As we head into fall and the eventual winter cold season, our littlest patients may once again be exposed to the RSV virus. Many practitioners, including myself, have noted a decrease in bronchiolitis admissions and even severity the last few years. However, this doesn’t appear to be due to efficacy of palivizumab (Synagis). Recently the AAP has released revised guidelines for the use of Synagis (I just hate trying to remember how to spell palivizumab every time) for this winter and beyond.

The guidelines were last revised in 2012 and since then more data has become available leading to the changes. This data shows an overall decline of hospitalization rates for RSV, a lack of difference in attack or hospitalization rates between African American and white children, and demonstrated only a limited reduction of wheezing  episodes in those infants prophylaxed. Also, other countries with more restrictive Synagis guidelines than ours showed no excess morbidity. In addition, cost-to-benefit analyses  “demonstrate the cost of palivizumab prophylaxis far exceeds the economic benefit of hospital avoidance, even among infants at highest risk.”

These are the new, current criteria for which infants need RSV prophylaxis:

• In the first year of life, infants born before 29 weeks, 0 days gestation.
• In the first year of life, infants born before 32 weeks, 0 days AND with chronic lung disease of prematurity (defined as  >= 28 days of > 21% oxygen after birth). In the second year of life those infants who still require medical intervention for their CLD (supplemental oxygen, chronic corticosteroid or diuretic therapy) may also qualify.
• In the first year of life, infants with hemodynamically significant heart disease. For patients with cyanotic heart disease a recommendation should come from their cardiologist.
• In the first year of life, children with pulmonary abnormalities or neuromuscular disease that impairs airway clearance may qualify.
• Children younger than 24 months who are profoundly immunocompromised.

Clinicians may administer up to 5 doses to those infants who qualify, with fewer doses to those born during the RSV season. The last dose is typically given in March. However any infant receiving Synagis who is hospitalized with an RSV infection should have their prophylaxis discontinued.

Hopefully this will help simplify the new guidelines well before we have to start ordering  Synagis.

Jeff Ribordy, MD