RSV: When less is more.

It’s that time of year again. No, not for Christmas shopping (although I should probably get on that soon). I’m talking about RSV season. Respiratory syncytial virus, or “RSV” for obvious reasons, is a particularly nasty virus that can cause a variety of symptoms in children–anywhere from common cold symptoms to respiratory problems bad enough to be potentially fatal.

RSV infections are very common, occurring in 90% of children before their second birthday. Fortunately, the majority of these infections cause relatively mild congestion and runny nose. But for a significant number of children (about 30-40%), the virus travels deep inside the lungs, resulting in a disease called bronchiolitis. This condition causes the small airways (or bronchioles) within the lungs to fill up with thick mucus and dead cells from the lining of the airway. And when this happens, it makes those airways narrower, forcing the child to work harder to move air through a smaller tube–like breathing through a soda straw instead of a snorkel. RSV tends to circulate in the winter and early spring–roughly December to April here in South Carolina, but it varies with your location.

Most children with RSV infections do not require hospitalization, but the sheer number of infections makes bronchiolitis one of the most common things we see in the hospital during the winter and early spring months. And because it’s so common, it would really be nice if we could fix it. But unfortunately, we have very little magic when it comes to treating this disease; despite amazing advances in other areas of medicine, caring for children with bronchiolitis remains very much a waiting game.

From the initial diagnosis, a less-is-more approach is best. Most children with bronchiolitis can be diagnosed with just a physical exam. We hear the cough from outside the door and see the snotty nose when we enter the room. When we listen to the lungs, it sounds like the airways are full of mucus (because they are). All the areas of the lungs sound about the same, which helps to rule out bacterial pneumonia. We’ll often hear wheezing–which doesn’t always mean asthma. And many children will breathe harder or faster than normal.

Sure, we could order a chest x-ray or a test to look for the RSV virus, but just because we can order tests doesn’t mean that we should. If a child’s symptoms and physical exam make sense for bronchiolitis, a slightly abnormal chest x-ray often leads to unnecessary antibiotic treatment–which doesn’t help, since the illness is caused by a virus. And while other viruses can cause similar symptoms, it almost never changes our treatment to know which one is responsible. Over-testing can lead to inaccurate diagnoses, unnecessary treatment, longer hospital stays, and dramatically increased costs (which is a big deal because our healthcare system spends $1.73 billion/year treating this disease). But these tests don’t make your child better any faster.

Once the diagnosis is made, we have to decide what to do about it. For the majority of kids, with relatively mild symptoms and without significant distress, the best treatment is “symptomatic care.” That means staying home, using saline drops and suction to keep the nose clear, encouraging fluid intake, and keeping an eye out for worsening symptoms. For children over 2 months of age, you can treat a fever with over-the-counter medications if you want, but except in very young infants or immunocompromised children, fever is rarely concerning. It’s a normal part of the body’s response to infection and isn’t harmful by itself. The good news is that the symptoms tend to peak around day 4 and then gradually resolve over the next few days. It might seem like it lasts forever, but you’ll both make it through.

Children with more severe symptoms may need to be admitted to the hospital overnight or for longer periods. But even there, the mainstays of our treatment are sucking out the snot and keeping the kid hydrated–we just have better tools to do it. Over the years, we’ve tried a lot of other things. Steroids seemed to make sense (because we use them for asthma and croup), but they don’t help with bronchiolitis. Inhaled albuterol or epinephrine doesn’t usually help either, because bronchiolitis isn’t an issue of constriction or swelling of the airways–it’s just that they are full of mucus. There are a few kids out there–mostly those who already have a history of recurrent wheezing–who may benefit from albuterol, but that benefit is usually pretty minimal.

In fact, if you read the current guidelines for caring for children with bronchiolitis, it sounds like a list of things not to do. That’s because there are very few interventions that actually help. We can run IV fluids for dehydrated kids. We can try some saline in a nebulizer to help loosen up the mucus. And we can help kids breathe with some oxygen or higher-flow air. (In really severe cases, we can put them on a ventilator until they get better–which isn’t what anyone wants for their child, but they do get better.) And then we wait until they’re ready to go home.

