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Treatment of respiratory syncytial virus (RSV) lower respiratory tract infection has historically been one of the most frequent reasons for admission to Driscoll Children’s Hospital.The objective of this study was to examine the relationship of risk factors for a severe and complicated disease course to the treatment and hospital length of stay.Subjects were identified through a retrospective review of the medical records of all patients discharged with a diagnosis of RSV lower respiratory tract infection during 9 of the 11 RSV seasons between July 1, 1991 and June 30, 2002. The RSV seasons from 1991–1992 to 1994–1995 were compared with the RSV seasons from 1995–1996 to 2001–2002 with regard to treatment and hospital course.There were a total of 3308 admissions. Compared with patients with no risk factors, higher percentages of patients with age <6 weeks, history of prematurity, congenital heart disease and neurologic disease were admitted to the pediatric intensive care unit (PICU) and required mechanical ventilation (P < 0.001). Also the hospital length of stay was longer for patients with each of these individual risk factors (P < 0.001). The hospital length of stay and the percentages of patients admitted to the PICU and requiring on mechanical ventilation increased as the number of risk factors increased from zero to 3 or more (P < 0.001). Of patients with 3 or more risk factors, the average hospital length of stay was 13.5 days; 67% were admitted to the PICU, and 47% required mechanical ventilation. Ribavirin use decreased in patients with each of the individual risk factors (P < 0.001) as well as in patients with one or more risk factors (P < 0.001). At the same time the PICU admission rate increased from 6.1% to 11.2% (P < 0.001).Patients with three or more risk factors were at very high risk for having a severe or complicated disease course associated with admission to the PICU, placement on mechanical ventilation and a longer hospital length of stay.