RSV 2025
Historically, severe RSV disease was the number one reason babies under 12 months old were admitted to hospitals in the US. With the new RSV shots, that number may be changing.
November is typically the start of RSV season but it has come earlier for the past couple of years. Some seasons feel more intense than others. Just two years ago there were so many cases that nationwide, some children’s hospitals were having trouble finding room for all the sick kids. Last year wasn’t quite as bad. We shall see what this season has in store.
This post will review
What is RSV?
When do you need to worry?
Symptomatic treatment
How is it spread and what is the exposure period?
Tips to prevent
Testing
The RSV shots for babies
The RSV vaccine for pregnant moms
FAQ (including daycare, siblings and nursing moms)
What is RSV disease?
Respiratory syncytial (sin-SI-shul) virus, or RSV, is NOT new. It is a common, seasonal virus that without the confirmation of a positive test, may often simply be considered an especially bad cold. Like most viruses, it ranges in its severity from case to case. More than 50% of all children will get their first RSV infection by age 2, and 90-100% will have had it by age 3. In other words, RSV infection is a matter of when, not if. Let me repeat - I am sorry to say, but your child is likely to get this! No need to freak out…keep reading.
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RSV often settles in the bronchioles. These are the little airways in the lungs that lead to the microscopic alveoli, the place where oxygen is pulled into the blood. They’re very deep, hence the deepness of the RSV cough.
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Source: https://www.afterhourskids.
The virus causes these little airways to get clogged with mucus, making it difficult for air to pass. This is part of why the virus is so much worse for younger kids. Their smaller airway gets clogged more easily.
Some studies show that somewhere between 25-40% of young infants with the RSV virus will end up having bronchiolitis or pneumonia. That is a scary statistic, but to balance it out, here is some reassuring data: in the US, 99.4% of kids under 5, and 98.5% of kids under 6 months will not need to be hospitalized with RSV. By far, the majority of cases can be safely managed at home.
With RSV, not only do you have a runny nose, sniffling and sneezing, but you also have a harsh, deep cough and fever. You know the wretched colds that knock you flat! We actually can almost diagnose it just by hearing the distinctive cough. It is deep, wet and sounds like it hurts.
RSV comes on slowly, unlike the flu that usually has a sudden ‘hit by a truck’ onset. Generally the first signs are runny nose and decreased appetite. The cough comes along a few days later. It is also common to have mild to moderate fevers that can come and go for several days.
The symptoms are usually at their peak at the 3-5 day mark, but often last 8-10 days total. Once the majority of the symptoms have resolved, it is common for the cough to linger for several weeks. Mentally prepare for 21 days of coughing. As long as it is clear that you are moving in the right direction, that cough usually just needs time, patience, hydration and adequate sleep. It will pass.
Unfortunately RSV is not one of those viruses that is ‘one and done’. Sadly it takes multiple exposures before you develop immunity. Adults don’t get as seriously ill, but they still get it and are in for a miserable week. Most folks get RSV about 8 times until they finally seem to be not as vulnerable!
It spikes again in older folks when the immunity tends to wane. It can sweep through retirement communities, so be cautious for the older adults in your life as well. While hospitalizations for RSV are less frequent than those due to flu or covid, the likelihood for invasive ventilation or death from RSV is double the number from the flu and about the same as covid (fortunately there is now a vaccine for people over 60).
When to worry
Severe RSV disease symptoms usually include some abnormal breathing but there are some specific things to watch out for.
As Dr. Ted says, “Respiratory distress looks like your kid ran a baby marathon. It’s not subtle, and kids are not happy.” We worry when:
The skin is sucking in between or under the ribs with inspiration. These are called retractions.
The nostrils might be flaring out, and the baby’s head might be bobbing up and down.
The belly might be pulling in and out dramatically with breaths.
They might be gasping or grunting
There might be a bluish color around the mouth or fingernails
There might be coughing or wheezing that feels constant
The rate of breathing is fast. Breaths per minute vary by age. To get a baseline, try counting breaths when your kid is calm. It is fine to do it while they are sleeping. Count for 30 seconds and multiply by 2.
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Also, check out the Tik Tok that Dr. Ted and I did. Seeing what labored breathing actually looks like is worth 1000 words
(if someone had told me a few years ago that I would be doing Tik Tok, I would not have believed them).
If you are reading this and your child is actually one of the few kids who is not coughing and doesn’t have a fever, we strongly recommend making note of what their normal breathing looks like before they get sick. Lift their shirt and get a baseline assessment.
Labored breathing is usually pretty obvious, but hydration is another big concern that sometimes gets missed. Warning signs include:
Dry mouth with cracked lips
Crying without tears
Urinating less often (smaller volume diapers that are happening a normal number of times per day are okay)
A dehydrated kid is almost never playing happily. They usually seem pretty droopy.
