerable of infants.

Information about the safety and effectiveness of Beyfortus is derived from 3 clinical trials where it was given to both term and preterm infants. The studies found that Beyfortus reduced the chance of an RSV infection by 70% and reduced the chance of an RSV-related hospitalization by 78%. The protection was greatest in the first 3 months but lasted up to 5 months. Side effects from Beyfortus were rare and mild. The side effects were similar to other injectable medications – mild rash or injection site pain or swelling.

Beyfortus was approved in Europe in November 2022 and by the US FDA in July 2023. The CDC provided recommendations for its use in August 2023.

How do I know if my child is eligible for Beyfortus?

The AAP and CDC recommend the use of Beyfortus for ALL infants under 8 months of age during RSV season. This recommendation is for both term and preterm infants and it includes children who are healthy and children with medical conditions.

For children 8 months to 19 months of age, only those with the following medical conditions are eligible – chronic lung disease of prematurity, cystic fibrosis, and severely immunocompromised. Additionally, due to their high risk for hospitalization, Native American and Native Alaskan children are eligible to receive Beyfortus when entering their second RSV season.

What if the infant’s mother received an RSV vaccine during pregnancy?  Does the infant still benefit from Beyfortus?

Infants born to mothers who received the maternal RSV vaccine (Abrysvo) while pregnant generally are not due for Beyfortus.  However, there are exceptions.   Make sure you notify your pediatrician if your infant falls in this category.

Does Heritage Pediatrics recommend Beyfortus?

The doctors at Heritage Pediatrics recommend the use of Beyfortus for all infants who are eligible. Every year we see patients with both mild and severe RSV infections. Every year we have patients that are hospitalized from this virus. We are confident that the research conducted on Beyfortus demonstrate that it is effective and safe. We have seen this medicine significantly reduce the burden of RSV infections in infants since it’s use began.

We also understand that Beyfortus is a newer medicine and that families will have varying degrees of comfort with accepting a new medication. We are here to answer any questions you have regarding this product and hope the above FAQ document will help your family make an informed decision.

Is my child required to receive Beyfortus by the State of Texas or Heritage Pediatrics?

Beyfortus is not a required vaccine for Texas nor Heritage Pediatrics.  It is optional risk reduction.

References:

• Glezen WP, Taber LH, Frank AL, Kasel JA. Risk of primary infection and reinfection with respiratory syncytial virus. Am J Dis Child 1986 140:543-546.
• Suh M, Movva N, Jiang X, et al. Respiratory Syncytial Virus Is the Leading Cause of United States Infant Hospitalizations, 2009-2019: A Study of the National (Nationwide) Inpatient Sample. J Infect Dis 2022 226(Suppl 2):S154-S163.
• Hall CB, Weinberg GA, Blumkin AK, et al. Respiratory syncytial virus-associated hospitalizations among children less than 24 months of age. Pediatrics 2013 132:e341-348.

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Open 12/24 and 12/31 for normal urgent care morning. Closed on 12/27/22 and 1/2/23 all day. Call (210)804-2301 to reach after hours nurses or doctors on call.

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Dear Heritage Families,

We are sure you were as alarmed and disappointed as we were on Saturday to get the emergency alert about staying home due to the rising cases of COVID-19 in Bexar County. This week is a reminder that we all must keep doing our part.

What can you do? It is so imperative that we wear masks when we are out. A recent article from UT Southwestern Medical Center explains myths vs. realities. When all parties are wearing masks the incidence of transmission is extremely low. We also need to practice social distancing. Being outside is not social distancing. Being outside at least 6 feet away is social distancing. If staying 6 feet away is not possible, a mask should be worn.

What is Heritage doing? In light of what we have learned about COVID-19 in the past 4 months and in continuing with our current policies and procedures, Heritage will continue seeing your children in our office. We have made many changes which are in place to make sure your visit is safe. You can read about that here. For the safety of you and our staff, we will be strictly enforcing mask wearing. Masks must cover the mouth and nose the entire time you are in the office (not just when the nurse/assistant or doctor is in the room).

If some of you still feel more comfortable with a telemedicine well visit, we are happy to do these as covered. Insurance companies are learning and adapting just like we are, so coverage may vary for telemedicine going forward. Call to find out more if you have questions.

