What can be done to prevent bronchiolitis in a 2-month-old premature baby, born at 29 weeks gestation, who was previously in the Neonatal Intensive Care Unit (NICU) and required oxygen therapy?

Palivizumab Prophylaxis for Prevention of Bronchiolitis

This 2-month-old infant born at 29 weeks gestation with a history of NICU stay and oxygen requirement should receive palivizumab (Option B) for RSV bronchiolitis prevention. 1, 2

Why Palivizumab is Indicated

Infants born before 29 weeks, 0 days' gestation who are younger than 12 months at the start of RSV season should receive palivizumab prophylaxis. 2 This infant meets clear criteria based on:

• Gestational age of 29 weeks - falls within the high-risk category for severe RSV disease 1
• History of oxygen requirement - indicates respiratory vulnerability and possible chronic lung disease of prematurity 1
• Age less than 12 weeks - identified as a specific risk factor for severe bronchiolitis 1
• NICU stay - suggests significant prematurity complications 1

Dosing Protocol

Administer 15 mg/kg intramuscularly monthly for 5 doses throughout RSV season (typically November through March). 1, 3

• The first dose should be given prior to commencement of RSV season 3
• Continue monthly doses even if the infant develops breakthrough RSV infection during the season 3
• Administer in the anterolateral aspect of the thigh (avoid gluteal muscle due to sciatic nerve risk) 3
• Injection volumes over 1 mL should be given as divided doses 3

Why Other Options Are Incorrect

Reassurance alone (Option A) is inadequate because this infant has multiple high-risk features that substantially increase morbidity and mortality from RSV infection. 1 Infants born at 28 weeks gestation or earlier benefit from prophylaxis during their entire first RSV season, whenever that occurs during the first 12 months of life. 1

Antibiotics (Option C) have no role in prevention and should only be used if specific bacterial coinfection is documented. 1 Antibacterial medications should only be used in children with bronchiolitis who have specific indications of coexisting bacterial infection. 1

While cough is indeed a route of transmission (Option D), this educational point does not constitute an actionable prevention strategy comparable to palivizumab prophylaxis. 1 Hand decontamination is the most important step in preventing nosocomial spread, but passive immunoprophylaxis with palivizumab provides direct protection for this high-risk infant. 1

Evidence Supporting Efficacy

Palivizumab reduces RSV hospitalization rates from 46.2% to 3.8-11.8% in severely premature infants with bronchopulmonary dysplasia. 4 In premature infants with gestational age ≤30 weeks without BPD, hospitalization rates decreased from 10.2-16.7% to 0-2% with prophylaxis. 5 The number needed to treat to prevent one hospitalization is 6 (95% CI: 4-11). 5

Additional Preventive Measures

Beyond palivizumab, counsel the mother on:

• Hand hygiene - alcohol-based rubs before and after contact with the infant 1
• Avoid passive smoke exposure - strong recommendation to prevent respiratory disease 1
• Encourage breastfeeding - decreases risk of lower respiratory tract disease 1
• Limit exposure to crowds and situations where contact with infected individuals cannot be controlled during RSV season 1
• Restrict group childcare participation during RSV season for high-risk infants 1

Critical Pitfalls to Avoid

Do not withhold palivizumab based on cost considerations alone - the FDA and AAP have determined benefits outweigh risks for infants meeting criteria. 3

Palivizumab is for prevention only, not treatment - it has no therapeutic benefit once RSV infection is established. 2, 3

Do not discontinue routine childhood immunizations - palivizumab does not interfere with standard vaccines. 2, 3