RSV in Children: Symptoms, Treatment & When to Seek Care

What Is RSV (Respiratory Syncytial Virus)?

RSV (Respiratory Syncytial Virus) is a highly contagious virus that causes infections of the lungs and respiratory tract. It is the most common cause of bronchiolitis (inflammation of the small airways) and pneumonia in children under one year of age worldwide. Nearly all children are infected with RSV at least once by age 2.

Respiratory Syncytial Virus, commonly known as RSV, is a virus that causes respiratory tract infections. The name "syncytial" comes from the virus's ability to cause infected cells to merge together (form syncytia). RSV belongs to the same family of viruses as the common cold, measles, and mumps, but it specifically targets the respiratory system.

For most healthy older children and adults, RSV causes symptoms similar to a common cold - runny nose, cough, and sometimes fever. However, RSV can be much more serious in young infants, particularly those under 6 months of age. In these vulnerable populations, the virus can spread from the upper respiratory tract (nose and throat) down into the lower respiratory tract (bronchioles and lungs), causing inflammation that makes breathing difficult.

RSV is responsible for approximately 33 million lower respiratory tract infections in children under 5 years old worldwide each year. It is the leading cause of hospitalization among infants in developed countries. Understanding RSV is crucial for parents because early recognition of warning signs can be life-saving, and new preventive treatments are now available to protect high-risk infants.

Why Is RSV More Dangerous for Young Infants?

Several factors make young infants particularly vulnerable to severe RSV infection. First, infant airways are much smaller than those of older children and adults - even a small amount of inflammation and mucus can significantly obstruct breathing. Second, an infant's immune system is still developing and may not mount an effective response to the virus. Third, very young infants have not yet developed the antibodies that provide protection against RSV.

The anatomical differences in infant lungs are significant. The bronchioles (small airways) in babies are only about 1-2 millimeters in diameter. When these tiny tubes become inflamed and filled with mucus due to RSV infection, the breathing space can be reduced by 50% or more, leading to the wheezing and breathing difficulty characteristic of bronchiolitis.

Which Children Are at Risk for Severe RSV?

Children at highest risk for severe RSV include infants under 3 months old, premature babies, and children under 2 years with chronic lung disease, heart defects, neuromuscular disorders, or weakened immune systems. These high-risk groups may need hospitalization and are prioritized for preventive antibody treatment.

While RSV can affect any child, certain groups face a significantly higher risk of developing severe disease that requires hospitalization or intensive care. Recognizing these risk factors helps parents and healthcare providers take appropriate preventive measures and seek care promptly when needed.

The most important risk factor is age. Infants under 3 months old have the highest risk of severe RSV infection because their airways are very small, their immune systems are immature, and they cannot effectively clear mucus from their respiratory tract. This age group is also most susceptible to apnea (breathing pauses), which can be a life-threatening complication of RSV.

High-Risk Categories

The following groups of children have increased risk of severe RSV disease and should be monitored closely if they develop respiratory symptoms:

• Age under 3 months: The youngest infants have the highest hospitalization rates and are at greatest risk for complications including apnea
• Premature birth: Babies born more than 5 weeks early (before 35 weeks gestation) have underdeveloped lungs and immune systems
• Chronic lung disease: Children under 2 years with conditions like bronchopulmonary dysplasia (BPD) have compromised lung function
• Congenital heart disease: Children with hemodynamically significant heart defects are more vulnerable to respiratory complications
• Neuromuscular disorders: Conditions affecting muscle strength can impair the ability to cough and clear secretions
• Immunodeficiency: Children with weakened immune systems cannot fight the infection effectively
• Down syndrome: Children with trisomy 21 have higher rates of severe RSV due to anatomical and immune factors

It is particularly important to protect children in these high-risk categories from RSV exposure. This may include limiting contact with people who have respiratory infections, practicing good hand hygiene, and considering preventive antibody treatment during RSV season.

What Are the Symptoms of RSV in Children?

RSV typically starts with cold-like symptoms: runny nose, nasal congestion, decreased appetite, and mild fever. In young infants, symptoms can progress to include rapid or labored breathing, wheezing, nasal flaring, and rib retractions. Children are usually sickest 4-6 days after symptoms begin, with full recovery taking 1-2 weeks.

RSV infection usually begins with symptoms that are indistinguishable from a common cold. In older children and adults, the infection may stay in the upper respiratory tract and resolve without complication. However, in infants and young children, especially those under 6 months, the infection can progress to affect the lower respiratory tract, causing more serious symptoms.