As you begin to feel the pressure of the rising cases, please know we remain encouraged that children typically to do well with COVID-19. They can still get sick and have more severe disease, but most will have mild to no symptoms. The vast majority of those with moderate to severe symptoms will still fully recover. We have not hospitalized any pediatric patients to date from our group. We are also encouraged that surfaces are not the primary means of COVID-19 being transmitted. However, this doesn’t mean it can’t be transmitted from surfaces so hand washing and wiping downs surfaces are still important. Though children do not appear to be the primary transmitters of this virus, it is clear that teens and your college age children are transmitting the disease. We realize that socialization is important for so many physical, emotional, mental, and spiritual reasons. We do need to continue to be creative in finding ways to have socialization. We just need to do so cautiously and remember to protect the elderly and those who are more vulnerable.

Heritage Pediatrics continues to operate normal business hours and to have 24 hour and 7 days a week physician after-hours coverage . These are tough times. We are all weary and done with this virus. Yet, the past week has shown that the virus is not done with us. Please keep your guard up, protect the elderly and vulnerable, be charitable with one another, and be creative to have safe social interaction. This season will pass. Let us come together as a community to do our part and weather this storm. Please call us if you have questions.

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We continue to modify and add changes to our patient care to maximize the safety of our patients, staff and doctors. Here is a list of many things we are now doing differently to reach this goal.

1. Masks: All persons able to wear masks inside our office must due so. This includes children at 10 years and younger if able.
2. Low Contact Visits: We escort you to and from your room, no surface contact, payment by phone.
3. COVID Visits Outdoors: All possible COVID cases or direct contacts are managed by telemedicine or as a car visit.
4. Cleaning: Every surface a visitor touches is cleaned.
5. Screening: We screen every visitor with COVID screening questions and take temperatures on every patient, and sanitize hands.
6. Reduced Bodies: We request only one parent and no siblings to each visit to reduce odds of COVID contact.
7. Telemedicine Options: As long as your insurance allows, we are happy to convert most any visit to telemedicine at your request.
8. Testing: All tests (COVID, Strep, Flu) are done outdoors.
9. No Waiting Room: You must wait in your car or outdoors until your escort is ready. Our lab area is also closed except for ear piercings.

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What if my child is exposed to COVID-19?

We have seen a large increase in patients for exposure to known cases of COVID-19. As the cases rise in Bexar County, it is increasingly likely that your family will come into contact with someone who tests positive for the disease.

We encourage you to call us with any questions if you think you have been in contact with a known or suspected case of novel coronavirus. Also, call us for any fevers over 100.4F or symptoms that are consistent with COVID-19. Below are basic guidelines from the CDC for suspected COVID contacts which we are using at Heritage Pediatrics.

I just found out that my child was around someone who tested positive for COVID-19. Now what?

First off, clarify what if your child meets the current definition of exposure. This is critical to knowing if you need to do anything more.

To be considered exposed, a person must have:

• Contacted someone with a positive nasal swab PCR or antigen test, NOT an antibody test AND
• Contacted that person intimately (hug/kiss) or been in close proximity (<6 feet) for >15 minutes AND
• Contacted that person while infectious; either 2 days before the positive test or symptoms began

If your child has been in contact with known COVID-19 person for the above criteria, the CDC currently recommends that you quarantine for 14 days, regardless of symptoms. This is very important to reducing the spread of the disease. Testing may also be warranted to determine whether further quarantining should start with the close contacts of your own child.

These guidelines are confusing. Please call us or the SA Metro Health Department for guidance on your child.

As we continue to move forward, please practice social distancing and wear your mask. Our collective willingness to practice these habits for the greater good of our community will define the amount of illness and death we have in those we love. Please be safe and be for others.

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All Well Checkups Now in Office

We continue to adjust our office visit policies as appropriate. Our current updates are as follows:

As of June 1, all well child visits are now being in person in the office. Contagious/sick visits will continue to be done via video and/or car visits.

Beginning June 1, if you would prefer to do your well visit by video, we will need you to sign a waiver that you would accept financial responsibility if your insurance company refused to cover video well visits. (Some insurance companies are dropping this coverage)

We will continue to use your car / the parking lot as our waiting room. We will still ask for one parent to bring the child and if feasible to leave siblings at home. We will take everyone’s temperature upon greeting you at the front door. We will continue to ask screening illness / exposure questions and if positive, will ask you to reschedule. These include:

Have you or your child had:

• Cough of new onset in the last 7 days
• Shortness of breath or difficulty breathing
• Fever within the last 7 days
• Chills or muscle aches
• Sore throat
• New loss of taste or smell
• Nausea, vomiting or diarrhea
• Contact with a Person Under Investigation (pending test) or having COVID in the last 14 days.

