What is the treatment for Respiratory Syncytial Virus (RSV) infection in children?

Treatment of RSV Infection in Children

The treatment of RSV infection in children is purely supportive care—there is no specific antiviral therapy for routine use, and management focuses on maintaining adequate hydration, oxygen supplementation, and respiratory support until the child's immune system controls the infection. 1, 2, 3

Primary Treatment Approach: Supportive Care Only

• Hydration is the cornerstone of management—assess fluid intake and provide oral fluids if tolerated, or use nasogastric/intravenous routes if the child cannot maintain adequate oral intake 1, 2, 3

• Oxygen therapy should be provided when oxygen saturation falls persistently below 90% in previously healthy infants, using low-flow nasal cannula or face mask 1, 3

• Fever and pain management with acetaminophen or ibuprofen as needed 3

• Nasal saline irrigation may provide symptomatic relief for upper respiratory symptoms 3

Critical Monitoring Parameters

• Monitor oxygen saturation levels, respiratory rate and work of breathing (especially retractions), ability to maintain oral hydration, and mental status 1

• Patients on oxygen therapy require at least 4-hourly observations including continuous oxygen saturation monitoring 1

• Clinical improvement should occur within 48-72 hours, including decreased fever, improved respiratory rate, decreased work of breathing, and stable oxygen saturation 1

Hospitalization Criteria

• Admit if the child has:

  • Hypoxemia (SpO2 persistently <90%) 1, 2, 3
  • Signs of severe respiratory distress with retractions 1
  • Inability to maintain adequate oral intake 1, 2
  • Underlying high-risk conditions (prematurity, chronic lung disease, congenital heart disease, immunocompromised status) 2, 3

• Escalate to intensive care if:

  • Worsening respiratory distress despite supplemental oxygen 1
  • Oxygen requirement of FiO2 ≥0.50 1
  • Development of apnea or persistent grunting 1
  • Altered mental status or sustained tachycardia 1

What NOT to Use: Common Pitfalls

• Palivizumab has NO therapeutic benefit for treating established RSV infection—it is only approved for prevention in high-risk infants and should never be used as treatment 2, 3, 4

• Do NOT routinely use antibiotics unless there is clear evidence of bacterial co-infection (clinical deterioration, increased inflammatory markers, no improvement within 48-72 hours) 1, 2, 3

• Do NOT routinely use corticosteroids in the management of bronchiolitis 3

• Ribavirin should NOT be used routinely in children with bronchiolitis 3

Special Population: Immunocompromised Children

For immunocompromised children (HSCT recipients, solid organ transplant, active chemotherapy, profound lymphopenia), a different approach applies:

• Ribavirin is the primary antiviral option for hematopoietic stem cell transplant patients and severely immunocompromised individuals with RSV lower respiratory tract infection 3

• Aerosolized ribavirin is the primary form for mechanically ventilated patients with documented severe RSV infection 3

• Systemic ribavirin (oral or intravenous at 10-30 mg/kg/day in 3 divided doses) can be used for patients unable to take oral medication 3

• Consider combination therapy with IVIG or anti-RSV-enriched antibody preparations for allogeneic HSCT patients with lower respiratory tract disease 3

• Defer conditioning therapy for patients with RSV infection planned for allogeneic HSCT 3

Prevention Strategies (Not Treatment)

• Nirsevimab, a long-acting monoclonal antibody, is recommended by the CDC for all infants <8 months entering their first RSV season as a single dose—this represents a significant advance over palivizumab 1

• Palivizumab may be administered monthly during RSV season for prophylaxis in high-risk infants (premature birth ≤35 weeks, bronchopulmonary dysplasia, hemodynamically significant congenital heart disease) 5, 3, 4

• Strict hand hygiene is the single most important measure to prevent transmission—hand decontamination before and after patient contact using alcohol-based rubs 3

• Breastfeeding is recommended to decrease risk of severe lower respiratory tract disease 3

• Avoid exposure to passive smoking and keep infants away from crowds and sick contacts 3

Infection Control in Healthcare Settings

• Hand decontamination before and after direct patient contact is crucial to prevent nosocomial spread 3

• Use alcohol-based rubs if hands are not visibly soiled 3

• Wear gowns for direct contact with the patient and use gloves with frequent changes 3

• Programs implementing strict hand hygiene and droplet precautions have decreased nosocomial RSV transmission by 39-50% 3