RSV bronchiolitis in kids
RSV is a virus that can (but does not always) cause serious respiratory symptoms. And now that we’re in the midst of RSV season, here’s what parents should know.
You can also learn more about the new RSV prevention options available for infants, or download a handy FREE RSV cheatsheet on the guides page.
What is the bottom line?
If your child is diagnosed with RSV, do not panic. Remember: the majority of children have had RSV by 2 years (and recovered fully). But for younger infants, who have less reserve and smaller airways, RSV infection can be very serious. About 1-3 of children under 1y are hospitalized due to RSV every year.
So we still need to take it seriously, especially if you will be around a child under 1-2 years this Winter.
RSV causes a lot of mucus - usually in the upper airway (nostrils, etc) and sometimes in the lower airways. It tends to get worse before it gets better. It has no treatment beyond supportive care. Which means three things:
If your child is seen by a healthcare provider and sent home, but seems to be getting worse: go back. Have them seen again. Trust your gut.
Know how to tell if your child is getting worse. This can include respiratory distress (click here for a video of what pediatricians look for), dehydration, or really any other red flags listed below.
If your child is eligible for the RSV monoclonal antibody, get it! If you are pregnant and can get the RSV vaccine, get it! And if you are a parent of an infant, pediatricians recommend minimizing exposure to sick people where you can.
The Pediatrician Mom Tip: This article might be helpful to share with any family or caregivers that will be around your higher risk child this Winter.
What is RSV?
Respiratory Syncytial Virus is the leading cause of bronchiolitis and pneumonia in young infants, but it is not the only cause. We see it every year, usually between October and March. Cases are increasing right now around the US, and I expect that trend to continue as people travel and gather for the holidays.
For healthy adults and older kids, RSV mostly looks like any other respiratory illness: lots of snot, cold symptoms, some cough, often mild. It may not seem like anything unusual. Most kids do just fine.
But younger children, infants, & those with underlying health issues can end up hospitalized for a range of reasons: wheezing, low oxygen, increased work of breathing, and dehydration.
What does bronchiolitis mean?
The simplest way to think about bronchiolitis is that it is inflammation and mucus plugging of the small airways in the lungs (bronchioles). It is not the same as bronchitis (inflammation of the larger airways), which is more common in adults.
Symptoms:
Congestion/runny nose (LOTS of mucus)
Cough
Sore throat
Wheezing
Fever
Pneumonia
Difficulty breathing
Fatigue
Difficulty feeding
Usually children start off with mild symptoms and then get worse around days 3-5 of the illness before gradually improving.
The Pediatrician Mom Tip: Days 3-5 into the illness is often when we see respiratory distress, wheezing, and decreased oxygen levels.
Transmission & Incubation:
You can catch RSV via:
contact with contaminated surfaces — the virus can live on surfaces for a few hours
contact with respiratory droplets (coughing, sneezing, etc)
If you are exposed, you typically develop symptoms within 4-6 days (although the incubation period can range from 2-8 days).
The Pediatrician Mom Tip: Typically, you are contagious for about a week after symptoms begin, but it can be even longer in young infants and immune-compromised people.
Timeline:
For most kids, the wheezing and cold symptoms can last up to 2 weeks. If they persist beyond that time or improve then worsen, go back to the doctor to make sure there is no secondary infection (such as a pneumonia).
Testing:
Many pediatricians don’t routinely test for RSV. This is often a point of confusion for parents.
The most important reason to do a test is if the result will change what you do (for example: a strep swab leading to a strep diagnosis and antibiotic treatment).
For RSV or bronchiolitis, a positive test result changes little for that patient: we would still manage the symptoms the same way and watch for the same red flags whether the test was positive or not.
A bronchiolitis diagnosis can be made clinically (based on symptoms, history and exam). But of course, that is not the same as definitively knowing the cause is specifically RSV.
One reason that I pursue testing is if it would change what precautions are taken to prevent spread (especially in the hospital setting). But testing, which is done via nasal swab or bloodwork, can also help predict the course of the illness, which I think is helpful for many families.
Treatment:
Like other viruses, recovering from RSV primarily involves giving your body time and support to fight the virus. It cannot be treated with antibiotics. At home, the best things to focus on are fluids, rest, and comfort (which can include fever-reducing medications).
