Clinical indications for palivizumab immunoprophylaxis against severe respiratory syncytial virus infections in infants

Population	Indications (only if nirsevimab is not available)
Preterm infants with BPD*	<12 months of age at the start of RSV season Age 12 through 23 months and required medical therapy (eg, supplemental oxygen, glucocorticoids, diuretics) for BPD within six months of the start of RSV season
Preterm infants without BPD	Infants born at <29 weeks GA who are <12 months of age at the start of the RSV season Preterm infants born at 29 to <32 weeks GA who are <12 months of age at the start of the RSV season and who have additional risk factors (eg, age <4 months at peak RSV season, attending daycare, older sibling in the household, parental smoking)^¶
Infants with CHD	Most likely to benefit: Infants <12 months of age with acyanotic heart disease who are receiving medication to control heart failure and will require cardiac surgery Infants <12 months of age with moderate to severe pulmonary hypertension May benefit: Infants <12 months of age with cyanotic heart disease (decisions should be made in consultation with the infant's cardiologist)
Other potential candidates^Δ	Infants and children <2 years of age with primary immunodeficiency syndrome (eg, SCID) or significant immunosuppression (eg, heart or lung transplant or HCT) Infants <12 months of age with severe neuromuscular disease Infants <12 months of age with severe pulmonary disease (eg, TEF) Infants <12 months of age with Down syndrome

This table summarizes our suggested indications for palivizumab in high-risk infants. NOTE: Palivizumab should only be used if nirsevimab is not available. In addition to immunoprophylaxis, other general measures to prevent RSV infection in high-risk infants include hand washing, practicing cough hygiene, avoidance of tobacco and other smoke, and restricting participation in childcare during RSV season (if possible). Refer to UpToDate's topic on RSV prevention for additional details, including a description of the evidence supporting the efficacy of palivizumab.

RSV: respiratory syncytial virus; BPD: bronchopulmonary dysplasia; GA: gestational age; CHD: congenital heart disease; TEF: tracheoesophageal fistula; SCID: severe combined immunodeficiency; HCT: hematopoietic cell transplant.

* BPD is variably defined. For the purpose of this table, we define BPD as GA <32 weeks and a requirement for supplementation oxygen for at least the first 28 days after birth.

¶ These risk factors plus out of pocket cost are taken into consideration on a case-by-case basis in consultation with the infant's caregiver(s).

Δ Use of palivizumab in these patient populations is not standardized and evidence is limited.

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Clinical indications for palivizumab immunoprophylaxis against severe respiratory syncytial virus infections in infants