RSV Archives - Keep Kids Healthy

Are We Going to See a Summer Surge of RSV This Year?

Folks need to understand that RSV might still be coming. If not in the next few months, then maybe this summer. And if there is no summer surge of RSV, then it will likely be back even worse next year.

A summer surge of RSV?

I know, it sounds ridiculous, right?

After all, in a typical year, RSV season begins in September or October and peaks in December or January.

Of course, this hasn’t been a typical year…

Are We Going to See a Summer Surge of RSV This Year?

Except for COVID-19, rhinovirus, enterovirus, and some adenovirus, we haven’t seen most of the seasonal viral outbreaks that we typically see each year.

There hasn't been any RSV in Texas this year. — There hasn’t been any RSV in Texas this year.

There was no RSV, flu, or seasonal coronavirus, etc.

Not that anyone has been complaining…

It was one of the bright spots that came out of all of the social distancing, mask wearing, and travel restrictions to control the COVID-19 pandemic!

So why would anyone think that we might see a summer surge of RSV?!?

The news that folks in Australia started getting hit with RSV a few months ago, when it was still summertime!

Remember, Australia is in the Southern Hemisphere and their summer runs from December to February and their autumn from March to May.

What caused the summer surge of RSV in Australia?

An unexpected surge that is also being reported in South Africa…

“Recent reports from Australia described an inter-seasonal RSV epidemic in Australian children following the reduction of COVID-19–related public health measures from September 2020 to January 2021.”
Delayed Start of the Respiratory Syncytial Virus Epidemic at the End of the 20/21 Northern Hemisphere Winter Season, Lyon, France

Is it because they got their COVID-19 cases under good control early and relaxed many of their COVID-19 related public health measures, including eliminating mandates to wear masks and most restrictions on public gathering, and allowed kids to go back to school?

Whatever the reason for the surge, what is most troubling is that we may not have to wait until this summer for our own surge!

“In 2020, the first RSV cases of the 20/21 season were detected in Lyon at week 46 and 47 (Figure 1) at the same time of the southern hemisphere outbreak. A sustained detection of cases was observed from week 51, which is the expected time of the epidemic peak, to week 5. On week 6, the RSV epidemic was declared in the first French region (Ile de France) while the number of RSV cases has continued to increase in the Lyon population.”
Delayed Start of the Respiratory Syncytial Virus Epidemic at the End of the 20/21 Northern Hemisphere Winter Season, Lyon, France

France is seeing RSV too – with a 4 month delay to the start of their season. And they haven’t relaxed their physical distancing recommendations as much as Australia, as they were still seeing cases of COVID-19.

And as if all of that wasn’t enough, the summer surge of RSV in Australia is at rates that are much higher than is seen in a typical RSV season!

Wasn’t that expected?

“Our results suggest that a buildup of susceptibility during these control periods may result in large outbreaks in the coming years.”
The impact of COVID-19 nonpharmaceutical interventions on the future dynamics of endemic infections

While larger future outbreaks have been expected, most people likely thought they would start with next year’s season.

“Our findings raise concerns for RSV control in the Northern Hemisphere, where a shortened season was experienced last winter. The eventual reduction of COVID-19–related public health measures may herald a significant rise in RSV. Depending on the timing, the accompanying morbidity and mortality, especially in older adults, may overburden already strained healthcare systems.”
The Interseasonal Resurgence of Respiratory Syncytial Virus in Australian Children Following the Reduction of Coronavirus Disease 2019–Related Public Health Measures

I’m not sure anyone is ready for RSV and COVID-19 at the same time. That’s not the Twindemic folks were warning us about!

But maybe we should get ready to start seeing some RSV.

March is typically close to the end of RSV season, not the beginning.

After all, rates of RSV are starting to increase in Florida and the South Atlantic division of the United States.

While there is no way to know if we will see this trend in other states and we may just be delaying when RSV season starts anyway, parents should know that we can always protect those who are most at risk from severe RSV disease.

“Ideally, people with cold-like symptoms should not interact with children at high risk for severe RSV disease, including premature infants, children younger than 2 years of age with chronic lung or heart conditions, and children with weakened immune systems.”
RSV Prevention

At some point, we might even have to consider changing when Synagis, the monthly shot that can help prevent RSV, is given. Should we continue giving Synagis to high risk infants this Spring and Summer, for example, instead of stopping in March?

Mostly, folks need to understand that RSV might be coming. If not in the next few months, then maybe this summer. And if not this summer, then it will likely be back with an even worse next year.

