Synagis® Referral Form To refer a patient for Synagis®, please print and complete this form, and FAX it to 585-275-8706 for review. If you think your baby might be a candidate for Synagis® please discuss with your baby’s doctor. Referrals must be initiated by a physician’s office—they can not be made by parents.

Services and Programs

Pediatric Pulmonology

Synagis® Program

We work closely with the community physicians and physicians within our Neonatal Care Unit to identify and provide care for premature newborns who are at high risk for Respiratory Syncytial Virus (RSV). Currently, there is no vaccine against RSV, however, our Division coordinates and administers Synagis®, a highly effective medication that can help prevent serious infections, and the resulting consequences.

Through the Synagis® program, we:

• Identify high risk premature babies
  
  
• Obtain insurance approval on your behalf (if eligible)
  
  
• Manage prescriptions and administration of the drug. Appointments and shots are scheduled either at the Pediatric Ambulatory Care Facility (ACF-6), Suite B, or we can coordinate with home care agencies for parents with travel restrictions. In all situations, we will work with your insurance provider for approval on how and where we can administer Synagis®.
  
  
• Monitor your child's health and provide follow-up care to ensure the proper procedures are followed so that premature babies experience the full benefit of the drug. It is imperative that shots are given in sequence and in a timely manner during the RVS season (November through April in our region). We will schedule your appointments and work with you throughout the winter season—the peak time for outbreaks.
  

The Synagis® Program is referral-based only. Because of the stringent eligibility criteria set forth by the American Academy of Pediatrics, appointments are only made for patients who are referred to us by either the NICU or their Primary Care Physician.

• What is Synagis®?
  Synagis® is a medication used to prevent certain infants from developing serious Respiratory Syncytial Virus (RSV) infection.
  
  
• Which infants should receive Synagis®?

  Infants at risk for severe RSV infection should receive Synagis®, including infants with a history of prematurity and/or chronic lung disease. The decision to give Synagis® to your baby is based on your doctor's opinion of your baby's risk.

• How is Synagis® given?
  Synagis® is given intramuscularly by injection. It must be given once a month, usually for 5 months during the RSV season.

• What are the side effects of Synagis®?
  Most infants who receive Synagis® do not experience side effects. When side effects do occur, they are usually not serious. Possible side effects include pain and redness at the injection site, runny nose, sore throat, rash, vomiting and diarrhea.

• Are there any other risks?
  Synagis® should not be used in children with a history of severe prior reaction to Synagis® or other components of this product. Call your doctor or pediatrician immediately if your baby experiences any reactions that you think may be due to Synagis®.

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