Overview: Respiratory Syncytial Virus (RSV) in Children

If you are a parent to an infant or young child, you may have seen or heard of scary headlines or videos on social media about the dangers of RSV in babies and small children. But what is it, how common is it, and do you really need to worry?

RSV is actually very common: According to the Centers for Disease Control and Prevention (CDC), almost all children will get RSV at least once by the time they are 2 years old—and can become re-infected again anytime throughout life. And while RSV may present like the common cold in many healthy children and adults, it can be dangerous in infants (babies less than 12 months old) and some young children. In fact, according to the CDC, RSV is the leading cause of hospitalization in infants! Because of this, it is important for parents of little ones and those with certain underlying conditions to understand the risks of RSV and the steps they can take to prevent it—as well as what to look out for and how to care for their child should they become infected.

What Is Respiratory Syncytial Virus (RSV)?

Respiratory Syncytial (pronounced sin-SISH-ul) Virus (RSV) is one of the many viral illnesses that affect the respiratory system—specifically the nose, throat, and lungs. It is a highly contagious infection that spreads easily from person to person. It is the most common cause of bronchiolitis (inflammation of the smallest air passages in the lungs) and pneumonia (infection of the lungs) in babies, and, according to the American Academy of Pediatrics (AAP), hospitalization may be required in two to three out of every 100 infants with RSV in the United States.

In healthy older children and adults, RSV can cause signs and symptoms that are similar to the common cold. However, RSV can cause severe illness and pneumonia in some children, such as infants (especially premature infants), babies with certain heart, lung, or neuromuscular diseases, and those that are immunocompromised (with a weakened immune system).

What Causes RSV?

RSV is highly contagious, usually for the first week or so after infection. In infants or those with a weakened immune system, the virus may continue to spread for even longer—sometimes up to 4 weeks after symptoms disappear! Because people and children could be contagious with RSV a day or two before they even know they are sick, it is easily transmitted from person to person.

RSV is spread through contact with someone who is infected, either through the air or through touch:

1. Air—When an infected person coughs or sneezes, virus particles (droplets) can travel up to 12 feet in the air and can stay suspended in the air for varying amounts of time. If your child breathes in this air, the virus can stick to their nasal membrane, infecting them.

2. Touch—If your child directly touches an infected person or a contaminated object then touches their eyes, nose, or mouth, the virus can enter the body. Children often touch their face as well as other people and objects (like shared toys), making viruses easy to spread in young kids.

RSV spreads in the fall and winter like many other respiratory viruses, typically peaking in December and January. It can spread quickly through schools and daycare centers—often times, babies pick up RSV from older siblings who carry the virus home from school with them.

What Are the Signs and Symptoms of RSV?

Infants with RSV almost always show symptoms—unlike adults, who may not show any symptoms with RSV infection. Symptoms usually appear about 2 to 5 days after contact with the virus. Typically, they start out as mild in young babies and children, similar to those of the common cold, and can become more severe a few days into the illness. According to the AAP, symptoms are often the worst on days 3 through 5 of illness and generally last about 7 to 14 days.

Upper Respiratory Infection (URI) Symptoms:

According to the CDC and AAP, early cold-like symptoms of RSV may include:

1. Fever—temperature of 100.4°F (38°C) or higher

2. Cough—dry or wet sounding

3. Congestion or runny nose

4. Sneezing

5. Fussiness

6. Poor feeding

7. Hoarse cry or voice

Lower Respiratory Tract Infection (LRTI) Symptoms:

RSV symptoms can turn severe, leading to bronchiolitis or pneumonia. According to the AAP, these severe symptoms may include cold symptoms and:

1. Difficulty breathing or breathing fast

2. Nasal flaring (when the nostrils widen with each breath) and head bobbing with breathing

3. Rhythmic grunting with breathing

4. Retractions (when the skin in the neck or between or below the ribs “sucks in” with each breath)

5. Belly breathing

6. Wheezing (a high-pitched whistling sound heard when exhaling [breathing out])

7. Turning blue around the lips

When Should I call My Child’s Primary Care Provider (PCP)?

It is important to call the pediatrician right away if your child has any of the following:

1. Any of the above severe symptoms of bronchiolitis or pneumonia

2. Dehydration (no urine output for 8 hours, dry mouth, no tears when crying)

3. Apnea (pauses in breathing)

4. Difficulty breathing

5. Blue lips or nails

6. Not alert or interactive when awake

Some children with RSV may be at an increased risk of developing a secondary bacterial infection, such as an ear infection. Call the pediatrician if your child also has any of the following:

1. Symptoms that worsen or do not improve after 7 days

2. Fever (rectal temperature of 100.4°F [38°C] or higher) in an infant less than 3 months old

3. A fever over 104℉ (40℃) repeatedly in a child of any age

4. Poor sleep or fussiness

5. Ear tugging or ear drainage

How Is RSV Diagnosed?