For kids who require hospitalization, they are often given oxygen and intravenous fluids. They may also get breathing treatments.
Complications:
RSV can be fatal in very young infants (especially in the first year of life), & in older adults with health problems. In the US, fatalities occur primarily in children born prematurely or those with complex heart and lung conditions.
What can I do to help my baby?
Download my free RSV cheatsheet here.
Nasal suction
Use saline mist and a bulb/nose frida to get the nasty mucus out. I also recently have really liked the saline misters that both Boogie Wipes and Frida have released. Caveat: remember your goal is comfort, which means you only want to use this when your child needs it (for example, before feeding or sleeping).
Humidified air
Cool mist humidifiers or a warm steamy bathroom. Simply run the shower until the mirrors are steamy and then sit in the bathroom with your child for 10-15 minutes. Ideal to do before suctioning!
I am a huge fan of the steamy bathroom - I personally find humidifiers to be annoying to maintain.
Honey (for children >1y only)
Has been shown to help with cough symptoms, especially at night.
Hydration
Coughing, rapid breathing, and fever increase the fluid requirements of the body, and most young kids are not as enthusiastic about feeding when they are congested/sick. Rapid breathing also functionally interferes with effective feeding.
Focus on smaller, more frequent feeds. Watch urine output. See this post for more.
Manage Fever
Remember, your goal is comfort! Don't obsess over numbers, but recognize that when children have fever they often are less comfortable, breathe more rapidly, and refuse fluids.
If your child is under 6 months and they have a fever, call your pediatrician.
Watch them closely and trust your gut.
Remember, RSV gets worse before it gets better. Even if you’ve already been checked out, if your child seems like they are getting worse — go back.
Prevention
The best way to prevent RSV is to use common sense infection control measures:
There are a few new prevention options available, which I discuss further here.
Frequent handwashing for 20 seconds using soap and water
Stay home when sick
Face masks
Distancing from others who are sick
Disinfect frequently touched household surfaces at least 1-2 times per day (doorknobs, counters, etc).
For toys: either run them through the sanicycle in your dishwasher, or if they are more delicate, wash with soap and water or a cleaning product that contains bleach.
When to call the pediatrician
This is not a comprehensive list. In general, always err on the side of calling your pediatrician if you have any concerns about your child. There is a lot to be said for a parent’s gut instinct, and I promise: your pediatrician would rather you called!
If your child is not improving within a few days, or if they seem to be getting worse, call your pediatrician. Other concerning symptoms include:
Breathing difficulty (see my video on instagram with more details).
Rapid breathing (Infant <12mo: more than 60 breaths/minute)
Download the free cheatsheet on my guides back that covers both how to check vital signs and what is normal.
Retractions: when the skin pulls in between the ribs or at the base of the throat with each breath
Pauses/irregular breathing
Nasal flaring
Grunting with each breath
Wheezing
Change in color (blue OR pale)
Excessive fatigue
Poor feeding
Dehydration — see my prior posts for signs to look for.
Fever is persistent beyond 3-5 days or goes away then comes back
Anything else tickling your spidey sense!!
FAQs
My child was prescribed Albuterol breathing treatments. Is this right?
In general, Albuterol has not been shown to improve RSV outcomes, but there is some clinical judgment here. Particularly for cases where a child has a history of asthma or recurrent wheezing, some physicians will try this — and in some cases it does help.
Can you get it more than once?
Yes. Although usually the first time is the worst.
Is there anything I should avoid?
Ie do not recommend nasal decongestants, cough suppressants, or essential oils in children because of potential side effects. In particular, certain essential oils like lavender, eucalyptus and tea tree oil can release VOCs and cause bronchospasm (spasming of the airways) which can worsen bronchiolitis or wheezing.
Does my child need to stay home from school?
Yes. Keep them home until they are feeling better (able to stay hydrated, acting more like themselves), fever free for >24h, no longer wheezing and respiratory symptoms are improving. Talk to your pediatrician for more guidance.
If my baby has RSV, will they be at higher risk for asthma or other long-term issues?
Some data does support the idea that RSV infection in infancy may increase the risk for recurrent wheezing and asthma over time. However, because most children get infected with RSV but not all have severe symptoms, the truth may be that there is a hereditary predisposition to develop bronchospasm (spasming of the airways) - which is a manifestation of both bronchiolitis and asthma.
