The Online Pediatrician

RSV - Respiratory Syncytial Virus

What is it?

    RSV is a common virus that causes a cold in most children. Almost all children will have this virus at least once by their second birthday. You have most likely had it many times in your lifetime. Many parents worry about their children getting it. I often say, don’t worry about getting it because they all do. Worry about getting bad with it, which most do not.

    Common symptoms are clear runny nose, mild fever, cough like every cold you have had in your lifetime.

How is it spread?

    RSV is spread by respiratory droplets. These are expelled when you cough, sneeze or even breathe. There are 3 strains of RSV and the immunity one gets from having a case does not last long. You can literally get a second case of RSV as short as a few weeks after recovery from the last case.

What do I do if my child has been exposed?

    The incubation period from contact to symptoms is 3-5 days. There is no treatment or prevention available to most children. There is an immune globulin injection given to extremely high risk premature infants. It is several thousand dollars a dose, given monthly through the respiratory season (usually October through April). They have been working on an RSV vaccine for 60 years with little success until recently. The technology used to produce the COVID vaccine finally may have given us something. As of late 2022, a vaccine was approved in Europe for pregnant women late in the pregnancy that given some protection for severe RSV cases in the first months after birth. More to come.

What should I worry about or watch for?

    This is the key. The vast majority of children with RSV simply have a cold and there is nothing to worry about. Rarely, some children develop significant problems breathing. It usually starts with rapid breathing. Most infants breath 25-35 breaths per minute. The respiratory rate will first go well above 40 breaths per minute and then you will notice signs of increased labor to breath. Some use the term belly breathing, but this can happen in children not infected. Look for the skin to cave in between the lower ribs and then the skin to cave in at the top of the breast bone when inhaling as a sign is labored breathing. Once the respiratory rate goes above 60 breaths per minute, there is significant labor and the child will have significant problems drinking. A good rule of thumb: If the child is drinking ok, they are not breathing that hard. If they are having significant problems drinking due to how hard they are breathing, then you have a problem. The  majority of kids that get severely ill with RSV get that way in the first 1-2 days of the illness. It is rare for them to worsen after the 3rd day.  RSV is well known to medical people to wax and wane. This means they can look mild for a few hours, then look bad for a few hours then look good for a few hours and then look horrible after that. Children often are seen in the ER, observed for a few hours and look better so they are sent home, only to look much worse a few hours later. If this happens, go back to the er. It is impossible to predict which children will worsen. We treat what we see in front of us, but every doctor and nurse who cares for RSV knows that they can worsen at any time.

How do we treat it?

    The answer that you are not going to like is that there is no treatment available out of the hospital. The same things you help your child with for a cold is what we usually recommend for RSV.

• Cold medicines do not work, they have significant side effects, and should not be used.
• Homeopathic alternative medicines do not help, but are rarely harmful. If you feel better using them, just follow dosing guidelines. But they primarily make the parent feel like they are doing something, they do nothing for the child’s illness.
• Elevating the head of the bed will help drain mucus in the back of the nose and throat. For infants, this is often easiest sitting them in a bouncy seat or car seat.
• A humidifier makes the air moist and this helps the child clear secretions better.
• Saline drops in the nose helps the child dissolve and clear the mucus better.
• As far as nasal suction, if you can see the mucus and it’s bothering the child, then use suction to remove it. If you can’t see it, then the suction usually just irritates them and can cause bleeding if done too vigorously.  Saline drops in the nose in this case should just be left in and the discharge will dissolve and the child will simply swallow it like usual.
• Cuddling the child on your chest or shoulder and walking around patting their back often helps them move mucus and discharge on their own.
• Vicks vapor rub or Vicks in the humidifier might give a little relief and is safe.
• For mild fevers, Tylenol or Motrin will lower the fever and make the child feel better. One note, fevers help the child fight the infection. So if the fever is mild and they don’t look that sick, the illness will go away quicker if you don’t treat it. On the other hand, a higher fever makes a child look sick. We then lower the fever as a test. If the fever comes down easily and the child looks much better, then we are not worried. If the fever does not come down or the child still looks very sick, then they are sicker than you think and you should call us.

    There are antiviral medications used as a last resort to keep kids off a ventilator or when severe on a ventilator. They are toxic and cost thousands of dollars. Breathing treatments with a nebulizer usually do not help most kids with a RSV alone (they do if they have asthma or other chronic lung issues). In the ER, we sometimes try albuterol nebulizers when they are significantly wheezing, but they often do not help. If they do, then the ER doctor might prescribe a nebulizer to take home. Having a nebulizer at home will not usually prevent worsening or hospitalization, except in those rare instances where the medicine has already been proven to help.

When do I need to call or go to the ER?

• BREATHING: If your child is breathing very hard and fast and looks like they are in distress, then go straight to the emergency room, do not wait for a call. If they are breathing less than 60 breaths a minute, are not drinking well and you are worried, then call us 24 hours a day. If they are breathing less than 40 breaths a minute, are drinking well, but you are concerned, then call us during business hours. If course you can call 24/7 if the condition worsens and you are not sure what to do.  NOTE: a fever makes you breath 4 breaths per minute faster for every degree of temperature. So a fever of 103 can almost double the respiratory rate. Get the fever down. If they are breathing easier, then it was just the fever causing the rapid rate. If they are still b breathing hard, then the labored breathing was not from the fever alone.
• NOT DRINKING: All children eat less when they are sick. If they are drinking 3/4 of their normal amount or more and urinating their usual amount, they are doing ok. If they are breathing so far that they are having a hard time drinking to the point of getting almost nothing, then call 24/7. If they have not drank anything in 12 hours and not urinate in (8 hours as infant, 12 hours for a 1 year old, 18 hours for anything above 2 years) then go to the er. They are probably dehydrated and will need fluids.
• FEVER: A fever of 101-102 is common with RSV. 103 and above is uncommon and might indicate other problems like pneumonia or ear infections. As note4d above, if the fever comes down easily and they don’t look too bad, then observe at home. If the fever does not come down or they look very sick when it is down, then call.
• EAR PAIN: Ear infections are not very common with RSV, but they do happen. If your child was seen in the ER or Urgent Care, they often over diagnose ear infections with RSV. RSV will make the ear drum look pink for a few hours, but not budge or have pus behind the ear drum. Remind the doctor of this, because we don’t want the child on an antibiotic if they don’t need it. Antibiotics won’t help viruses (like RSV).