It is normal for the appetite to be very off. We don’t even worry if kids lose a bit of weight from a week of pathetic eating. They will gain it back when they are recovered. However if they are not drinking adequately, they may need to get checked to see if they need to get an IV for some hydration and nourishment.
Having an elevated fever is a symptom that often gets the parents the most worried. In general our attitude is that fevers are part of the package and can usually be managed with fever reducing meds or a tepid bath.
If the fever is making your child fussy and not responding to medication (meaning it isn’t coming down an hour after fever-reducing medications) or it is lasting longer than 5 days, then we would want to have your kid checked. This could be a sign that the RSV has turned into an ear infection and/or pneumonia (high fevers over 102 that respond to medications can usually wait for the next day to be evaluated. Click the link for more on fever management).
Bottom line - If your child is having trouble breathing, or significant trouble feeding, they may need to be hospitalized for a night or two for fluids, oxygen and observation.
Symptomatic Treatment
For mild cases, time tends to be the great healer. Your medical team can simply suggest the same symptomatic treatment and supportive care that we would do for any bad cold and cough.
Treat the fever as needed. Fevers need treatment if they’re interfering with your child’s ability to hydrate or sleep. These kids tend to look pretty miserable. If they are just warm but happy and drinking, they don’t require medication.
If you need some tips and trick getting the medicine in check out this post
If your child is having trouble eating because of all the congestion, try doing some clearing about ten minutes before a feeding.
To clear the nose, squirt some saline, xlear nose spray, or breast milk in each nostril. Next step is to suck it back out with either a Nose Frida/ aspirator or the Neil Med Naspira. I think these products are easier to use than the standard bulb aspirators. Some parents swear by the Oogie bear. This is a safe little scoop that can safely get into the nostril and remove the more stubborn boogers.
It is also helpful to keep their heads elevated. They may be more comfortable on a bit of an incline. Try to raise the mattress a bit. You can do this by putting a towel underneath or place thin books under two of the legs of the crib. For older kids, add an extra pillow. The American Academy of Pediatrics guidelines specify not to raise the head more than 10% when they are sleeping and you are not keeping an eye on them. If they’re napping but you’re in the room keeping an eye on them, you can raise the bed to 30% for easier breathing.
Let them sit in a steamy bathroom, and use a humidifier at night. Increase fluids during the day.
Warm fluids are great. For kids older than a year, honey is terrific. I especially like the manuka honey. Have a little tea party, invite the teddy bears. Boys can have tea parties, too. This can also be a good way to encourage them to drink.
If your little one is having a rough time your doctor may do a one-time trial of a nebulizer or inhaler to see if it helps. Some children may be prescribed steroids.
Traditional Chinese medicine can be very helpful to some as the infection runs its course. Dr. Den of the Acupuncture Den in SF keeps high quality pediatric herbal tinctures stocked in her office, and encourages the families in her practice to keep a bottle or two on hand, as they are most effective when used at the first signs of trouble. While some of the tinctures are highly specific, others can be used more generally (when you know your child is getting sick but you’re not sure yet what’s going on). In terms of the common cold, the flu, and RSV, the two tinctures Dr. Den recommends to keep in your medicine cabinet are CQ Jr (perfect for the first signs of illness) and Lung Qi Jr. (if it starts to move into the chest).
Here is Nurse Judy’s blog post with her anecdotal list of things you can do to boost and protect your immune system.
How is RSV spread and what is the exposure period?
This is NOT spread the same way as COVID which easily spreads through the air. RSV spreads through heavy droplets:
An infected person coughs or sneezes
You get virus droplets from a cough or sneeze in your eyes, nose, or mouth
You have direct contact with the virus, like kissing the face of a child with RSV
You touch a surface that has the virus on it, like a doorknob, and then touch your face before washing your hands.
According to the CDC, people infected with RSV are usually contagious for 3 to 8 days and may become contagious a day or two before they start showing signs of illness. However, some infants, and people with weakened immune systems, can continue to spread the virus even after they stop showing symptoms, for as long as 4 weeks.
Common Sense Advice on Infectious Containment
Wash your hands before touching your child.
Make sure others wash up too.
Clean toys, crib rails, and any other surfaces your baby might touch.
Try to keep your baby away from crowds.
Avoid anyone with a cold or fever. Snotty nosed toddlers are the biggest carriers. See suggestions below for dealing with this circumstance.
Don’t let anyone smoke near your baby. Tobacco smoke exposure can increase the risk of severe RSV disease.
After the Illness
If your child is unfortunate enough to get a nasty case of RSV, it may take a few weeks for the lungs to calm down. Many of them have an extra tough winter season.