Can Your Sick Child Still Go to Daycare or School?

Is your child to sick to go to school or daycare?

There are a lot of different rules that dictate when kids can go to daycare or school when they are sick.

Kids don't always have to stay at home from daycare or school when they are sick. — Kids don’t always have to stay home from daycare or school when they are sick.

The actual rules of your daycare or school are the ones that you are likely most familiar with, but there are also recommendations from the American Academy of Pediatrics and the CDC, in addition to state-specific regulations.

Can Your Sick Child Still Go to Daycare or School?

Most people know to stay home when they are sick.

“Stay home when you are sick. If possible, stay home from work, school, and errands when you are sick. You will help prevent others from catching your illness. Avoid close contact with people who are sick.”

CDC on Information for Schools & Childcare Providers

But what exactly does it mean to be “sick” and how long are you supposed to stay home and avoid other people?

“Most minor illnesses do not constitute a reason for excluding a child from child care, unless the illness prevents the child from participating in normal activities, as determined by the child care staff, or the illness requires a need for care that is greater than staff can provide.”

Recommendations for Inclusion or Exclusion (Red Book)

In general, your child does not need to be kept home and out of daycare or school if they are able to participate in routine activities, do not need extra care, and have:

a cold (unless they have a fever) or other upper respiratory infection, even if they have a green or yellow runny nose
RSV (unless they have a fever)
croup (unless they have a fever)
diarrhea that can be contained in a diaper or the child can make it to the bathroom without having an accident, as long as they aren’t having more than 2 stools above their usual or stools that contain blood or mucus
a rash without fever – most skin rashes won’t keep your kids out of school, like if they have poison ivy, hives, or even molluscum contagiosum and warts
Fifth disease – interestingly, you aren’t contagious once you have the characteristic Fifth disease rash
head lice – why not keep kids out of school if they have lice? It doesn’t stop them from spreading. They can get them treated at the end of the day.
pinworms – like lice, keeping kids out of school with pinworms isn’t going to stop them from spreading, although kids should be treated
pink eye – if caused by an infection, in general, should be able to stay or return if is improving, but keep in mind that most experts now think that kids with pink eye do not need to be excluded from daycare or school at all
oral lesions and are able to contain their drool (unless they have a fever), which would include hand foot mouth disease
skin lesions that can be covered, and if they can’t, then they can return after they have been on antibiotics for 24 hours (impetigo) or have started treatment (ringworm)
strep throat and have been fever free and on antibiotics for 24 hours
scabies – if you have started treatment
a sore throat (unless they have a fever)

Why don’t you have to keep your kids home when they have RSV or many of these other common childhood diseases?

In addition to the fact that some kids would never get to go to daycare or school, since these diseases are so common, many kids continue to be contagious even after their symptoms have gone away. So excluding them doesn’t really keep the illnesses from spreading through the daycare or school.

So why not just send them when they have a fever or really don’t feel well?

In addition to the possibility that they might be a little more contagious at those times, it is because the typical daycare or school isn’t able to provide the one-on-one care that your child would likely need when feeling that sick, as your child probably isn’t going to want to participate in typical group activities.

Policies that are overly strict at excluding children from daycare and school may also lead to antibiotic overuse, as parents rush their kids to the doctor for and push for a quick cure because they need to go back to work.

Exclusion Criteria for Vaccine Preventable Diseases

While the exclusion criteria for many diseases simply extends to when your child is fever free, starts treatment, or feels well enough to return to daycare or school, for many now vaccine-preventable diseases, you will be excluded (quarantined) for much longer:

hepatitis A virus infection – exclusion for one week after illness starts
measles – exclusion until four days after start of rash
mumps – exclusion until five days after start of parotid gland swelling
pertussis – exclusion until completes five days of antibiotics or has had cough for at least 21 days
rubella – exclusion until seven days after start of rash
chicken pox – exclusion until all lesions have crusted
diphtheria – if survives having respiratory diphtheria, would likely be excluded until finishes treatment and has two negative cultures at least 24 hours apart
rotavirus – as with other diseases that causes diarrhea, children should be excluded until “stool frequency becomes no more than 2 stools above that child’s normal frequency” as diarrhea is contained in the child’s diaper or they aren’t having accidents
tetanus – if survives having tetanus, wouldn’t be excluded, as tetanus is not contagious

Unfortunately, kids are often contagious with many of these diseases, especially measles and chicken pox, even before they have obvious symptoms, which is why large outbreaks used to be so common.

