What are the next steps in diagnosis and treatment for a 4-year-old patient weighing 19 kg with a 3-day history of non-stop coughing, now diagnosed with Respiratory Syncytial Virus (RSV)?

Management of RSV in a 4-Year-Old with Persistent Cough

For this 4-year-old with confirmed RSV and 3 days of non-stop coughing, provide supportive care only—no further diagnostic testing is needed, and avoid bronchodilators, corticosteroids, antibiotics, or over-the-counter cough medications, as none have proven benefit and may cause harm. 1, 2, 3

No Additional Diagnostic Testing Required

• RSV remains a clinical diagnosis and routine diagnostic testing beyond the initial RSV confirmation is not recommended. 2, 3
• Chest radiography should not be obtained unless the child develops signs of severe bacterial infection, respiratory distress, or hypoxia. 4, 1
• Laboratory testing and additional viral panels are unnecessary and do not change management. 5

Treatment: Supportive Care Only

What TO Do

• Maintain adequate hydration through oral fluids; consider nasogastric or intravenous fluids only if the child cannot maintain hydration orally. 2, 3
• Use antipyretics (acetaminophen or ibuprofen) for fever and discomfort to keep the child comfortable. 1
• Nasal saline drops or irrigation may provide symptomatic relief for nasal congestion with minimal risk. 1, 6
• Ensure oxygen saturation remains above 90% if measured; supplemental oxygen is indicated only if saturation falls below this threshold. 2, 3
• Elevate the head of the bed during sleep to help with breathing. 6

What NOT To Do

• Do not prescribe bronchodilators (β-agonists) as they are non-beneficial for RSV bronchiolitis and have adverse events. 1, 2, 3
• Do not prescribe systemic corticosteroids as they provide no benefit in RSV infection. 2, 3
• Do not prescribe antibiotics unless specific signs of bacterial superinfection develop (high fever ≥39°C for 3+ consecutive days, respiratory distress, hypoxia). 1, 2, 3
• Do not use over-the-counter cough and cold medications in children under 6 years due to lack of efficacy and potential for serious toxicity. 1
• Do not use nebulized hypertonic saline or epinephrine as routine treatment. 2, 3
• Do not perform chest physiotherapy as it is not beneficial. 1

Expected Clinical Course

• Most children with RSV bronchiolitis recover within 1-2 weeks, with 90% being cough-free by day 21 (mean resolution 8-15 days). 1, 2
• Initial upper respiratory symptoms (fever, rhinorrhea, congestion) typically precede lower respiratory symptoms (cough, wheezing, increased respiratory effort) by 2-4 days. 2

When to Escalate Care

Immediate Medical Attention Required If:

• Respiratory rate >50 breaths/min for a 4-year-old. 1
• Difficulty breathing, grunting, or cyanosis develops. 1
• Oxygen saturation <92% if measured. 1
• Not feeding well or signs of dehydration appear. 1
• Persistent high fever ≥39°C for 3+ consecutive days. 1

Follow-Up Timing

• Review within 48 hours if symptoms are deteriorating or not improving. 1, 6
• If cough persists beyond 4 weeks, this transitions to chronic cough requiring systematic evaluation including chest radiograph and consideration of protracted bacterial bronchitis with a 2-week antibiotic trial targeting Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. 1, 6

Infection Control and Prevention

• Educate parents on frequent hand-washing as RSV spreads through respiratory droplets and contaminated surfaces, with organisms remaining viable for several hours on fomites. 4
• Minimize exposure to tobacco smoke as passive smoking increases risk of respiratory illness (odds ratio 1.57-1.72). 4
• Avoid contact with sick individuals during the illness and recovery period. 3

Important Caveats

At 4 years old, this child is beyond the typical age for severe RSV bronchiolitis (which primarily affects infants <2 years), so the clinical course should be milder than in younger children. 2, 7 However, the same supportive care principles apply, and the key is avoiding unnecessary interventions that lack evidence of benefit while monitoring for signs of deterioration that would warrant escalation of care.