What can be done to prevent bronchiolitis in a premature infant, born at 29 weeks gestation, who has been discharged from the Neonatal Intensive Care Unit (NICU) and is no longer requiring oxygen therapy?

Palivizumab Prophylaxis for RSV Prevention

This 1-month-old infant born at 29 weeks gestation qualifies for palivizumab (Synagis) prophylaxis and should receive it immediately—the answer is B. 1, 2, 3

Why Palivizumab is Indicated

Infants born at 29 weeks gestation meet criteria for RSV prophylaxis based on gestational age alone, regardless of whether they currently require oxygen or have chronic lung disease. 1, 2 The American Academy of Pediatrics specifically recommends palivizumab for infants born at 29-32 weeks gestation who are younger than 6 months of age at the start of RSV season. 1

Key Clinical Decision Points

• Gestational age of ≤32 weeks, 0 days is the primary qualifying criterion for infants up to 6 months of age at RSV season onset 1, 3
• Current oxygen requirement is NOT necessary for qualification—this infant's discharge from oxygen does not disqualify them from prophylaxis 1
• The infant is currently 1 month old, well within the 6-month age window for 29-32 week gestational age infants 1

Administration Protocol

Palivizumab should be given as 15 mg/kg intramuscularly every 30 days for a total of 5 monthly doses throughout RSV season (typically November through March in the Northern Hemisphere). 1, 2, 3, 4

• The first dose should be administered before RSV season begins or as soon as possible if the season has already started 2, 4
• Each injection provides approximately 1 month of protection, making monthly dosing critical 4
• Palivizumab reduces RSV hospitalization risk by approximately 45-55% in high-risk infants 4, 5, 6

Why Other Options Are Incorrect

Reassurance Alone (Option A) is Inadequate

• Simply reassuring the mother ignores evidence-based prevention for a high-risk infant who clearly qualifies for prophylaxis 1, 2
• Premature infants born at 29 weeks have significantly elevated risk of severe RSV disease requiring hospitalization 1

Antibiotics (Option C) Have No Role

• Antibiotics should only be used if there is specific evidence of bacterial co-infection, not for viral bronchiolitis prevention 1
• RSV bronchiolitis is viral, and prophylactic antibiotics provide no benefit and promote resistance 1

Cough Transmission Education (Option D) is Insufficient

• While hand hygiene and avoiding exposure are important adjunctive measures, they do not replace indicated pharmacologic prophylaxis 1
• Hand decontamination with alcohol-based rubs before and after patient contact is recommended but as an additional measure, not a replacement for palivizumab 1

Additional Preventive Measures to Discuss

Beyond palivizumab, counsel the mother on:

• Complete avoidance of tobacco smoke exposure, which is a controllable risk factor that increases RSV hospitalization risk 1
• Limiting exposure to crowds and group childcare during RSV season 1
• Strict hand hygiene for all caregivers and visitors using alcohol-based sanitizers 1
• Encouraging breastfeeding to decrease risk of lower respiratory tract disease 1
• Ensuring influenza vaccination for all household contacts (infant can receive at 6 months) 1

Critical Pitfalls to Avoid

• Do not withhold palivizumab because the infant is off oxygen—current respiratory status does not determine eligibility for 29-week gestational age infants 1
• Do not delay initiation—protection is time-sensitive and should begin before or early in RSV season 2, 4
• Palivizumab is for prevention only, not treatment—it has no role once RSV infection is established 4, 7
• Do not stop prophylaxis if the infant develops RSV—continue monthly doses throughout the season to prevent reinfection 4