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

What Is RSV and Why Is It Serious in Children?

RSV (Respiratory Syncytial Virus) is a common virus that infects the lungs and breathing passages. While it causes mild cold symptoms in most children and adults, RSV can lead to serious respiratory illness in infants, particularly those under 6 months old, premature babies, and children with chronic health conditions.

RSV stands for Respiratory Syncytial Virus, and it is one of the most common causes of respiratory infections in young children worldwide. The virus primarily affects the airways, including the bronchioles (small breathing tubes in the lungs), which is why severe RSV infection is often called bronchiolitis. Almost every child will be infected with RSV at least once before their second birthday, making it an almost universal childhood experience.

The reason RSV is particularly concerning in infants relates to the anatomy and immune development of young children. Infants have very narrow airways that can easily become blocked by inflammation and mucus. Additionally, babies' immune systems are still developing, making them less able to fight off respiratory infections effectively. When the tiny airways in an infant's lungs become inflamed and filled with mucus from RSV infection, breathing can become significantly more difficult.

RSV follows a seasonal pattern in most parts of the world, with outbreaks typically occurring during fall and winter months. In temperate climates, RSV season usually runs from November through March, though the timing and severity can vary from year to year. During peak RSV season, the virus is responsible for a significant proportion of pediatric hospital admissions, placing considerable strain on healthcare systems.

Children at Higher Risk of Severe RSV Illness

While any child can develop RSV infection, certain groups face significantly higher risks of developing severe disease that may require hospitalization. Understanding these risk factors helps parents and healthcare providers identify children who need closer monitoring and may benefit from preventive measures.

The highest risk group includes infants under 3 months of age, regardless of whether they were born full-term or premature. These very young babies have the smallest airways and least developed immune systems, making them most vulnerable to severe RSV complications. Any fever in a baby under 3 months old warrants immediate medical evaluation.

• Premature infants: Babies born more than 5 weeks early have underdeveloped lungs and are at increased risk
• Infants under 6 months: Young babies are more likely to develop severe breathing difficulties
• Children with chronic lung disease: Including bronchopulmonary dysplasia (BPD) in children under 2 years
• Congenital heart disease: Children under 2 years with significant heart conditions
• Immunocompromised children: Those with weakened immune systems from any cause
• Neuromuscular disorders: Conditions affecting the ability to cough and clear secretions

What Are the Symptoms of RSV in Babies and Children?

RSV symptoms typically begin like a common cold with runny nose, decreased appetite, and mild fever. Over 1-3 days, symptoms may progress to coughing, wheezing, and rapid or labored breathing. Infants under 6 months often develop more severe symptoms and may have difficulty feeding. The illness is usually worst around days 4-6.

RSV infection in children typically follows a predictable pattern, though the severity varies considerably based on the child's age and overall health. Understanding this progression helps parents know what to expect and when symptoms might indicate a more serious problem requiring medical attention.

The illness usually begins with upper respiratory symptoms that closely resemble a common cold. During the first 1-3 days, children typically develop a runny nose with clear or slightly colored discharge, mild nasal congestion, decreased appetite, and possibly a low-grade fever. At this stage, it may be impossible to distinguish RSV from other viral respiratory infections without testing.

As the infection progresses into the lower respiratory tract over the following 2-4 days, more concerning symptoms may develop. This is when the characteristic features of RSV bronchiolitis often appear: a persistent cough that may sound harsh or barking, wheezing or whistling sounds during breathing, and increasingly rapid or labored breathing. Children may also become more irritable and have significant difficulty with feeding.

Early Symptoms (Days 1-3)

The initial symptoms of RSV infection are often indistinguishable from other common viral illnesses. Parents should be aware that these seemingly mild symptoms can progress, particularly in young infants. During this early phase, maintaining good hydration and monitoring for any worsening is key.

