There are still some unanswered questions about the New RSV shots, but with RSV starting to make the rounds, Dr. Ted and I decided it was worth sharing what we do know.
Every year, severe RSV disease is the number one reason babies under 12 months old have to be admitted to hospitals in the US. November is typically the start of RSV season but it has come earlier for the past couple of years. Last year at this time there were so many cases that nationwide, some children's hospitals were having trouble finding room for all the sick kids. We are currently starting to see an uptick. If you want to track the numbers for your location, click here
This post will review
What is RSV disease?
Respiratory syncytial (sin-SI-shul) virus, or RSV, is NOT new. It is a common, seasonal virus that is often simply referred to as an especially bad cold. Nearly all children will get their first RSV infection by age 2. Like most viruses, it ranges in its severity from case to case. Let me repeat - I am sorry to say, but your child is likely to get this! No need to freak out…Keep reading.
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. 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 have 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.
You know the wretched colds that knock you flat? Not only do you have a runny nose, sniffling and sneezing, but you also have a harsh, deep cough and fever. That might well be RSV. I actually can almost diagnose it just by hearing the distinctive cough. It is deep, wet and sounds like it hurts.
RSV can come 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 days total. It is common for the cough to linger for several weeks.
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!
So how do you know if you need 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:
See the chart at the bottom of the post for a list of respiratory rates/age.
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, I 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:
A dehydrated kid is almost never playing happily. They usually seem pretty droopy.
It is normal for the appetite to be very off. I 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 my 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 higher than 103 and not responding to medication or it is lasting longer than 5 days, then I would want to have your kid checked. This could be a sign that the RSV has turned into an ear infection and/or pneumonia. (103 fevers that respond to medications can usually wait for the next day to be evaluated. Click the link below 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.
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.
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.
According to our local pediatric acupuncturist, Dr. Den, at The Acupuncture Den, the actual symptoms are more important than any official western medicine diagnosis. Whether or not it is RSV, a common cold or even teething, if seen in the office early on, a treatment can help the body to heal itself more easily and will also help with symptom relief (non-needle treatment options are available!)
If you don't manage to stop it in its tracks quickly enough, traditional Chinese medicine can still be very helpful as the infection runs its course. Dr. Den 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).
For more information about pediatric acupuncture (or grown-up acupuncture!) and/or herbal medicine, please reach out to Dr. Den. She’d love to hear from you!
How is it 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.
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. General common sense
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. Every new cold seems to re-trigger the wheeze.
With any cold or illness, your best bet is to pay attention to the first sign of illness. Here is my blog post with my list of things you can do to boost and protect your immune system.
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 might not be worth an actual office visit 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.
Prevention An RSV immunization 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? While the FDA approved Beyfortus for all newborns under 1 year of life, the Advisory Committee on Immunization Practices, the government panel that makes recommendations on shots (and whom insurance companies use to decide what to pay for) advised that children under 8 months 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. There is also a new RSV shot for adults called Abrysvo (who comes up with these names?) This vaccine is 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. This shot 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 case the decision needs to be made as to whether or not mom gets the shot or waits for the baby to get it.
A note on payment Beyfortus is a new medication, a monoclonal antibody. It’s not a vaccine. Because of this, insurance companies have not universally agreed upon reimbursement rates. Please check with your pediatrician’s office to see what their protocol is. I will update this post when more information is available.
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 I am 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, I 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. |
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