Impact of palivizumab on admission to the ICU for respiratory syncytial virus bronchiolitis: a national survey

Children born preterm admitted to paediatric intensive care for bronchiolitis: a systematic review and meta-analysis

BACKGROUND

To undertake a systematic review of studies describing the proportion of children admitted to a paediatric intensive care unit (PICU) for respiratory syncytial virus (RSV) and/or bronchiolitis who were born preterm, and compare their outcomes in PICU with children born at term.

METHODS

We searched Medline, Embase and Scopus. Citations and references of included articles were searched. We included studies published from the year 2000 onwards, from high-income countries, that examined children 0-18 years of age, admitted to PICU from the year 2000 onwards for RSV and/or bronchiolitis. The primary outcome was the percentage of PICU admissions born preterm, and secondary outcomes were observed relative risks of invasive mechanical ventilation and mortality within PICU. We used the Joanna Briggs Institute Checklist for Analytical Cross-Sectional Studies to assess risk of bias.

RESULTS

We included 31 studies, from 16 countries, including a total of 18,331 children. Following meta-analysis, the pooled estimate for percentage of PICU admissions for RSV/bronchiolitis who were born preterm was 31% (95% confidence interval: 27% to 35%). Children born preterm had a greater risk of requiring invasive ventilation compared to children born at term (relative risk 1.57, 95% confidence interval 1.25 to 1.97, I2 = 38%). However, we did not observe a significant increase in the relative risk for mortality within PICU for preterm-born children (relative risk 1.10, 95% confidence interval: 0.70 to 1.72, I2 = 0%), although the mortality rate was low across both groups. The majority of studies (n = 26, 84%) were at high risk of bias.

CONCLUSIONS

Among PICU admissions for bronchiolitis, preterm-born children are over-represented compared with the preterm birth rate (preterm birth rate 4.4% to 14.4% across countries included in review). Preterm-born children are at higher risk of mechanical ventilation compared to those born at term.

Variability of Care of Infants With Severe Respiratory Syncytial Virus Bronchiolitis: A Multicenter Study

BACKGROUND

Viral bronchiolitis caused by respiratory syncytial virus (RSV) is a common childhood disease accounting for many hospitalizations worldwide. Some infants may clinically deteriorate, requiring admission to an intensive care unit. We aimed to describe diagnostic and therapeutic measures of bronchiolitis in Israeli pediatric intensive care units (PICUs) and evaluate intercenter variability of care.

METHODS

Medical records of all RSV-infected infants admitted to 5 Israeli PICUs over 4 RSV seasons were retrospectively reviewed.

RESULTS

Data on 276 infants with RSV-positive bronchiolitis, admitted to the participating PICUs were analyzed. Most of the infants were males with a mean admission age of 4.7 months. Approximately half of the infants had pre-existing conditions such as prematurity, cardiac disease or chronic lung disease. Respiratory distress was the most common symptom at presentation followed by hypoxemia and fever. There was significant variation in the methods used for RSV diagnosis, medical management and respiratory support of the infants. Furthermore, utilization of inhalational therapy and transfusion of blood products differed significantly between the centers. Although a bacterial pathogen was isolated in only 13.4% of the infants, 82.6% of the cohort was treated with antibiotics.

CONCLUSIONS

Significant variation was found between the different PICUs regarding RSV bronchiolitis diagnosis, medical management and respiratory support, which may not be accounted for by the differences in baseline and clinical characteristics of the infants. Some of these differences may be explained by uneven resource allocations. This diversity and the documented routine use of medications with weak evidence of efficacy calls for national guidelines for bronchiolitis management.

Should we use Palivizumab immunoprophylaxis for infants against respiratory syncytial virus? - a cost-utility analysis

BACKGROUND

Passive immunization against RSV (Respiratory Syncytial Virus) is given in most western countries (including Israel) to infants of high risk groups such as premature babies, and infants with Congenital Heart Disease or Congenital Lung Disease. However, immunoprophylaxis costs are extremely high ($2800-$4200 per infant). Using cost-utility analysis criteria, we evaluate whether it is justified to expand, continue or restrict nationwide immunoprophylaxis using palivizumab of high risk infants against RSV.