The typical course of RSV follows a predictable pattern. Initial symptoms appear 3-5 days after exposure to the virus. During the first 2-3 days, symptoms are usually mild and cold-like. The illness typically peaks around days 4-6, when breathing problems are most pronounced. Most children begin improving after the peak, though cough and congestion may persist for 2-3 weeks.

Early Symptoms (Days 1-3)

The initial phase of RSV infection presents with upper respiratory symptoms that can easily be mistaken for a common cold. Parents should monitor their child closely during this phase, especially if the child is under 6 months old or has risk factors for severe disease.

• Runny nose: Clear nasal discharge that may become thicker and more colored as the illness progresses
• Nasal congestion: Stuffy nose with thick, sticky mucus that may interfere with feeding
• Mild fever: Temperature typically between 100-102°F (38-39°C), though some children may not have fever
• Decreased appetite: Reduced interest in feeding, especially in infants who are congested
• Mild cough: Dry cough that may develop in the first few days
• Sneezing: Frequent sneezing as the body tries to clear nasal secretions

Progression to Lower Respiratory Symptoms (Days 3-7)

In some children, particularly infants under 6 months, RSV spreads from the upper to lower respiratory tract. This progression causes inflammation of the bronchioles (small airways) and can lead to breathing difficulties. Parents should watch carefully for these signs:

• Wheezing: A high-pitched whistling sound when breathing out, caused by narrowed airways
• Rapid breathing: Breathing rate faster than normal (more than 60 breaths per minute in infants)
• Labored breathing: Visible effort when breathing, appearing to work hard to breathe
• Nasal flaring: Nostrils widening with each breath, indicating breathing difficulty
• Retractions: Skin pulling in between the ribs, below the ribcage, or at the neck with each breath
• Worsening cough: Cough becomes more frequent and may sound wet or productive
• Feeding difficulties: Unable to drink well due to breathing problems; stops feeding to catch breath

Apnea in Young Infants

One of the most concerning complications of RSV in very young infants (especially those under 2 months) is apnea - brief pauses in breathing. Apnea can occur early in the course of RSV infection, sometimes even before other symptoms are apparent. It happens because RSV can affect the brain's respiratory control centers in immature infants.

If you notice your infant stopping breathing for more than 10-15 seconds, or if they become blue or limp during a breathing pause, call emergency services immediately. Apnea is a medical emergency that requires immediate intervention.

When Should You Seek Medical Care for RSV?

Seek immediate medical care if your child has difficulty breathing, is breathing very fast, shows retractions (skin pulling in around ribs), has blue lips or fingernails, is extremely lethargic, or refuses to drink. For infants under 3 months with any respiratory symptoms or fever, contact a healthcare provider promptly.

Knowing when to seek medical care is one of the most important things parents can do during RSV season. While most RSV infections are mild and can be managed at home, some children develop complications that require medical intervention. The key is to recognize warning signs early and act quickly.

The timing of when to seek care depends on your child's age, underlying health conditions, and the severity of symptoms. Younger infants and those with risk factors have a lower threshold for needing medical evaluation. Trust your parental instincts - if something doesn't seem right with your child, it's better to have them evaluated.

Seek Emergency Care Immediately For:

• Apnea: Any breathing pauses lasting more than 10 seconds
• Cyanosis: Blue or gray coloring of lips, tongue, or fingernails
• Severe respiratory distress: Very rapid breathing with significant retractions or grunting
• Unresponsiveness: Difficulty waking your child or extreme lethargy
• Complete refusal to feed: Infant won't drink anything for 6+ hours
• Signs of dehydration: No wet diapers for 6-8 hours, dry mouth, no tears

Contact Your Healthcare Provider Promptly For:

• Infant under 3 months with fever: Any fever in this age group needs evaluation
• Difficulty breathing: Fast breathing, noisy breathing, or visible effort to breathe
• Poor feeding: Drinking less than half of usual amount
• Symptoms getting worse: Deterioration after initial improvement
• High-risk child with cold symptoms: Children with heart, lung, or immune problems need earlier evaluation

How Can You Care for a Child with RSV at Home?

Home care for mild RSV focuses on relieving congestion, ensuring hydration, and monitoring for worsening symptoms. Use saline nasal drops and gentle suctioning to clear mucus, offer frequent small feedings, keep the head elevated during sleep, and avoid smoke exposure. Most children recover with supportive care alone.