• Runny nose with clear to slightly thick nasal discharge
• Sneezing and mild nasal congestion
• Decreased appetite or reluctance to feed
• Low-grade fever (though many children have no fever)
• Mild fussiness or irritability
• Slightly reduced energy level

Progressive Symptoms (Days 3-6)

As RSV spreads to the lower respiratory tract, symptoms typically intensify. This period usually represents the worst of the illness, and parents should monitor their child closely for signs of breathing difficulty. Most children begin to improve after day 6, though recovery can take another week or more.

• Persistent cough: May be harsh, barking, or wheezy
• Wheezing: High-pitched whistling sound, especially when breathing out
• Rapid breathing: Faster than normal respiratory rate for age
• Labored breathing: Visible effort to breathe, using extra muscles
• Difficulty feeding: Unable to eat or drink normally due to congestion and breathing effort
• Increased irritability: Due to discomfort from breathing difficulty

Signs of Breathing Difficulty to Watch For

Recognizing breathing difficulty in children requires knowing what to look for. Parents should observe their child's breathing when the child is calm and not crying. Certain visual signs indicate significant respiratory distress that requires prompt medical evaluation.

Breathing Pauses (Apnea) in Young Infants

One of the most concerning complications of RSV in young infants is apnea - brief pauses in breathing. This is most common in babies under 2 months of age and in premature infants. Apnea can sometimes occur early in the illness, before other symptoms become prominent, making it particularly dangerous.

When Should You Seek Medical Care for RSV?

Seek immediate medical care if your child has difficulty breathing, breathing pauses, blue or gray skin color, extreme fatigue, or is unable to drink fluids. For babies under 3 months with any fever, seek medical evaluation right away. Most children with mild symptoms can be cared for at home with supportive measures.

Knowing when to seek medical care is one of the most important aspects of managing RSV in children. While most children recover from RSV at home with supportive care, some develop complications that require medical intervention. The challenge for parents is distinguishing normal illness progression from signs that warrant urgent evaluation.

The decision to seek medical care depends on several factors, including your child's age, overall health, and the specific symptoms they are experiencing. In general, younger infants require more careful monitoring and have a lower threshold for seeking care. Children with known risk factors for severe RSV disease should be evaluated sooner rather than later if symptoms develop.

It's important to understand that RSV illness typically worsens before it improves. Symptoms usually peak around days 4-6 of the illness. This means that a child who seems somewhat worse on day 3 or 4 may be following the expected course of the illness. However, certain warning signs indicate the illness is becoming more severe than typical and requires medical evaluation.

Call Emergency Services Immediately If:

• Your child has breathing pauses (stops breathing, even briefly)
• Blue or gray color appears around lips, tongue, or fingernails
• Your child is extremely difficult to wake or unresponsive
• Your child has severe difficulty breathing and cannot speak or cry normally
• Your child appears to be struggling significantly to breathe

Seek Prompt Medical Care If:

• Your baby is under 3 months old and has any fever
• Your child has visible breathing difficulty (retractions, nasal flaring)
• Your child is breathing very rapidly for their age
• Your child is unable or unwilling to drink fluids
• Your child has signs of dehydration (no wet diapers for 8+ hours, no tears when crying)
• Symptoms are worsening rather than improving after day 7
• Your child has an underlying health condition that increases RSV risk

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

Home care for RSV focuses on relieving symptoms and preventing dehydration. Use saline nasal drops and gentle suctioning to clear congestion, offer frequent small feedings or fluids, elevate the head of the bed, and use a cool-mist humidifier. Monitor for warning signs and give fever-reducing medication if needed for discomfort.

Most children with RSV can be safely cared for at home with supportive measures. The goals of home care are to keep your child comfortable, maintain adequate hydration and nutrition, and monitor for any signs that the illness is becoming more severe. While there is no specific treatment that cures RSV, proper supportive care helps children recover more comfortably.

Nasal congestion is one of the most troublesome symptoms of RSV, particularly for young infants who cannot breathe through their mouths effectively. Babies rely on nose breathing, especially during feeding, so clearing nasal congestion can significantly improve their comfort and ability to eat. A systematic approach to managing congestion can make a meaningful difference in how your child feels.