Children will often be excluded from daycare or school if they are unvaccinated or not completely vaccinated and they are exposed to a vaccine-preventable disease.

Does Your Child Need an RSV Test?

It is hard to avoid RSV season, but a lot easier than you think to avoid an RSV test.

A lot has changed since this Kansas City RSV outbreak back in 2013.

Your toddler has a cough and runny nose and there is a notice that RSV is going around at daycare…

Do you need to rush to your pediatrician?

Does your child need an RSV test?

Like many things, it depends on who you ask.

For example, the folks at your child’s daycare might push for a visit and an RSV test, thinking it will help them keep the virus from spreading to other kids.

It won’t.

Does Your Child Need an RSV Test?

If an RSV test is available, why not do it?

“Our study showed that a simple nasal swab, while less painful for infants than NPA, failed to detect about one third of cases that were RSV positive by nasopharyngeal aspirate.”

Macfarlane et al on RSV testing in bronchiolitis: which nasal sampling method is best?

For one thing, the test isn’t that accurate, especially when done with a nasal swab, the most commonly used method. And while less invasive than a nasopharyngeal aspirate, if done correctly, sticking a nasal swab up your child’s nose, rotating it around a few times, and then getting a sample isn’t exactly something kids enjoy.

Mostly though, since there is no treatment for RSV, what are you going to do with those test results, whether or not they are positive?

Remember, RSV is a very common respiratory virus that can cause a cold, bronchiolitis, or pneumonia. But testing positive for RSV doesn’t mean that your child has bronchiolitis or pneumonia. Those are typically diagnosed clinically, based on the signs and symptoms that your child has, such as wheezing and trouble breathing.

Similarly, testing negative for RSV doesn’t mean that your child doesn’t have bronchiolitis or pneumonia.

“Clinicians should diagnose bronchiolitis and assess disease severity on the basis of history and physical exam.

When clinicians diagnose bronchiolitis on the basis of history and physical examination, radiographic or laboratory studies should not be obtained routinely.”

AAP on the Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis

Is there ever a role for RSV testing?

RSV testing might be a good idea when an infant has apnea or other uncommon symptoms.

And if a child is getting monthly Synagis injections and has a suspected case of RSV, it is a good idea to confirm that they actually have RSV.

Why?

If they really do, then you can stop getting Synagis injections, as they are unlikely to get RSV again in the same season.

“In the event an infant receiving monthly prophylaxis is hospitalized with bronchiolitis, testing should performed to determine if RSV is the etiologic agent. If a breakthrough RSV infection is determined to be present based on antigen detection or other assay, monthly palivizumab prophylaxis should be discontinued because of the very low likelihood of a second RSV infection in the same year. Apart from this setting, routine virologic testing is not recommended.”

AAP on the Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis

That’s pretty clear.

The American Academy of Pediatrics guidelines say that routine RSV testing is not recommended.

Need another good reason to avoid routine RSV testing?

Do you know how long kids with RSV shed the virus or can test positive after having an RSV infection?

“People infected with RSV are usually contagious for 3 to 8 days. However, some infants, and people with weakened immune systems, can continue to spread the virus even after they stop showing symptoms, for as long as 4 weeks.”

CDC on RSV Transmission

Apparently, it is a long time, which means that your child might have a new respiratory infection, but still test positive for RSV because they had it a month ago.

You might actually be “diagnosing” an old infection and not the virus that is causing your child’s current symptoms.

Do you still want an RSV test anyway? Talk to your pediatrician.

Did someone order an RSV test, but you are now wondering if it was necessary? Talk to your pediatrician.

Remember that an RSV test won’t change your child’s treatment (breathing treatments and steroids are no longer routinely recommended when infants have RSV), won’t help predict how sick your child might get, and won’t tell you if your child can return to daycare.

What To Know About RSV Tests

You likely won’t be able to avoid RSV season, especially if your kids are in daycare, but you can avoid RSV testing season.

It’s Not Always the Flu When You Get Sick During Cold and Flu Season

Flu isn’t the only virus that is going around during cold and flu season. Many others can cause flu-like illnesses, croup, bronchiolitis, or just a cold.

We hear a lot about flu season.

It typically starts in late fall, peaks in mid-to-late winter, and can continue through early spring.

Cold and Flu Season Viruses

It’s important to understand that a lot more is going on, and going around, during flu season than just the flu.

That’s why it is likely more appropriate to think of flu season as just a part of the overall cold and flu season that we see during the late fall to early spring.

