(4) Long term follow-up until 20 months corrected age (approximately 2 years of life) was completed with Bayley III evaluation done at this visit. Results were presented at the Pediatric Academic Socities meeing in 2019 in Baltimore, Maryland and will be published in the future. We have no plans for follow-up beyond this point. We agree that the time has come for large clinical trials to further evaluate optimal dose, timing, and route of administration. Steven B. Powell, MD Jean M. Silvestri, MD Department of Pediatrics Rush University Children’s Hospital Chicago, Illinois https://doi.org/10.1016/j.jpeds.2019.05.064 More on the impact of American Academy of Pediatrics palivizumab guidance for infants with respiratory syncytial virus infection To the Editor: According to the 2014 American Academy of Pediatrics (AAP) recommendations, preterm infants born at ³29 weeks’ gestational age (WGA) no longer qualify for palivizumab prophylaxis, unless they have additional risks. 1 To evaluate the effects of this AAP restriction on respiratory syncytial vi- rus (RSV) infections, Zembles et al 2 compared data on RSV- associated hospitalizations (RSVaH) related to 2 seasons before (pre-AAP) and 3 seasons after (post-APP) the imple- mentation of the revised recommendations. Evaluating records from 91 preterm infants (³29-<35 WGA) hospital- ized within the first year of life, they found that rates of sup- plemental oxygen, intensive care, or mechanical ventilation trended greater, but not significantly so, in the 3 post-APP seasons, whereas the duration of hospitalization was statisti- cally longer (P = .02) in these seasons. In addition, they did not detect any significant increase in RSVaH in the 3 post-APP seasons. The authors did not perform an analysis of the ratios of RSVaH in preterm infants to RSVaH in the total popula- tion, however. These ratios were 14/82 (7.7%) and 16/128 (12.5%) in the 2 pre-AAP seasons and 30/143 (21%), 21/ 137 (15%), and 10/74 (13.5%), in the 3 post-AAP seasons. The frequency of RSVaH was significantly lower in the 2 pre-AAP seasons compared with the 3 post-AAP seasons (9.7% [30 of 310] vs 17.2% [61 of 354]; OR, 0.51; 95% CI, 0.32-0.82; P = .0047, c 2 test). Thus, preterm infants had a 50% lower risk of RSVaH before implementation of the revised AAP recommendations. Similar results were found when comparing seasons 1 and 3, the 2 peak RSV seasons in the pre-AAP and post-AAP periods (P = .0005). These data for a low number of ³29-<35 WGA infants and in seasons without a clear RSVaH pattern have low statistical power, and thus the results cannot be generalized. Taking into account the findings on duration of hospital- ization and the discrepant RSVaH ratios between preterm infants and the total population, we feel that the authors’ conclusions should have been softened. Michela Silvestri, PhD Oliviero Sacco, MD Giovanni A. Rossi, MD Department of Pediatrics Pediatric Pulmonary Disease Unit IRCCS Istituto Giannina Gaslini Genoa, Italy https://doi.org/10.1016/j.jpeds.2019.05.044 References 1. American Academy of Pediatrics Committee on Infectious Diseases, Bronchiolitis Guidelines Committee. Updated guidance for palivizumab prophylaxis among infants and young children at increased risk of hospi- talization for respiratory syncytial virus infection. Pediatrics 2014;134: e620-38. 2. Zembles TN, Bushee GM, Willoughby RE. Impact of American Academy of Pediatrics palivizumab guidance for children ³29 and <35 weeks of gestational age. J Pediatr 2019. https://doi.org/10.1016/ j.jpeds.2019.02.020. Reply To the Editor: We thank Rossi et al for commenting on our study sup- porting adherence to the American Academy of Pediatrics (AAP) recommendations for palivizumab prophylaxis among children at ³29 and <35 weeks gestational age at risk for respiratory syncytial virus (RSV). Rossi et al calcu- lated the aggregate ratios of RSV-associated hospitalizations over 2 periods. We provided the number of total RSV hospi- talizations as a metric for infection pressure by RSV in the community, not as a denominator. Total RSV admissions, the great majority of which are infants born at term, are declining. Using a declining denominator will always result in an increased proportion. The aggregated odds of RSV infection among children born at ³29 and <35 weeks gesta- tional age relative to those born at <29 weeks receiving pro- phylaxis (a better comparator) was not significant (P = .513). The summary Fisher exact test chosen by Rossi et al ob- scures yearly variation in RSV activity and associated hospi- talizations. We illustrated that a simpler study involving 1 year before and 1 year after the AAP policy change would have demonstrated a deleterious effect, as others have re- ported. That facile conclusion was not supported by our 5-year study, the longest study reported to date. Using 1-way ANOVA across 5 RSV seasons rather than the Fisher test, there was no statistical difference for any gestational age group (<29 weeks, P = .336; ³29 and <35 weeks gestational 247 Volume 212  September 2019