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Parenting Resources: APA

More parenting resources for managing the chaos and anxiety from social isolation may be found at the American Psychology Association.

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Thank you all for your continued support for Heritage Pediatrics as we try to figure out how to best care for your families. These past few months have been trying and your kindness and well wishes have helped keep us all going. Your willingness to allow us virtually into your homes is humbling, encouraging and even funny at times.

These are indeed unique times. We give shots in the parking lot, we have been blowing up Tik-Tok, and we even have got Dr. Fitch and Dr. Hall doing electronic scripts now. Things must be crazy!

As social distancing begins to loosen at the guidance of our authorities, we want to give you continued guidance. Trust us, we want to get you back in our office as much as you want to get out of your houses. We feel a slow and thoughtful move towards opening social contact is best. For now, we have begun to see up to 15 month-olds for checkups in our office and we reconsider these ages every week. We continue to do all other well checks and all sick visits via telemedicine and/or car visits. There may be some 4 year olds who disagree, but shots in the car have gone very smoothly and efficiently. Over the next few days we will try to address your many questions about how to open your circle, what to do about camps, and when and how to plan your summer.

Summer Plans

I know many of you are wondering and asking: What about summer camps? What about public pools? What about play dates for my kids? What about my child going to swim at a friend’s house? My child care is opening up, is it safe to send my kids back since I need to go back to work?

Many of you who have asked us these questions are not surprised that we don’t have a simple “yes” or “no” answer. I think we all agree we want our current situation to be over. Like us, many are worrying about the, neglect, abuse, depression, delayed care, poverty and homelessness that this pandemic has produced.

As our government authorities relax social isolation, when is it safe for my children and family to be back into their normal routines? In general COVID-19 has not been as severe in children as it is in the elderly and vulnerable. Yet children can still be silent carriers of this deadly disease, and we have to consider this as we balance moving forward.

So, our first advice over the next couple weeks as things open up is to be cautious. Moving forward is going to be about managing risk. And your risk will look different than others. But we all live in the same community and share risk.

Consider your risks of opening your social circle: The risk of our kids going back to daycare, camps and public pools is low but real. Your child may be fine, but can you miss work or be hospitalized? Would that put people around you who are vulnerable at risk? Think of all of your contacts and balance that with your own comfort of contracting illness.

Consider the risks of keeping your circle closed: How are you and your family handling the mental strain of isolation? If your source of income manageable from home? Do you have family members that really need you?

We recommend you balance these risks and consider your obligation to self, family, and community. It is so important to remember that we live in community. Our actions are clear to our neighbors and may leave them feeling uncomfortable or even excluded. Even if we think we are being responsible, are we hurting our relationship with our neighbor because they don’t agree with us?

So, our last encouragement is that we need to be charitable with one another. Obviously none of us should be foolish or reckless. We need to follow city and state ordinances. We should wear our masks in public and maintain social distance as best we can. But, some families will have more comfort with risk than others. So please, don’t judge a family because they are making a decision that is different than you are making. And, don’t get your feeling hurt if a family turns down an offer to come over to your house. We are all learning what our comfort level is. So, we must be patient with each other.

Writer Damien Barr noted that “we are all in the same storm, but we are all not in the same boat.” Some of your boats look pretty good right now. Your jobs are secure, your children healthier than ever and you are enjoying your extra time with your family. Others of you have a boat that seems to have too many holes to fix and you feel like you are drowning. If you are a patient at Heritage, you are our community. Please reach out to us if you are in one of those boats that is going down. We may not be in the same boat, but we want to help your boat get safely to the shore. The storm will end!! Let’s all work together to help each other to weather this storm.

Heritage Pediatrics continues to maintain the same hours and there is always a doctor on call when the office is closed. Please don’t hesitate to call if we can help you in any way.

The Doctors and Staff of Heritage Pediatrics

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Importance of Vaccines

Your doctors at Heritage Pediatrics agree with the AAP feel strongly that you should continue all vaccinations along with your preventative care. We are concerned that vaccinations rates in our community are declining throughout this pandemic (figure 1). Vaccine preventable diseases come from many sources: soil, others, and even yourself. We have a system of outdoor car vaccinations which allows us to continue your child’s vaccines on schedule with much less risk to COVID exposure.

Figure 1 (source: National Pediatric Billing Data):

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