During cold and flu season, in addition to the multiple strains of the flu, we see diseases caused by:

respiratory adenovirus – can cause bronchitis, colds, croup, viral pneumonia, pink eye, and diarrhea
Human metapneumovirus (HMPV) – can cause bronchiolitis, colds, and viral pneumonia
Human parainfluenza viruses (HPIVs) – can cause bronchiolitis, bronchitis, colds, croup, or viral pneumonia
rhinovirus – the classic common cold
Respiratory syncytial virus (RSV) – can cause wheezing and bronchiolitis in younger children, but colds in older kids and adults
seasonal coronavirus – can cause colds, bronchitis, and viral pneumonia
norovirus – diarrhea and vomiting
rotavirus – diarrhea and vomiting, was much more common in the pre-vaccine era

That there are so many different respiratory viruses that can cause bronchiolitis, colds, croup, and flu-like illnesses helps explain why some kids get sick so many times during cold and flu season.

It also helps explain why some folks think they might have gotten the flu despite having been vaccinated, especially in a year when the flu vaccine is very effective.

Is It a Cold or the Flu?

So how do you know if you have the flu or one of these flu viruses during cold and flu season?

Signs and symptoms of the flu vs a cold.

While the symptoms can be similar, flu symptoms are usually more severe and come on more suddenly.

Can’t you just get a flu test?

While rapid flu tests are fast and easy to do, they are likely not as accurate as you think.

“This variation in ability to detect viruses can result in some people who are infected with the flu having a negative rapid test result. (This situation is called a false negative test result.) Despite a negative rapid test result, your health care provider may diagnose you with flu based on your symptoms and their clinical judgment.”

CDC on Diagnosing Flu

If your pediatrician is going to diagnose your child with the flu because of their symptoms, even if they have a negative flu test, then why do the test?

Rapid flu tests are usually invalid if they are positive for A and B, but many folks are told that they have both. — Rapid flu tests are usually invalid if they are positive for A and B, but many folks are told that they have both flu virus strains.

Can you test for all of the other viruses that are going around during cold and flu season?

Tests can be done to detect most cold and flu viruses.

Sure.

The real question is should you.

Like the rapid flu test, many pediatricians can do an RSV test in their office. But like many other viruses, there is no treatment for RSV and the American Academy of Pediatrics actually recommends against routine RSV testing. Whether your child’s test is positive or negative, it is not going to change how he or she is treated.

And the other viruses? Not surprisingly, there are respiratory panels that can test for most or all of these viruses. They also usually include flu and RSV.

The problem with these tests is cost. They are not inexpensive, and again, in most cases, the results aren’t going to change how your pediatrician treats your child.

And they all involve sticking a nasal swab far up your child’s nose…

What About Strep?

While strep throat can occur year round, it does seem to be more common in the winter and spring.

And while you can certainly have two different infections at the same time, such as strep throat and the flu, it is important to remember that the rate of strep throat carriers is fairly high. These are kids who regularly test positive for strep, even though they don’t have an active group A strep infection.

During cold and flu season, if kids routinely get a “strep/flu” combo test, it is possible, or even likely, that many of the positive strep tests are simply catching these carriers.

Remember that a cough, runny nose, hoarse voice, and pink eye are not typical symptoms of strep throat and are more commonly caused by cold viruses. Adenovirus is especially notorious for causing a sore throat, fever, pink eye, runny nose, with swollen lymph nodes = pharyngoconjunctival fever.

Kids who are likely to have strep throat usually have a sore throat, with red and swollen tonsils, and may have swollen lymph nodes, fever, stomach pain, and vomiting, but won’t have typical cold symptoms.

Why does it matter?

Viral causes of a sore throat don’t need antibiotics, while a true strep infection does.

And remember that none of the other cold and flu viruses need antibiotics either, unless your child gets worse and develops a secondary bacterial infection.

What to Know About Cold and Flu Season Viruses

Flu isn’t the only virus that is going around during cold and flu season. Many others can cause flu-like illnesses, croup, bronchiolitis, or just a cold.

Treating Hard to Control RSV

RSV is never really easy to control for infants and toddlers, as there is no treatment or cure, but fortunately, most kids do not have severe symptoms that require hospitalizations.

With a cough, wheezing, and trouble breathing that can linger for weeks, all RSV infections probably seem like they are hard to control, especially since up to 2% of kids, mostly high-risk infants, with RSV require hospitalization.

Still, it’s important to remember that for many kids, RSV is just a cold.