For children with mild RSV symptoms who don't need hospital care, supportive treatment at home can help them feel more comfortable and recover more quickly. RSV is a viral infection, which means antibiotics won't help - the focus is on managing symptoms while the body fights off the virus.

The main goals of home care are to keep the airways as clear as possible, maintain adequate hydration and nutrition, and monitor for any signs that the illness is becoming more severe. With good supportive care, most children start improving within a week, though cough and congestion may linger for several weeks.

Clearing Nasal Congestion

Nasal congestion is one of the most troublesome symptoms for infants with RSV because they primarily breathe through their nose, especially during feeding. Keeping the nose clear can make a significant difference in comfort and ability to feed.

Use saline (salt water) nasal drops to thin and loosen mucus. Put 2-3 drops in each nostril, wait a minute or two, then use a bulb syringe or nasal aspirator to gently suction out the loosened mucus. The best times to do this are before feedings (so baby can breathe while eating) and before sleep. You can use saline drops as often as needed - they're safe and won't cause side effects.

For children over 1 year old, you may also use over-the-counter decongestant nasal drops or sprays for short periods (no more than 3 days to avoid rebound congestion). Always check with your healthcare provider before using any medication in children under 2 years.

Maintaining Hydration and Nutrition

Children with RSV often don't want to eat or drink as much as usual because congestion makes feeding difficult and they simply don't feel well. However, staying hydrated is crucial, especially if they have fever. Dehydration can make symptoms worse and may lead to hospitalization.

For breastfed or bottle-fed infants, offer smaller, more frequent feedings. A congested baby may need to stop and breathe more often during feeding, so be patient. Clear the nose before feeding when possible. If your baby is having significant trouble with bottle or breast, you may need to offer small amounts of breast milk or formula by spoon or syringe.

Signs of adequate hydration include: regular wet diapers (at least 4-6 wet diapers per 24 hours), moist mouth and lips, tears when crying, and normal skin elasticity. If you notice decreased urination, dry mouth, or no tears, contact your healthcare provider.

Other Supportive Measures

• Elevate the head during sleep: Place a rolled towel under the mattress to slightly raise the head of the crib (never use pillows in cribs for infants under 1 year). This can help with drainage and breathing.
• Use a cool-mist humidifier: Adding moisture to the air can help loosen congestion and soothe irritated airways. Clean the humidifier daily to prevent mold growth.
• Manage fever if needed: If your child is uncomfortable from fever, you can give age-appropriate doses of acetaminophen (for infants over 2 months) or ibuprofen (for children over 6 months). Always consult your healthcare provider before giving medication to infants under 6 months.
• Keep the environment smoke-free: Tobacco smoke significantly worsens respiratory symptoms and increases the risk of complications. Never smoke around a child with RSV.
• Clean irritated eyes: If eyes are watery or crusty, gently clean them with a cotton ball moistened with warm water or saline.

What Happens If a Child Needs Hospital Care for RSV?

Children hospitalized for RSV receive supportive care including oxygen therapy, IV fluids if dehydrated, and continuous monitoring. Nasal suctioning and sometimes nebulized treatments are used. Severe cases may require intensive care with respiratory support. There is no antiviral medication that treats RSV - care focuses on supporting the child while the infection resolves.

When home care isn't enough to manage RSV symptoms, hospitalization may be necessary. The decision to hospitalize depends on factors including the child's age, severity of breathing difficulty, ability to maintain hydration, and oxygen levels. Younger infants and those with underlying health conditions are more likely to need hospital care.

Hospital treatment for RSV is primarily supportive - there is no medication that kills the virus or speeds up recovery. Instead, the medical team focuses on helping the child breathe more easily, preventing dehydration, and monitoring for complications. Most children who are hospitalized for RSV stay 2-5 days, though those needing intensive care may stay longer.

Oxygen Therapy

If your child's blood oxygen level is low (typically below 90-92%), supplemental oxygen will be provided. This may be given through small tubes placed in the nostrils (nasal cannula) or through a mask. The amount of oxygen is adjusted based on continuous monitoring of oxygen saturation levels.

Hydration and Nutrition Support

Children who cannot drink enough fluids due to breathing difficulty may receive IV fluids to prevent dehydration. Some children may need to be fed through a thin tube that goes through the nose into the stomach (nasogastric or NG tube). This allows them to receive breast milk, formula, or special nutrition while saving their energy for breathing.

