How to Keep Your Child Healthy During RSV Season with Kristin Barrett, MD

Podcast Transcript

John Horton:

Hey, there, and welcome to another Health Essentials Podcast. I'm John Horton, your host.

It's 15 minutes before the school bus is scheduled to roll up, and your kid looks a little iffy. Their nose is drippy, they're coughing over their cereal and they seem to be dragging even more than usual. What do you do? Keep them home for a sick day, or send them on their way with the expectation that they'll perk up during classes? It's a question every parent will face at some point. The judgment call isn't always easy.

To help you make the best decision, we asked pediatrician Kristin Barrett to join us and offer advice on determining when your kid is too sick to go to school. Dr. Barrett is one of the many experts at Cleveland Clinic who visit our weekly podcast to chat about issues common to so many families. Looking at the clock, the bus is getting closer, so let's find out whether your kid should stay or go.

Dr. Barrett, welcome to the podcast. Thanks for stopping by to talk shop.

Dr. Kristin Barrett:

Hey, John, thanks so much for having me on today. This is a perfect time of year to talk about RSV. We're coming right into the season, so this is a very relevant topic for a lot of families right now.

John Horton:

Well, it definitely is. I have to say, when I started doing a little research on RSV, I was shocked to see just how long it has been around. I never remember hearing that much about the virus when my kids were little, but now, it is in the headlines all the time. Why does it seem to be capturing so much more attention?

Dr. Kristin Barrett:

I think there's a couple different reasons for that. RSV is the most common cause of lower respiratory tract infections in infants. It's actually the No. 1 reason that babies under 1 year of age get admitted to the hospital. In addition to that, there's also been some pretty significant advancements in RSV prevention over the last couple years, so that's probably contributing to why you're hearing so much about it recently.

John Horton:

All right. Well, we're going to get into all of that in this conversation. To get things started and get everyone up to speed on RSV, can you give us a little background on the virus? When it typically spreads, the symptoms, and just the larger health concerns and complications that come with it?

Dr. Kristin Barrett:

Yeah. RSV, which stands for “respiratory syncytial virus,” is a viral illness that causes lower airway infections. In babies or kids less than 2, this is known as bronchiolitis. It's called bronchiolitis because the small parts of your airways are the bronchioles. Bronchiolitis is inflammation of the small part of the airways. In older people who have larger airways, usually, RSV is just a head cold. But in younger children, it can cause significant problems with obstruction of those small airways, and that can lead to problems breathing. In addition to the breathing problems, we can see coughing, running nose, wheeziness, fussiness, fevers.

This tends to peak in most areas in the winter. It starts in the fall, around October, and then, usually peaks around December to February. Then, we start to see it trail off in March and April.

John Horton:

Lately, I think one of the headlines I remember seeing … it's been going off-season a little bit, too, hasn't it?

Dr. Kristin Barrett:

It has. I believe it was the 2022 season, we were seeing babies with RSV in June. By October, we had already had high numbers of RSV, which is quite unusual. There's definitely some year-to-year variability.

I haven't seen any RSV in my clinic yet this fall, but I've heard some rumors that the East Coast is starting to pick up some cases already this year.

John Horton:

Wow. It always seems like it hits. Even when you think it's not going to be that bad, it just comes.

Now, one of the things I thought that really makes RSV stand out is just how contagious it is. Can you tell us a little bit about that?

Dr. Kristin Barrett:

Yeah. RSV is definitely one of the more contagious viral illnesses that we know of. There's pretty good evidence that, by the age of 2, almost all babies have been exposed and infected with RSV.

One of the reasons it's so contagious is because it's spread via our respiratory droplets. Whether we're coughing, we've got some sputum, we've got some mucus from our nose — that is how the virus is spread. But part of what makes it so contagious is that it can actually live on surfaces for several hours after it comes out of your body.

John Horton:

Wow.

Dr. Kristin Barrett:

It could be that that Target run, your little baby's touching the cart, chewing on the handle — they can get RSV there without ever being exposed to the person who initially had it.

John Horton:

Oh, that's hard to believe, that something can just live on a surface. Somebody can go by an hour or two before you, they cough, and you touch it, and you pick it up?

Dr. Kristin Barrett:

Exactly. That's part of why RSV is so contagious.

The other thing that makes it pretty contagious is that the period of viral shedding actually lasts for quite a while. After somebody starts showing symptoms, they can spread the virus for days afterward. Some people say anywhere from eight to 11 days of shedding the virus is around average.

John Horton:

Holy cow. Now, how does that compare to the flu and the common cold? Two things that I think a lot of us are really familiar with.

Dr. Kristin Barrett:

With influenza, you can actually infect people before you even start having symptoms, which is one of the reasons flu is so contagious. But I think, in general, probably around a few days for flu to continue to spread after somebody has started having symptoms with it.

