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With masks off and kids back in school, respiratory infections are making the rounds—and it’s not even winter yet. In New York and across the nation, a surge in cases of respiratory syncytial virus, or RSV, is putting parents and doctors on alert.

RSV, a common childhood illness known for producing cold-like symptoms, is on the rise just as flu season kicks off. Add to that a predicted COVID-19 surge this winter and you have the makings of what some experts are calling a “tripledemic” of flu, COVID-19, and RSV—though questions remain about whether all three will peak at the same time.

“Usually, one virus dominates at a time,” notes Jennifer L. Lighter, MD, a pediatric infectious disease specialist and hospital epidemiologist at Hassenfeld Children’s Hospital at �ٺ���Ƶ.

RSV cases in the United States typically peak in late December to mid-February. But that pattern changed with the start of the COVID-19 pandemic in early 2020, when cases nearly disappeared, says Arun Chopra, MD, pediatric service chief at Hassenfeld Children’s Hospital. The Centers for Disease Control and Prevention (CDC) notes that cases fell to historically low levels during the 2020–2021 season.

What is behind the current surge? No one knows for sure, but many experts suspect the end of COVID-19 masking and social distancing is playing a role. Now that more people are out and about—unmasked and in crowds—the virus is circulating again. People who are susceptible to the virus are becoming infected, including some older children who never had RSV before because of masking and distancing over the past two years. The uptick in infections this year may also reflect a more aggressive RSV season.

“It’s probably a combination of all those things that’s leading to more viral spread,” says Dr. Chopra.

Here’s how RSV affects children, how it differs from the flu and COVID-19, and what to do if your child develops symptoms.

What Is RSV?

Respiratory syncytial (pronounced sin-SISH-uhl) virus is a common respiratory illness, one that most children get before the age of 2. Symptoms are often mild, and the infection usually resolves on its own.

However, RSV can lead to serious infection, particularly in infants and young children, and in older children who have certain chronic conditions, such as asthma.

“Once in a while, it can reach the lower airways, and that’s when it can cause a problem,” says Dr. Lighter.

Among children under 5 years of age, RSV accounts for roughly 2.1 million outpatient visits and 58,000 hospitalizations in the United States each year, according to the CDC.

Adults can get RSV, too. And while most cases are mild, older adults and people who are immunocompromised can experience severe symptoms.

Because immunity to the virus is short-lived, it is possible for your child to get RSV more than once—even in the same season. But reinfections are usually less severe than the initial illness.

How RSV Spreads

RSV spreads from person to person mostly through coughs and sneezes. Children can get RSV when respiratory droplets containing the virus enter their eyes, nose, or mouth.

RSV can live outside of the human body for many hours, so it is also possible for children to pick up the virus via contact with contaminated surfaces. That can happen when little hands handle germy objects, such as doorknobs and tables, and then children touch their eyes, nose, or mouth before washing their hands.

Symptoms of RSV

RSV often mimics a bad cold. Your child may have one or more symptoms, such as a runny or stuffy nose, cough, sneezing, or fever. Children may develop additional symptoms over the course of the illness.

In infants, RSV may show up in other ways. Your child may be irritable or less active or less hungry than usual.

In more severe cases, the infection can lead to trouble breathing, and that is when babies require medical care. Their breathing is faster than usual, and they will look like they are working to breathe. Their nostrils may flare, their stomach looks like it is being sucked in, and the rib cage becomes more accentuated. If a baby’s blood oxygen level dips, the lips may appear bluish in color.

When to See a Doctor

Whether your child has RSV or some other infection, do not hesitate to seek help. “Parents’ instincts are usually pretty good,” says Dr. Chopra, so if you are worried, trust your gut and call your pediatrician. Sometimes a doctor can provide help over the phone or by a video doctor visit. Other times they want to see your child in person.

A baby who isn’t eating or drinking as usual and produces fewer wet diapers than usual may be getting dehydrated, observes Dr. Chopra. In that case, says Dr. Chopra, it’s time to visit the pediatrician’s office for evaluation.

Doctors may perform rapid testing to determine whether a child has RSV, the flu, or COVID-19. During an office visit, a doctor can also check a child’s blood oxygen level. If it is low, the doctor can provide addition oxygen and, if necessary, arrange for the child to go to the hospital.