Respiratory Support

Hospital staff will regularly suction mucus from the nose and sometimes the throat to help keep airways clear. Some children receive nebulized treatments (medicine breathed in as a mist) to help open the airways, though the evidence for bronchodilators in RSV bronchiolitis is limited. In severe cases, children may need more intensive respiratory support such as high-flow nasal cannula oxygen, CPAP (continuous positive airway pressure), or rarely, mechanical ventilation.

Monitoring

Children in the hospital are continuously monitored for heart rate, breathing rate, and oxygen saturation. Staff regularly assess feeding, urine output, and overall clinical status. Apnea monitoring is especially important for young infants who are at risk for breathing pauses.

How Does RSV Spread?

RSV spreads through respiratory droplets when an infected person coughs, sneezes, or breathes. The virus can also survive on surfaces like doorknobs and toys for several hours, spreading through touch. The incubation period is 3-5 days. RSV is highly contagious and spreads easily in families, especially from older siblings to younger infants.

Understanding how RSV spreads is essential for prevention, especially when trying to protect vulnerable infants. RSV is one of the most contagious respiratory viruses, and most children will be infected during their first two winters of life, often multiple times. The virus spreads through several routes.

The primary mode of transmission is through respiratory droplets. When an infected person coughs, sneezes, or even talks, tiny droplets containing the virus are released into the air. These droplets can travel short distances and infect someone who inhales them or gets them in their eyes. Close contact with an infected person - such as kissing, sharing utensils, or touching hands - can also spread the virus.

RSV can survive on hard surfaces for several hours or even up to a day. This means the virus can spread when someone touches a contaminated surface (like a doorknob, toy, or crib rail) and then touches their face. This is particularly relevant in households with multiple children, where toys and surfaces are frequently shared.

Common Sources of Infection

Newborns and young infants most commonly catch RSV from household contacts, particularly older siblings who attend daycare or school. Older children and adults with RSV often have mild cold symptoms and may not even realize they're sick, but they can easily transmit the virus to vulnerable infants through normal close contact.

Parents and caregivers can also bring RSV home from work or public places. The virus circulates widely in the community during RSV season, making complete avoidance difficult. However, understanding transmission routes helps families take practical precautions to reduce risk.

RSV Season

In most regions, RSV follows a seasonal pattern, with cases increasing in late fall and peaking in winter (typically January-February in the Northern Hemisphere). However, the timing and severity of RSV season varies from year to year and by geographic location. During peak season, RSV spreads rapidly through communities, schools, and daycare centers.

How Can You Prevent RSV Infection?

Prevent RSV through good hygiene: wash hands frequently, avoid close contact with sick people, and clean frequently-touched surfaces. Protect infants by limiting exposure to crowds during RSV season. New preventive treatments include nirsevimab antibody injection for all infants and maternal RSV vaccination during pregnancy. Breastfeeding provides some protection.

While it's difficult to completely prevent RSV infection - the virus is extremely common and nearly all children will be infected by age 2 - there are effective strategies to reduce the risk and, more importantly, to protect the most vulnerable infants from severe disease.

Prevention strategies fall into two categories: behavioral measures that reduce virus exposure, and medical interventions that provide protection against severe disease. Both approaches are valuable, and families of high-risk infants may want to implement multiple strategies during RSV season.

Hygiene and Exposure Reduction

• Hand washing: Wash hands thoroughly with soap and water for at least 20 seconds, especially before touching infants. Use alcohol-based hand sanitizer when soap isn't available.
• Avoid close contact with sick people: Keep infants away from anyone with cold symptoms. Ask family members and visitors to stay away if they're unwell.
• Don't kiss babies on the face: RSV spreads easily through saliva and respiratory secretions. Kiss babies on the head or feet instead.
• Clean surfaces: Regularly clean and disinfect frequently-touched surfaces and toys, especially during RSV season.
• Limit crowds: During peak RSV season, avoid taking young infants to crowded indoor spaces where exposure risk is high.
• Cough and sneeze etiquette: Teach family members to cough and sneeze into their elbow or a tissue, not their hands.
• Keep the home smoke-free: Smoke exposure damages respiratory tissues and increases susceptibility to infection.

Breastfeeding

Breastfeeding provides some protection against respiratory infections including RSV. Breast milk contains antibodies, immune cells, and other factors that help protect infants from infection. While breastfeeding doesn't prevent RSV completely, breastfed infants may have milder illness and are less likely to be hospitalized for RSV. Exclusive breastfeeding for the first 6 months, when possible, offers the greatest protection.