After recovery, the lungs are unfortunately sensitive for a couple months. Every new cold seems to re-trigger the rattling in the chest, and some children can develop what sounds like a “wheeze” with illnesses. This doesn’t always mean that they have asthma.
Testing
There is a rapid test (a swab to the nose) that many offices can do to see if it is RSV or not. Usually they will test for flu and covid while they are at it. Believe it or not, some unfortunate kids can have more than one of those at the same time!
Unless your child is looking really sick, it is not always necessary to drag your kid in to get an official diagnosis since it doesn’t necessarily change the approach. Since RSV is a virus, the treatments are usually simply those listed above. Antibiotics would not be appropriate unless it progresses to a secondary infection.
That said, having an official diagnosis is sometimes helpful to know what to expect. Remember, RSV lasts a long time. Knowing that RSV is the cause of your symptoms can help you to avoid unnecessary antibiotics from an eager prescriber. It also never hurts to have the ears checked and the lungs listened to.
The RSV shot for infants
An RSV shot called nirsevimad (Beyfortus) is a novel shot for all newborns entering their first RSV season (historically winter or fall). It gives about 5+ months of protection and in full term newborns it decreases the chances of needing to go to a doctor for RSV by about 74%, and decreases the need for hospitalization by about 62%. These numbers are even higher when studied in preemies (29 to 35 weeks).
Beyfortus is not an immunization; it’s a pre-made antibody (it’s been approved as a medication). This is an important distinction, because unlike other childhood vaccines, it doesn’t stimulate the immune system. A typical tetanus shot gives a small piece of the tetanus bacteria to the immune system. In response, the immune system mounts an attack, which leads to the “yucky” feelings we get with shots: achiness, fatigue, sometimes even fevers. Beyfortus, as a pre-made antibody, just gives the immune system the final product. You get to skip all the steps in between, and all the accompanying side effects. The most common side effect is a small rash at the site of injection, which occurs in less than 1% of kids who get the shot.
Who gets Beyfortus?
The FDA approved Beyfortus for all children under 12 months old. It’s advised that infants get it right at the beginning of their first RSV season. It has been studied and is safe to give in the hospital after birth, during the first few days of life. It’s only 1 shot, there are no boosters.
The RSV shot for adults
There is also an RSV shot for adults called Abrysvo or Arexvy (who comes up with these names?)
These vaccines are available for folks over 60 who are more at risk for severe RSV. It is fine to get it at the same time as other vaccines.
Abrysvo is also approved for pregnant people. When given to someone who is pregnant the primary goal is to protect the fetus. The placenta loves antibodies, so any immune system activity in mom often goes to the baby ten-fold. When given between 32 and 36 weeks gestation, the RSV vaccine for pregnant people is able to decrease the rate of severe disease in babies by about 80% in the first 3 months of life, and more than 50% after 6 months. Moms can get the RSV vaccine at the same time as others, such as flu, Tdap and Covid.
Abrysvo or Beyfortus, which to get, or both?
Because nothing is ever simple, in most cases the decision needs to be made as to whether or not mom gets the shot or waits for the baby to get it.
Pregnant parents are advised to get the RSV vaccine for themselves between 32 and 36 weeks gestation during RSV season because protection takes 2 weeks to pass from mother to baby through the placenta. In most of the country, RSV season is considered to be from September to January.
Because of the 2-week delay in immunity for babies, anyone born before 34 weeks, or within 2 weeks of parental vaccination, are all advised to get Beyfortus.
If mom got her RSV vaccine and the baby was born 2 weeks or more later, the baby should not need Beyfortus.
Frequently asked questions
When can my little one go back to school?
Keeping your child home because they have a mild runny nose or lingering cough is not reasonable. However, kids with fevers and/or copious mucus should stay home.
I am nursing, do I need to stop? Can I still be around the baby?
Nursing moms who test positive should still continue to nurse their babies. This includes newborns. Just wear a mask and do thorough and frequent hand washing (and we are so sorry if you are dealing with this).
Do I need to keep my kids apart from each other?
Sigh, this is SO hard. It is almost impossible to quarantine family members. If there is an infant in the house, we would try hard to keep toddlers who have been exposed at least 6 feet apart (sneezing distance) from the baby. No kissing or hugging. Put them in charge of the ‘magic soap’ otherwise known as hand sanitizer. Tell them to make sure that anyone who is having direct contact with their new baby needs to use the magic soap first. Maybe furnish them with a new baby doll that they can cuddle with instead.
Dr Ted is currently starting to see a mild uptick in RSV cases. If you want to track the numbers for your location, click here
In normal times the site is updated weekly, That might be impacted by the current turmoil at the CDC.
California numbers are still being reported weekly
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