METHODS

Epidemiological, demographic, health service utilisation and economic data were integrated from primary (National Hospitalization Data, etc.) and secondary data sources (ie: from published articles) into a spread-sheet to calculate the cost per averted disability-adjusted life year (DALY) of vaccinating various infant risk groups. Costs of intervention included antibody plus administration costs. Treatment savings and DALYs averted were estimated from applying vaccine efficacy data to relative risks of being hospitalised and treated for RSV, including possible long-term sequelae like asthma and wheezing.

RESULTS

For all the groups RSV immunoprophylaxis is clearly not cost effective as its cost per averted DALY exceeds the $105,986 guideline representing thrice the per capita Gross Domestic Product. Vaccine price would have to fall by 48.1% in order to justify vaccinating Congenital Heart Disease or Congenital Lung Disease risk groups respectively on pure cost-effectiveness grounds. For premature babies of < 29 weeks, 29-32 and 33-36 weeks gestation, decreases of 36.8%, 54.5% and 83.3% respectively in vaccine price are required.

CONCLUSIONS

Based solely on cost-utility analysis, at current price levels it is difficult to justify the current indications for passive vaccination with Palivizumab against RSV. However, if the manufacturers would reduce the price by 54.5% then it would be cost-effective to vaccinate the Congenital Heart Disease or Congenital Lung Disease risk groups as well as premature babies born before the 33rd week of gestation.

Viral Infection in the Development and Progression of Pediatric Acute Respiratory Distress Syndrome

Viral infections are an important cause of pediatric acute respiratory distress syndrome (ARDS). Numerous viruses, including respiratory syncytial virus (RSV) and influenza A (H1N1) virus, have been implicated in the progression of pneumonia to ARDS; yet the incidence of progression is unknown. Despite acute and chronic morbidity associated with respiratory viral infections, particularly in "at risk" populations, treatment options are limited. Thus, with few exceptions, care is symptomatic. In addition, mortality rates for viral-related ARDS have yet to be determined. This review outlines what is known about ARDS secondary to viral infections including the epidemiology, the pathophysiology, and diagnosis. In addition, emerging treatment options to prevent infection, and to decrease disease burden will be outlined. We focused on RSV and influenza A (H1N1) viral-induced ARDS, as these are the most common viruses leading to pediatric ARDS, and have specific prophylactic and definitive treatment options.

Matrix Metalloproteinase-9 Mediates RSV Infection in Vitro and in Vivo

Respiratory Syncytial Virus (RSV) is an important human pathogen associated with substantial morbidity and mortality. The present study tested the hypothesis that RSV infection would increase matrix metalloproteinase (MMP)-9 expression, and that MMP-9 inhibition would decrease RSV replication both in vitro and in vivo. RSV A2 infection of human bronchial epithelial cells increased MMP-9 mRNA and protein release. Cells transfected with siRNA against MMP-9 following RSV infection had lower viral titers. In RSV infected wild-type (WT) mice, MMP-9, airway resistance and viral load peaked at day 2 post infection, and remained elevated on days 4 and 7. RSV infected MMP-9 knockout (KO) mice had decreased lung inflammation. On days 2 and 4 post inoculation, the RSV burden was lower in the MMP-9 KO mice compared to WT controls. In conclusion, our studies demonstrate that RSV infection is a potent stimulus of MMP-9 expression both in vitro and in vivo. Reduction of MMP-9 (via siRNA knockdown, and in MMP-9 KO mice) resulted in decreased viral replication. Our findings suggest MMP-9 is a potential therapeutic target for RSV disease.

Olfactomedin 4 Serves as a Marker for Disease Severity in Pediatric Respiratory Syncytial Virus (RSV) Infection

Background

Respiratory viral infections follow an unpredictable clinical course in young children ranging from a common cold to respiratory failure. The transition from mild to severe disease occurs rapidly and is difficult to predict. The pathophysiology underlying disease severity has remained elusive. There is an urgent need to better understand the immune response in this disease to come up with biomarkers that may aid clinical decision making.

Methods

In a prospective study, flow cytometric and genome-wide gene expression analyses were performed on blood samples of 26 children with a diagnosis of severe, moderate or mild Respiratory Syncytial Virus (RSV) infection. Differentially expressed genes were validated using Q-PCR in a second cohort of 80 children during three consecutive winter seasons. FACS analyses were also performed in the second cohort and on recovery samples of severe cases in the first cohort.

