Winter is upon us, and it is proving to be a “robust” flu season. Mrs. X brought her 4 month old daughter, Allie, to the office for a sick visit and she told the nurses she was afraid that Allie might have the flu. She had a low grade fever, congestion and a hacky cough for the past 2 days. Two of Allie’s cousins were just diagnosed with the flu and they were together over the past weekend.

 

As the nurse put Allie in a room, she did a nasal swab that would check for influenza A and B. When I entered the room, Allie was sitting in mom’s lap and clearly had an upper respiratory tract infection of some sort. She had weepy eyes, a thick cloudy runny nose, and a harsh, hacky cough. Her temperature was 99.2 degrees and she was breathing a bit fast at 36 respirations per minute. Mrs X told me that this started about 2 days ago and that it progressively worsened over the past 24 hours. Allie was eating “OK”, but her overall intake had decreased significantly. I was pleased to know that her urine output was normal which meant that she was not dehydrated.

 

On my exam, Allie did not appear toxic or ill-appearing, although she did look miserable. I could get her to smile and interact which was most re-assuring.

 

Her ear drums were normal and she did have a red throat. She was breathing a bit fast and her lungs had coarse crackles throughout. I did not hear any wheezing. While I was finishing my exam, the nurse knocked on the door and showed me the results of the flu test and it was negative for influenza A and B. Mom let out a sigh of relief, but was stunned when I asked the nurse to swab her nose for RSV. “You don’t think she could have RSV do you” she asked. “I’ve heard horror stories about RSV,” she went on to say as she had tears in her eyes.

 

When the test came back positive for RSV, mom seemed very distressed so I told her we needed to discuss RSV to help put her mind at ease. RSV is a very common viral illness that occurs every winter. We refer to this as “RSV season” and pediatric hospitals always plan for this well in advance. RSV causes an upper respiratory tract infection known as bronchiolitis. Bronchiolitis refers to inflammation of the smaller bronchioles in the lungs which can lead to a persistent hacking cough and often times actual wheezing. In addition, RSV may cause fever, congestion, copious nasal secretions and a decreased appetite. RSV is very common, and virtually every child by the age of 2 years has been infected with RSV at least once. Every winter, 57,000 children under 5 years of age are hospitalized with RSV. Around 3 out of 100 infants with RSV under the age of 6 months are hospitalized with RSV.

 

Infants who are at risk for a more severe case of RSV are premature infants, infants with heart defects, infants with chronic lung disease and infants with immune deficiencies. Adults can be infected with RSV but it is more likely to cause mild cold-like symptoms. The virus is spread through secretions from the upper respiratory tract and it is highly contagious. The virus can survive for hours on tables and crib rails so good hand washing is critical to prevent its spread.

 

RSV lasts for a week to 10 days and usually peaks at around day 3-4. Most babies are contagious for 8-10 days. As RSV is a virus, it does not respond to antibiotics and the treatment is primarily supportive. Parents should elevate the head of the crib to around 20 degrees, should run a cool mist humidifier in the room to prevent the secretions from drying out and can suction the nose of mucus to allow the baby to breathe easier. I always instruct parents to suction only what they can see, because too frequent suctioning may irritate the nose and be of no benefit. If there is fever above 100.5 degrees, they can give Tylenol to make the baby more comfortable. If the baby is not eating as much as usual, it is important to be sure that the urine output is good which means that the baby is sufficiently hydrated.

 

Babies with RSV are admitted to the hospital for various reasons. If their oxygenation is low, they may need to be admitted for supplemental oxygen which is usually given through a nasal cannula and this is titrated down as the baby improves. If the baby is not taking enough fluids, they may need IV fluids. The nurses will suction the nose to clear the mucus and quite often they will need to “deep suction” the nose which means they pass a thin catheter through the nose into the back of the throat to clear any deep secretions. This is something that cannot be done at home. When I admit a baby to the hospital for RSV, I tell the parents that their baby will be ready to go home when we know that 1) the illness has peaked and the baby is getting better 2) the baby doesn’t need supplemental oxygen 3) the nurse doesn’t need to do any deep suctioning 4) the baby is eating well…basically the baby can demonstrate that he/she can do everything that she will need to do at home. This can take anywhere from 1-4 days and it just depends on the individual case.

 

Some babies, usually those under a few months of age may have a more severe case of RSV where they have increased work of breathing where the concern is that they may tire out, or they may need extra oxygen and these babies may need to be closely monitored in the intensive care unit until they turn they improve enough to go back to the regular floor.

 

I told Mrs X that Allie actually looked good for having RSV and since this was going into day 3 of her illness, I didn’t expect her to get much worse. We discussed the things that she should do for Allie at home, and for peace of mind I asked mom to call the office at the end of the day with a phone update, and I made a follow-up appointment for the next day.