Any time a child is working hard to breathe, that is a sign of distress that needs immediate attention. Children who are having difficulty breathing need to go to the emergency department.

There is no specific treatment for RSV, but doctors can provide supportive care, including supplemental oxygen. “We just make sure that if they need help breathing that they get the help to breathe when they’re in the hospital,” says Dr. Lighter.

In addition, children with fever or dehydration can receive needed medication, fluids, and nutrition during their hospital stay. Most children get better in two to three days, although sometimes very sick children may remain in the hospital longer, adds Dr. Chopra.

How Serious Is RSV?

RSV typically lasts a week or two, and most kids get better on their own. But the virus can cause more serious infections.

Sometimes RSV can lead to bronchiolitis, an infection of the lower respiratory tract, or pneumonia, a lung infection. Infants, especially those who are under 6 months of age, are particularly vulnerable to having more severe RSV.

“The smaller you are, the more at risk you are, partly because your lungs are smaller,” explains Dr. Chopra. “The smaller airways lower down in the lungs get inflamed and get more plugged up and narrow.”

Very young infants and babies born prematurely are even more prone to serious infection, as are children who have heart and lung disease, adds Dr. Chopra.

Among infants younger than 6 months of age who have RSV, roughly 1 to 2 percent may need to be hospitalized, CDC data show.

Also at increased risk are children under the age of 2 who were born with a heart condition or who have another chronic condition. For example, having a condition that makes it difficult to swallow or to cough up mucus, or having a weak immune system, can put a child at greater risk of RSV.

Is It the Flu, COVID-19, or RSV?

RSV produces some of the same symptoms as the flu and COVID-19. Cough and fever are common symptoms of each infection. “They all present very similarly,” Dr. Lighter points out.

So how do you know if your child has RSV and not another respiratory virus? One telltale difference: Kids with RSV usually do not develop gastrointestinal (GI) symptoms, like nausea, vomiting, or diarrhea. GI involvement is more common in cases of the flu and COVID-19 in children, while RSV, for the most part, is limited to the upper respiratory tract.

If a child has moderate to severe symptoms, your child’s doctor can test for each of these viruses to help determine treatment. If it’s the flu, your doctor may prescribe oseltamivir, a medication approved for flu treatment in children 2 weeks of age and older.

Whether it’s the flu, COVID-19, or RSV, you should keep your child home to recover and prevent others around your child from getting sick.

Caring for a Child with RSV

Most children with mild RSV symptoms need little more than supportive care. Make sure that your child is getting lots of rest and drinking enough water and other fluids to prevent dehydration.

If your child is congested, gently squeeze and hold a bulb syringe at the base of the baby’s nostril and release. The suction will extract mucus from your child’s nose. Expel the secretions into a tissue by squeezing the bulb. Repeat the process on the other nostril.

Over-the-counter medication, such as acetaminophen, can help relieve pain and bring down a fever.

Contact your child’s doctor if symptoms persist or worsen. Consider it a medical emergency if your child is having difficulty breathing.

Preventing RSV

Currently, there is no vaccination to protect against RSV. But there are several potential vaccines in the pipeline. “It’s a really exciting time. I think in the next couple of years we’ll have a few choices,” says Dr. Lighter.

In the meantime, everyone can help to lower the risk of getting or spreading RSV by taking the following steps:

• wash hands frequently with soap and water
• cover coughs and sneezes
• help your child keep germy hands away from their eyes, nose, and mouth
• avoid close contact with people who are sick: no kissing, handshaking, or sharing cups and utensils
• disinfect frequently touched surfaces
• stay home if you are sick

Since infants are at greater risk of severe RSV, you may need to take additional precautions if there’s a newborn at home. It’s prudent during respiratory season for visitors to wear a face mask around the baby, at least during the first few months of the child’s life, Dr. Lighter explains.

The most vulnerable infants—those born prematurely or those who have heart or lung disease—may be eligible for a type of medication called palivizumab. The drug is administered by injection once a month for 5 months during respiratory season to prevent severe RSV, explains Dr. Lighter.

It’s also important for anyone eligible for a flu or COVID-19 vaccine to stay to up to date on their shots to help slow the spread of these respiratory illnesses and prevent children from getting sick.

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