Results

Severe RSV infection was associated with a transient but marked decrease in CD4+ T, CD8+ T, and NK cells in peripheral blood. Gene expression analyses in both cohorts identified Olfactomedin4 (OLFM4) as a fully discriminative marker between children with mild and severe RSV infection, giving a PAM cross-validation error of 0%. Patients with an OLFM4 gene expression level above -7.5 were 6 times more likely to develop severe disease, after correction for age at hospitalization and gestational age.

Conclusion

By combining genome-wide expression profiling of blood cell subsets with clinically well-annotated samples, OLFM4 was identified as a biomarker for severity of pediatric RSV infection.

Epidemiology and risk factors for severe respiratory syncytial virus infections requiring pediatric intensive care admission in Hong Kong children

PURPOSE

Respiratory syncytial virus (RSV) is a common cause of lower respiratory tract infection in young children. However, there are limited data on severe RSV infection requiring pediatric intensive care unit (PICU) admission. This retrospective study described features of RSV-associated PICU admissions in Hong Kong and investigated factors for mortality and duration of PICU stay.

METHODS

Children with laboratory-confirmed RSV infection and admitted to the PICUs of all eight government hospitals in Hong Kong between January 2009 and June 2011 were identified from computerized auditing systems and PICU databases. RSV in respiratory samples was detected by direct immunofluorescence and/or viral culture. The relationships between mortality and PICU duration and demographic and clinical factors were analyzed.

RESULTS

A total of 118 (2.4 %) PICU admissions were identified among 4,912 RSV-positive pediatric cases in all hospitals. Sixty-five (55.6 %) patients were infants. PICU admissions were higher between October and March. Eight (6.8 %) patients died, but only two were infants. RSV-associated mortality was related to prior sick contact, presence of older siblings, neurodevelopmental conditions, chromosomal and genetic diseases, and bacterial co-infections, but none was significant following logistic regression analyses (odds ratio 9.36, 95 % confidence interval 0.91-96.03 for prior sick contact, p = 0.060). Chronic lung disease was the only risk factor for the duration of PICU admission (β = 0.218, p = 0.017).

CONCLUSIONS

The majority of RSV-infected children do not require PICU support. There is winter seasonality for RSV-associated PICU admission in Hong Kong. Prior sick contact is the only risk factor for RSV-associated mortality, whereas the presence of chronic lung disease is associated with longer PICU stay. The current risk-based approach of RSV prophylaxis may not be effective in reducing severe RSV infections.

CD4+ T-cell counts and interleukin-8 and CCL-5 plasma concentrations discriminate disease severity in children with RSV infection

BACKGROUND

Current tools to predict the severity of respiratory syncytial virus (RSV) infection might be improved by including immunological parameters. We hypothesized that a combination of inflammatory markers would differentiate between severe and mild disease in RSV-infected children.

METHODS

Blood and nasopharyngeal samples from 52 RSV-infected children were collected during acute infection and after recovery. Retrospectively, patients were categorized into three groups based on disease severity: mild (no supportive treatment), moderate (supplemental oxygen and/or nasogastric feeding), and severe (mechanical ventilation). Clinical data, number of flow-defined leukocyte subsets, and cytokine concentrations were compared.

RESULTS

Children with severe RSV infection were characterized by young age; lymphocytopenia; increased interleukin (IL)-8, granulocyte colony-stimulating factor (G-CSF), and IL-6 concentrations; and decreased chemokine (C-C motif) ligand (CCL-5) concentrations in plasma. The combination of plasma levels of IL-8 and CCL-5, and CD4+ T-cell counts, with cutoff values of 67 pg/ml, 13 ng/ml, and 2.3 × 10(6)/ml, respectively, discriminated severe from mild RSV infection with 82% sensitivity and 96% specificity.

CONCLUSION

This study demonstrates that the combination of CD4+ T-cell counts and IL-8 and CCL-5 plasma concentrations correlates with disease severity in RSV-infected children. In addition to clinical features, these immunological markers may be used to assess severity of RSV infection and guide clinical management.

