RSV recommendations unchanged after review of new data
Flor M.Munoz, M.D., FAAP, Shawn L.Ralston, M.D., FAAP and H. CodyMeissner, M.D., FAAP
In the Northern Hemisphere, the autumnal equinox marks the first day of autumn. This
is a time when the sun is directly over the equator so that the length of night and
day is almost equal. For pediatricians, it also is a time to anticipate the upcoming
respiratory virus season and to educate families on the importance of handwashing,
respiratory etiquette and influenza vaccination.
All children 6 months of age or older should receive age-appropriate influenza immunizations.
For infants and young children at increased risk of respiratory syncytial virus (RSV)
infection, monthly prophylaxis with palivizumab may be considered.
In August 2014, the Academy published the most recent guidelines to assist with identification
of young children at increased risk of RSV hospitalization and most likely to benefit
from prophylaxis. For a complete discussion of the basis for each recommendation,
see the AAP policy statement (Pediatrics. 2014;134:415-420, http://bit.ly/2kwhSpF) and technical report (Pediatrics. 2014;134:e620-e638, http://bit.ly/2kvU3yr), both titled Updated Guidance for Palivizumab Prophylaxis Among Infants and Young Children at Increased
Risk of Hospitalization for Respiratory Syncytial Virus Infection and Clinical Practice Guideline: The Diagnosis, Management and Prevention of Bronchiolitis (Pediatrics. 2014;134:e1474-e1502, http://bit.ly/2hVvCcO).
Following recent reviews by the Committee on Infectious Diseases and the Subcommittee
on Bronchiolitis, these recommendations remain unchanged from 2014. A summary of current
recommendations is presented here.
In the first year of life, palivizumab prophylaxis is recommended for infants born
before 29 weeks, 0 days’ gestation.
Palivizumab prophylaxis is not recommended for otherwise healthy infants born at or
after 29 weeks, 0 days’ gestation.
In the first year of life, palivizumab prophylaxis is recommended for preterm infants
born before 32 weeks, 0 days’ gestation with chronic lung disease of prematurity defined
as a need for greater than 21% oxygen for at least 28 days after birth.
Clinicians may administer palivizumab prophylaxis in the first year of life to certain
infants with hemodynamically significant heart disease. Consultation with a cardiologist
for decisions about prophylaxis is recommended for patients with cyanotic heart disease.
For qualifying infants who require five doses, a dose beginning in November and continuing
for a total of five monthly doses will provide protection for most infants through
April and is recommended for most areas in the U.S.
Clinicians may administer up to a maximum of five monthly doses of palivizumab during
the RSV season to infants who qualify for prophylaxis in the first year of life (including
those in Florida). Qualifying infants born during the RSV season will require fewer
doses. For example, infants born in January would receive their last dose in March.
Palivizumab prophylaxis is not recommended in the second year of life except for children
who require at least 28 days of supplemental oxygen after birth and who continue to
require medical intervention (supplemental oxygen, chronic corticosteroid or diuretic
therapy) during the second RSV season.
Monthly prophylaxis should be discontinued in any child who experiences an outpatient
RSV infection or breakthrough RSV hospitalization.
Children with a pulmonary abnormality or neuromuscular disease that impairs the ability
to clear secretions from the lower airways may be considered for prophylaxis in the
first year of life.
Children younger than 24 months of age who will be profoundly immunocompromised during
the RSV season may be considered for prophylaxis.
Insufficient data are available to recommend palivizumab prophylaxis routinely for
children with cystic fibrosis or Down syndrome.
The burden of RSV disease in certain remote areas may result in a broader use of palivizumab
for RSV prevention in Alaska Native populations and possibly in other selected Native
Palivizumab prophylaxis is not recommended for prevention of nosocomial acquired RSV
Detailed input regarding current guidelines was solicited from 21 AAP committees,
councils, sections and advisory groups as well as from organizations outside the Academy.
Outside groups that contributed to and concur with the updated guidance include the
American Academy of Family Physicians, American College of Chest Physicians, American
College of Emergency Physicians, American Thoracic Society, Emergency Nurses Association,
and Society of Hospital Medicine.
The Committee on Infectious Diseases and the Subcommittee on Bronchiolitis regularly
review and evaluate all data and as they become available. In September 2017, all
available data regarding palivizumab were considered, and both groups reaffirmed the
recommendations in the RSV policy statement and technical report.
Dr. Munoz is a member of the AAP Committee on Infectious Diseases. Dr. Ralston was
co-chair of the AAP Subcommittee on Bronchiolitis, which authored the 2014 guidelines.
Dr. Meissner is an ex officio member of the AAP Committee on Infectious Diseases and associate editor
of the AAPVisual Red Book.