Viral illnesses can be tricky because we can shed them for really long times after we've been sick, even when we're feeling better. There have been cases of people continuing to shed RSV for 21 days after they initially had symptoms.

John Horton:

Wow.

Dr. Kristin Barrett:

It sometimes makes knowing when they can go back to daycare ... yeah.

John Horton:

I was going to ask you how long someone is contagious with RSV. It can be weeks.

Dr. Kristin Barrett:

It definitely can be weeks. Obviously, we can't test every baby's boogers for whether or not they're still shedding the virus, so we have some general contagion guidelines that we follow. But most things seem to suggest most people will shed for three to 11 days.

John Horton:

Obviously, you have to know you have RSV.

Dr. Kristin Barrett:

That’s right.

John Horton:

I take it there are tests, if you go in, to determine whether you have RSV versus the flu or just a common cold?

Dr. Kristin Barrett:

Yeah, exactly. In our offices, we have a nasal swab that we can do, and it tests for a couple different viral illnesses. Right now we test for COVID, flu and RSV. Those tests are pretty accurate, and we usually get them back within about 12 to 24 hours. It doesn't necessarily change how we're treating or managing the patient, but it can give us an idea of the clinical course to expect. But also, how long they might be contagious for.

John Horton:

I take it you have to go up real high with that nasal swab, just like the COVID rubs that they did?

Dr. Kristin Barrett:

I try to be pretty gentle. If I can get some good boogers, I feel like that's a pretty good sample.

John Horton:

Well, that's good news.

When you talk about how contagious RSV is, it seems like then protecting everyone around you from RSV has got to be very, very difficult.

Dr. Kristin Barrett:

Absolutely.

John Horton:

Let's talk about some ways in which we can get these protections in place, starting with the RSV vaccine. How effective is this?

Dr. Kristin Barrett:

Last RSV season was the first year that an RSV injection was available to the general baby public. The initial data was great. Essentially, the study showed that, of the babies who got the RSV injection, it reduced their need for medical attention by 70%. The main marker we looked at was if these babies got the injection, did they have to go see their pediatrician? Did they have to go to the ER? Did they need oxygen? Did they need hospitalization? They lumped all of that medical attention into one. Babies who got the injection had 70% less usage of medical facilities compared to babies who did not get the vaccine.

John Horton:

That's huge, especially with that sort of population. I think we had gone over the ages, but you said mostly it's kids under 1 who are most susceptible to it, right?

Dr. Kristin Barrett:

Yeah. Typically, by age 2, everybody has gotten the RSV vaccine — sorry — by the age of 2, most kids have been exposed to and infected with RSV. It tends to cause the most issues in babies less than 6 months of age, just because of how small their airways are. It really doesn't take much inflammation or mucus for the airways to get closed off.

John Horton:

With the vaccine, who really should be looking to get that? What age group are we talking?

Dr. Kristin Barrett:

This vaccine is eligible for all babies between the ages of zero to 8 months who are entering their first RSV season. We will start offering this injection to all of our newborns starting on October 1st of this year. It's typically available from October 1st through sometime in March.

John Horton:

Now, if your kid's a little older than that, if they're about to turn 1, or in between 1 and 1, in that toddling stage, are they not eligible for it? Or is that a case-by-case basis?

Dr. Kristin Barrett:

The only people who are eligible for RSV outside of that zero to 8-month age range are people who are considered to have high-risk diseases. These are kids with congenital heart diseases, cystic fibrosis, other severe pulmonary diseases that put them at high risk.

For the general population, your chance of getting protected is really limited right now to zero to 8 months of age.

John Horton:

Now, have there been any concerns or side effects that have come up with the vaccine? Because that is always a question parents have.

Dr. Kristin Barrett:

Yeah. When this vaccine was given last year and we followed for any side effects, the only side effects that really were reported were localized reactions. This includes redness, pain, maybe a little bit of swelling at the injection site or a rash at the injection site. Even those minor side effects occurred in less than 1% of the babies who got the vaccine.

John Horton:

Yeah. It seems like then, for the protection that you're getting, that's really not much to worry about.

Dr. Kristin Barrett:

I think one thing that might be helpful for some parents to know is that calling this a vaccine is a little bit of a misnomer. This is actually a monoclonal antibody. Most of the vaccines that we give for things like measles, mumps, chicken pox, pneumonia, we are giving a small portion of the virus or the bacteria, usually in the form of a protein. Then, once your body's exposed to that protein, it makes the antibodies to protect you in case you are exposed to this illness.

With this RSV injection, we are actually directly giving the baby antibodies to RSV. They do not have to be exposed to the virus to make antibodies, they are just directly giving medically derived antibodies directly to the baby. The protection is instant.

John Horton:

That's nice to know.

Dr. Kristin Barrett:

Yeah.