[Consensus conference on acute bronchiolitis (v): prevention of acute bronchiolitis. Review of scientific evidence]

A review of the evidence on prevention of acute bronchiolitis is presented. Acute bronchiolitis prevention arises from three basic approaches: preventive treatment to reduce recurrent wheezing following an episode of acute bronchiolitis, preventive treatment to reduce the frequency and severity of RSV bronchiolitis in the population at risk (prematurity, bronchopulmonary dysplasia, congenital heart disease, etc.), and general preventive measures to reduce nosocomial infection with RSV. There is sufficient evidence on the lack of efficacy of inhaled corticosteroids, oral corticosteroids and montelukast. Intravenous RSV immunoglobulin has an unfavorable risk-benefit balance, particularly with the availability of monoclonal antibodies. Palivizumab is effective as preventive treatment of RSV infection in risk populations (high risk preterm infants and hemodynamically significant congenital heart disease), but not in the frequency and severity (ICU admission, need for mechanical ventilation and mortality) of the acute bronchiolitis. The benefits of palivizumab (less admissions) seem to be worth the adverse effects, but we do not know the cost-benefit ratio. The control and prevention measures of nosocomial transmission of RSV infection (isolation, hand washing, use of mask, gloves, cap and shoes) are based on indirect evidence.

Predictive value of the respiratory syncytial virus risk-scoring tool in the term infant in Canada

BACKGROUND

Palivizumab prophylaxis against respiratory syncytial virus (RSV) infection has been widely adopted for high-risk infants during the RSV season, based on country-specific guidelines.

OBJECTIVE

To determine if a validated, risk-scoring tool (RST), can be applied to term, RSV-positive infants seen in the emergency room (ER) to predict need for hospitalization, in order to target prophylaxis cost effectively at a selected group of children.

DESIGN

Retrospective, descriptive study.

SETTING

McMaster Children's Hospital in Hamilton, Ontario, Canada.

PARTICIPANTS

A total of 72, consecutive, term, RSV-positive cases were identified retrospectively, from November through April during the 2006-2007 RSV season.

METHODS

A questionnaire/chart review was conducted on 68 of 72 cases, to determine risk categories based on the RST. Four, trained abstractors, extracted pertinent data from the medical records of RSV-positive patients. Means, standard deviations (SD), and percents were used to describe the study variables for hospitalized and ER patients discharged home. Chi-square tests were used to compare infants' risk factors to hospitalization. ANOVA was used for comparisons within and between risk groups and RST scores. A p-value of <0.05 was considered statistically significant.

RESULTS

The majority of infants scored in the low-risk category (n = 44), versus moderate (n = 16) or high risk (n = 8). Within the low-risk category, 27 (61%) of children were admitted to hospital compared to 17 (39%) who were treated in the ER and discharged home. The mean RST scores for those admitted to the pediatric intensive care unit/ward, the ward only, or those discharged home from the ER were 48.3 (n = 10), 41.0 (n = 36), and 36.5 (n = 22), respectively (p = 0.17). The mean number of risk factors for those discharged home versus hospitalized patients was 2.5 (1.3) and 2.97 (1.13), respectively (p = 0.15). Only two of eight cases in the high-risk group required intensive care.

CONCLUSIONS

Overall, the risk-scoring tool did not discriminate between low versus moderate- to high-risk RSV-positive term infants who require hospitalization which has cost implications, since universal prophylaxis of this cohort would be financially prohibitive. A larger study is necessary to establish risk factors that more accurately determine RSV hospitalization among term infants.

Risk-Scoring Tool for respiratory syncytial virus prophylaxis in premature infants born at 33-35 completed weeks' gestational age in Canada

OBJECTIVE

To study the impact of the Risk-Scoring Tool (RST) as a strategy for targeting prophylaxis effectively in 33-35-week gestational age (GA) Canadian infants who range from low to high risk by evaluating the subsequent incidence of respiratory syncytial virus (RSV) infections resulting in emergency room (ER) visits and hospitalization.

DESIGN

Prospective, descriptive study.

SETTING

McMaster Children's Hospital and St Joseph's Healthcare in Hamilton, Ontario.

PARTICIPANTS

Premature infants between 33 and 35 weeks' completed gestation who were less than 6 months' chronological age at the start of, or during, the local 2005-2008 RSV winter seasons.

METHODS

A validated, Canadian RST was used to calculate a total risk score based on seven risk factors. Only infants at moderate (RST score 49-64) and high risk (RST score 65-100) received palivizumab at monthly intervals from November to April and were followed during the respective RSV seasons. All parents received information on RSV prevention at hospital discharge. Parents of all recruited infants were contacted by telephone in May at the end of each season, and medical records were checked to determine ER visits for RSV-related respiratory tract infections and RSV hospitalization. Means, standard deviations, ranges, and percents were used to describe the variables for patients enrolled in the study.