Hydration is critically important during RSV illness. Children with respiratory infections often have decreased appetite and may resist feeding due to nasal congestion and breathing difficulty. Dehydration can develop quickly in young children, so offering frequent small amounts of fluids is essential. For breastfed babies, continue breastfeeding and offer feeds more frequently than usual.

Managing Nasal Congestion

Effective management of nasal congestion can significantly improve your child's comfort and ability to feed and sleep. The technique matters as much as the tools used. Saline drops work by loosening and thinning the mucus, making it easier to remove.

• Saline nasal drops: Place 2-3 drops in each nostril to loosen mucus before suctioning or feeding
• Nasal suctioning: Use a bulb syringe or nasal aspirator to gently remove mucus after saline drops
• Timing: Clear the nose before feedings and before sleep for best results
• Frequency: Can be repeated several times daily as needed, but avoid over-suctioning which can cause irritation
• Decongestant nasal drops: For children over 1 year, over-the-counter decongestant drops may help but should not be used for more than 10 days

Maintaining Hydration and Nutrition

Children with RSV often have difficulty maintaining adequate fluid intake due to congestion and fatigue. Smaller, more frequent feedings or drinks are generally better tolerated than normal-sized feeds. Signs of dehydration include decreased wet diapers, dry mouth, no tears when crying, and unusual sleepiness.

• Breastfed babies: Continue breastfeeding and offer the breast more frequently
• Formula-fed babies: Offer smaller amounts more often; consider pumped breast milk or formula in a bottle if nursing is difficult
• Older children: Offer clear fluids, ice chips, or popsicles; avoid sugary drinks
• Clear the nose first: Suction the nose before feeding to make eating easier

Improving Breathing Comfort

Several measures can help make breathing easier for children with RSV. These supportive strategies work together to reduce congestion and ease the work of breathing.

• Elevate the head: Place a pillow under the mattress (not under the baby directly) to slightly elevate the head of the crib or bed
• Cool-mist humidifier: Adds moisture to the air, helping to loosen mucus and ease breathing
• Avoid smoke exposure: Keep children away from cigarette smoke and other respiratory irritants
• Monitor breathing: Check on your child regularly, especially at night

Fever and Discomfort Management

Fever itself is not harmful and is part of the body's immune response to infection. However, if fever is making your child uncomfortable or affecting their ability to drink, fever-reducing medication can help. Always use the correct dosing for your child's weight and age.

How Is RSV Diagnosed?

RSV is diagnosed through clinical examination and, when needed, a nasal swab test. The doctor evaluates breathing patterns, listens to the lungs, and assesses oxygen levels. A rapid RSV test from nasal secretions can confirm the diagnosis, with results often available the same day.

When you bring your child to a healthcare provider with suspected RSV, the evaluation begins with a thorough clinical examination. The doctor will assess your child's overall appearance, breathing pattern, and vital signs including respiratory rate and oxygen saturation. Listening to the lungs with a stethoscope can reveal characteristic sounds of bronchiolitis, such as wheezing and crackles.

The physical examination provides important information about the severity of the illness. The healthcare provider will look for signs of respiratory distress such as retractions (skin pulling in around the ribs), nasal flaring, and the use of accessory muscles to breathe. These findings help determine whether your child needs hospitalization or can be safely managed at home.

RSV Testing

A specific test for RSV involves collecting a sample of nasal secretions, usually using a soft swab inserted into the nose or by suctioning mucus from the nose with a thin tube. The procedure is quick and not painful, though it may be slightly uncomfortable. The sample is then analyzed to detect the presence of RSV.

Rapid antigen tests can provide results within minutes to hours, while more sensitive PCR tests may take longer but can detect lower levels of virus. Testing is not always necessary for diagnosis, as healthcare providers can often recognize RSV bronchiolitis based on clinical presentation, especially during RSV season. However, testing may be performed in hospitalized children, young infants, or to help guide infection control measures.

How Is RSV Treated?

There is no specific antiviral medication for RSV. Treatment focuses on supportive care: maintaining hydration, managing fever, clearing nasal congestion, and ensuring adequate oxygen. Most children recover at home. Hospitalized children may receive supplemental oxygen, IV fluids, and respiratory support as needed.

