Full Clinical Guidelines - Community First Health Plans.

18.1 RSV Prophylaxis
RESPIRATORY SYNCYTIAL VIRUS (RSV) PROPHYLAXIS GUIDELINES
Respiratory syncytial virus (RSV) is a virus that causes serious respiratory illness in preterm infants, especially those who
develop perinatal respiratory problems. RSV prophylaxis drugs palivizumab (immune globulin intramuscular) (RSV-IgIM)) and
(immune globulin intravenous (RSV-IGIV) are covered benefits which require authorization for Community First eligible children
including members enrolled in HMO, Medicaid and CHIP plans. The immunity imparted by these immune globulins is effective
for approximately 28 days.
Palivizumab RSV immune globulin for intramuscular use (RSV-IgM or Synagis) and RSV immune globulin for intravenous use
(RSV-IGIV or Respigam) are appropriate for at-risk children age 0 through 34 months of age according to the AAP guidelines
below.
The dose of palivizumab is 15 mg/kg and is supplied in 50 or 100 mg vials and is administered intramuscularly. RSV-IGIV is
administered intravenously at a dosage of 750 mg/kg (15mL/Kg). RSV prophylaxis should be given monthly starting at the
beginning of the RSV season and stopping at the end of the season (October through April in Texas). Once a child qualifies for
initiation of prophylaxis at the start of the RSV season, administration should continue throughout the season regardless of the
point where a child reaches 6 or 12 months of age. Hospitalized infants determined to be at risk of severe RSV disease should
receive RSV-IGIV or palivizumab 48 to 72 hours before discharge home from the hospital during the RSV season and then every
28-30 days until the end of the season.
AMERICAN ACADEMY OF PEDIATRICS GUIDELINES:
• Infants born at 28 weeks gestation or earlier during RSV season, whenever that occurs during the first 12 months of life
• Infants born at 29–32 weeks gestation if they are younger than 6 months of age at the start of the RSV season
• Infants born at 32–35 weeks gestation who are younger than 3 months of age at the start of the RSV season or who are
born during RSV season if they have at least one of the following 2 risk factors: 1) infant attends child care; 2) infant has a
sibling younger than 5 years of age
• Infants and children younger than 2 years with cyanotic or complicated congenital heart disease
• Infants and children younger than 2 years who have been treated for chronic lung disease within 6 months of the start of
the RSV season.
• Infants born before 35 weeks of gestation who have either congenital abnormalities of the airway or neuromuscular
disease that compromises handling of respiratory secretions
NOTE: Palivizumab does not interfere with routine childhood vaccine administration. See AAP guidelines for specific
exceptions to vaccine administration when RSV-IGIV is used.
152 H EALTH PLANS
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