Everything you need to know about rapidly-spreading RSV, according to a Houston pediatrician

RSV, a respiratory virus that along with COVID is spreading like wildfire among young children, is nothing new.

Pediatricians typically see cases of RSV, or respiratory syncytial virus, from October through April. But this summer, doctors like Christina Propst, a pediatrician at a private practice in Houston, have seen an unusually-timed explosion of RSV cases in toddlers and babies, resulting in some children becoming severely ill and needing to be hospitalized. Children's hospitals are full, with some like Texas Children's seeing younger kids with both RSV and COVID at the same time.

Pediatricians typically see cases of RSV, or respiratory syncytial virus, from October through April. But this summer has seen an unusual, massive uptick in cases. 



Premature babies and children with sensitive airways, certain cardiopulmonary disorders or immune disorders are at the highest risk of infection. But Propst said this summer in particular, she and other pediatricians are seeing more and more serious infections among previously healthy babies and toddlers. And the looming school year could pose an even bigger threat to already-strained facilities and burnt-out doctors and pediatricians.

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Propst is also a member of the American Academy of Pediatrics’ Council on Children and Disasters and of the Texas Pediatric Society Committee on Infectious Diseases and Immunizations. Here she answers 11 questions parents and the community should know about RSV. 

What are the most common symptoms of RSV - what should parents be looking out for?

The most common symptoms of RSV are runny nose, nasal congestion, fever, cough. That’s usually how it starts. What parents imagine as the typical "cold." For some children, it can progress from there to a more significant, productive, wet-sounding cough and wheezing. And that can reflect an illness called bronchiolitis. RSV bronchiolitis is what ends up requiring hospitalization for a subset of babies and toddlers who do get the infection. Bronchiolitis is an inflammation of the small airways in a baby’s lungs; those airways get inflamed, they secrete mucus, there is a decrease in air exchange and oxygen flow in those areas of the lungs, so that results in wheezing and in an increased work of breathing.

So, a baby who is starting to develop severe RSV bronchiolitis will not just have a runny nose and a cough, but they will be working harder to breathe; they will have air hunger. So they will often have a rapid, shallow breathing pattern, and what is called retractions, meaning you can really see their ribs or their clavicle when they are breathing because they are using all of their muscles to get the air in and out of their lungs. And those babies often have sort of an anxious expression on their face throughout this as well. 

How is RSV spread? It is similar to COVID?

It is. It is less contagious, or less easily transmitted than COVID-19, at least the delta virus, which is so easily transmitted. But it is transmitted the same way so, through aerosolization of respiratory droplets, that’s the main mode of transmission just like influenza. Every kid who is sneezing in daycare has the potential to be spreading these viruses, particularly for those young kids who are too young to mask.

This would be the nightmare scenario: a child could have RSV and COVID and influenza at the same time. So that’s why it’s going to be so important for every child over the age of 6 months to get vaccinated against influenza. And that should be available starting in September in most areas. I think every infectious disease specialist, critical care pediatrician, anyone involved in the care of children - that is probably the most terrible scenario that we see looming. 

How is RSV different from the flu? 

It’s just a completely different organism. Yes, they are both viruses, and they are both respiratory viruses, but they can do different things once you are infected with them. Children with the flu certainly can get severely ill and develop secondary pneumonia and other issues from the influenza virus. But the RSV virus specifically targets the airways and is again, most serious for toddlers and for babies.  

Can adults get RSV?

They can. For adults in particular often it can be that nagging, annoying cough that doesn’t go away. Often they will have a significant cough at night that will continue or persist for several weeks. They just feel kind of run down and worn out. Older people, the elderly, and those who are really immunosuppressed can get severely ill with RSV, but the vast majority of hospitalizations attributed to RSV are among toddlers and babies.

How many RSV cases are you seeing in your practice?

