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

Prevention of Bronchiolitis in a 2-Month-Old Former Premature Infant (29 Weeks Gestation)

This infant qualifies for palivizumab (Synagis) prophylaxis and should receive it immediately, as infants born at 29 weeks gestation are eligible for RSV immunoprophylaxis during their first RSV season whenever that occurs during the first 12 months of life. 1

Palivizumab Prophylaxis - Primary Prevention Strategy

Immediate administration of palivizumab is indicated because:

• Infants born at 29 weeks gestation qualify for palivizumab based on gestational age alone, even without chronic lung disease of prematurity 2, 3
• The American Academy of Pediatrics recommends palivizumab for infants born at 28 weeks gestation or earlier, and for those born at 29-32 weeks who are at high risk, during their first RSV season 1, 2
• At 2 months chronological age (approximately 2 months corrected age), this infant is well within the eligibility window 1, 3

Dosing Protocol

• Administer 15 mg/kg intramuscularly monthly for 5 doses throughout RSV season (typically November through March, though timing varies by region) 2, 3
• The first dose should be given before RSV season starts when possible, but if the season has already begun, administer as soon as possible 2, 3
• Continue monthly injections every 28-30 days regardless of whether the infant reaches 6 or 12 months of age during the season 1, 2
• Palivizumab reduces RSV hospitalization risk by approximately 45-55% in high-risk infants 2, 3

Important Considerations for Palivizumab

• Severe allergic reactions including anaphylaxis can occur; caregivers should be counseled on signs (severe rash, hives, lip/tongue/face swelling, difficulty breathing, bluish skin color) 3
• Even if the infant develops RSV infection during the season, continue scheduled monthly injections to prevent severe disease from new RSV infections 3
• The injection is given intramuscularly, preferably in the anterolateral thigh 3

Essential Non-Pharmacologic Prevention Measures

Beyond palivizumab, the mother must implement strict preventive measures, as these are the foundation of RSV prevention:

Hand Hygiene - The Single Most Critical Intervention

• Hand decontamination is the single most important step in preventing RSV and other viral causes of bronchiolitis 4
• Use alcohol-based hand rubs (preferred when hands are not visibly soiled) or antimicrobial soap before and after direct contact with the infant, after contact with objects near the infant, and after removing gloves 4, 2
• All family members and caregivers must be educated on proper hand sanitation techniques 4

Understanding and Interrupting Transmission

• RSV spreads through respiratory droplets from coughing and sneezing, and the virus can survive on hard surfaces for ≥6 hours, on gowns/tissues for 20-30 minutes, and on skin for up to 20 minutes 4
• Regularly clean and disinfect surfaces and toys in the infant's environment, including beds, crib railings, and tabletops 4
• Avoid contact with individuals who have respiratory symptoms, particularly during RSV season 4

Environmental and Lifestyle Modifications

• The infant must not be exposed to passive tobacco smoke under any circumstances - tobacco exposure increases RSV infection risk with an odds ratio of 3.87 and increases both severity and hospitalization risk 4, 2
• Limit exposure to crowds and restrict participation in group childcare during RSV season (November through March in most regions) 1, 2
• Breastfeeding should be encouraged as it provides protective antibodies and decreases the child's risk of lower respiratory tract disease 4, 2

Additional Protective Measures

• Ensure influenza vaccination for all household contacts (the infant can receive influenza vaccine starting at 6 months of age) 1, 2
• Keep the infant away from situations where exposure to infected individuals cannot be controlled 1

Clinical Context and Prognosis

• Very preterm infants (<29 weeks gestation) have a 3-4 times higher relative risk of RSV hospitalization compared to term infants, with more frequent ICU admissions and mechanical ventilation during RSV-related hospitalizations 5
• However, outcomes are significantly better in very preterm infants who receive palivizumab, despite their higher baseline risk 5
• Approximately 90% of children are infected with RSV within the first 2 years of life, making prevention challenging but achievable with consistent adherence to these measures 4

Common Pitfalls to Avoid

• Do not delay palivizumab initiation - even if RSV season has started, begin immediately rather than waiting until next season 2, 3
• Do not discontinue palivizumab when the infant reaches 6 months of age if RSV season is still ongoing - continue through the entire season 1, 2
• Reassurance alone is insufficient - active preventive measures with both palivizumab and environmental controls are necessary 4
• Do not assume that a history of NICU stay with oxygen requirement automatically qualifies as "chronic lung disease of prematurity" for palivizumab purposes - this infant qualifies based on gestational age alone 1, 3