Transcription:
RSV in Infants and Children

Prakash Chandran Host): This is Children's Health Checkup, where we answer parents' most common questions about raising healthy and happy kids. Today, we're talking about respiratory syncytial virus or RSV in infants and children. And joining us is our expert, Dr. Andrew Gelfand. He's the Chief of Pediatric Pulmonology and Sleep Medicine at Children's Health and is an Associate Professor at UT Southwestern. Dr. Gelfand, it is really great to have you here today. First of all, let's just start with the basics. What exactly is RSV?

Andrew Gelfand, MD (Guest): Well, first, I want to thank you for having me. RSV is actually the most common cause of bronchiolitis in children. And it's one of those diseases that potentially everybody gets. You can't avoid getting it. It kind of acts like a cold in many children, but in a lot of children, especially infants and younger and premature kids; and there's other risk groups that can cause very serious lung condition and significant increased work of breathing.

Host: Got it. Now, you know, I have heard of bronchitis before. I haven't necessarily heard of bronchiolitis. Can you just give a quick primer and explain the differences?

Dr. Gelfand: Bronchitis is when you have inflammation of the bronchi or the larger airways in the body so, starting from the trachea and maybe what we call where it branches off to the right mainstem and left mainstem, part of your lungs. But bronchiolitis implies the smallest part of your lungs in the smallest part of the airways. And these, with this disease, get very swollen and inflamed, and it's the swelling that causes difficulty for air to get out of your lungs. And so we call this a bronchiolitis, cause it really affects the smallest airways that you have.

Host: Yeah, I do want to get to the symptoms and signs that a child might have RSV. But before that, I just wanted to get a general understanding of the age group that RSV affects.

Dr. Gelfand: Everybody can get RSV. But when adults get it, or bigger children, it just kind of acts like a cold. So you get runny nose, nasal congestion, maybe a little bit of cough, but because RSV really affects the smallest airways and the significant issue is swelling in the smallest of airways; then the smallest of children, it seems to affect the most. So, premature infants are at a very high risk. The younger the infant is, like less than six months, they can be really affected, but we really worry about kids two years of age or less, as kind of in the highest risk group. They tend to have the most difficulty. Other children who tend to have problems with RSV are those who are chronic wheezers or, you know, may be predisposed to asthma like symptoms, or patients who are weak, who have like neuromuscular problems; they can be more effected by this because they have trouble clearing their secretions and kids with congenital heart disease are also considered to be at high risk for RSV bronchiolitis.

Host: OKay. And is RSV something that is seasonal or can anyone get it at all times of the year?

Dr. Gelfand: Well, that's a very interesting question. So typically, RSV is quite seasonal and typically it starts around November and lasts through approximately April. So, there are certain people, depending on where you live, the more tropical the environment or closest to the equator, sometimes those places have a longer season and RSV can occur around 10 months out of the year.

But typically in most places, especially in the United States, our season is November through April. This year, we're seeing a very, very interesting phenomenon, and that is because of the pandemic and because of the masking, we really did not see any RSV in the Dallas area this winter, which was shocking, we were waiting for it and it never came.

But as soon as the masks started going down and the pandemic was a little bit under better control; we now started to see RSV appear in the community, starting in June. And actually now our numbers are very high and are hitting levels that we would see in a typical winter and actually almost greater than numbers that we see in a typical winter, because RSV affects everybody. We're seeing the kids who did not get it this past winter and the kids now who are more vulnerable to it because it's a very contagious disease.

Host: It's pretty crazy what masking up and protecting yourself can help prevent right?

Dr. Gelfand: It is crazy how masking and social distancing and good hand washing have really made an effect. The pediatric hospitals, the adult hospital are crazy busy with COVID, but the pediatric hospitals this winter were actually relatively slower because we did not have this significant respiratory viral illnesses that we typically see in the winter season.

Host: Okay, so just on RSV, I wanted to understand a little bit more about the signs or symptoms that tell a parent that their child might have RSV. And also another thing I wanted to ask was it seems like these symptoms might be similar to a cold. So how does one tell the difference?

Dr. Gelfand: Well, some of the symptoms are exactly the same. And typically what we see is the kids can have cough. Kids can say I have runny nose, a very significant nasal congestion, but what makes RSV a little bit different or how we sometimes know, is just the severity of it. And then sometimes what we see it's a little bit less common with colds, but we can see wheezing and something called signs of respiratory distress, we call it retractions or where we see them use their rib muscles and their diaphragms to breathe or we'll see nasal flaring where their little nostrils will open and close as they're breathing. And sometimes in very small babies who are really having trouble breathing, they actually stop breathing and have apnea.

The other sign that we know that children are having trouble is, infants are what we call obligate nose breathers, meaning they have to breathe through the nose to eat and drink. So if their nose is so congested that they can't eat and drink, they're also going to be very prone to dehydration. So we need to make sure that they're hydrated in order to do well with the disease.

Host: Got it. So, speaking about those babies specifically, for example, if their noses are so congested that they can't feed, is that when parents should consider taking them to the doctor, like, is there a certain time or signs that parents should say, hey, listen, this is something that won't really just run its course. I need to take my baby to the doctor.

Dr. Gelfand: Absolutely. The times that parents should consider taking their child to the doctor, is when they're breathing very rapidly. So, if they're breathing more than 50 to 60 times a minute, the child is breathing too fast and is likely having difficulty. If they're not able to eat and drink. So, they're seeing less wet diapers that would be a sign to take them to the doctor. And if they're really seeing the significant retractions or the evidence of work of breathing and the nasal flaring, or they're doing something called grunting where they make extra sounds as they breathe out; then that would be a sign that the child's getting into distress and should see a doctor.