We admit to several different hospitals. I know that at both Children’s Memorial Hermann in the Medical Center and Texas Children’s, the volume is very high right now and for weeks it was extremely high with RSV. Now the number of COVID cases is piling up as well, so that’s why we are really in a crisis. We also have some children who are requiring hospitalization for those post COVID symptoms like MIS-C and then there is the really unfortunate subset who are hospitalized for both RSV and COVID. 

Are there any reasons being discussed in the medical community for why we are seeing such a surge in RSV cases?

Some virologists I have spoken with feel that this past winter, number one, more people got the influenza vaccine so we had a less crushing influenza season than some other recent years. There was more hygiene and more spacing and distancing. There was what some virologists refer to as viral competition, meaning as COVID became more prevalent, it sort of "crowded out" some of the other viruses. And then when COVID subsided a bit, RSV took the opportunity to come roaring back. So there is a lot of discussion about that; I don’t think anyone knows the exact reason.

How is RSV treated?

If there is respiratory failure, full respiratory support by intubating that baby or child and having that child on a ventilator is the way to go. Beyond that, those children with more mild cases, even babies that are treated at home, need really frequent suctioning, often deep suctioning. Which as you can imagine children do not enjoy. But often we will use nasal saline and then use a suction tube to really try to clear out their upper airway. Some babies benefit from inhaled saline or inhaled steam or some babies benefit from inhaled medications or medications that can help decrease mucous production or thickness. There isn’t a specific anti-viral treatment that is widely available to treat RSV.

What are the long-term effects, if there are any?

There can be. For anyone who has been intubated, whether it’s from RSV, pneumonia, flu, COVID, or any serious respiratory condition where they have had respiratory collapse or failure, intubation can have both short and medium-term side effects. You can have something called stridor which is upper airway inflation after being intubated; some people can have vocal cord or laryngeal dysfunction. And of course, if you are at the point where you had to be in the intensive care unit on a ventilator, that is a condition where you can have long-term lung damage.

With RSV we are fortunate that to some extent the children who get it, while it can be life-threatening and there certainly are babies who die of RSV every year in this country, their lungs are still maturing and are still developing so they have a higher potential for lung repair than do older people.

How would you describe your work life these days, and what you are seeing?

This summer has been so unprecedented in terms of the volume of patients in our office who are sick. It’s been relentless. I think what’s most frustrating for so many of us is just trying to balance doing what we can to counsel parents who are reluctant to have their 12 and up kids vaccinated. Even now, we are having to have those conversations and that takes up a significant part of our day, and then we know that in the next three rooms we are going into, at least one kid will have COVID and one will have RSV. Pediatricians are pretty worn out, [but] I wouldn’t say we are hopeless.

Is back to school a major concern, especially with all of the debate over masking? 

We are all bracing ourselves for all of the schools opening up. That is something we are all exhausted and weary and frustrated about. I would say that brings an element of fear if not terror into the picture for a huge number of pediatricians in this country.

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Is there anything people can be doing to help?

Number one would be getting vaccinated as soon as possible. That is the most important thing we can do for ourselves, for our loved ones, for our community, for the country, and just to get us out of this. Because the longer we have a large proportion of the population that is not vaccinated, the more likely we are to get the next variant which could be worse than delta.

Number two is to mask and distance, in particular, to mask. That is a physical barrier to the virus; it prevents you from passing on an asymptomatic case to an unvaccinated baby or child and minimizes your risk of acquiring the virus from others.

Then finally, children under 12 as of right now are still ineligible to get vaccinated. We need the age for the EUA (Emergency Use Authorization) for the COVID vaccines to be lowered, and we needed it a month ago, a week ago, yesterday. Pediatricians are screaming for it. The American Academy of Pediatrics put out a statement essentially urging the FDA to lower the age because we all see this coming and it is not pretty with school starting. It is so critical that schools listen to the experts, listen to the American Academy of Pediatrics, and the CDC, and their recommendations for universal masking in the school setting, particularly indoors. That’s really the last best hope to try and mitigate the spread of the delta variant once school starts among these vulnerable, ineligible children. 

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