Understanding RSV

Since there is no cure or treatment, it is best to learn to protect your kids from RSV.

The first thing to understand about RSV is that it isn’t a disease.

Instead, RSV, or the respiratory syncytial virus, can cause many different kinds of upper and lower respiratory infections, ranging from the common cold and croup to bronchiolitis and viral pneumonia.

And almost all kids get sick with RSV at some point during the first few years of their life, especially if they are in daycare.

Fortunately, although RSV can cause life-threatening infections, especially in high-risk infants, the great majority of children get over their symptoms without any special treatments.

And infants who are the most high risk, including premature babies who were born at less than 29 weeks, can get five monthly doses of palivizumab (Synagis) during RSV reason to reduce their chances of getting sick. Infants with hemodynamically significant heart disease or chronic lung disease of prematurity can also get palivizumab.

Treating RSV

Many of the classic treatments for RSV have now fallen out of favor with pediatricians. In fact, the American Academy of Pediatricians now advises against using albuterol breathing treatments, epinephrine, steroids, or chest physiotherapy (CPT) for infants with RSV bronchiolitis.

What’s left?

Not much, except pushing your child to drink and treating cold symptoms as possible.

The AAP even advises against routinely testing kids for RSV. That makes sense, since there is no treatment, kids can sometimes be contagious for 3 to 4 weeks, long after they have returned to daycare without symptoms, and other viruses can cause similar symptoms.

Instead, if your child has symptoms of RSV, especially if she was around someone else with RSV symptoms about two to eight days ago or is simply in daycare during RSV season (usually November to April), then it is safe to assume that your child has RSV.

Also understand that antibiotics have no role in the treatment of uncomplicated RSV infections. RSV is a virus. Antibiotics do not work against viral infections.

Going to Day Care with RSV

Since many kids who get RSV are in day care, the million dollar question often becomes, when can my child with RSV go back to day care?

“Most minor illnesses do not constitute a reason for excluding a child from child care, unless the illness prevents the child from participating in normal activities, as determined by the child care staff, or the illness requires a need for care that is greater than staff can provide.”

AAP Red Book 2015

Although I once had the manager of a day care argue with me that a child needed to test RSV negative before being allowed back into her day care, kids can usually go back, even if they still have cold symptoms, as long as they:

don’t have a fever for 24 hours
don’t have any trouble breathing
are not fussy or irritable

Since these kids will likely be contagious, the AAP recommends that “In child care centers, good hygiene practices should be used by the staff and the children, including frequent and thorough hand washing.”

Treating Hard to Control RSV

If your child has RSV symptoms and isn’t getting better, ask yourself these questions and bring the answers to your pediatrician or seek quick medical attention:

“Some youngsters with bronchiolitis may have to be hospitalized for treatment with oxygen. If your child is unable to drink because of rapid breathing, he may need to receive intravenous fluids.”

American Academy of Pediatrics

Do you think your child’s symptoms are hard to control, not because they are getting worse, but rather because they are lingering for several weeks, which can be normal when young kids have RSV?
Does your newborn or infant under two or three months have a fever (temperature at or above 100.4F/38C)?
Is your child having trouble breathing, such as breathing fast or hard, with chest retractions (chest caving in), nasal flaring, trouble catching his breath, or a non-stop, continuous cough?
Do you see any signs that your child isn’t getting enough oxygen, including that “his fingertips and the area around his lips may turn a bluish color?”
Is your child dehydrated, with less urine output, dry mouth, or no tears?
Does your child have any medical problems that put her at higher risk for a severe RSV infection, including extreme prematurity, having complex heart disease, chronic lung disease of prematurity, or immune system problems?
Is your child lethargic, which doesn’t simply mean that he is just playing less, but rather that he is actually hard to wake up and is maybe skipping feedings?

If your child with RSV is getting worse, although there aren’t any special treatments to make the RSV infection go away, supportive care is available to help your child through it, including IV fluids and supplemental oxygen. Those who are most sick sometimes end up on a ventilator to help them breath, and tragically, some infants with RSV die.

What To Know About Treating Hard to Control RSV

RSV is never really easy to control for infants and toddlers, as there is no treatment or cure, but fortunately, most kids do not have severe symptoms that require hospitalizations.

More Information About Treating Hard to Control RSV

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Can Your Sick Child Still Go to Daycare or School?

Can Your Sick Child Still Go to Daycare or School?

Exclusion Criteria for Vaccine Preventable Diseases

More on Sending Your Sick Child to Daycare or School

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