How To Treat Your Infant With RSV

Respiratory syncytial virus (or RSV) is a common respiratory virus — so common that almost all children will have had RSV by the age of 2. Yet despite its prevalence, it often throws parents, especially new parents, into a panic because while RSV can present itself like a bad cough or cold, it can also cause serious respiratory problems — most often in newborns and infants, who have less respiratory reserve and smaller airways.

How? Well, “RSV can affect the small airways in the lung,” explains Dr. Roberto Posada, M.D., a pediatric infectious disease specialist at Mount Sinai Kravis Children’s Hospital. “In more serious cases, there is difficulty breathing so children will be breathing faster, faster than usual, and their oxygen concentration in their blood can really drop.” It sounds scary, sure, but knowing what to look out for and when to call the doctor can help parents navigate the seemingly never-ending season of respiratory viruses.

Here’s a guide for parents on what to do if an infant is diagnosed with RSV — from monitoring the symptoms that had them initially seek medical guidance to helping their little ones through their coughs and sniffles.

What exactly is RSV?

RSV is a common respiratory virus that can present itself in a variety of ways — from regular cold and cough symptoms to those that indicate bronchiolitis, which is an inflammation and congestion of the small airways in the lung. “When these are irritated or inflamed, it can lead to poor oxygen exchange — and a drop in the oxygen levels of the blood — wheezing and difficulty breathing, along with fatigue and dehydration,” explains Dr. Krupa Playforth, M.D., a board-certified pediatrician in northern Virginia.

RSV is the most common cause for hospitalization in infants and can result in the need for oxygen, IV fluids, or mechanical ventilation. But still, Playforth maintains that “the majority of children by age 2 years have had RSV and recovered from it without complication.”

Who is most at risk for severe RSV infection?

Basically, the younger or older one is, the more vulnerable they are to the dangers that RSV can present.

Those at the greatest risk for severe illness from RSV include:

• Infants younger than 12 months (and especially those 6 months and younger)
• Premature infants (meaning those born before 37 weeks)
• Children younger than 2 years with chronic lung disease or congenital heart disease
• Children with weakened immune systems or neuromuscular disorders, including those who have difficulty swallowing or clearing mucus secretions
• Children with asthma or asthma-like conditions
• Adults 60 and older (with the risk increasing with age)
• Adults with chronic heart and lung conditions, weakened immune systems, or other underlying conditions

What are the symptoms of RSV?

While some upper respiratory symptoms are consistent with a host of other viruses and are often treated with common supportive care, others (like those indicating bronchiolitis or pneumonia) are red flags that indicate the need for urgent attention. Doctors say symptoms often worsen around Days Three to Five of illness — and even those that start out like a common cold have the potential to become more significant in children, especially in newborns and infants.

Mild-moderate symptoms include:

• Cough
• Runny nose and congestion
• Sore throat
• Eating or drinking less
• Headaches

Moderate-severe symptoms include:

• Wheezing, difficulty breathing, and low oxygen saturation in the blood (which are signs of bronchiolitis)
• Dehydration and difficulty feeding
• Fatigue, decreased activity, and/or irritability
• Fever
• Apnea (pauses in breathing for more than 10 seconds)

When to seek immediate medical attention

Dr. Priya Soni, M.D., a pediatric infectious disease specialist at Cedars-Sinai Guerin Children’s, says that “our threshold for having the pediatrician evaluate the baby is particularly low if the baby is less than 3 months old and develops respiratory distress with difficulty feeding.” Respiratory distress, difficulty feeding, vomiting after feeds, noisy and rapid breathing, and lethargy — with or without a fever — in newborns are all indications for prompt medical evaluation, she notes. Likewise, rapid breathing, wheezing, a barking cough, and fever are seen in older infants and also require prompt evaluation, she adds. It’s important to be vigilant of symptoms and call with any concerns, as RSV infection can become severe in even the healthiest of young children.

Across the board for newborns (babies younger than 30 days old), infants (those younger than 12 months), toddlers, and even older children, the doctors agree that the following symptoms require immediate medical attention and are the main reasons (along with low oxygen saturation) to admit a child with RSV to the hospital. And “if something feels like an emergency… never delay seeking emergent care,” advises Dr. Rebekah Diamond, M.D., pediatrician and author of Parent Like a Pediatrician.

• Difficulty breathing: Breathing very fast and/or having retractions (or sucking in of the muscles in between the ribs or above the collarbone while breathing), wheezing, nostrils flaring or the belly moving more than usual during breathing, grunting with each breath, and an inability to speak in full sentences in older children.
• Signs of dehydration or difficulty feeding: An inability to feed (either to nurse or take a bottle) due to breathing issues, coughing, or sheer lethargy; decreased urine output (or fewer wet diapers); fatigue and dizziness; sunken eyes; and fewer tears.
• Fever in babies younger than 2 months: Babies younger than 2 months with a fever (100.4 degrees Fahrenheit or above) need immediate medical attention — even if they do not have any other symptoms — to rule out a bacterial infection. The American Academy of Pediatrics (AAP) also recommends calling the doctor right away for fever in babies younger than 12 weeks and in all children with fever more than 104 degrees Fahrenheit.