RESULTS

Over 3 years, 430 infants were recruited. Of these, 346 (81%), 57 (13%), and 27 (6%) were in the low-, moderate- and high-risk categories, respectively, based on their risk scores. A total of 78 (18.1%) infants received full courses of palivizumab. Six out of 57 (10.5%) infants in the moderate-risk group did not receive prophylaxis, while all 27 high-risk group infants received palivizumab. Seven (1.6%) infants were RSV-positive and five (low-risk) infants were hospitalized. One high-risk, RSV-positive infant, was seen in the ER, and discharged home. There were no statistical differences in the number of infants with RSV-related ER visits and hospitalizations within the risk category groups (p = 0.43). The limitations of this study include the observational design and the relatively small sample size.

CONCLUSIONS

The RST is a practical, easy-to-use instrument to guide judicious RSV prophylaxis for moderate-high-risk, 33-35-week GA infants. It is cost-effective, reducing hospitalization in infants who are most 'at-risk', while avoiding prophylaxis in a large segment (81.9%) of this GA cohort who are considered low risk for RSV infection.

Prospective population-based study of RSV-related intermediate care and intensive care unit admissions in Switzerland over a 4-year period (2001-2005)

OBJECTIVES

Respiratory syncytial virus (RSV) infections are a leading cause of hospital admissions in small children. A substantial proportion of these patients require medical and nursing care, which can only be provided in intermediate (IMC) or intensive care units (ICU). This article reports on all children aged < 3 years who required admission to IMC and/or ICU between October 1, 2001 and September 30, 2005 in Switzerland.

PATIENTS AND METHODS

We prospectively collected data on all children aged < 3 years who were admitted to an IMC or ICU for an RSV-related illness. Using a detailed questionnaire, we collected information on risk factors, therapy requirements, length of stay in the IMC/ICU and hospital, and outcome.

RESULTS

Of the 577 cases reported during the study period, 90 were excluded because the patients did not fulfill the inclusion criteria; data were incomplete in another 25 cases (5%). Therefore, a total of 462 verified cases were eligible for analysis. At the time of hospital admission, only 31 patients (11%) were older than 12 months. Since RSV infection was not the main reason for IMC/ICU admission in 52% of these patients, we chose to exclude this subgroup from further analyses. Among the 431 infants aged < 12 months, the majority (77%) were former near term or full term (NT/FT) infants with a gestational age > or = 35 weeks without additional risk factors who were hospitalized at a median age of 1.5 months. Gestational age (GA) < 32 weeks, moderate to severe bronchopulmonary dysplasia (BPD), and congenital heart disease (CHD) were all associated with a significant risk increase for IMC/ICU admission (relative risk 14, 56, and 10, for GA < or = 32 weeks, BPD, and CHD, respectively). Compared with NT/FT infants, high-risk infants were hospitalized at an older age (except for infants with CHD), required more invasive and longer respiratory support, and had longer stays in the IMC/ICU and hospital.

CONCLUSIONS

In Switzerland, RSV infections lead to the IMC/ICU admission of approximately 1%-2% of each annual birth cohort. Although prematurity, BPD, and CHD are significant risk factors, non-pharmacological preventive strategies should not be restricted to these high-risk patients but also target young NT/FT infants since they constitute 77% of infants requiring IMC/ICU admission.

Asthma

Asthma has been recognized as a disease since the earliest times. In the Corpus Hippocraticum, Hippocrates used the term “ασθμα” to indicate any form of breathing difficulty manifesting itself by panting. Aretaeus of Cappadocia, a well-known Greek physician (second century A.D.), is credited with providing the first detailed description of an asthma attack [13], and to Celsus it was a disease with wheezing and noisy, violent breathing. In the history of Rome, we find many members of the Julio-Claudian family affected with probable atopic respiratory disorders: Caesar Augustus suffered from bronchoconstriction, seasonal rhinitis as well as a highly pruritic skin disease. Claudius suffered from rhinoconjunctivitis and Britannicus was allergic to horse dander [529]. Maimonides (1136–1204) warned that to neglect treatment of asthma could prove fatal, whereas until the 19th century, European scholars defined it as “nervous asthma,” a term that was given to mean a defect of conductivity of the ninth pair of cranial nerves.

