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                     Respiratory syncytial virus (RSV)

What is RSV?

• RSV is a highly contagious virus that can cause both an upper respiratory illness (a cold) and a lower respiratory illness (bronchiolitis) in infants and children.
  
  
• Approximately 70% of all bronchiolitis cases are attributed to RSV (1).
  
  
• As a child gets older or has repeated RSV infections involvement of the lower respiratory tract is less likely; school-aged children with RSV usually just have a cold.
  
  
• Approximately two-thirds of all infants are infected with RSV during the first year of life and almost 90% by the age of two (2).
  
  
• RSV infections are the leading cause of hospitalization for infants (3).
  
  
• RSV occurs typically in late fall until early to late spring.

Children that are most at risk of serious complications from RSV include:

• Premature infants (less than 35 weeks)
  
• Infants with one of the following:
  
  §  chronic lung disease or bronchopulmonary dysplasia (BPD)
  §  immune system problems
  §  neuromuscular disorders
  §  cystic fibrosis
  §  congenital heart disease
  
  

How does a child get RSV?

• As with many upper respiratory tract infections, viruses are spread by respiratory droplets from an infected person’s nose or mouth.
  
  
• The droplets can spread through the air directly onto another person, or may land or be placed on another surface, which is then touched by another person. If that person then touches his eyes or mouth, he can become infected.

How long will it take my child to become ill after being exposed to someone else with RSV?

• Remember, just because your child is exposed to an ill person does not necessarily mean they too will become ill.
  
  
• But if your child is to become ill, it usually takes 2 – 4 days after being exposed to someone with RSV.

What are the signs and symptoms of RSV?

• An infant or child with RSV usually begins to have the symptoms of a common cold, with a runny nose, mild cough and maybe a mild fever.
  
  
• Over the next few days the cough may worsen and in 1/3 of cases children may develop wheezing and difficulty breathing (bronchiolitis). 

How can RSV be diagnosed?

• RSV can be detected in a very short period of time by testing your child’s nasal secretions.

What is the treatment for RSV?

• Plenty of rest and fluids
  
  
• Acetaminophen (Tylenol) or ibuprofen (Advil, Motrin) for discomfort or fever
  
  
• Antibiotics, which treat bacteria, are not helpful for RSV
  
  
• To unstuff your babys or toddlers nose before bed, put a drop of saline nose drops in each nostril, then suction with a bulb syringe.
  
  
• A cool-mist humidifier in your childs room may keep their nasal secretions moist and help loosen mucus.
  
  
• Feed your baby smaller amounts, but more frequently. Also, suction your baby before feeds.
  
  
• A minority of infants (1 in 7) have a transient modest improvement with the use of a bronchodilator such as albuterol (4). The American Academy of Pediatrics (AAP) stance is that the use of a bronchodilator is a treatment option; however, only when there is a positive response documented following their use.
  
  
• The antiviral medication, ribavirin, may be used in the treatment of hospitalized infants and young children with severe lower respiratory tract infection due to RSV.

How long will my child be sick with RSV?

• This depends on several factors including age of the child, whether or not the child’s illness includes the lower respiratory tract (the lungs), and how strong the child’s immune system is at the time of the illness.
  
  
• Full recovery from RSV may take up to 1 – 2 weeks. The average duration of cough in infants with bronchiolitis in one study was 12 days, with almost 20% coughing intermittently at 3 weeks (5).

When can my child return to daycare or school?

• For RSV, it will depend on how quickly your child’s symptoms go away, especially their fever and trouble breathing.

When should I call my pediatrician concerning RSV in my child?

• It is best to call your pediatrician for specific instructions when you first suspect that your child has an illness resembling RSV.
  
  
• You should also call your doctor if the fever last for more than 2 –3 days or your child is having breathing problems (nostrils flaring, you see tugging between the ribs when breathing, blue lips).

How can RSV be prevented?

• Frequent hand washing is recommended to decrease the chance of becoming infected. Click on how to prevent infection for more details.
  
  
• Although there is no cure or vaccine for RSV, it is possible to prevent infection in high risk children by giving them antibodies against RSV.
  
  
• Currently, palivizumab (Synagis) and RSV-IGIV (Intravenous Gamma Globulin) are the only FDA approved medications for the reducing the risk of getting RSV disease in children at high-risk of RSV complications.
  

Palivizumab is given as a monthly injection at the start of and during RSV season.

• In general, 4 subsequent monthly doses (total of 5 doses) are sufficient to provide protection throughout the RSV season.  
  
  
• The length of active RSV season can vary and additional doses may be recommended. 
  
  
• Summarized below are the American Academy of Pediatrics recommendations for the use of palivizumab:

1. Children < 2 years of age with significant Congenital Heart Disease (CHD)
   
   
2. Children < 2 years of age with Chronic Lung Disease who have required medical therapy (supplemental oxygen, bronchodilator, diuretic or corticosteroid therapy) within 6 months of the start of the RSV season.
   
   
3. Infants < 28 weeks gestation who are less than one year of age at the time of the initial injection. 
   
   
4. Infants 29 - 32 weeks gestation who are less than 6 months of age at the time of the initial injection. 
   
   
5. Infants born between 32 and 35 weeks of gestation and who are less than 6 months of age at the time of the initial injection should have at least two of the following risk factors before being considered for treatment with either palivizumab or RSV-IGIV:

                    o  attend child care (CDC definition:  being with 2 or more
                        children for >4 hours/week)
                    o  school-aged siblings
                    o  exposure to environmental air pollutants
                    o  congenital abnormalities of the airways  
                    o  severe neuromuscular disease

References

1. Kahn JS: Epidemiology of human metapneumovirus. Clin Microbiol Rev 2006;19:546.
2. Subcommittee on Diagnosis and Management of Bronchiolitis. Pediatrics 2006;118:1774.
3. Leader S. Recent trends in severe RSV among US infants, 1997 to 2000. J Peds 2003;143:S127.
4. Gadomski AM: Bronchodilators for bronchiolitis. Cochrane Database Syst Rev 2006 (3);CD001266.
5. Swingler GH: Duration of illness in ambulatory children diagnosed with bronchiolitis. Arch Pediatr Adolesc Med 2000;154:997.