RSV- Don’t Panic?

This week’s guest columnists are Drs. Brian Allen and Chris Fontenot, Family Practice residents at University Hospital and Clinics here in Lafayette.

Winter- the season of holidays, travel, and people congregating indoors. Friends and family share hugs, gifts, food, and germs.  Just as common as sharing good tidings and Mardi Gras are those three letters that strike fear into parents: RSV.

RSV, or Respiratory Syncytial Virus, is the most common cause of a condition called Bronchiolitis.  Bronchiolitis is an illness in babies and toddlers where the smallest airways in the lungs get inflamed, decreasing oxygen delivery to the bloodstream. Worsening inflammation causes a “whistling” sound as the air squeaks through those narrowed airways, a.k.a. wheezing.

Anyone can get RSV.  For people over age 2 and adults, it’s simply a cold.  Only babies under age 2 get bronchiolitis.  Even then, if your kid has RSV, don’t panic. Most babies have only a cold as well. RSV is rampant from November through April, particularly in January and February.  Also know that kids don’t stay immune to RSV: some unlucky babies get it twice in a season!

The basic symptoms of RSV are runny nose and congestion, cough, fever, and decreased appetite.  Babies with colds can have trouble feeding, because clogged noses make it hard to suck the bottle or breast, and breath.  More concerning signs of RSV, when we call it bronchiolitis, are rapid breathing (breathing 60-80 times per minute), wheezing, and worsening feeding.  Kids may have “retractions,” where the skin over the ribcage sucks in as they tug in breaths. Infants may grunt with every breath. Children with grunting, retractions, fast breathing, or worsening drinking need attention immediately.

RSV is highly contagious.  It travels on water droplets that are coughed, sneezed, or breathed out.  The virus lasts up to two hours after landing on surfaces like furniture and counters, where others can unknowingly touch, pick it up, and infect themselves.

“Your child tested positive for RSV” is a painful phrase for parents.  Parents ask, “Are you sure,” and “Will she have to stay in the hospital?”  The answer to “Are you sure”, weirdly, doesn’t matter!  As we alluded above, RSV isn’t the only virus to cause bronchiolitis, that condition with coughing, fever, wheezing, and  congestion- many others cause it too.  We don’t recommend testing most kids for RSV, since whether the test is positive or negative, what’s important is how your child is handling bronchiolitis, not which virus caused it.

The mainstay of treatment is “supportive care.”  The first support is hydration.  It’s important that children drink plenty, to keep mucus moist, thin, and easy to handle. When an infant or toddler can’t drink because of congestion, they begin to dehydrate.  Their mucus gets dried and sticky and gums up their already inflamed airways.

Breast milk or formula are best, but extra clear fluids can help.  Pedialyte is a good option for infants; its designed to hydrate babies if they can’t handle milk.  Babies tend to vomit with bronchiolitis when they gag on mucus and have upset stomachs from swallowing it, and Pedialyte is easier to absorb than milk. However, Pedialyte tastes a little too salty for older children, so these kids can hydrate with dilute juices and sports drinks.  If a kid just won’t drink, he may need admission for IV fluids.

Breathing also needs support.  Bedside humidifiers and nasal saline may help hydrate and thin mucus.  Elevating the head helps noses and upper airways stay clear too. When babies starts to struggle to breathe like we discussed above, need oxygen and other respiratory support, it’s time for admission.  Unfortunately, nebulizer breathing treatments don’t help.  Breathing treatments are often prescribed with bronchiolitis since the symptoms look like asthma, which treatments do help.  However, multiple studies have shown that nebulizers for bronchiolitis are a waste of time and money.

Finally, keeping your child isolated is important for others to not get RSV- it’s highly contagious, and the cough and “viral shedding” last for weeks.  No daycare until baby is fever free and coughing much less.

So don’t panic if your child has RSV. Like we said above, most kids will just have a nasty cold, only a few need hospitalization.  Fever medicine, fluids, patience, and TLC usually take care of it.

Whaddya Mean “It’s Just A Virus?”

Some parents are disappointed with the diagnosis “virus” and not getting antibiotics. The only two times in my career a parent has outright yelled in my face were when I didn’t prescribe antibiotics. Today’s guest columnist, Dr. Seth Koster, explains viruses and when antibiotics are needed.  Dr. Koster is a resident at the University Hospital and Clinics here in Lafayette.

A lot of parents aren’t sure what to expect with their first child.  Did he just cough?  He sneezed twice, is that bad?  Do I need to go to the doctor?  Some things are common, yet seem complicated.  Let’s talk about some common conditions that are usually a virus that get better with a little TLC, and some “red flags,” things that need to be checked right away.

I think my kid is wheezing, should I bring her in?  Many parents hear baby make funny sounds, and call it wheezing.  Sometimes the sound they are trying to describe is the rattling of nose congestion.  True wheezing that we worry about is a whistling, gaspy tone in the lungs.  Either way you would be safe calling your doctor for a next day appointment if the wheezing doesn’t get better.  But if your child seems to be breathing fast or is having to pull in breaths, then he needs to be seen right away.

