RSV Management in Babies
Acute Management: Supportive Care Only
The management of RSV infection in babies is purely supportive—there is no effective antiviral treatment for otherwise healthy infants, and the cornerstone of care is hydration and oxygenation. 1, 2, 3
Core Supportive Measures
- Maintain adequate hydration by assessing fluid intake and providing nasogastric or intravenous fluids if oral intake is insufficient 2, 4
- Provide supplemental oxygen if oxygen saturation falls persistently below 90% in previously healthy infants 2, 4
- Use analgesics (acetaminophen or ibuprofen) for fever or pain management as needed 2, 5
- Monitor respiratory status closely, including mental status, work of breathing, and oxygen requirements 2
What NOT to Use in Otherwise Healthy Infants
Do not use corticosteroids routinely—the American Academy of Pediatrics states definitively that steroids should not be used in bronchiolitis management, as no evidence demonstrates improvement in mortality, morbidity, or quality of life 2, 5
- Do not use bronchodilators unless there is documented clinical improvement after a trial dose 2, 4
- Do not use antibiotics unless there are specific indications of bacterial co-infection 2, 5
- Do not use ribavirin routinely—it should be reserved only for severely immunocompromised patients, hematopoietic stem cell transplant recipients, or mechanically ventilated infants with documented severe RSV infection 2, 5
- Do not use chest physiotherapy—it provides no benefit 4
- Palivizumab has no therapeutic benefit for treating established RSV infection and should never be used as treatment; it is only approved for prevention 2, 6
Prevention Strategies
High-Risk Infants: Palivizumab Prophylaxis
Palivizumab should be administered to infants born before 29 weeks gestation who are younger than 12 months at the start of RSV season. 1, 7
Eligibility Criteria by Gestational Age
- Infants born ≤28 weeks gestation: May receive prophylaxis during their first RSV season, whenever that occurs during the first 12 months of life 1, 7
- Infants born 29-31 weeks gestation: May benefit from prophylaxis up to 6 months of age 1
- Infants born 32-34 weeks gestation: Should receive prophylaxis only if they have at least one of these risk factors AND are born within 3 months before or during RSV season: (1) child care attendance, or (2) siblings or other children <5 years living in the household 1
- These infants receive a maximum of 3 doses or until 90 days of age, whichever comes first 1
Other High-Risk Groups Eligible for Prophylaxis
- Chronic lung disease (CLD) of prematurity: Infants ≤24 months who required medical treatment (supplemental oxygen, bronchodilators, diuretics, or corticosteroids) within the previous 6 months 1, 6
- Hemodynamically significant congenital heart disease: Infants ≤24 months, particularly those receiving medication for congestive heart failure, requiring cardiac surgery, or with moderate-to-severe pulmonary hypertension 1, 6
- Profoundly immunocompromised children: Those <24 months during RSV season may be considered for prophylaxis 1
Palivizumab Administration Details
- Dosing: 15 mg/kg intramuscularly monthly throughout RSV season (typically November through March in the Northern Hemisphere) 7, 6
- Timing: First dose should be administered before RSV season starts; if season has begun, give as soon as possible 7, 6
- Number of doses: Typically 5 monthly injections for most high-risk infants 7, 6
- Special consideration: Children undergoing cardiopulmonary bypass should receive an additional dose as soon as possible after the procedure, even if sooner than one month from the previous dose 6
- Efficacy: Reduces RSV hospitalization by 45-55% in high-risk populations 1, 6
Important Safety Considerations
- Severe allergic reactions including anaphylaxis can occur—signs include severe rash, hives, swelling of lips/tongue/face, difficulty breathing, bluish skin color, or unresponsiveness 7, 6
- Bleeding precautions: Use caution in infants with bleeding disorders or thrombocytopenia, as intramuscular injection may cause problems 6
Universal Prevention Measures for All Infants
Hand hygiene is the single most important measure to prevent RSV transmission—hands should be decontaminated before and after contact with the infant using alcohol-based rubs or antimicrobial soap 7, 2
Environmental and Behavioral Interventions
- Avoid tobacco smoke exposure completely—this is a controllable risk factor that increases RSV hospitalization risk 1, 7
- Limit exposure to crowds and group childcare during RSV season (November through March in most regions) 1, 7
- Keep infants away from sick contacts and situations where exposure to infected individuals cannot be controlled 1, 2
- Encourage breastfeeding to potentially decrease the risk of lower respiratory tract disease 1, 7, 2
- Ensure influenza vaccination for the infant (starting at 6 months) and all household contacts 1, 7
When to Hospitalize
Consider hospitalization if the infant has hypoxemia (SpO₂ persistently <90%), signs of severe respiratory distress, inability to maintain adequate oral intake, or underlying high-risk conditions. 2
Criteria for ICU Transfer
- Escalate to intensive care if the infant has worsening respiratory distress despite supplemental oxygen, oxygen requirement of FiO₂ ≥50-60%, development of apnea, persistent grunting, or rising PaCO₂ (>6.5 kPa) 2
- Consider early intubation if respiratory distress worsens or oxygen requirements cannot be met with standard supplementation 2
Special Population: Immunocompromised Infants
Hematopoietic stem cell transplant recipients and severely immunocompromised infants with RSV lower respiratory tract infection should receive ribavirin therapy. 2
Ribavirin Administration Options
- Aerosolized ribavirin: Primary option for mechanically ventilated patients with documented severe RSV infection 2
- Systemic ribavirin: Can be administered orally or intravenously (10-30 mg/kg/day in 3 divided doses) for patients unable to take oral medication 2
- Combination therapy: Consider combining ribavirin with intravenous immunoglobulin (IVIG) or anti-RSV-enriched antibody preparations for allogeneic HSCT patients 2
Monitoring for Ribavirin Adverse Effects
- Aerosolized form: Monitor for claustrophobia, bronchospasm, nausea, conjunctivitis, and declining pulmonary function 2
- Systemic form: Monitor for hemolysis, abnormal liver function tests, and declining renal function 2
- Pregnancy precaution: Avoid environmental exposure in pregnant healthcare workers due to teratogenic effects 2
Common Pitfalls to Avoid
- Do not continue bronchodilator therapy without documented clinical improvement 2
- Do not overuse antibiotics when there is no evidence of bacterial co-infection 2, 5
- Do not use palivizumab to treat active RSV infection—it has no therapeutic benefit and is only for prevention 2, 6
- Do not stop continuous oxygen saturation monitoring prematurely—infants with hemodynamically significant heart or lung disease and premature infants require close monitoring as oxygen is being weaned 2
- Do not implement inadequate infection control measures—this leads to nosocomial transmission, which is associated with poorer clinical outcomes including increased mortality 2, 8