Host: Okay, understood. And that's for the babies, but what about for the older kids? I'm assuming wheezing, or that nostril flaring, those are signs that they might want to see a doctor. Is that correct?

Dr. Gelfand: They may want to see a doctor as well, especially, you know, depending on how hard they're breathing, how fast they're breathing, how uncomfortable, if the child's able to talk, they can tell you mom, I'm having a lot of trouble breathing. And so, sometimes we, especially if they're asthmatic, then those kids might have more difficulty handling the virus.

Host: Okay. So, we talked about some of these signs and symptoms and when they might want to bring their child in to see the doctor, but maybe talk a little bit about how RSV is officially diagnosed, and then maybe talk about some of the first-line treatments as well.

Dr. Gelfand: The diagnosis is generally made just by clinical impression. So, there's times of the year when we see lots and lots of RSV, and if you can go to the doctor and they see all the nasal congestion and they hear the cough and they hear the wheeze, a lot of doctors will just say, it appears that your child has RSV and they just leave it at that because it's not really going to change any treatment plans that they do. Now, if they do come into the hospital and the child is severe enough and potentially needing oxygen or just can't get enough air in and out of their lungs; then there is a nose swab that we do that can help diagnose that the child has RSV, but we mostly do that for isolation reasons. We want to know, what isolation protocols need to be taken since the RSV is so contagious.

Host: Okay. And I'd love for you to expand a little bit more on how RSV is specifically treated.

Dr. Gelfand: RSV is a disease that we basically say is treated with supportive care. And what does that mean? So supportive care, we just have to make sure that the babies are doing okay. There's not really specific treatments. So, for example, if the baby is too congested to drink, well, we do a lot of nasal suctioning to try to clear the nasal passages.

I try to emphasize to parents that you should maybe suction the nose before they take their bottles, since they have to breathe through the nose in order to suck well. So, nasal suctioning with saline is kind of a treatment plan. If they're are sick enough to be in the hospital, sometimes we add something called a heated high flow nasal cannula or a way to put heated moist air into the lungs and sometimes that helps. Sometimes humidification in the house will help, but there's no real specific medications that we use routinely to this. It's just to make sure the baby is doing okay. Keeping themselves hydrated and then letting the virus run its course.

Host: Okay, that makes sense. So, let's talk a little bit about preventative measures. Now we've obviously talked about masking and all of the benefits that has, proactive hand washing and things of that nature, but in a world that seemingly is starting to open up again, what is the best way that people or parents can be proactive about helping their child not get RSV?

Dr. Gelfand: The key thing with RSV to remember is that it's really spread by contact and it also has some very large respiratory particles. So, if they get enough load, you can get it that way too, but it's a contact thing. So, hand-washing is truly the best way to try to prevent things. So, before you touch a baby, you should wash your hands. After you touch a baby with runny nose and nasal condition, you should wash your hands. Obviously avoidance of somebody who's sick. If you have a child who's at high risk, let's say a former premature baby, try to avoid kids who have runny noses and nasal congestion, try to avoid church nurseries during the time of year that RSV is there.

So, it's kind of avoidance, hand-washing are the best ways to try to prevent it. For high risk infants, who qualify, there's a medication called palivizumab, otherwise known as Synagis that can be a monthly injection that provides what we call passive immunity, it gives you an immunoglobulin to try to protect you from the effects of RSV. And that works quite well, but it's not available to everybody. You have to fit into one of the high risk categories.

Host: So, Dr. Gelfand, you know, one of the things I wanted to ask you about is because RSV presents itself very similar to a cold, a parent might think, hey, you know what, I can just go to the pharmacy. I can pick up a nasal decongestant and give it to my child or my infant. Do you have any thoughts around this?

Dr. Gelfand: Yes, I do. Actually, nasal decongestants and cough medicines have actually been found not to be helpful at all with RSV and potentially it can be harmful. So, over the counter medications, short of medication like to help with fever like Tylenol, but medications to try to help prevent cough and congestion have not been helpful. And so we don't recommend that at all for children with RSV.

Host: Understood. So, that really the best thing to do is to watch your child, if they express the wheezing or the breathing patterns that we discussed, to bring them in to the doctor and sooner is better. But other than that, just kind of that supportive, I guess, letting it run its course is the best way to treat it.

Dr. Gelfand: Absolutely. Well, letting them run the course, make sure they stay hydrated, keeping the nose clear. And then if their work of breathing becomes very significant, then seek help.

Host: So, you know, just as we close here, Dr. Gelfand, you have seen, potentially hundreds of different patients with RSV, what is one tip or one thing that you wish more parents knew before they brought their child in?

Dr. Gelfand: Wow. Probably the importance of making sure that the nose gets suctioned well, in order for the patients to eat and drink and keep themselves hydrated. And then the second thing would be if the baby is having respiratory distress, don't wait too long to get help. It's important that if they're really working hard, seek medical help. Cause there are potential ways that we can help ease the work of breathing if necessary.

Host: Okay. Well, I think, Dr. Gelfand, that is the perfect place to end. Thank you so much for your time.

Dr. Gelfand: Sure. Thank you so much. I enjoyed having this conversation with you.

Host: That's Dr. Andrew Gelfand, Chief of Pediatric Pulmonology and Sleep Medicine at Children's Health and an Associate Professor at UT Southwestern. For more information, please visit children's.com and search RSV. If you found this podcast helpful, please rate and review or share the episode, and please be sure to follow Children's Health on your social channels.

This has been Children's Health Checkup from Children's Health. My name is Prakash Chandran and we'll talk next time.