Respiratory syncytial virus (RSV)
RSV is one of the most ordinary winter viruses, and almost every child has had it by the age of two.
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RSV is one of the most ordinary winter viruses, and almost every child has had it by the age of two. In an adult or a school-age child it looks like a cold that drags on, and nobody thinks to give it a name. All the attention it gets is explained by one group: in babies under a year the same virus travels further down and causes bronchiolitis, and there parents need to know precisely what to watch and which signs mean going to hospital rather than waiting until morning. That is what follows, along with what does not work in bronchiolitis despite being prescribed often.
One virus, two different illnesses
In adults, teenagers and older children RSV runs as a cold with a cough: a blocked nose, sneezing, a sore throat, a mild temperature, tiredness. It lasts a week or ten days, and the cough can go on longer. Such a cold is not given a name of its own and the virus is usually not looked for, because it changes nothing.
Immunity after the infection is short and incomplete, so people catch RSV again and again throughout life, more mildly each time. It is adults who most often bring it home, without suspecting that their ordinary cold is nothing of the sort for the baby in the same flat.
In babies under a year the airways are still very narrow. The virus travels down into the smallest bronchi, their lining swells, the space fills with mucus, and air struggles both to get in and to get out. That is bronchiolitis. It begins as the same cold, and on the second or third day a cough, wheezy or rattling breathing and fast breathing are added.
How bronchiolitis usually runs
The illness has a fairly predictable course, and knowing it helps you not to be frightened by the normal and not to miss what is not.
The first two days are an ordinary cold. Then the cough and the breathing get worse, and the third to fifth days are the hardest; that is when most hospital attendances happen. After that the breathing gradually settles, while the cough stays for another two or three weeks, sometimes longer — that is normal and does not mean your child is failing to recover.
The great majority of children get through bronchiolitis at home. A minority end up in hospital, and there are only two main reasons for it: the child is short of oxygen, or has stopped drinking enough. And that is largely what hospital provides — oxygen and fluids, while the virus runs its course.
Signs that mean going to hospital
Watch the breathing and the feeding, not the temperature. Get ready to go if you see any of this:
- the skin pulling in between the ribs, under the ribs or in the hollow above the breastbone with every breath;
- the nostrils flaring with each breath;
- a grunt on breathing out — a short groaning sound with every breath out;
- very fast breathing: in a baby, more than sixty breaths a minute when settled;
- pauses in the breathing, with your child going still for several seconds and not breathing;
- the skin around the mouth, the lips or the tongue turning blue or grey;
- taking less than half the usual amount over several feeds in a row, or being unable to suck because of the breathlessness;
- nappies staying dry for far longer than usual, a dry mouth, crying without tears, a sunken fontanelle;
- floppiness, being hard to wake, or not staying awake;
- your baby is under three months old and has developed a temperature;
- you feel your child is getting worse — a parent's impression deserves trust here.
Pauses in breathing, a blue colour and a child who will not come round mean calling an ambulance at once (in Europe the single number is 112). The rest of the list means being seen today, not tomorrow. And in that situation the person holding the baby should not be the one driving.
Who is at greater risk
The worst illness falls on those with the least reserve, whether by age, by lungs or by heart.
- Babies under three months: their airways are the narrowest, and they are the ones who most often have pauses in breathing, sometimes even before a strong cough appears.
- Premature babies, particularly those born a long way early or who had lung disease as newborns.
- Children with a congenital heart defect, with chronic lung disease, with neuromuscular conditions that make coughing difficult, or with Down's syndrome.
- Children whose immune system is weakened, including those on treatment that suppresses it.
- Children who breathe tobacco smoke at home.
Among adults, severe illness is mostly a matter of older people, especially with chronic lung disease, heart failure or diabetes, and of anyone with a suppressed immune system at any age. In them RSV can end in pneumonia or in a flare of the underlying condition; confusion and sudden weakness in an older person with a cold are a reason to seek help the same day.
