What counsel should be given to a mother of a 29-week premature baby who is concerned about bronchiolitis during a vaccination visit?

Counsel the Mother About Palivizumab Prophylaxis for RSV Prevention

This 29-week premature infant should receive palivizumab (Synagis) prophylaxis during RSV season to prevent severe bronchiolitis caused by respiratory syncytial virus (RSV). 1

Why Palivizumab is Recommended for This Infant

Infants born at 29 weeks gestation qualify for palivizumab prophylaxis based on gestational age alone, even without chronic lung disease. 1 The American Academy of Pediatrics guidelines specifically state that infants born at 28 weeks gestation or earlier benefit from prophylaxis during their first RSV season, whenever that occurs during the first 12 months of life, and infants born at 29 to 32 weeks gestation benefit most from prophylaxis up to 6 months of age. 1

However, updated 2014 guidance narrowed these recommendations: palivizumab prophylaxis may be administered to infants born before 29 weeks, 0 days' gestation who are younger than 12 months at the start of RSV season, but infants born at 29 weeks, 0 days' gestation or later may not universally be recommended to receive prophylaxis unless they have chronic lung disease, congenital heart disease, or other qualifying conditions. 1

Critical Counseling Points About Palivizumab

Administration Details

• Palivizumab is given as 5 monthly intramuscular injections at 15 mg/kg per dose, typically beginning in November or December and continuing throughout RSV season. 1, 2
• Each injection must be given every 28-30 days during RSV season, as each dose provides protection for approximately one month. 2
• The first dose should be administered before RSV season starts (typically November) to provide protection when exposure risk is highest. 3

What Palivizumab Does and Does Not Do

• Palivizumab is prophylaxis (prevention), not treatment—it helps prevent severe RSV disease but does not treat active infection. 2
• The benefit is limited: palivizumab reduces RSV hospitalizations but has no measurable effect on mortality and minimal effect on subsequent wheezing. 1
• Palivizumab reduces hospitalization risk by approximately 45-55% in high-risk infants. 2

Important Safety Information

• Severe allergic reactions (anaphylaxis) can occur, including fatal cases, even on first exposure. 2 Signs include severe rash, hives, swelling of lips/tongue/face, difficulty breathing, bluish skin color, or unresponsiveness. 2
• Seek immediate medical attention if any signs of severe allergic reaction occur. 2
• The injection site is typically the thigh muscle, and mild injection site reactions may occur. 2

Why the Other Options Are Incorrect

Option A: Cough as Source of Transmission

While RSV is transmitted through respiratory droplets and contact with contaminated surfaces, counseling about transmission alone does not address the mother's specific concern about prevention in this high-risk premature infant. 1 Hand hygiene is the most important preventive measure for nosocomial spread, but this infant qualifies for specific pharmacologic prophylaxis. 1

Option B: Oral Antibiotics

Antibiotics have no role in preventing or treating viral bronchiolitis caused by RSV. 1 Antibacterial medications should only be used in children with bronchiolitis who have specific indications of coexisting bacterial infection. 1

Option D: Reassurance

Reassurance alone is inadequate for a 29-week premature infant who is at significantly increased risk for severe RSV disease requiring hospitalization. 1 Premature infants have abnormal baseline oxygenation coupled with an inability to cope with pulmonary inflammation seen in bronchiolitis, resulting in more severe and prolonged hypoxia compared with term infants. 1

Additional Preventive Measures to Discuss

• Hand hygiene is critical: hands should be decontaminated before and after contact with the infant using alcohol-based rubs or antimicrobial soap. 1
• Avoid tobacco smoke exposure completely—this is a controllable risk factor that increases RSV hospitalization risk. 1
• Limit exposure to crowds and group childcare during RSV season (November through March in most regions). 1, 3
• Encourage breastfeeding to decrease the child's risk of lower respiratory tract disease. 1
• Ensure influenza vaccination for the infant (starting at 6 months) and all household contacts. 1

Clinical Decision Point

Given the conflicting guidance between 2006 (which includes 29-week infants) and 2014 (which may not universally recommend for 29-week infants), the decision should be based on the infant's current age, presence of additional risk factors, and local RSV season timing. If this infant is younger than 6 months at RSV season start, has any additional risk factors (childcare attendance, school-aged siblings, environmental pollutants, airway abnormalities), or has any residual lung disease, palivizumab is strongly indicated. 1