Unlike some other viral infections, there is currently no antiviral medication that effectively treats RSV once infection has occurred. The mainstay of RSV treatment is supportive care - helping the child's body fight the infection while managing symptoms and preventing complications. This means the treatment approach is the same whether the child is at home or in the hospital, though the intensity of support varies based on illness severity.

For most children, home care with the measures described above is sufficient. The immune system will clear the RSV infection over time, typically within 1-2 weeks. Parents should focus on keeping the child comfortable, maintaining hydration, and monitoring for any warning signs that suggest the illness is worsening.

When Hospital Care Is Needed

Approximately 1-2% of infants with RSV require hospitalization. Hospital admission is typically necessary when a child cannot maintain adequate oxygen levels on their own, cannot take enough fluids by mouth, has significant breathing difficulty, or is at high risk for complications. Hospital care allows for closer monitoring and more intensive supportive treatments.

• Supplemental oxygen: Delivered through nasal prongs or a mask to maintain adequate oxygen levels
• IV fluids: If the child cannot drink enough to stay hydrated
• Tube feeding: Nutrition delivered through a soft tube from nose to stomach if the child cannot feed normally
• Respiratory support: In severe cases, children may need help from machines to breathe
• Inhaled medications: Breathing treatments may be tried, though their effectiveness in RSV is limited

Intensive Care for Severe Cases

A small proportion of hospitalized children with RSV require intensive care. This is most common in very young infants, premature babies, and those with underlying health conditions. Intensive care may involve various forms of respiratory support, including non-invasive support (like CPAP) or, rarely, mechanical ventilation for children with respiratory failure.

How Can RSV Be Prevented?

RSV prevention includes immunization with monoclonal antibodies (like nirsevimab) for infants, maternal RSV vaccination during pregnancy, hand hygiene, avoiding sick contacts, and breastfeeding. All infants are now recommended to receive preventive antibody treatment during their first RSV season.

Significant advances in RSV prevention have been made in recent years, providing new tools to protect vulnerable infants from severe RSV disease. These preventive measures work by providing antibodies that help fight RSV infection before it can cause severe illness. Combined with good hygiene practices, these interventions can substantially reduce the burden of RSV disease in young children.

The development of monoclonal antibody products represents a major breakthrough in RSV prevention. Unlike vaccines that stimulate the body to produce its own antibodies, these products provide ready-made antibodies that offer immediate protection. This approach is particularly well-suited for young infants whose immune systems may not respond well to traditional vaccines.

Immunization for Infants

Monoclonal antibody treatment (such as nirsevimab) is now recommended for all infants during their first RSV season. This single injection provides protection lasting approximately 6 months, covering the typical RSV season. The treatment is given to newborns shortly after birth or during their first RSV season for older infants.

Children at higher risk for severe RSV may need additional doses or different preventive protocols. Your healthcare provider can advise on the specific recommendations for your child based on their risk factors and the timing of RSV season in your area.

Maternal Vaccination

Pregnant women can receive RSV vaccination between weeks 24 and 36 of pregnancy. This maternal vaccination stimulates the mother's immune system to produce antibodies that cross the placenta and provide protection to the baby for the first months of life. If vaccination occurs at least 2 weeks before delivery, adequate antibodies will have transferred to the baby.

The combination of maternal vaccination and infant monoclonal antibody treatment provides overlapping protection strategies. Typically, if a mother is vaccinated close to delivery (within 2 weeks), infant monoclonal antibodies may not be needed as the transferred maternal antibodies provide sufficient protection.

Everyday Prevention Measures

• Frequent handwashing: Wash hands before touching babies and after contact with sick individuals
• Avoid sick contacts: Keep infants away from people with cold symptoms
• Limit crowded indoor spaces: Especially during RSV season
• Clean and disinfect surfaces: RSV can survive on hard surfaces for several hours
• Breastfeeding: Breast milk provides antibodies that may help protect against respiratory infections
• Avoid smoke exposure: Tobacco smoke increases the risk of respiratory infections
• Cover coughs and sneezes: Teach older children to cough into their elbow

How Does RSV Spread?