Medical Prevention: Monoclonal Antibodies

A major advancement in RSV prevention is the availability of monoclonal antibody products that can protect infants during RSV season. These are laboratory-made antibodies that work by blocking the RSV virus from infecting cells.

Nirsevimab (Beyfortus) is a single-injection antibody treatment recommended for all infants in their first RSV season and for high-risk children up to 24 months entering their second season. One dose provides protection for approximately 5-6 months. It is typically given before or during RSV season.

Palivizumab (Synagis) is an older product that requires monthly injections throughout RSV season. It is now primarily reserved for certain high-risk infants who need additional protection beyond what nirsevimab provides.

Maternal RSV Vaccination

Pregnant women can receive RSV vaccination between 32-36 weeks of pregnancy. This vaccine stimulates the mother's immune system to produce antibodies against RSV, which are then transferred to the baby before birth. The baby is born with protection that lasts for the first several months of life - the highest-risk period for severe RSV disease.

Maternal vaccination and infant nirsevimab both provide protection, so only one is typically needed. If the mother received RSV vaccine at least 2 weeks before delivery, the infant generally does not need nirsevimab. Discuss options with your healthcare provider to determine the best approach for your situation.

Can Children Get RSV More Than Once?

Yes, children can get RSV multiple times because the immune protection from infection is not complete or long-lasting. However, repeat infections are usually milder than the first. The first RSV infection in infancy is typically the most severe, which is why prevention efforts focus on protecting young infants during their first RSV season.

Unlike some viral infections that provide lifelong immunity, RSV infection provides only partial protection. This means that children - and adults - can be infected with RSV repeatedly throughout their lives. However, the pattern of disease changes with each infection.

The first RSV infection is typically the most severe, especially when it occurs in the first year of life. The immature immune system hasn't encountered the virus before, airways are very small, and babies haven't developed the cough strength to clear secretions effectively. Subsequent infections, while still possible, are usually milder because the immune system has developed some memory of the virus.

By adulthood, most people have been infected with RSV many times and typically experience only mild cold symptoms, if any. However, RSV can cause severe illness in adults with weakened immune systems or chronic lung disease, and in elderly individuals.

Can RSV Cause Long-Term Problems?

Severe RSV infection in infancy, particularly bronchiolitis, is associated with increased risk of recurrent wheezing and possibly asthma in later childhood. Children who had severe RSV may wheeze with subsequent colds for months or years. However, most children fully recover without lasting effects.

For the majority of children who get RSV, recovery is complete and there are no long-term consequences. However, research has shown a connection between severe RSV bronchiolitis in infancy and later respiratory problems, particularly in children who have a genetic predisposition to asthma.

Children who have had severe RSV infection, especially those who were hospitalized, have a higher risk of developing recurrent wheezing episodes when they get subsequent respiratory infections. This pattern, sometimes called post-bronchiolitis wheezing, can persist for several years but often improves as children get older and their airways grow larger.

The relationship between RSV and asthma is complex and not fully understood. Some studies suggest RSV infection may trigger asthma development in genetically susceptible children, while others suggest that children destined to develop asthma simply have a more severe response to RSV. Either way, children with a family history of asthma or allergies may be at higher risk for long-term respiratory effects following RSV.

When Can Children Return to Normal Activities?

Children can return to daycare, school, or other activities when they are well enough to participate comfortably in normal daily routines. They should be fever-free for at least 24 hours without fever-reducing medication. Mild residual cough or congestion is acceptable, but children with significant symptoms should stay home.

Determining when a child can return to normal activities after RSV depends on how they feel and their ability to participate, rather than waiting for all symptoms to resolve completely. RSV causes lingering symptoms, particularly cough, that can persist for weeks after the acute illness has passed.

A child is ready to return to daycare or school when they have been fever-free for at least 24 hours without using fever-reducing medications, can eat and drink normally, have enough energy to participate in regular activities, and are not having difficulty breathing. Mild residual cough or nasal congestion is acceptable - these symptoms may last 2-3 weeks and don't indicate ongoing contagiousness.

Keep in mind that RSV is most contagious during the first few days of symptoms when viral shedding is highest. By the time a child has recovered enough to return to activities, they are typically much less contagious, though they may still shed virus for 1-2 weeks.