John Horton:

Because I know a lot of people do worry about having the virus introduced.

Dr. Kristin Barrett:

Exactly.

John Horton:

This is just introducing the fighters that are going to take on the virus if your kid were to come across it.

Dr. Kristin Barrett:

Exactly.

John Horton:

Wow. Well, that's always good. What other precautions can you take to guard against RSV?

Dr. Kristin Barrett:

Yeah. One other thing I'll throw out there is also, during the last RSV season, there was a new vaccine that was available to pregnant women. I am not the expert on that, I tend to take care of the babies after they pop out. But pregnant women are not eligible to receive an RSV vaccine between 32 to 36 weeks of pregnancy. I encourage any pregnant woman listening who's interested in that to talk to their Ob/Gyn more about that option as well. If moms get the vaccine while they’re pregnant, their baby will not need the RSV injection once they’re born because they'll already have that protection from mom's vaccine. That's one great option.

Then, obviously, we just talk about general precautions. Nobody should be visiting your baby if they're sick. Obviously, people with fevers, coughs, runny nose really shouldn't be holding your baby. If they are sick, wearing a mask, making sure we're washing our hands before we pick baby up are really important.

I'm a big fan of people not kissing babies on the face, especially during the winter. I usually say if somebody needs to put their mouth on baby, it should be the back of the head or their butt, not their hands or their face where you're more likely to expose them to viral particles.

John Horton:

I tend to be a baby kisser. I'll stick to the top of the head if I'm going to do it, or just try to hold off a little bit during the flu season there, and RSV season.

I think disinfecting surfaces, it sounds like, is critical?

Dr. Kristin Barrett:

Yeah, especially since RSV is really good at living on surfaces. Using a disinfectant like a Lysol® that has 99% activity against viruses and bacteria will help reduce the risk of spread on those high-risk surfaces.

John Horton:

It sounds like you should definitely do it when you go out in public. I know my wife is vigilant when you go to the grocery store and getting one of those wipes and hitting the handle of the cart every time. I'm not so good at it. But it sounds like it's a good idea if you've got a baby at home.

Dr. Kristin Barrett:

Yeah. I would say if that's something you are committed to doing, you want … your baby licking the grocery cart, that's probably a good thing.

John Horton:

They just do. Every time I had a kid, I don't know why, they want to lean forward and just mouth that bar, but they just put their mouths on gross stuff all the time.

Dr. Kristin Barrett:

All the time.

John Horton:

It's just part of being a baby. Even if you take every precaution, those pesky germs still seem like they can manage to get through and leave you with a sick kid. What's the best route for comfort and treatment when you hit that point?

Dr. Kristin Barrett:

Yeah. This will depend a little bit on your baby's age. If your baby is over 2 months of age, and they're fussy or they have a fever, then, you can use some Tylenol® to offer some comfort. We don't recommend any Motrin® or ibuprofen use until at least 6 months of age. Once they're 6 months of age, they can use Tylenol and ibuprofen.

Really, there's no other medications, though, on the market for coughing for babies this age. Really, a lot of it is secretion management. The nasal saline spray and a suctioning device is really going to be your best friend.

John Horton:

I still remember using those suction devices a lot. It's a little bit gross.

Dr. Kristin Barrett:

Yeah. I don't know how old your kids are, but they've come a long way in the last couple years.

John Horton:

OK.

Dr. Kristin Barrett:

Now, you have ones you can suck out with a straw in your mouth, and there's electric ones. There's ones that hook up to breast pumps. There's all sorts of variations these days.

John Horton:

I just remember having the little ball thing that you put up there.

Dr. Kristin Barrett:

Yeah.

John Horton:

And you squeeze it, and it would pull it out.

Dr. Kristin Barrett:

Yeah.

John Horton:

My kids are all in their 20s and probably mortified that I'm talking about this.

Dr. Kristin Barrett:

One thing that I talk to parents about a lot when I see a baby with RSV or bronchiolitis is that there's really just not a lot that we can do. It's really secretion management and time. I think sometimes, they find some reassurance that, even if I were to admit your baby to the hospital for RSV, unless your baby is needing breathing support in the form of a breathing machine or oxygen, or they're dehydrated, there's nothing special that the hospital is offering. They don't have any medications we're not offering. They don't have any magic IV or cough medications that we're not giving as an outpatient pediatrician. I think what I usually tell my families are the main things we look for are problems with breathing and signs of dehydration.

John Horton:

It's probably just treatment stuff at home. I take it rest is big. You had mentioned fluids. So make sure that your baby's getting all the fluid intake that they usually do, that that's not going down. Should you try things like humidifiers? Which I know is always a line of defense parents seem to go to.