RSV spreads through respiratory droplets when an infected person coughs or sneezes, through direct contact with infected secretions, and by touching contaminated surfaces then touching the face. RSV can survive on hard surfaces for several hours. The incubation period is 3-5 days, and infected people are contagious for 3-8 days.

Understanding how RSV spreads helps parents take effective steps to protect their children. RSV is highly contagious and spreads easily within families, childcare settings, and schools. The virus primarily spreads through the respiratory route, but can also be transmitted through contact with contaminated surfaces.

When an infected person coughs, sneezes, or even breathes, they release tiny droplets containing RSV particles. These droplets can directly infect someone nearby who inhales them or who gets the droplets in their eyes, nose, or mouth. This is why close contact with sick individuals - such as within families - is a common way for RSV to spread.

RSV Survival and Transmission

• Surface survival: RSV can live on hard surfaces (doorknobs, toys, counters) for several hours
• Hand transmission: The virus easily transfers from hands to face, especially eyes, nose, and mouth
• Incubation period: 3-5 days from exposure to symptom onset
• Contagious period: Usually 3-8 days, but young infants may spread virus for up to 4 weeks
• Common source: Older siblings often bring RSV home from school or daycare

RSV Season

RSV follows a seasonal pattern in most regions, with cases increasing in fall and winter. In temperate climates, the season typically runs from November through March, though timing varies by location and year. During peak season, RSV is responsible for a significant proportion of respiratory infections in young children.

What Is the Recovery Timeline for RSV?

Most children recover from RSV within 1-2 weeks. Cold symptoms appear first (days 1-3), peak illness occurs around days 4-6, then gradual improvement follows. Coughing may persist for several weeks after other symptoms resolve. Children can return to daycare or school when they feel well enough and have been fever-free for 24 hours.

Recovery from RSV follows a fairly predictable timeline, though individual children may vary. Understanding this timeline helps parents know what to expect and when to become concerned if recovery is not progressing as expected. In most cases, children begin to improve noticeably after the first week of illness.

The cough associated with RSV often persists longer than other symptoms. It is common for children to continue coughing for 2-3 weeks or even longer after the acute illness has resolved. This lingering cough usually does not indicate ongoing infection but rather reflects ongoing healing of the irritated airways. Physical activity may trigger coughing even after the child feels otherwise well.

Typical Recovery Timeline

• Days 1-3: Cold-like symptoms develop (runny nose, mild fever, decreased appetite)
• Days 3-6: Symptoms often worsen as infection spreads to lower airways
• Days 4-6: Peak illness - breathing difficulty and wheezing usually most pronounced
• Days 7-10: Gradual improvement in breathing and feeding
• Weeks 2-3: Most symptoms resolve, though cough may persist
• Weeks 3-4+: Lingering cough gradually improves

Returning to Daycare or School

Children can generally return to childcare or school when they feel well enough to participate in normal activities and have been fever-free for at least 24 hours without fever-reducing medication. Mild residual symptoms like a lingering cough or runny nose do not necessarily require staying home, as long as the child is otherwise feeling well.

Can RSV Cause Long-Term Problems?

Some children who have severe RSV infection in infancy may have an increased risk of developing reactive airway disease or asthma-like symptoms, particularly with subsequent respiratory infections. However, most children recover completely from RSV without long-term effects.

Research has shown a connection between severe RSV infection in infancy and later respiratory problems, particularly wheezing with subsequent viral infections. Children who had RSV bronchiolitis may be more likely to experience breathing difficulties during future colds, a condition sometimes called reactive airway disease. This association is strongest in children who already have a genetic predisposition to asthma.

It remains unclear whether RSV directly causes these long-term problems or whether children who develop severe RSV were already predisposed to respiratory issues. What is clear is that most children who have RSV recover fully without lasting effects, and even those who do experience increased wheezing with subsequent infections often improve as they get older.