Respiratory syncytial virus prophylaxis for children with chronic lung disease: have we got the criteria right?

INTRODUCTION: The use of palivizumab for the prevention of respiratory syncytial virus-related hospitalization is well-established and has been adopted universally in pediatric position statements. Areas covered: The definition of chronic lung disease (CLD, bronchopulmonary dysplasia) has evolved over time and has significantly impacted the reported incidence of the condition, and the description of mild, moderate and severe disease in published studies. We reviewed lung function in infancy, childhood and adulthood of healthy preterm infants and those with CLD and how alterations in airway function, especially following respiratory syncytial virus infection may set the stage for chronic obstructive pulmonary disease in adults. We also characterized the real-world experience of the use of palivizumab compared to the single, randomized trial and examined the socioeconomic burden of respiratory syncytial virus hospitalization, an element that is commonly overlooked, when considering the value of prevention in the extremely high-risk, CLD population. Expert opinion: Based on the current evidence, we propose that palivizumab should be offered to all children with CLD in the first two years of life, irrespective of CLD disease severity. This may positively influence pulmonary maturation and normalize the trajectory of compromised lung function in these children into adulthood.