What would be really great is if we could prevent RSV infections altogether. Unfortunately, we’re not there yet. There is no vaccine for RSV, although scientists are working to develop one. At this time, the best thing we have is a monthly injection of antibodies to RSV (called pavilizumab, or Synagis), which is intended to minimize the severity of a potential infection. This medication is lifesaving for some infants, but also very expensive (about $2,000 per dose or $10,000 for the season). Because of the cost, it’s reserved for those at the highest risk for complications–those who were extremely premature, or who have heart defects or chronic lung disease. For the average healthy baby, breastfeeding and standard hygiene practices–like hand washing and keeping your infant away from sick people–are all we have.

But no matter how careful we are, kids get sick, so it’s important to know what to watch for. Here are some signs that your child may need medical attention (but I can’t anticipate every situation, so call your child’s doctor if you have concerns):

  • An infant under 2 months of age with a temperature of 100.4 F or higher requires medical evaluation to rule out other possible life-threatening causes for the fever.
  • Any child who stops breathing, turns blue or gray, or doesn’t respond to stimulation needs emergent medical attention.
  • Children who are not able to drink enough fluids to stay hydrated should be evaluated for dehydration.
  • Any child who is breathing harder or faster than usual or seems to have difficulty breathing should be evaluated.
  • In kids who seemed to be recovering, worsening symptoms or a new fever could indicate pneumonia, an ear infection, or other complications.

If your child needs to be seen, try your best to get an appointment with her regular doctor. It’s much easier to evaluate a child at her worst when you’ve seen her at her best. And if your child’s doctor isn’t available, try to find an urgent care or emergency facility that sees children frequently (or exclusively). Because bronchiolitis occurs only in very young children, those seen in an adult-focused ER or urgent care center are often treated unnecessarily with antibiotics due to misdiagnosis as pneumonia or bronchitis (which is an altogether different disease)–and when used inappropriately, antibiotics have a lot of potential for harm.

But hopefully, your kids will manage to evade RSV this winter–or at least, to keep the symptoms to a minimum, so that you can get your Christmas shopping done between rounds of snot-sucking. Best wishes to you all this RSV holiday season!

Thanks for reading! I’d love to connect with you on social media to hear your thoughts and keep you up to date on future posts. You can find me on Facebook or Twitter. -Chad

As always, your comments are welcomed (even if you happen to disagree). I'll get back to you as soon as I can. Please try to keep it civil--I reserve the right to delete comments that are offensive or off-topic.

4 thoughts on “RSV: When less is more.

  1. My first child was hospitalized for RSV when he was 10 months old! (Elevated pulse and high respiratory rate with retraction, low O2 sats, etc.). He definitely got both antibiotics and albuterol, six years ago. Vaccine would be fantastic.

  2. My son was diagnosed at 3 months. Intubation for 2 weeks and 2 more weeks because he had to relearn how to latch. The entire episode cost over 350,000. Horrific and terrifying, the same week our little man left the pic the little girl next to us lost her battle with rsv. I hate this virus.

  3. Kids with RSV infections almost universally have fluid in the middle ear giving various acuity as this is the only virus demonstrated to cause AOM. If acute disease is present with classic symptoms of pain and bulging of the TM, it is probably wise to give antibiotics particularly in children under 2 years of age as the etiology of the AOM cannot be determined on examination and concomitant infection with bacterial pathogens may be present in an already debilitated patient.

  4. I have had give children and my son he is six months and we went threw this and it was terrifying because i felt helpless i couldn’t help my child other then do all those things and console him i never went threw this with my other children but i can say i had got a nebulizer and it helped alot with the wheezing he just seemed to get worse so i took him to egleston children’s hospital and they did a deep suction from his nose and a couple days later he was feeling better i do not wish this on any child it is the worse hope they find a resolution for it

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