What is the management approach for Respiratory Syncytial Virus (RSV) in children, particularly those under 2 years of age or with high-risk conditions such as preterm birth, heart disease, or lung disease?

RSV Management in Children

Acute RSV Infection: Supportive Care Only

The cornerstone of RSV management in children is supportive care—no pharmacologic interventions (bronchodilators, corticosteroids, ribavirin, or antibiotics) are recommended for routine use, as they show no meaningful impact on morbidity, mortality, or quality of life outcomes. 1, 2, 3

Core Supportive Measures

• Oxygen supplementation should be provided if oxygen saturation falls persistently below 90% in previously healthy infants 2, 3
• Hydration support through adequate fluid intake assessment, with intravenous or nasogastric fluids for infants unable to maintain oral intake 2, 3
• Fever and pain management with acetaminophen or ibuprofen as needed 2
• Nasal saline irrigation may provide symptomatic relief for upper respiratory symptoms 2

What NOT to Use

• Palivizumab has zero therapeutic benefit for treating established RSV infection—it is only approved for prevention in high-risk infants and should never be used as treatment 1, 2, 4
• Bronchodilators and epinephrine do not reduce length of hospital stay, decrease mortality, improve long-term outcomes, or prevent progression to severe disease 3
• Corticosteroids are not recommended for routine management of bronchiolitis 1, 2
• Ribavirin should not be used routinely in children with bronchiolitis 1, 2
• Antibiotics should only be used when specific indications of bacterial co-infection exist 2

Prevention: Palivizumab Prophylaxis for High-Risk Infants

Indications for Palivizumab (15 mg/kg IM monthly, maximum 5 doses)

Preterm infants:

• Infants born before 29 weeks, 0 days' gestation who are younger than 12 months at the start of RSV season 1, 4
• Infants born at 29 weeks or later do NOT universally qualify unless they have chronic lung disease or congenital heart disease 1

Chronic lung disease (CLD):

• Infants ≤24 months with bronchopulmonary dysplasia that required medical treatment within the previous 6 months 1, 4
• In the second year of life, only continue if the infant requires ongoing medical support (chronic corticosteroids, diuretics, or supplemental oxygen) during the 6-month period before RSV season 1

Hemodynamically significant congenital heart disease (CHD):

• Infants ≤12 months with acyanotic heart disease receiving medication for congestive heart failure who will require cardiac surgery 1
• Infants with moderate to severe pulmonary hypertension 1
• Decisions for cyanotic heart defects should be made in consultation with a pediatric cardiologist 1
• Infants with hemodynamically insignificant heart disease (e.g., secundum atrial septal defect) should NOT receive prophylaxis 1

Special Populations for Palivizumab Consideration

• Profoundly immunocompromised children <24 months during RSV season 1
• Cardiac transplant recipients <2 years during RSV season 1
• Post-cardiopulmonary bypass: Give an additional dose (15 mg/kg) after cardiac bypass or ECMO, as serum levels decrease by 58% 1

Populations That Do NOT Require Routine Palivizumab

• Down syndrome unless qualifying heart disease, CLD, airway clearance issues, or prematurity (<29 weeks) is present 1
• Cystic fibrosis unless clinical evidence of CLD and/or nutritional compromise in the first year of life 1
• Breakthrough RSV hospitalization: Discontinue prophylaxis immediately, as the likelihood of a second RSV hospitalization in the same season is <0.5% 1

Palivizumab Efficacy and Limitations

• Reduces RSV hospitalization by 45-55% in high-risk populations 5, 4
• No measurable effect on mortality 1
• Minimal effect on subsequent wheezing 1
• Limited to RSV-specific disease prevention, not other respiratory infections 5

High-Risk and Immunocompromised Patients: Ribavirin Consideration

Ribavirin is the only antiviral option for severely immunocompromised patients, particularly hematopoietic stem cell transplant (HSCT) recipients with RSV lower respiratory tract infection, though evidence is based mainly on observational data. 2

Indications for Ribavirin

• HSCT patients with RSV lower respiratory tract disease or at high risk for progression 2
• Severely immunocompromised patients with profound lymphopenia (<100 cells/mm³) 2
• Mechanically ventilated infants with documented severe RSV infection 2

Ribavirin Administration Options

• Aerosolized ribavirin is the primary option for HSCT patients and mechanically ventilated patients 2
• Systemic ribavirin (oral or IV, 10-30 mg/kg/day in 3 divided doses) for patients unable to take oral medication 2
• Combination therapy with IVIG or anti-RSV-enriched antibody preparations may be considered for allogeneic HSCT patients 2

Ribavirin Monitoring

• Monitor for claustrophobia, bronchospasm, nausea, conjunctivitis with aerosolized form 2
• Monitor for hemolysis, abnormal liver function, declining renal function with systemic form 2
• Avoid environmental exposure in pregnant healthcare workers due to teratogenic effects 2

Infection Control: Critical for Preventing Nosocomial Spread

Hand hygiene is the single most important measure to prevent RSV transmission—programs implementing strict hand hygiene and droplet precautions have decreased nosocomial RSV transmission by 39-50%. 2

Infection Control Measures

• Hand decontamination before and after direct patient contact, after contact with objects near the patient, and after removing gloves 2
• Alcohol-based rubs are preferred if hands are not visibly soiled 2
• Gowns should be worn for direct patient contact 2
• Education of personnel and family members on hand sanitation is essential 2
• Palivizumab is NOT recommended for controlling outbreaks of healthcare-associated disease 1

Hospitalization and ICU Criteria

Indications for Hospitalization

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

ICU Transfer Criteria

• Failure to maintain SaO2 >92% in FiO2 >60% 2
• Shock 2
• Severe respiratory distress with rising PaCO2 (>6.5 kPa) 2
• Development of apnea or persistent grunting 2

Universal Prevention Measures for All Infants

• Avoid tobacco smoke exposure completely, as it increases RSV hospitalization risk 2
• Limit exposure to crowds and group childcare during RSV season (November through March in most regions) 2
• Keep infants away from sick contacts 2
• Encourage breastfeeding to potentially decrease the risk of lower respiratory tract disease 2
• Ensure influenza vaccination for the infant (starting at 6 months) and all household contacts 2

Common Pitfalls to Avoid

• Do not use palivizumab to treat active RSV infection—it has no therapeutic benefit 1, 2, 4
• Do not continue bronchodilator therapy without documented clinical improvement 2
• Do not overuse antibiotics when there is no evidence of bacterial co-infection 2
• Do not use palivizumab for nosocomial outbreak control—strict infection control practices are the basis for reducing healthcare-associated RSV disease 1