RESPIRATORY SYNCYTIAL VIRUS (RSV)

One of our Arizona neighbors recently shared with us that her daughter and son-in-law, had just welcomed a new baby to the family. She was born two months ago, but the grandparents had been told they couldn’t see her. The family lives in another state so getting there involved travel and expense they didn’t want to risk spending unnecessarily, so they reluctantly complied with the parents’ wishes. The first question I asked was, “Why are you being denied the chance to see your granddaughter?” Their answer was the parents were trying to avoid exposing the child to respiratory illness. 

As far as I know, the baby was not premature, had normal birth weight, didn’t have any delivery complications, and had a normal newborn exam. The reason for the parents’ concern was the  baby’s pediatrician had insisted she be isolated for the first four months of life to prevent exposure to anyone who might be ill or who might have Respiratory Syncytial Virus (RSV). That included grandparents who definitely wanted to see their new grandchild and hold her in their arms. What a disappointment!

I had never heard of a doctor recommending this to new parents except in situations where the baby’s immune system was severely compromised, it was severely premature, or the child needed isolation for another reason. There are, however, some parents who have a great deal of anxiety about their infant getting sick so they self-quarantine the child. I can see this to a degree, but to deny the grandparents access to the newborn is a bit much. Whatever happened to gowns and masks?

RSV (full name above) is the most common respiratory infection in children five years and younger and may be these parents’ concern. Like most respiratory illnesses, it is spread through droplets in the air that come from other children, or adults, sick with the virus. After exposure, there is a 4-6 day incubation period before symptoms develop. The symptoms are cough, poor oral intake, runny nose, congestion, fever, and of greatest concern, rapid, labored breathing. Some infants will wheeze. The younger the child, the more severe are the symptoms. 

RSV and croup (Laryngotracheobronchitis) both affect infants, are caused by viruses, and  cause difficulty breathing. Both are diagnosed by clinical presentation—the symptoms they cause are easily recognizable. However, they differ in the location where breathing troubles originate. RSV attacks the bronchioles, the much smaller bronchial airways, while croup affects the upper trachea and larynx (voice box). RSV causes “bronchiolitis,” while croup causes swelling and obstruction of the upper airway and inspiratory stridor. One form of croup is the life-threatening, bacterial infection of the epiglottis, the cartilage flap that covers the windpipe during swallowing. Called epiglotitis, it causes severely restricted breathing occasionally requiring tracheotomy. 

I actually saw more patients with croup than RSV, and worried more about croupers than I did about RSV babies. But viruses make babies very sick. The clinical differences are obvious to the trained physician. Croup causes upper airway swelling so babies have stridor, or trouble getting air through the opening of the windpipe. Kids with RSV have rapid, short, labored breathing and often wheeze because the small airways were swollen. These differences lead to different treatments. 

RSV can be prevented by avoiding contact with sick individuals as was noted in the case cited here. Hand washing and careful hygiene are important, too. There is a vaccine for RSV, but it’s recommended for adults over age 60. A single-dose experimental injection given to pregnant patients to prevent RSV in newborns is in clinical trials. It appears to be 81.8% effective up to 90 days of life and 69.4% effective up to 180 days. Recently, the CDC began recommending a monoclonal antibody, nirsevimab, for preventing lower respiratory tract disease, ie. RSV, in newborns and infants below 8 months of age born during their first RSV season. 8-19 month olds susceptible to RSV are prime candidates, too. RSV season is typically from November through March so it’s hoped this drug will be available for widespread use by this Fall.

RSV is treated aggressively with oxygen, IV fluids, and nutrition. Worse cases require chest physiotherapy, inhaled, nebulized epinephrine, or even IV steroids. Inhaled steroids are helpful, too. The usual course of the disease is for it to get better on its own after a week or two, but infants with RSV infection have a three times greater chance of having asthma later in childhood. In the U.S., an estimated 2.9 cases of RSV per 1000 children per year are hospitalized.  

Dr. G’s Opinion: infants infected with Respiratory Syncytial Virus can be very frightening. A little baby lying on his/her back, breathing rapidly, wheezing, and coughing gets the doctor’s heart rate going and stirs anxiety. Bronchiolitis (RSV) and croup are two diseases that always worried me. Perhaps soon there will be a vaccine to prevent newborn RSV. It sounds like it may be coming. Unfortunately, it will come too late for my neighbors to see their grandchild.

Reference: Oppenlander KE, Chung AA. Respiratory Syncytial Virus Bronchiolitis: Rapid Evidence Review Am Fam Phys 2023 July;108(1):52-57.

AAFP Family Medicine Today 2023 August 4.