Dr. Kristin Barrett:

Yeah. Running a humidifier can be helpful, just to keep the airways moist, and it makes it a little easier to get things out. Running a humidifier in the room is definitely not a bad idea. I don't usually recommend adding any medications to that, like menthol, or Vicks®, or things like that because in some babies, that can cause lung irritation to breathe those things in.

Another thing that is sometimes helpful is just having families run a warm, steamy shower, and sitting in the bathroom with the infant because that moisture can help bring out some of those secretions and make them a little easier to suction out.

John Horton:

Now, you had mentioned hospital stays. Obviously, that does happen from time to time. If you're doing these at-home treatments, and this virus, it's going, and going and going, what is the point where you should reach out and get a little more medical attention for your child?

Dr. Kristin Barrett:

I think if you're concerned in general, it's never going to be the wrong answer to call your pediatrician or to schedule an appointment for an assessment.

My usual hard and fast rules for infants is if they have retractions where you can see them sucking in at their ribs by their armpit, that almost always needs medical attention urgently. Or if you feel like they're really having to use their neck and their shoulders to help them breathe, again, medical attention instantly. Then, signs of dehydration. They're not making tears, their mouth is really dry, they've gone more than eight hours without a wet diaper. Those are some pretty easy guidelines or check marks to make. And be like, "If my baby's not doing this, I really need to see my pediatrician."

John Horton:

Yeah. Because it's really hard sometimes when you have a child that young. They can't tell you anything verbally, obviously. It really is up to you to look and catch these subtle signs that maybe there's a little more distress than what you might think.

Dr. Kristin Barrett:

Bronchiolitis can be a rollercoaster. For most babies, the symptoms usually peak around days three to five illness. A lot of times, if I'm seeing baby on the first one or two days, I will tell families, "This may get worse before it gets better." But it can also have times where you're like, "My baby looks really good," and then an hour later you're like, "Oh my gosh, they look terrible." That, unfortunately, is part of bronchiolitis, and it has to do with those little airways getting clogged, and then clearing themselves. They'll look a little better, and then they get clogged again, and they look a little worse. It's really normal to notice some variation in how your baby's doing, even just hour-to-hour, with RSV.

John Horton:

It'll go through that process where you'll see it, it'll pick up and just get gunked up or inflamed, and then, go back a little, and then come roaring back a little bit all through the cycle of the virus?

Dr. Kristin Barrett:

It does. When we were training in the hospital, we would always make jokes because we'd come around and see the baby early in the morning, and be like, "Oh my gosh, they look great. They're going home today." Then, we'd come around with the attending on rounds, and they'd be like, "That baby looks bad. They're not going anywhere." We're like, "Well, bronchiolitis."

Yes. Really, I have seen babies change how they're breathing in an hour or two can make a huge difference in RSV. It is something you have to be diligent about watching because it can change quickly.

John Horton:

Now, I know, because parents — and we are all prone to just worrying, it sounds like despite the possibility of things getting pretty serious, for the most part, it sounds like these RSV cases, they run their course. It's just a matter of making your kid feel better, making sure they have their fluids, they're getting their rest and just letting their bodies work through it.

Dr. Kristin Barrett:

Yeah. Even though this is the most common cause for babies under a year of age to be hospitalized, out of all the babies under a year of age in the US, less than 5% of them will be hospitalized for RSV. Even though the disease itself is really common, severe disease or complications from it are relatively rare.

John Horton:

Well, that's good news, which everyone wants to hear.

Dr. Kristin Barrett:

Yeah.

John Horton:

It seems like a good note to start saying our goodbyes on. Looking at everything that we've talked about, giving parents a game plan to protect their kids from RSV and make them feel better if they get it, do you have any other words of wisdom to share as we start entering that season of coughing and ickiness?

Dr. Kristin Barrett:

I think just being mindful of who is visiting your baby, and who and what they're being exposed to is really important going into this time of year, especially if your baby is less than 2 months of age. I hope you never feel like you can't call your pediatrician and ask them questions or get an appointment. Because really, at the end of the day, that's what we're here for. Bronchiolitis is our bread and butter. If you're worried about your baby or you have questions about RSV, we're always here and happy to answer them.

John Horton:

As far as the vaccine, I take it if you have a child in that age group, get it?

Dr. Kristin Barrett:

Absolutely. Yeah. I wish it was around when my kids were babies.

John Horton:

A perfect way to end. Dr. Barrett, thank you very much for coming on today, and just for sharing so much great information as far as how to protect young kids from RSV.

Dr. Kristin Barrett:

Awesome. Thanks so much, John.

John Horton:

Is a case of the sniffles enough to keep your kid home from school? It might be. Trust your instincts as a parent and give your child a sick day if you suspect they'll have trouble making it through the day. By doing so, you might even help keep that ick from spreading and save another parent from wrestling with the same question.

If you like what you heard today, please hit the subscribe button, and leave a comment to share your thoughts. Until next time, be well.

Speaker 3:

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