What are the recommendations for Respiratory Syncytial Virus (RSV) prophylaxis and vaccination in pediatric (peds) patients?

RSV Prophylaxis and Vaccination Recommendations for Pediatric Patients

Palivizumab prophylaxis is recommended only for specific high-risk pediatric populations, including infants born before 29 weeks' gestation who are younger than 12 months at RSV season start, those with chronic lung disease requiring medical treatment, and those with hemodynamically significant congenital heart disease. 1

High-Risk Groups Eligible for RSV Prophylaxis

Premature Infants

• Infants born before 29 weeks, 0 days' gestation who are younger than 12 months at the start of RSV season 1
• Infants born at 29 weeks' gestation or later generally do not qualify for prophylaxis unless they have other qualifying conditions 1

Chronic Lung Disease (CLD) of Prematurity

• Infants and children younger than 24 months with CLD who received medical therapy (supplemental oxygen, bronchodilator, diuretic, or chronic corticosteroid therapy) within 6 months before the start of RSV season 1
• During the second year of life, prophylaxis is only recommended for children with CLD who continue to require medical support (chronic corticosteroid therapy, diuretic therapy, or supplemental oxygen) 1

Congenital Heart Disease (CHD)

• Children 12 months or younger with hemodynamically significant CHD, particularly: 1
  • Infants with acyanotic heart disease receiving medication for congestive heart failure who will require cardiac surgical procedures
  • Infants with moderate to severe pulmonary hypertension
  • Infants with cyanotic heart defects (consultation with a pediatric cardiologist recommended)

NOT Recommended for Prophylaxis

• Infants with hemodynamically insignificant heart disease (e.g., secundum atrial septal defect) 1
• Infants with lesions adequately corrected by surgery (unless they continue to require medication for congestive heart failure) 1
• Infants with mild cardiomyopathy not receiving medical therapy 1
• Children with Down syndrome without qualifying heart disease, CLD, airway clearance issues, or prematurity 1

Dosing and Administration

• Recommended dose: 15 mg/kg body weight given monthly by intramuscular injection 2
• Maximum number of doses:
  • 5 doses for infants with hemodynamically significant CHD, CLD, or birth before 32 weeks' gestation 1
  • 3 doses for qualifying infants born at 32-34 weeks' gestation (or until they reach 90 days of age, whichever comes first) 1
• First dose should be administered prior to RSV season commencement 2
• For infants undergoing cardiac procedures with cardiopulmonary bypass, administer an additional dose post-procedure due to 58% decrease in palivizumab serum concentration 1, 2

Special Considerations

Breakthrough RSV Infection

• If a child receiving prophylaxis is hospitalized with RSV, monthly prophylaxis should be discontinued due to extremely low likelihood (<0.5%) of a second RSV hospitalization in the same season 1

Immunocompromised Children

• May be considered for children younger than 24 months who are profoundly immunocompromised during RSV season 1

Cystic Fibrosis

• Routine prophylaxis not recommended unless other qualifying conditions are present 1
• May be considered for infants with clinical evidence of CLD and/or nutritional compromise in the first year of life 1

Practical Implementation

• Hospitalized infants who qualify for prophylaxis should receive the first dose 48-72 hours before discharge or promptly after discharge 1
• RSV season typically runs from November through April in the northern hemisphere, but may vary by region 2
• Palivizumab does not interfere with response to vaccines 1

Common Pitfalls to Avoid

1. Overuse in non-qualifying patients: Following the 2014 AAP guidance update, prophylaxis was limited to the highest-risk groups, particularly premature infants born at <29 weeks' gestational age 3

2. Continuing prophylaxis after breakthrough infection: Discontinue monthly prophylaxis if the child experiences an RSV hospitalization 1

3. Inappropriate use in older children: Prophylaxis is not recommended for children older than 24 months at the start of RSV season 2

4. Failure to recognize the limitations: Palivizumab is indicated for prevention, not treatment of RSV disease 2

5. Inadequate post-cardiac surgery dosing: Failure to administer an additional dose after cardiopulmonary bypass 1

The recommendations have evolved over time to target those at highest risk of severe disease while balancing cost-effectiveness, as palivizumab is an expensive intervention 1, 4.