How to treat your child with RSV

There is no specific treatment for RSV, which for many children might look like a severe cold. And while an official RSV diagnosis — meaning a positive RSV test — doesn’t necessarily change the course of care, it can help parents navigate the illness and know what to look out for as the infection runs its course. Treatment, therefore, requires a continued look at the symptoms that may have brought you to the doctor in the first place. Parents should monitor a child’s breathing, feeding, and temperature throughout the illness and seek ongoing medical care or hospitalization should symptoms change or worsen, advises Posada.

Respiratory symptoms like a common cough and runny nose can linger for a week or two — but they aren’t necessarily dangerous, says Posada, “as long as the child is not breathing too fast or working too hard to breathe” and taking in enough fluids to avoid dehydration. For these, it is all about supportive care: making the child feel more comfortable (after checking in with your pediatrician) and staying hydrated. “This varies a lot based on each case so definitely chat with your pediatrician with any questions or concerns,” suggests Diamond. Care might include:

• Using saline drops in babies’ tiny and easily clogged noses and then gently aspirating with a bulb syringe to clear mucus secretions. Older children should be encouraged to blow their noses every few hours or as needed.
• Bringing a baby or child into a room with humidified warm air (such as a bathroom after a steamy shower) to help clear clogged passageways.
• Administering fever reducers after discussing the symptoms and getting the go-ahead from the pediatrician.
• Making sure your child is staying hydrated. In newborns and infants that may mean giving feeds more slowly, as it is harder for them to eat while breathing faster than usual or congested, and making sure they have several wet diapers in a 24-hour period.
• If the child is older than 12 months, giving a spoonful of honey to children to help with a cough — but avoiding over-the-counter decongestants and cough and cold medication (if a child is even old enough to consider these), as they are often ineffective and can cause an increased heart rate and elevated blood pressure.
• Make sure they get lots of rest and TLC.

AAP’s guidance on pediatric fever protocol and treatment:

• Seek immediate care for a fever of 100.4 degrees Fahrenheit or more in babies younger than 2 months.
• Call ASAP for fever in all babies younger than 12 weeks.
• Call within 24 hours for fever in infants 3 to 6 months (more urgently if fever is more than 102 degrees Fahrenheit.
• Call ASAP if fever in babies and all children repeatedly reaches 104 degrees Fahrenheit or more.
• Call for a fever that lasts longer than 24 hours in children 6 months to 2 years and for fever that lasts more than three days in all children.
• Never administer Tylenol (or any medication) for babies younger than 3 months old unless told to do so.
• Always consult with a pediatrician or medical professional before administering fever reducers to any child younger than 2 years.

How to reduce future RSV illness and severity

There is no specific treatment for those already infected with RSV — but preventative measures can go a long way in helping others from getting sick or severely ill. That includes good hygiene, like handwashing, and minimizing exposure to germs during RSV season (especially for newborns and infants) — as well as seeking available vaccines (for both pregnant people and those older than 60) and preventative monoclonal antibody treatments.

Pfizer’s recombinant RSV vaccine is administered to pregnant people toward the end of pregnancy (and not to children) — but Posada explains that “the idea is to give pregnant women the RSV vaccine so they develop antibodies and they pass them to the baby and that way the baby is born with immunity from those antibodies.” He says that this can both decrease the number of infections and the severity of illness should infection occur.

Likewise, while there has been an antibody treatment available for high-risk infants, there is now a new monoclonal antibody called nirsevimab — which is recommended once during RSV season for all infants younger than 8 months (and up to 19 months for certain children) who weren’t born to a person who received the vaccine during weeks 32 to 36 of pregnancy. While the shot is approved and said to be effective in preventing severe RSV disease, doctors currently cite supply issues preventing all eligible infants from receiving it and say parents should talk to their doctors both about its availability and their options.

Of course the hope is that these new preventative medicines will start to make RSV season less severe, help children (especially those most vulnerable little ones) avoid serious illness, and bring a bit of relief to panicked parents.

Experts:

Roberto Posada, M.D., professor of pediatrics in the Division of Pediatric Infectious Diseases of the Jack and Lucy Clark Department of Pediatrics and the Mount Sinai Kravis Children Hospital

Krupa Playforth, M.D., a board-certified pediatrician at Warm Heart Pediatrics in Northern Virginia and founder of The Pediatrician Mom

Priya Soni, M.D., a pediatric infectious disease specialist at Cedars-Sinai Guerin Children’s

Rebekah Diamond, M.D., a hospital pediatrician in New York City, assistant professor at Columbia University, and the author of books Parent Like A Pediatrician and upcoming Eat Sleep Tantrum Repeat