Immunization in children with congenital heart disease

DR John Selvan, consultant Paediatric Cardiologist, Chest diseases hospital, Kuwait.

Congenital heart disease (CHD) is a general term used for a range of birth defects that affect the normal workings of the heart.  The term congenital means the condition is present at birth.  CHD is one of the most common types of birth defect affecting up to 8 in every 1000 babies born. In an interview held with DR John Selvan, consultant Paediatric Cardiologist, Chest diseases hospital, Kuwait, Selvan explains in details about the subject. Some excerpts.

Q: Is congenital heart disease (CHD) common in Kuwait?
A: Yes it is. The incidence of CHD is about 1% in the world while it is almost 2% in Kuwait. In addition, the complexity of CHD is also much higher in Kuwait.

Q: What are the precautions a family can do to take care of such babies?
A: Precaution starts in early pregnancy.  Mothers should undergo foetal echocardiograms in the second trimester onwards to see whether the hearts of the unborn babies are normal.

Q: How does that help?
A: If one knows that the baby has an important CHD, then the baby can be delivered in a facility where immediate expert paediatric cardiologist consultation is available.

Q: How important is immunization in these children?
A: Immunization is very important in all infants and children to protect them from vaccine preventable diseases. It is even more important to protect the children with CHD, because of their increased risk of morbidity and mortality.

Q: Does the immunization schedule differ for the children with CHD?
A: If they have simple CHD and are clinically normal, then there will be no change in the immunization schedule. However if they have complex CHD with compromised clinical status i.e. heart failure or severe cyanosis or if they are awaiting cardiac surgeries, parents have to get a clearance from their paediatric cardiologist prior to vaccination. Children who underwent cardiac surgeries are not given vaccinations in the first month after surgery.

Q: What are the common viral infections in children that cause respiratory disease?
A: Common viral respiratory tract infections include common cold and influenza while respiratory syncytial virus is particularly common in the winter months.

Q: What is Respiratory syncytial Virus (RSV)?
A: RSV is a common viral infection affecting most of the children in the winter season all over the world. It is notorious because it can cause a serious form of lower respiratory tract infection with wheezing called Bronchiolitis. It is often a devastating disease in infants less than two years with CHD, chronic lung disease, in preterm babies and in children with poor immunity.

Q: How does one protect children from RSV infection?
A: There is a prophylactic or preventive medication, a monoclonal antibody, which is given as five monthly doses during winter months all over the world or during rainy season in the tropics.

Q: Why is it highly recommended in children with CHD?
A: The common viral lung infection can become a severe wheezy respiratory disease in small children with CHD, preterm babies, children with chronic lung disease and with immune compromised status. In these children the severity of illness leads to more hospitalization, assisted ventilation, intensive care and even death.
RSV prophylaxis when given as monthly intramuscular injection over 5 months maintains IgG antibody level in body, which protects these children from falling ill and also from developing severe wheezy respiratory infection.

Q:  What is your experience in Kuwait?
A: We have been implementing the RSV prevention program against RSV infections over the last 9 years. About 200 infants per year less than 2 years of age with important CHD receive this protection. The results are excellent.
In the past, 30 to 40% of our beds in the wards and ICU during winter months were occupied with small children with severe lung infections. There were a few deaths every year as well in these children. Since we started this RSV prevention program admission of CHD children with severe respiratory infection has been declining and seldom occurs now.
This has resulted in the use of the limited hospital resources better for the children with heart disease and surgeries.

Q: What is your advice to parents of children with CHD regarding immunization?
A: 1- Parents should get an antenatal foetal echocardiogram by a paediatric cardiologist to plan the delivery of the baby in a set up with paediatric cardiologist guidance.
2-    In most of the infants with CHD normal immunization schedule can be followed.
3-    If the baby has an important CHD, then the parents should follow the paediatric cardiologist advise regarding immunization.
4-    Children under 2 years of age with important CHD should be given RSV prophylaxis during winter months to protect these babies from RSV infection because Synagis protection significantly decreases the morbidity and mortality from this disease.

Q:   Are there any side effects with this medicine?
A: RSV prophylactic medication is a monoclonal antibody, which targets specifically against the RSV virus. Side effects are uncommon. If at all any, they are mostly mild symptoms of common viral illness. Anaphylaxis can seldom occur and we have not seen one in our experience over last nine years.

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