A parent’s guide to RSV

Endless coughs and sneezes, runny noses, and unexplained itchy bumps—kids seem to be a magnet for germs. In our parent’s guide to childhood illnesses, we talk about the symptoms and treatments for the most common conditions. Read the full series here.

What is RSV? | Symptoms | Diagnosis | Treatments | Prevention

When I was pregnant with my first child and reading all the information about newborns I could get my hands on, one of the “watch out for” topics that caught my attention was RSV. In my super-cautious new-mom-to-be state, RSV became a lurking monster, particularly with a baby due in February—right in the middle of RSV season. I knew it could be serious for young babies, and so in my head, it became enemy number one. Thankfully, once I got past the visceral reaction, I learned that most of the time, RSV is not serious. In fact, almost all children will have had at least one RSV infection by the time they reach 2 years old, usually without serious effects.

What is RSV?

“Respiratory syncytial virus (RSV) is a respiratory virus which usually causes mild, cold symptoms,” says Soma Mandal, MD, a board-certified internist at Summit Medical Group. “It can be problematic in infants and older adults. It is the most common cause of bronchiolitis (inflammation of the small airways of the lungs) and pneumonia in children who are less than 1 year old.”

RSV is very common and very contagious, spreading easily through places like daycare centers and schools. An infected person is usually contagious with RSV for three to eight days, according to the Centers for Disease Control and Prevention (CDC), but some infants and people with weakened immune systems may remain contagious for up to four weeks, even if they are no longer symptomatic.

While it is possible to catch RSV at any time of year, RSV is most common between late fall and early spring, around the same time period as flu season.

People of any age can catch RSV, but some demographics are at a higher risk for complications. “Infants and older adults, especially those older than 65, are at [higher] risk for RSV,” says Dr. Mandal. “Adults with chronic heart or lung disease or those that are immunocompromised are also at particular risk. RSV can sometimes worsen conditions for people with asthma, COPD, and congestive heart failure.”

Risk factors for RSV in a baby or young child include:

• Premature infants, particularly before the 29th week of pregnancy
• Low birth weight
• Younger than 12 weeks old during RSV season
• Chronic lung disease of prematurity
• Weak immune system (due to illness or treatment)
• Certain heart defects
• Having siblings (RSV can be passed from older children to babies and young children)
• Maternal smoking during pregnancy
• Exposure to secondhand smoke
• History of atopy (allergies/eczema)
• Not breastfeeding (breastfeeding passes antibodies from adult to baby/child)
• Regular exposure to higher numbers of people such as in a childcare setting or crowded living conditions

RSV symptoms

RSV generally appears like the common cold, especially in adults and older children. Though symptoms overlap with some hallmark signs of COVID-19, it doesn’t typically cause dry cough or loss of smell and taste. Symptoms of RSV include:

• Cough
• Very stuffy/runny nose
• Fever
• Decrease in appetite
• Generally feeling unwell
• Sore throat
• Mild headache

For most people, symptoms will not progress past this stage. For some babies and children, RSV can lead to more serious conditions, such as pneumonia (infection and inflammation of the air sacs in one or both lungs), bronchiolitis (mucus in the upper and lower airways), or apnea (stopping breathing).

More serious symptoms of a severe RSV infection to look for in babies and children, in addition to cold symptoms, include:

• Fast breathing
• Flaring of the nostrils
• Wheezing
• Head bobbing with breathing
• Rhythmic grunting during breathing
• Belly breathing, tugging between the ribs and/or tugging at the lower neck. (If the rib cage is “caving in” when the baby/child inhales, forming an upside-down “V” under the neck, they are having difficulty breathing.)
• Pauses in breathing

Should I seek medical care for a child with RSV?

Because RSV can resemble a common cold, it can be difficult to determine if a doctor’s appointment is necessary. Call your primary healthcare provider if your baby or child:

• Is younger than 6 months of age and has cold symptoms
• Is at high risk for RSV and has cold symptoms
• Has trouble eating, drinking, or sleeping
• Seems very sick or is very cranky
• Has a high fever (greater than 100.3 F if less than 4 weeks old, or greater than 100.9 F of more than 4 weeks old)
• Is too sleepy or not active
• Has a cough that gets worse or produces yellow, green, or grey mucus

RSV can become serious. “RSV is usually a mild or moderate disease that does not require hospitalization,” says Ashanti Woods, MD, a pediatrician at Mercy Medical Center in Baltimore. “However, in some cases, both moderate and severe cases can require hospitalization, sometimes even in the intensive care unit setting. If a child is having difficulty breathing, that child may need to have a tube inserted into their lungs to assist them with breathing. RSV can be quite serious and even life-threatening in some cases.”

