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Editor,—Following a recent study demonstrating the lack of efficacy of dexamethasone in bronchiolitis,1Everard has commented that there is little evidence that any specific treatment for bronchiolitis is of major clinical benefit.2The American Academy of Pediatrics (AAP) has issued guidelines for the use of ribavirin in respiratory syncytial virus (RSV) bronchiolitis.3 These guidelines have not been widely accepted in the UK and the indications for ribavirin use remain controversial.
To investigate this further we have recently conducted a nationwide survey of UK paediatricians’ attitudes and use of ribavirin, related to their experience of bronchiolitis. A structured questionnaire was sent to all UK consultant hospital paediatricians, requesting one reply from each hospital unit. Paediatricians were asked which groups of children at risk of severe RSV disease (from the AAP guidelines), who had been hospitalised with RSV bronchiolitis, they would routinely treat with ribavirin. We also asked how many children with bronchiolitis they had admitted, ventilated, or treated with ribavirin during the winter 1 October 1993 to 30 April 1994. Replies were received from 73% of all hospitals. For the following high risk groups the percentage of paediatricians who indicated that they would routinely use ribavirin in the treatment of an infant hospitalised with RSV bronchiolitis was: congenital heart disease 62%, bronchopulmonary dysplasia 69%, cystic fibrosis 62%, immunodeficiency 67%; for those severely ill requiring fractional inspiratory oxygen >0.5 35%, and with raised carbon dioxide tension 30%, neonates 15%, infants with multiple congenital abnormalities 9%, and with significant neurological disease 7%.
From the replies, we estimated (by extrapolating from the infant population of each district), that there were 20 000 infants admitted, 640 ventilated and 620 treated with ribavirin in the UK during the 1993–4 season. From a similar questionnaire we sent to pharmacy departments (response rate 84%), we estimated that 1700 vials of ribavirin were dispensed for use in children, at a cost of over a third of a million pounds, although many of the larger units in the UK are no longer using ribavirin at all. The results of this survey demonstrate that only two thirds of UK paediatricians would routinely use ribavirin for children with underlying heart or lung disease and those with immunodeficiency. For the other clinical indications recommended or suggested by the AAP, most paediatricians in this country would not routinely use ribavirin. This study confirms that there is considerable uncertainty and variation in the use of ribavirin in high risk infants among UK paediatricians.
Mortality rates for high risk infants with RSV bronchiolitis seem now to be lower than previously quoted.4 American critical care paediatricians remain unconvinced about the safety and efficacy of ribavirin, and are unhappy with the AAP guidelines.5 There are no published data on the cost effectiveness of ribavirin treatment. As the mortality of RSV bronchiolitis now appears very low, a large double blind placebo controlled trial assessing the clinical and cost effectiveness of ribavirin treatment in high risk infants is both ethical and essential for evidence-based decision making.
We thank the Royal College of Paediatrics and Child Health for help with information, and Professor Martin Bland (St George’s Hospital) for statistical advice.
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