The vast majority of colds and coughs are viral.  Even with true wheezing, this is usually a virus and not pneumonia, and antibiotics won’t help.  Hundreds of viruses cause coughs and runny noses and wheezing: adenoviruses, rhinoviruses, enteroviruses, and many more.  Antibiotics do not kill viruses.  What kids with these need is supportive care, meaning fluids and fever and pain medicine.  If they get really sick with wheezing and shortness of breath, they may need IV fluids, breathing treatments, and observation in the hospital.

My child is pulling at his ears.  Does she need antibiotics?  Most of the time “ear pulling” is not from ear infection.  Kids pull on their ears when they are stuffy from congestion, if they have a headache, or some kids just play with their ears.  If the child is not fussy and doesn’t have fever, they don’t have to see the doctor.

What if she has fever-rush her to the Emergency Department?  No.  Ear infections may hurt, but that can be controlled with ibuprofen or acetaminophen (Tylenol) for fever and pain.  Over 70% of ear infections are viral and don’t need antibiotics.  That being said, if your child is having ear pain and fever, see your doctor.  After an exam the doctor can decide if antibiotics or pain drops will help.  But ear pain is rarely an emergency that can’t wait until tomorrow.

My child is vomiting, what to do?  Whether vomiting needs to be checked out by the doctor depends on how much and how long.  Some kids are brought in to the ER when they vomit only once or twice, or only for a few hours. However, that is not enough time for a child to get dehydrated, and most will quit vomiting soon after.

A simple “stomach virus” is usually not serious and will resolve in 1-3 days.  If the child vomits, wait an hour for his stomach to settle, then start clear liquids (gatorade, dilute juice, pedialyte), sipping slowly.  After the child has stopped vomiting for about 6 hours, you can start bland foods.  No fast food.  If your child has a fever, ibuprofen or acetaminophen will help with that. For most stomach illnesses antibiotics will not help, and even make vomiting and diarrhea worse.

So when does your child need to be seen?  If she is having worsening belly pain, that is worrisome.  If your child is vomiting all day or is vomiting blood or dark green, bring them in.  If your kid is having diarrhea for more than a week, that is one of the few times an antibiotic may help, since that may be a bacterial illness and not a virus.

Your child will get sick, there’s no avoiding it.  You usually don’t need antibiotics to treat them.  Most of the time your kid just needs rest, fluids, ibuprofen, and TLC.

 

 

 

My Baby Is Choking In Her Sleep!

A frantic mom rushes up to the Triage window in the Emergency Department, her eyes wild.  “My baby is choking!” she cries.  The staff scramble to get the baby in back and assessed.

Yet in the mom’s arms is a pink, calm infant.  After a few moments of reassurance by the triage nurse, the mom begins to breathe normally.  Thus begins a common evening visit to the ED.

Many moms lie awake at night listening to their babies breathe.  Most worry: what if she stops?  Then when baby gets her first cold, mom worries that her worst fear is about to come true.  Mucus in the baby’s nose runs to the back of her throat as she lies flat in bed.  The baby gags, then coughs, then splutters, then gives a single sharp cry, gags and coughs and splutters again.

By this time mom is on her feet and baby in her arms in one panic-driven motion.  Baby continues to gag.  Mom’ mind races between suctioning baby’s mouth with the bulb syringe, giving back blows, or giving mouth-to-mouth breaths.  Maybe she calls the ambulance, sometimes calls a nurse or paramedic friend who lives nearby.  Eventually mom and baby end up at the triage window and baby is back to normal.

What mom has witnessed is a normal event in many little babies’ lives.  Despite mom’s fears, the episode is not life-threatening.  It is not the beginning of Sudden Infant Death Syndrome (SIDS), also called “crib death.”  Baby will not choke to death on mucus or vomit lying on her back in the middle of the night.  The coughing and gagging and spluttering and vigorous swallowing baby does are the normal reflexes babies use to clear her airway. 

The fear that baby will choke to death is made worse by the stories of so many rock-and-roll stars dying of lying on their backs and vomiting.   The problem with theses music icons is that their normal cough and gag reflexes have been numbed by drugs and alcohol so that they can not cough and gag and clear their airways like babies do.  Thus they drown on the little pool of vomit in their throats.

Thus the recommendation by the American Academy of Pediatrics holds true- but babies to sleep on their backs.  SIDS happens twice as often to babies put to sleep on their stomachs because they are more likely to smother in thick bedclothes. 

So what should mom’s do to make babies with colds sleep better?  One thing to try is to put baby to sleep in a car seat, swing, or bouncer.  When baby is upright, the mucus does not hit the back of the throat and cause coughing and gagging.  Strap baby in!  Do not put baby on a pillow, which greatly increases the risk of SIDS.

A second thing to try is a vaporizer at the bedside- indoor air at night is dry, and it dries out mucus so that it is thicker and harder to clear, and airways get more dry and irritated.  A vaporizer putting out mist may moisten baby’s throat and thin the mucus.  Finally, it is okay to give baby tylenol for pain before bedtime- baby may have some sore throat and other pain from the virus that she cannot tell us about.

Next time your baby gets a cold, don’t panic.  Try the car seat for bed, try the vaporizer, try tylenol.  And if baby gags in bed, sure, go ahead and call your doctor or your medical neighbor.  But if baby recovers on her own in a few minutes, take a deep breath yourself- baby is okay!