Seek immediate/emergency medical attention if your baby or child:

• Is having trouble breathing, is breathing rapidly, or too slowly
• Has pauses in breathing
• Is very drowsy, lethargic, or has a significant decrease in activity and alertness
• Has lips, skin, tongue, or fingernails that look bluish or grayish in color
• Shows signs of dehydration (reduced urination, sunken soft spot on head, dry mouth, fewer tears while crying, etc.)
• Has symptoms of pneumonia or bronchiolitis (see list of serious symptoms above)
• If you believe the baby/child needs immediate medical attention

Thankfully, hospitalization for RSV is uncommon—only 3% of children with RSV will require a hospital stay, and most of those children go home within a few days. It is rare for a child to stay in the pediatric intensive care unit (PICU).

How is RSV diagnosed?

“RSV is usually a clinical diagnosis, meaning the physician or nurse practitioner gets a history from the patient and does an exam to make the diagnosis,” says Dr. Woods. “RSV can be detected through nasal washings, or collecting the mucus from one’s nose or throat and sending it to the lab to be tested.”
A healthcare provider may also do chest X-rays or other tests for conditions related to RSV. 

RSV treatment

Most RSV infections go away on their own, usually within one to two weeks.

“Treatment for RSV is primarily supportive, which includes frequent monitoring, and administration of fluid and respiratory support as needed,” Dr. Mandal says.

Ideally, hydration is given orally and rarely an IV is required. For babies and children older than 6 months, fever can be managed with over-the-counter medications such as Advil, Motrin (ibuprofen), or Tylenol (acetaminophen). Do NOT use aspirin, as it is linked to Reye’s syndrome in children with viral illnesses.

Other at-home treatments include:

• Using a cool mist humidifier (never use a warm or hot mist humidifier, which is a burn risk).
• Giving plenty of liquids (breast milk or formula only for babies under 6 months. Water or Pedialyte, in addition to breast milk or formula (if applicable), for babies and children over 6 months.)
• Loosening and removing nasal mucus in babies and children too young to blow their nose with saline (salt water) drops and a bulb syringe.

“There are a few instances where a breathing treatment may be given,” says Dr. Woods. “Medicines that are used for an asthma attack such as albuterol or steroids often are ineffective in the treatment of RSV, although they are sometimes used in cases where the patient is a known asthmatic.”

In more severe cases, breathing assistance such as oxygen may be given, or intubation (a tube inserted down the throat to the airway, with breathing assisted by a machine) may be necessary.

RSV prevention

RSV is highly contagious. Like the common cold, RSV spreads through droplets (saliva, mucus, nasal discharge) from person to person (via coughs, sneezes, spit), and from contact with RSV-contaminated surfaces. RSV can survive on surfaces such as toys and door knobs for up to six hours.

The best way to prevent the spread of RSV (and other communicable illnesses) is by practicing proper hygiene.

• Wash hands regularly and thoroughly with soap and warm water for at least 20 seconds, especially before touching babies, cooking, or eating, and after sneezing/coughing, or changing diapers. RSV can live on unwashed hands for at least 30 minutes.
• Clean and disinfect commonly used items regularly.
• Wash baby and children’s toys and clothes frequently.
• Do not share items like pacifiers, towels, cutlery, cups, etc.
• Discourage kissing the baby.
• Ensure your child and all family members are up-to-date on routine vaccinations, including annual flu vaccines.

Avoiding close contact with those who can spread RSV is also important, especially for those who are at higher risk.

• Keep those at higher risk away from anyone with cold-like symptoms
• Limit your baby’s exposure to crowds
• If possible, avoid childcare centers with lots of children for the baby’s first winter season

It is possible to catch RSV more than once, even within the same season, so these measures need to be taken with everyone, including healthy children and even children who have previously been infected with RSV.

“Currently there is no widely accepted antiviral for RSV once a patient has it,” Dr. Woods says. “There is a vaccine (Palivizumab) available for high-risk patients including children born extremely prematurely (usually 10 weeks or more before their due date) that is given early in RSV season to prevent them from getting it.” A healthcare provider can determine if this medication (multiple injections) is advised for specific patients as a preventative measure. There are very strict criteria for this treatment as it is very expensive and insurances use these criteria to determine coverage.

While RSV can be scary and should be taken very seriously, it’s comforting to know that for most children, it doesn’t constitute a crisis. Practice preventative measures to protect the most vulnerable among us, monitor those colds, and keep those hands clean!