To examine the relationship between changes in American Academy of Pediatrics (AAP) guidance and palivizumab use for infants admitted to the NICU. We hypothesized that each change in guidance would be associated with a change in palivizumab usage.


This is a retrospective repeated cross-sectional study of palivizumab usage in defined subgroups of infants discharged between 1999 and 2020 using the Pediatrix Clinical Data Warehouse.


Palivizumab utilization increased in all groups between 1999 and 2003 and remained stable until 2013. Large changes in palivizumab use occurred between 2013 and 2015 followed by slower changes from 2016 to 2020. The largest decrease was in infants born between 29 0/7 and 31 6/7 weeks’ gestational age without chronic lung disease (decreased from 87% to 21%; P < .001). The second largest absolute decrease was infants born at 32 0/7 to 34 6/7 weeks’ gestational age without chronic lung disease and no major anomalies (decreased from 52% to 6%; P < .001). The decrease in term infants with major congenital heart problem was smaller (25 to 17%; P < .001). Even in the most vulnerable infants born between 22 0/7 and 28 6/7 estimated gestational age, palivizumab use declined (88% in 2013 to 74% in 2020; P < .001).


Early AAP guidelines had minor impacts on palivizumab use in infants discharged from the hospital from the NICU. The 2014 guidelines resulted in major changes in palivizumab use and extended into populations for which the AAP guidance remained unchanged.

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