Your child’s PCP may perform a physical exam where your child will be assessed. Since the signs and symptoms of RSV can present similarly to other conditions, a nasal swab test may be ordered to determine if it is RSV or another infection.

Since there is no specific treatment for RSV and most children recover fully without difficulty, determining an official diagnosis may not be necessary. A chest x-ray and/or an oxygen saturation test may also be ordered if a lung infection is suspected.

How Is RSV Treated at Home?

Your child’s primary care provider will determine how best to treat your child based on their age, severity of symptoms, and overall health. The goal of treatment is supportive to help relieve and prevent symptoms and discomfort. This may include over-the-counter pain relievers and fever reducers such as acetaminophen and ibuprofen—do not give ibuprofen if your child is under 6 months old or if your child is dehydrated. Also, it is important to not give your child aspirin or other salicylates as it has been linked to a serious, potentially life-threatening disease called Reye syndrome that affects the liver and brain.

Other ways to help keep your child comfortable at home include:

1. Ensure they get proper rest

2. Encourage plenty of fluids such as breastmilk or formula for infants and water, electrolyte drinks (like Pedialyte, Enfalyte, or store brands), soup broth, popsicles, or flavored gelatin for older children

3. Cool mist humidifiers to moisten air and help clear nasal passages—Use distilled water; Place near your child but keep out of their reach; Clean humidifier often according to the manufacturer to prevent mold or mineral buildup

4. Saline (saltwater) drops to clear stuffy nose and congestion—Use 1 to 2 drops in each nostril; For infants, use bulb syringe to remove mucus and extra saline

5. Hot showers to create a steam-filled bathroom where your child can sit to relieve stuffiness

Your child should stay home from school or daycare until feeling better and fever-free for 24 hours without the aid of over-the-counter fever-reducing medications.

It is important to remember that antibiotics do not work against viral infections; they are used to fight against infections caused by bacteria. Since RSV is caused by a virus—not bacteria—your PCP will not prescribe an antibiotic for your child’s illness. However, sometimes children may develop complications or secondary infections during RSV from bacteria, like an ear infection. Your child’s PCP may order an antibiotic to treat one of these secondary infections if present.

Also, keep in mind that children and adults can become infected with RSV multiple times, even during a single season. According to the AAP, repeat infections, however, are usually less severe than the first one.

How Can RSV Be Prevented?

Immunizations

There are two new types of RSV immunizations available to help protect babies from severe illness: RSV vaccine during pregnancy (Abrysvo) and RSV vaccine for infants and toddlers (nirsevimab, or Beyfortus). Most babies usually only need protection from either maternal RSV vaccine or infant/toddler immunization, but not both.

RSV Vaccine During Pregnancy

The maternal RSV vaccine, Abrysvo, can be given September through January to pregnant people at 32 through 36 weeks of pregnancy if their baby will be born during RSV season. This vaccine reduces the risk of hospitalization from RSV by 57% in the child’s first 6 months of life.

This vaccine can only be given to a person once; if the maternal RSV vaccine was given during any pregnancy, it cannot be given again in any subsequent pregnancies. Any babies born from subsequent pregnancies should receive the RSV for infants and toddlers (see below).

RSV Vaccine for Infants and Toddlers

The vaccine nirsevimab (Beyfortus) is a single-dose “monoclonal antibody” that can be given as an injection just before or during RSV season. This vaccine has shown to reduce the risk of hospitalization from RSV by approximately 80-90% in infants.

Palivizumab for High-Risk Children

Palivizumab may be recommended for high-risk children under the age of 24 months with certain conditions. It is a monthly injection given during RSV season.

Other ways to help prevent RSV include keeping your child away from a person who has cold symptoms. Encourage proper handwashing techniques both with soap and water and with hand sanitizer (containing at least 60% alcohol), and teach your child not to touch their nose, mouth, or eyes until their hands are properly washed. Additionally, children can be taught how to cough or sneeze into a tissue or their elbow (not their hands) and to not share towels, drinking glasses, or eating utensils. Toys and common play areas should be cleaned and sanitized regularly.

The AAP also encourages breastfeeding when possible as it contains unique antibodies that help to prevent and fight infections.

Key Points to Remember

RSV is a highly contagious viral illness that affects the respiratory system. In healthy children, RSV can seem like the common cold requiring supportive care at home, but in young children and infants (particularly those less than 6 months old), RSV can cause severe illness and complications such as bronchiolitis or pneumonia. These children may need to be treated in the hospital. Immunizations are available and recommended for pregnant people and young children to help prevent severe illness from RSV. Vaccination and other prevention strategies such as good hand hygiene and avoidance of those with cold symptoms are key to navigating this RSV season and keeping your child safe and healthy!

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