Fast Five Quiz: Pediatric Respiratory Syncytial Virus Management

Asif Noor, MD


March 03, 2022

According to the 2014 update to recommendations from the AAP, palivizumab prophylaxis for RSV should be limited to infants born before 29 weeks' gestation and to infants with chronic illness such as congenital heart disease or chronic lung disease. Prophylaxis with palivizumab should be considered in these situations:

  • Premature infants who are born before 29 weeks', 0 days' gestation and are younger than 1 year chronological age at the start of the RSV season.

  • Premature infants who are born before 32 weeks', 0 days' gestation and are younger than 1 year chronological age at the start of the RSV season with chronic lung disease (CLD) of prematurity, defined as the need for greater than 21% oxygen for at least 28 days after birth.

  • Infants younger than 24 months and who have hemodynamically significant cyanotic congenital heart disease requiring medications for heart failure or will need heart transplant, or infants with moderate to severe pulmonary hypertension. The decision of prophylaxis is infants with cyanotic heart disease may be made in consultation with pediatric cardiologist as the benefit of palivizumab prophylaxis in cyanotic heart disease in unknown.

  • An infant with cystic fibrosis with clinical evidence of CLD and/or nutritional compromise in the first year may be considered for prophylaxis. Continued use of palivizumab prophylaxis in the second year may be considered for infants with manifestations of severe lung disease (previous hospitalization for pulmonary exacerbation in the first year or abnormalities on chest radiography or chest CT that persist when stable) or weight-for-length less than the 10th percentile.

Other updated recommendations include:

  • Give infants who qualify for prophylaxis in the first year of life no more than five monthly doses of palivizumab (15 mg/kg per dose) during the RSV season.

  • In the second year of life, palivizumab prophylaxis is recommended only for children who needed supplemental oxygen for 28 days or more after birth and who continue to need medical intervention (supplemental oxygen, chronic corticosteroid, or diuretic therapy).

  • Clinicians may consider prophylaxis for children younger than 24 months if they will be profoundly immunocompromised during the RSV season.

RSV spreads through respiratory droplet and physical contact. Facial masks can reduce the spread of RSV infection and are recommended while taking care of hospitalized infants. According to Kutter and colleagues, aerosolized secretions appear to be less important in RSV transmission; however, there is evidence that aerosolized particles are sufficiently small to remain airborne for a significant length of time and small enough to be inhaled and deposited throughout the respiratory tract.

In the hospital setting, isolating patients who are infected with RSV as well as wearing masks and gowns during close contact with infected cases are important in controlling nosocomial spread.

Despite good environmental hygiene, RSV infection can still occur. Transmission of RSV is via contact with infected secretions through respiratory droplets and hand-to-hand contact primarily and to a lesser extent via fomites and aerosols. Attention to handwashing and cleaning of environmental surfaces are important to prevent RSV transmission.

Learn more about the prevention of RSV.


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