How should I manage a cough caused by respiratory syncytial virus (RSV) in an infant or young child?

Management of RSV Cough in Infants and Young Children

Treatment for RSV cough is purely supportive care—there is no effective antiviral therapy for routine use in otherwise healthy children. 1, 2

Core Supportive Management

The cornerstone of RSV management focuses on maintaining adequate hydration and oxygenation while the viral illness runs its course:

• Ensure adequate hydration through oral fluids, or nasogastric/intravenous routes if the infant cannot maintain adequate oral intake 1, 2
• Provide supplemental oxygen if oxygen saturation falls persistently below 90% in previously healthy infants 1, 2
• Use acetaminophen or ibuprofen for fever or discomfort management as needed (never aspirin in children under 16 years) 3, 1
• Consider nasal saline irrigation for symptomatic relief of upper respiratory congestion 1, 2

What NOT to Use

Several therapies have been proven ineffective or are not recommended for routine RSV management:

• Do not use palivizumab for treatment—it has no therapeutic benefit for established RSV infection and is only approved for prevention in high-risk infants 1, 2, 4
• Do not routinely use corticosteroids in the management of RSV bronchiolitis 1
• Do not routinely use ribavirin in otherwise healthy children with RSV 1, 5
• Avoid antibiotics unless there is specific evidence of bacterial co-infection 1, 4

When to Hospitalize

Hospitalization is indicated when infants demonstrate:

• Hypoxemia with oxygen saturation persistently <90% 2, 4
• Severe respiratory distress (increased work of breathing, grunting, retractions) 3, 2
• Inability to maintain adequate oral intake 2, 4
• Age under 3 months (highest risk for severe disease) 2, 4
• Underlying high-risk conditions (prematurity, chronic lung disease, congenital heart disease, immunocompromised status) 3, 2

Criteria for ICU Transfer

Escalate to intensive care if the child demonstrates:

• Failure to maintain oxygen saturation >92% despite FiO2 >60% 3, 1
• Shock or hemodynamic instability 3, 1
• Severe respiratory distress with rising PaCO2 (>6.5 kPa) 3, 1
• Recurrent apnea or irregular breathing 3
• Evidence of encephalopathy or altered mental status 3

Special Population: Immunocompromised Patients

Ribavirin may be considered for severely immunocompromised patients, particularly:

• Hematopoietic stem cell transplant recipients with RSV lower respiratory tract infection 1, 2, 5
• Patients with profound lymphopenia (<100 cells/mm³) 1, 2
• Mechanically ventilated infants with documented severe RSV infection 1, 5

The FDA-approved indication for aerosolized ribavirin is limited to hospitalized infants and young children with severe lower respiratory tract RSV infection, though its use should be restricted to truly severe cases due to concerns about efficacy, safety, and cost 5, 6, 7.

Infection Control: Critical to Prevent Spread

Hand hygiene is the single most important measure to prevent RSV transmission:

• Perform hand decontamination before and after direct patient contact 1, 2, 4
• Use alcohol-based hand rubs when hands are not visibly soiled 1, 4
• Wear gowns for direct patient contact and use gloves with frequent changes 1, 4
• Implement droplet precautions for all children <2 years with respiratory symptoms during RSV season 1

RSV can survive on countertops for ≥6 hours, on gowns for 20-30 minutes, and on skin for up to 20 minutes, making strict infection control essential 1.

Discharge Criteria

A child is ready for discharge when:

• Oxygen saturation consistently >90% in room air for at least 12-24 hours 1, 4
• Clinical improvement with better activity level and improved appetite 1, 4
• Absence of substantially increased work of breathing, sustained tachypnea, or tachycardia 1, 4
• Normal or baseline mental status 1, 4
• Ability to maintain adequate oral intake 4

Prevention Strategies

For future RSV seasons in high-risk infants:

• Nirsevimab (long-acting monoclonal antibody) is now recommended for all infants <8 months entering their first RSV season 1, 2
• Palivizumab prophylaxis may be considered for infants born ≤28 weeks gestation, those with bronchopulmonary dysplasia, or hemodynamically significant congenital heart disease 1, 2, 4
• Avoid tobacco smoke exposure completely—a controllable risk factor that increases RSV hospitalization risk 1
• Encourage breastfeeding to potentially decrease the risk of lower respiratory tract disease 1, 4

Common Pitfalls to Avoid

• Do not overuse antibiotics when there is no evidence of bacterial co-infection—RSV is a viral infection 1, 4
• Do not continue bronchodilator therapy without documented clinical improvement 1
• Do not use palivizumab as treatment for active RSV infection—it is only for prevention 1, 2, 4
• Do not discharge prematurely—ensure oxygen saturation remains stable for 12-24 hours before discharge 1, 4