Respiratory syncytial virus infection in 406 hospitalized premature infants: results from a prospective German multicentre database

Premature birth, chronic lung disease of prematurity (CLD), congenital heart disease and immunodeficiency predispose to a higher morbidity and mortality in respiratory syncytial virus (RSV) infection. This study describes the preterms hospitalised with RSV infection from the prospective German DSM RSV Paed database. The DMS RSV Paed database was designed for the prospective multicentre documentation and analysis of clinically relevant aspects of the management of inpatients with RSV infection. This study covers six consecutive RSV seasons (1999-2005); the surveillance took place in 14 paediatric hospitals in Germany. Of the 1,568 prospectively documented RSV infections, 26% (n=406) were observed in preterms [vs. 1,162 children born at term (74%)] and 3% (n=50) had CLD, of which 49 had received treatment in the last 6 months ('CLDplus'). A significantly higher proportion in the preterm group had congenital heart disease, nosocomial infection, and neuromuscular impairment. There were significantly more children older than 24 months in the preterm group. The attributable mortality was 0.2% (n=2) in children born at term vs. 1.2% (n=5) in the preterm group (p=0.015) [preterm plus CLD 8.0% (n=4 of 50); McIntosh grade 1, 8.6% (n=3 of 35) and McIntosh Grade 4, 15% (n=3 of 20)]. Eight patients were categorized as 'palivizumab failures'. In the multivariate analysis, premature birth, CLD(plus), and nosocomial infection were significantly and independently associated with the combined outcome 'complicated course of disease'. In conclusion, this is the first prospective multicentre study from Germany that confirms the increased risk for severe RSV disease in preterms, in particular in those with CLD treated in the last 6 months before the onset of the infection. From the perspective of our results, the statements of the German Society of Paediatric Infectious Diseases considering the use of passive immunisation (2003) seem reasonable.

Palivizumab in congenital heart disease: should international guidelines be revised?

Palivizumab has reduced the incidence of respiratory syncytial virus hospitalization in infants and children with congenital heart disease by 45%. Although the mortality rate of children with congenital heart disease hospitalized with respiratory syncytial virus infection has declined from 37% to approximately 3% over the past 3 decades, palivizumab has not been shown to improve mortality. There has been considerable controversy over the cost-effectiveness of administering palivizumab according to international guidelines, including children with congenital heart disease. In particular, the number of children that need to be treated with palivizumab to prevent one respiratory syncytial virus hospitalization increases dramatically in children > 12 months of age. As a result, the authors recommend that countries re-examine their recommendations for providing palivizumab up to age 24 months in children with congenital heart disease.

Evaluation of compliance with palivizumab recommendations in a multicenter study of young children presenting to the emergency department with bronchiolitis

OBJECTIVE

Monthly palivizumab injections from November to March decrease risk of respiratory syncytial virus (RSV)-related hospitalization during RSV season in high-risk infants born less than 35 weeks of gestation. Our objective was to investigate compliance with the American Academy of Pediatrics (AAP) recommendations for palivizumab prophylaxis among children who present to the emergency department (ED) with bronchiolitis.

METHODS

Seventeen centers, from 9 US states, performed a prospective, observational study of ED patients less than 2 years with an attending physician diagnosis of bronchiolitis. Researchers conducted a structured interview, followed by a chart review, and a 2-week follow-up phone call.

RESULTS

Of 825 eligible children, 624 (73%) were enrolled. According to AAP recommendations, 35 children (6%) should have received palivizumab, but only 17 (49%; 95% confidence interval, 31%-66%) did. Prophylaxis with palivizumab did not differ by US region (P > 0.50). The ED clinical presentations were similar when comparing those children that did and did not receive prophylaxis (all P > 0.27). Those receiving palivizumab were more likely to come to the ED using systemic corticosteroids (22% vs 7%; P = 0.003) and to be treated with corticosteroids in the ED (31% vs 15%; P = 0.02). The 2 groups were at similar risk of hospitalization (52% vs 39%; P = 0.11).

CONCLUSIONS

According to parental report, only half of children presenting to the ED with bronchiolitis who met AAP criteria for palivizumab prophylaxis received this monoclonal antibody. Emergency department visits provide an untapped opportunity for staff to educate families and communicate with PCPs about RSV prophylaxis.