Peds Question 967 Discrepancy

Question:

Baby Boy Smith is born prematurely on 1/5/10 in San Francisco at the age of 28 weeks.  How many TOTAL doses of palivizumab (Synagis) should he receive?

A.  8
B.  5
C.  3
D.  0

Current Answer:

B.  Infants born at 28 weeks' gestation or earlier may benefit from prophylaxis during the RSV season whenever that occurs during the first 12 months of life.  Because the RSV season in this region of the country typically runs from November-March, Baby Boy Smith can receive monthly injections in January, February, and March of 2010 as prophylaxis for the 2009-2010 RSV season  Because he will still be < 12 months old at the start of the 2010-2011 RSV season, however, he will require additional prophylaxis starting November 2010.  Finally, although he will be > 12 months old part of the way through the 2010-2011 RSV season, the AAP recommends that "once an infant qualifies for initiation of prophylaxis at the start of the RSV season, administration should continue throughout the season and not stop when the infant reaches...12 months of age."  This means Baby Boy Smith will receive all 5 doses, Nov-March 2011, and 8 doses total during his first 15 months of life.

Reference:  American Academy of Pediatrics Committee on Infectious Diseases.  Policy statement--modified recommendations for use of palivizumab for prevention of respiratory syncytial virus infections.  Pediatrics.2009;124(6):1694-1701.

Discrepancy

Based on new guideline, no more than 5 doses is recommended. (For infants with hemodynamically significant CHD, CLD, or birth before 32 weeks 0 days of gestation, the updated guidelines recommend no more than 5 doses for all geographic locations, regardless of the month in which the first dose is administered. Infants with a gestational age of 32 weeks 0 days to 34 weeks 6 days who qualify for prophylaxis but who do not have hemodynamically significant CHD or CLD should receive no more than 3 doses).

Response:

Good point. The wording of the recommendations seem a bit vague in regards to the time period the maximum amount doses can be given (per season or lifetime). However, it appears the  recommendtion of maximum of 5 doses should be interpreted as per season, as oppose to a lifetime maximum of 5 doses.  In my opinion, the statement of "regardless of the month in which the first dose is administered," is referring to the regions where RSV season is >5 months  such as in Southeast Florida where RSV season is from July-March (7 months). Refer to http://www.ppag.org/en/art/703/ for more info.  I have attached two tables (above) that may clarify this point. Please note picture 2, subnote "c"

Please share your thoughts!!!!