Looking after a child at home
There is no treatment that kills this virus, and none is needed: the body deals with it. The job of home care is to make sure your child has something to breathe through and something to drink.
- Offer smaller feeds more often. A baby with a blocked nose and fast breathing cannot suck for long, but will take small amounts willingly. Count the wet nappies — that is the simplest way to tell whether enough is going in.
- Rinse the nose with saline drops and clear the mucus with a nasal aspirator before feeds and before sleep. A baby breathes through the nose, and a clear nose changes a great deal.
- Hold your child more upright in your arms while they are awake. But sleep still follows the usual rules — on the back and flat; the cot should not be tilted.
- If a temperature is clearly making your child miserable, give infant paracetamol or infant ibuprofen at the dose for their weight and age; read the leaflet for the particular product and ask a pharmacist if you are unsure. Aspirin is not given to children and teenagers.
- Do not smoke in the house and do not let smokers in: even the smell on clothing makes the illness worse.
- Do not try to bring the temperature down by sponging with cool water or stripping your child completely.
- Cough medicines are not given to young children: they bring no benefit and can bring side effects.
- Honey is not given in any form to babies under one year.
What does not work in bronchiolitis
This is worth knowing in advance, so that you are not hunting for "real treatment" and not agreeing to things you do not need.
Antibiotics do not act on viruses and do not help in bronchiolitis. They do not shorten the illness, do not prevent admission and do not protect against complications, while they do cause diarrhoea and rashes and drive bacterial resistance. An antibiotic is only needed when a doctor finds signs of an added bacterial infection, and that is a separate decision rather than an insurance policy.
Inhaled bronchodilators generally do not help in typical bronchiolitis in a baby either: the mechanism here is different from asthma, because the airways are blocked with mucus rather than squeezed shut by spasm. Oral steroids, chest physiotherapy for drainage and cough suppressants have not shown benefit either.
What works is the simple things: fluids, a clear nose, watching carefully and, if it comes to it, oxygen in hospital. In this illness, the feeling that "they didn't give us anything" means that nobody gave you anything unnecessary.
Lowering the risk
Avoiding RSV altogether is not possible — it is wherever people are. But a baby's most vulnerable weeks can be spent more carefully.
- During the season, keep a newborn away from anyone with a cold and away from crowds, particularly if they were born early or have a heart or lung condition.
- Wash your hands before picking your baby up, and ask everyone else to do the same. The virus survives easily on hands and objects: wipe toys and surfaces regularly, and use disposable tissues and throw them away straight after.
- Breastfeeding slightly lowers the risk of severe illness.
- A smoke-free home is one of the few measures that genuinely changes the outcome.
There is also protection by medicine. Ready-made monoclonal antibodies exist that are given to a baby before the season or soon after birth and that appreciably reduce the risk of severe bronchiolitis and admission; they are not a vaccine and protect for one season only. Vaccination exists too — for pregnant women, so that antibodies pass to the baby and protect them through the first months, and for older adults. Which products are available, who is eligible and at what point they are given is set by your country's immunisation schedule, and the differences between countries are substantial. That is a question for your own doctor, not for a page on the internet.
Online consultation
A remote appointment settles two questions well. The first: whether this is an ordinary cold or already bronchiolitis, and what stage it has reached. The doctor will ask which day of the illness you are on, how your child is breathing and feeding, how many wet nappies there have been, will ask to see how the chest moves on breathing in, and will explain what to watch over the next twenty-four hours and which signs mean setting off. The second: what to do about adults and older relatives in the household who have long-term conditions, and whether vaccination is worth raising with a doctor. It is also a good place to go over treatment already prescribed — why an antibiotic has been given, for instance, and whether there are grounds for it. The signs in the list above are not assessed remotely: difficulty breathing, pauses, a blue colour and refusal to drink need examination, and some of them need an ambulance.
This material is for information only and does not replace medical advice.
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