AAP’s Inconsistent Stance on Infant Care is Cause for Concern

May 5, 2014

by Judith Bernbaum, M.D.

Last week was World Immunization Week, an apt time for the American Academy of Pediatrics (AAP) to question a controversial proposal from the Centers for Disease Control (CDC) to reduce children’s pneumococcal vaccine schedule.  As AAP’s infectious diseases committee chair explained, shifting from four to three vaccine doses could increase children’s health risk – particularly for minority children.  But while I commend the AAP for censuring restricted vaccine access, I can’t help but note the sad irony of its stance.  Regarding treatment for premature infants with respiratory syncytial virus (RSV), a similarly important childhood health issue, AAP takes a restrictive approach.  The organization’s mixed messaging is problematic.

Like RSV, pneumococcal disease affects infants – a uniquely vulnerable population.  Thus, the CDC currently recommends pneumococcal vaccines at two, four, six and 12-14 months of age.  Reducing the vaccine schedule would result in more than two additional deaths per year; 12,000 more cases of pneumonia; and 261,000 ear infections.  According to AAP, it could also reintroduce disparities in disease rates for African American children.

RSV among premature infants likewise affects minority children disproportionately.  Prematurity, which characterizes 12 percent of pregnancies, is particularly prevalent among minority mothers.  Premature infants’ fragile immune systems make them both more likely to develop RSV and less equipped than full-term babies to fight off the virus.

Although no RSV vaccine exists, at risk babies who receive monthly treatment shots for four-five months have a greater chance of not contracting the virus.  The treatment also improves the infant’s health over his or her lifetime.  In one study, infants who had received treatment shots experienced significantly fewer wheezing days, even after treatment concluded.

Despite these factors, AAP revised its treatment recommendation in 2009, limiting the number of infants who should receive treatment and the number of treatments infants should receive.  As explanation, the AAP cited its effort to “ensure the optimal balance of benefit and cost from this expensive intervention.” Treatment averages $6,400 per child.

The CDC’s proposed reduction in pneumococcal vaccines also hinges on cost considerations; the move could save as much as $500 million a year.  In both cases, the federal and state government carries the brunt of the expenses through Medicaid coverage of affected children.

I recognize these figures’ significance.  Nevertheless, I must urge caution regarding cost-benefit analysis for infant patients.  While such calculations may, unfortunately, be increasingly considered for treatment of geriatric patients and those suffering from terminal disease, pediatric care demands a different perspective.  This isn’t end-of-life care; it’s beginning-of-life care.  With proper treatment, these children stand to gain 80 or more years of healthy, productive life free of chronic respiratory illness.  By comparison, limited medical access could result in as many years of life marred by wheezing, asthma and expensive treatments – or cut short by infection and related complications.

In light of these scenarios, AAP would do well to align its stance on RSV treatment with its pro-access view on the pneumococcal vaccine regimen.  In both cases, protecting a fragile patient population requires supporting access, prevention and full treatment for infants whose health depends upon proper care.

Dr. Bernbaum is Director, Neonatal Follow Up Program at The Children’s Hospital of PhiladelphiaandProfessor of Pediatricsat The Perelman School of Medicine at The University of Pennsylvania.

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