Palivizumab is a RESTRICTED formulary item. A one time discharge dose may be given within 72 hours of discharge to patients who meet the below criteria from October to February if nirsevimab is not available. Exception: BMT patients may receive palivizumab under the below restrictions even if nirsevimab is available.
Dr. Brett Turner (pulmonologist) or his designee must approve all doses given. No other uses of Palivizumab are allowed at Children's of Alabama.
Patients who meet the below criteria are eligible to receive Palivizumab:
Gestational Age
Current Age
Additional Criteria
Less than 29 weeks
Less than 12 months
Less than 32 weeks
Less than 12 months
Chronic Lung disease of prematurity*
Less than 32 weeks
Less than 24 months
Chronic Lung Disease of Prematurity* AND required medical support** during the 6 month period before the start of the second RSV season
***Hemodynamically significant Congenital Heart Disease: acyanotic heart disease patients who are receiving medication to control congestive heart failure and will require cardiac surgical procedures and infants with moderate to severe pulmonary hypertension. NOTE: patients should not receive palivizumab while on cardiac bypass or extracorporeal membrane oxygenation. A dose should be considered after cardiac bypass, at the conclusion of extracorporal membrane oxygenation, or after cardiac transplantation.
****Profoundly immunocompromised: children who undergo solid organ or hematopoietic stem cell transplantation, are receiving chemotherapy, or are immunocompromised because of other conditions
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Palivizumab is a RESTRICTED formulary item. A one time discharge dose may be given within 72 hours of discharge to patients who meet the below criteria from October to February if nirsevimab is not available. Exception: BMT patients may receive palivizumab under the below restrictions even if nirsevimab is available.
Dr. Brett Turner (pulmonologist) or his designee must approve all doses given. No other uses of Palivizumab are allowed at Children's of Alabama.
Patients who meet the below criteria are eligible to receive Palivizumab:
Gestational Age
Current Age
Additional Criteria
Less than 29 weeks
Less than 12 months
Less than 32 weeks
Less than 12 months
Chronic Lung disease of prematurity*
Less than 32 weeks
Less than 24 months
Chronic Lung Disease of Prematurity* AND required medical support** during the 6 month period before the start of the second RSV season
Any gestational age AND
Less than 12 months
Hemodynamically significant Congenital Heart Disease***
Any gestational age AND
Less than 12 months
Neuromuscular or congenital anomaly that impairs clearance of secretions
Any gestational age AND
Less than 24 months
Profoundly immunocompromised****
*Chronic Lung Disease of prematurity: Gestational age <32 weeks, 0 days and a requirement for >21% oxygen for at least the first 28 days after birth
**Medical support: chronic corticosteroid therapy, diuretic therapy, bronchodilator therapy or supplemental oxygen
***Hemodynamically significant Congenital Heart Disease: acyanotic heart disease patients who are receiving medication to control congestive heart failure and will require cardiac surgical procedures and infants with moderate to severe pulmonary hypertension. NOTE: patients should not receive palivizumab while on cardiac bypass or extracorporeal membrane oxygenation. A dose should be considered after cardiac bypass, at the conclusion of extracorporal membrane oxygenation, or after cardiac transplantation.
****Profoundly immunocompromised: children who undergo solid organ or hematopoietic stem cell transplantation, are receiving chemotherapy, or are immunocompromised because of other conditions