Survival Guide: RSV
What Is RSV? What Are The Symptoms?
RSV is shorthand for respiratory syncytial virus. It infects the upper and lower respiratory tract and causes significant nasal congestion, coughing, mild fever, and decreased appetite. It’s also the main cause of bronchiolitis, a fancy name for “inflammation of the smallest airways of the lungs.”
Almost all children are infected with this virus before their 2nd birthday. In older children and adults, RSV typically causes mild cold-like symptoms. In younger infants, however, it can cause severe illness (dehydration, wheezing, and difficulty breathing).
Why Are Younger Infants Affected More?
It’s all due to anatomy! In smaller babies, the airways are tinier. With RSV, there’s inflammation of the lung tissue from the virus in addition to lots of mucus production. To make matters worse, infants don’t have the ability to blow their own noses (or as strong of a cough as older children do), so that mucous tends to stay stuck in the breathing passages unless we help it out. This combination of factors leads to “plugging up” of the airways one by one, and is the reason why so many younger infants get admitted to the hospital for breathing support.
When Do Symptoms Peak?
Symptoms usually are worst on the 3rd to 5th days. This is when you should most closely monitor work of breathing and hydration status. After that, you should see an upswing.
What About Vomiting After Coughing (Post-Tussive Emesis)?
This is common, though it can be scary to witness. Coughing fits can lead to the muscles involved in vomiting getting activated and overstimulated, which is why this occurs. It can occur multiple times in a single illness, though usually slows down once the coughing improves.
How Do I Monitor Work of Breathing?
This can feel complicated, but is actually very simple! There’s a few ways we look at breathing.
The key to managing RSV is helping to remove mucus.
What About Treatment?
It’s all about supportive care! There’s unfortunately not a magic medication that we can give to relieve RSV symptoms (i.e., there’s no “Tamiflu” equivalent for treatment of RSV). That means it comes down to helping to relieve your infant of all that mucus so they can breathe more easily.
Nasal Saline and Suctioning: Nasal saline drops or sprays can be very helpful. This salt solution helps loosen up thick mucus, so that it can then be removed more easily. I recommend 1-2 drops in each nostril, and ideally let it sit there for 1-2 minutes. Then, use either a bulb suction or other nasal aspiration device (NoseFrida, Pumpinose, etc.) to remove the mucus. I advise 4 times daily, specifically before meals (since congestion can affect breast/chest-feeding and formula-feeding) and bedtime (to help with sleep). It’s important to note that while nasal saline isn’t harmful, you can suction too much and worsen nasal inflammation, so avoid overdoing it.
Cool Mist Humidifier: These add moisture to the air, which can calm down inflammation in the airways, soothe sore throats, and alleviate congestion.
Hydration: This is extremely important, since infants lose a lot of fluid when they’re working hard to breathe. You can give breastmilk, formula, or an oral rehydration solution (Pedialyte) for children <1 year of age. In children >1 year, some families find that milk makes mucus worse, though it’s still safe to give. You can try warming it up, which is sometimes helpful.
Fever Control: RSV can sometimes cause fevers, though they tend to be lower-grade and shorter-lived. You can use Tylenol every 6 hours as needed, or add Motrin every 6 hours as needed into the mix if your infant is over 6 months.
When Do I Need to Go To The ER?
If you scroll up to the section on how to monitor breathing, this is key. If your infant has retractions, a fast respiratory rate, is grunting, has pauses in breathing, or appears to be “tiring out,” this requires the ER for respiratory support with oxygen. If they’re dehydrated (<3 wet diapers in a 24-hour period, not making tears when they cry, a sunken “soft spot” in the skull, and a dry or cracked mouth), they need the ER as well for IV fluids.
What About Prevention?
In infants with certain conditions (extreme prematurity, congenital heart or lung disease), there is a preventative medication that can be given monthly during RSV season called Palivizumab (Synagis), which helps minimize risk of transmission and complications. While infants outside of these categories are not eligible, there are still small things you can do to help. Wash hands frequently with soap and water, avoid outings in crowded settings in the wintertime, make sure that visiting family members wear masks, and minimize sharing of cups, bottles, and toys with other children, since RSV can linger on these surfaces.
2023 Update: This year, there were two different preventative therapies approved and are recommended for the upcoming RSV season to limit risk of complications in newborns and young infants.
Abrysvo: Vaccine given in pregnancy (32-36 weeks) to reduce risk of lower respiratory tract infection from RSV, which was highly effective in clinical trials (showing a 90% reduction of severe LRTI in infants <90 days of age, and 75% in infants <180 days). Side effects were local reactions and slightly higher risk of pre-eclampsia for moms. In newborns, jaundice and low birth weight were seen at a slightly higher risk, as was prematurity (while the last didn’t have evidence to list it as a true side effect, it’s still included in counseling about this vaccine).
Nirsevimab / Beyfortus: This is a monoclonal antibody that works similar to Synagis, listed above. While it’s not a vaccine, it still offers robust protection. It’s recommended for all infants <8 months entering their first RSV season. Though it helps reduce risk of lower respiratory tract infections, there are issues with distribution and fair access for this season, so it may be challenging to find. Side effects include rash and local reactions (soreness, redness) at the injection site. It’s advised to be given with caution in those with bleeding disorders, and advised against for babies with a history of hypersensitivity or allergic reaction to any of the medication components.
