RSV Prevention in Children

Nebulizer treatments are no longer a routine treatment for RSV.
Nebulizer treatments are no longer a routine treatment for RSV. Photo by Steve Debenport/Getty Images

The respiratory syncytial virus (RSV) is a common cause of infections in people of all ages. While it often just causes symptoms similar to the common cold in older children and adults, in infants and younger children, it can cause bronchiolitis, a more serious infection, associated with inflammation in the lungs, wheezing and difficulty breathing.

RSV can also cause croup, ear infections, and pneumonia.

RSV Season

RSV infections are seasonal, and in the United States, most infections begin in November or December and continue until March to May. So, the RSV season extends from November to May.

RSV infections are so common that about two-thirds of children are infected during their first year of life and almost all children have had an RSV infection by the time they are two years old. Most of these are mild infections, but RSV leads to about 125,000 Pediatric hospitalizations each year and 1-2% of these hospitalized children die.

Children usually develop symptoms about 2-8 days after being exposed to someone with an RSV infection (the incubation period). These symptoms initially include just a clear runny nose, but as the virus spreads, symptoms may worsen and may include coughing, vomiting, fever (which can range from low grade to very high), rapid breathing with retractions and nasal flaring, wheezing, and poor feeding. In severe cases, children may have apnea and respiratory failure.

Treating RSV Infections

Like most viral infections, treatment of RSV infections are usually symptomatic. In children with wheezing and difficulty breathing, nebulized treatments with albuterol were once thought to be helpful  but now aren't recommended.

Other treatments may include supplemental oxygen and intravenous fluids if your child is not able to eat and drink well. Treatment of bronchiolitis with steroids is controversial and is generally not thought to be helpful. Since it is a virus, treatment with antibiotics is also not usually helpful, unless your child develops a secondary bacterial infection.

Although most children with RSV infections can be safely treated at home, about 1% of children, especially younger infants or those with a chronic medical condition, need to be hospitalized and closely monitored. Occasionally, children with severe difficulty breathing and/or apnea need to be placed on a ventilator to help them breathe. RSV can also be fatal in some children.

Preventing RSV Infections

Children most at risk for serious complications of an RSV infection include premature infants with or without chronic lung disease and term infants with chronic lung disease. Fortunately, medications are available to prevent RSV infections in these high-risk patients.

RespiGam (RSV-IVIG) was licensed in 1996 to prevent RSV infections in high-risk patients. It is available as a monthly intravenous infusion and provides children with antibodies against RSV and some other respiratory viruses to give protection against getting infected.

Synagis (palivizumab), a monoclonal antibody against RSV, became available a few years later, in 1998.

Although it is also given monthly, Synagis is available as an intramuscular injection. And unlike RespiGam, Synagis is not a blood product and won't interfere with your child's immunizations (children can't receive the MMR or chickenpox vaccine until after 9 months of finishing their RespiGam infusions).

The American Academy of Pediatrics updated their guidelines for which children should receive RSV prophylaxis with Synagis in the 2014. While premature infants who premature infants who were born between 32-35 weeks and who are less than three months old at the start of RSV season and who have at least one risk factors could once qualify for Synagis, the latest recommendations are that Synagis is recommended for:

  • Premature infants who were born at less than 29 weeks and who are less than twelve months old at the start of RSV season (typically October to March).
  • Certain infants with hemodynamically significant heart disease who are less than twelve months old at the start of RSV season, especially children with acyanotic heart disease who are receiving medication to control congestive heart failure and will require cardiac surgical procedures and infants with moderate to severe pulmonary hypertension.
  • Premature infants with chronic lung disease, who were born at less than 32 weeks, who are less than twelve months old at the start of RSV season, and had a requirement for > 21% oxygen for at least 28 days after birth.
  • Children less than two years of age who are profoundly immunocompromised during RSV season.
  • Certain children who are younger than two years with chronic lung disease who continue to require supplemental oxygen, chronic corticosteroids, or diuretic therapy, etc.
  • Certain infants with pulmonary abnormalities or neuromuscular disease that impairs their ability to clear secretions from their upper airways who are less than twelve months old at the start of RSV season.

    Since RSV infections are so common and the symptoms can be so severe, why doesn't everyone get Synagis? One of the reasons is that it is the youngest infants, especially if they were born premature, are most at risk of the serious complications of RSV infections. The other reason is the cost. Synagis injections cost about $900 a month and require a monthly injection during RSV season.

    Mostly it is because many studies find that there is "limited clinical benefit derived from palivizumab prophylaxis." Still, it is better than nothing until we get a true RSV vaccine.

    Getting Synagis Shots

    Where do you get Synagis injections?

    In our area, Synagis is usually available from our local Pediatric Pulmonologists (lung specialists), or from Synagis clinics at local major hospitals, especially those with a large Neonatal Intensive Care Unit. If you have a preemie that is going to be discharged around RSV season, then your doctors will likely talk to you about Synagis before your discharge and will likely give the first shot before you are sent home.

    Children usually get a total of five shots to last them through RSV season.

    Whether or not your child is at high risk of having complications from an RSV infection, there are other ways to lessen the chances that your child will get infected. These include:

    • teaching your children and care providers to practice frequent handwashing, especially after using the bathroom (including diaper changes) and before eating. You should also frequently wash toys and other objects that your children put in their mouth and all other surfaces and dispose of tissues after wiping or blowing your child's nose.
    • avoiding close contact with other people who are sick. Make sure that your daycare has a strict policy about excluding children with contagious illnesses. and don't let anyone smoke around your baby. If you do smoke, simply smoking outside is usually not enough to decrease your child's risk of problems.

    Talk to your pediatrician if you think that your baby needs Synagis or if you are worried about RSV.

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    Article Sources

    • American Academy of Pediatrics Policy Statement. Updated Guidance for Palivizumab Prophylaxis Among Infants and Young Children at Increased Risk of Hospitalization for Respiratory Syncytial Virus Infection. PEDIATRICS Volume 134, Number 2, August 2014.