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Guideline source: American Academy of Pediatrics

Literature search described? No

Evidence rating system used? Yes

Published source: Pediatrics, December 2009

Respiratory syncytial virus (RSV) bronchiolitis is one of the most common diseases of childhood. Most infants are infected in the first year of life, and virtually all children have been infected by two years of age. Although RSV bronchiolitis usually manifests as acute upper respiratory tract infection, more serious disease involving the lower respiratory tract can develop. Preterm infants and those with congenital heart disease (CHD) or chronic lung disease of prematurity (also called bronchopulmonary dysplasia) are particularly at risk of developing lower respiratory tract illness, which is associated with recurrent wheezing, reactive airway disease, and pulmonary function abnormalities.

Palivizumab (Synagis) is the only drug approved by the U.S. Food and Drug Administration (FDA) for prevention of RSV lower respiratory tract disease in preterm infants and in children with CHD or chronic lung disease of prematurity. Immunoprophylaxis with palivizumab is effective but expensive; therefore, for optimal cost benefit it should be given only during peak RSV outbreak months (November through March in most of North America).

Since palivizumab was approved by the FDA, new data have become available on the seasonality of RSV disease and on risk factors for identifying children at increased risk of serious RSV lower respiratory tract disease. Based on these data, the American Academy of Pediatrics (AAP) recently updated its recommendations on the use of palivizumab for immunoprophylaxis of RSV infection.

Infants who were born at a gestational age of at least 32 weeks but less than 35 weeks qualify for prophylaxis with palivizumab if they were born within three months of the start of RSV season or at any time throughout the season, and if they attend child care or if another child younger than five years lives in the same household. Infants who qualify for prophylaxis should receive up to three doses of palivizumab if they do not have hemodynamically significant CHD or chronic lung disease of prematurity. Prophylaxis should continue until 90 days of age or until three doses have been given (whichever comes first).

Recommendations are unchanged for premature infants born before 32 weeks' gestation and for those with hemodynamically significant CHD or chronic lung disease of prematurity. These infants should receive up to five doses of palivizumab, regardless of when the first dose is given.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Michael J. Arnold, MD, associate medical editor.

A collection of Practice Guidelines published in AFP is available at

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