Respiratory Illness Surge: Differentiating and Treating RSV, COVID, and Flu in Children

Concern about a respiratory ‘triple-demic.’

Take a walk through many of the country’s pediatric emergency departments (EDs) and inpatient units right now and you will be greeted with the sounds of pinging monitors, suction, and coughing as “respiratory season” settles in.

This will be the first fall and winter that many young children have been back at schools and day cares, largely unmasked, in nearly three years. While respiratory syncytial virus (RSV) and influenza are yearly problems in pediatrics, an unseasonably early and severe surge in RSV is causing an unprecedented number of hospital admissions that is already straining many health systems.

Public health officials are already warning of a “triple-demic” this year as the current RSV surge coalesces with expected rises in influenza and COVID cases. This, of course, does not include the dozens of other respiratory viruses that affect children each winter, including the atypically severe cases of rhinoviruses/enteroviruses and parainfluenza that have already been reported this year.

RSV, influenza, COVID have subtly different symptoms.

While RSV, COVID, and influenza are all viral infections that cause acute respiratory symptoms, they can present with subtly different symptoms. The mainstays of treating these illnesses are the same—supportive respiratory care and adequate hydration—but identifying the causative virus can help clinicians anticipate a child’s illness progression, recognize potential complications, and access illness-specific treatments if they are available. Fortunately, many health care systems in the United States have access to reliable and rapid testing for all three of these viruses.

Influenza.

Influenza tends to have the most generalized symptoms of these three viruses, with children and families often reporting a combination of fever, headaches, sore throat, myalgias, nausea, vomiting, cough, congestion, and sneezing.

Most children with seasonal influenza, especially those who have been vaccinated, will typically recover well at home with symptom management. Children who are immunocompromised or have chronic medical conditions may benefit from antiviral therapy, such as oseltamivir, if the infection is identified very early in its course (typically less than 48 hours since the onset of symptoms). Some children can develop severe symptoms with influenza and require hospital admission for respiratory failure, secondary infections, shock, or dehydration. The CDC reported the first pediatric death from influenza for the 2022-2023 season in its October 28 Weekly U.S. Influenza Surveillance Report.

COVID.

Similar to influenza symptoms in children, COVID symptoms are quite general and often very difficult to differentiate. Positive exposure to COVID and sudden loss of taste or smell are features that may help to distinguish COVID from other illnesses. COVID is also associated with fewer upper respiratory symptoms such as nasal congestion and rhinorrhea than are influenza and other viruses.

As with influenza, most children with COVID do well with symptomatic care at home and will not require hospital admission. Those who do require hospital admission will likely need intensive respiratory support and hydration management. COVID is also associated with a number of post-illness complications, ranging from “long COVID” symptoms of shortness of breath and fatigue to life- threatening multisystem inflammatory syndrome in children (MIS-C). Vaccination of children for COVID has proven to be safe and effective. For children with high-risk medical conditions, antiviral treatments such as remdesivir and monoclonal antibodies may be beneficial in preventing the severe symptoms or other complications.

Respiratory syncytial virus (RSV).

Virtually all individuals will experience RSV infection during their lifetime and most infections are mild, with general cold-like symptoms. Children under two, however, are particularly susceptible to developing more severe symptoms, including those of bronchiolitis (lower airway inflammation).

Symptoms generally start with mild nasal congestion, rhinorrhea, and cough, but in some will progress into significant difficulty breathing, wheezing, and anorexia; many children with RSV will never develop a fever. Often young children and infants with RSV bronchiolitis can be safely managed at home, but hospital admission is indicated for severe difficulty breathing, inability to take oral fluids, or hypoxia. Newborns and young infants may also require hospital admission for observation as periods of apnea are a known complication in this age group.

Beyond supportive respiratory care and hydration support, there are no pharmacologic treatments that have been found to be beneficial in the management of these patients. Palivizumab, a monoclonal antibody injection, is approved for the prevention of RSV in some premature and medically complex infants but there is no generally approved vaccine available for all pediatric patients.

Keeping children with respiratory illness out of the hospital.

As those of us in pediatrics anticipate what the rest of our fall and winter will look like, here are some things we can do to help keep our children with respiratory illnesses out of the hospital:

1. Prevent illness. As always, we should encourage and model good hand hygiene and respiratory etiquette for our youngest patients and their families. Keep the conversation open about vaccination as an effective means of preventing illness.
2. Maximize supportive care. Many aspects of supportive care can be performed effectively by parents at home, keeping children out of the ED and hospital. Teach parents to safely suction babies, review over-the-counter medication dosing with families, and provide detailed information on warning signs to watch for at home.
3. Escalate care. Good outcomes for children with all forms of severe respiratory illnesses are dependent on rapid intervention. As more children present in respiratory distress, encourage open communications between all team members regarding appropriate escalation of interventions.

Amanda Good, MPH, MSN, APRN, CPNP-PC, is a nurse practitioner in emergency medicine at Connecticut Children’s Medical Center and in pediatric rehabilitation at Spaulding Rehabilitation Hospital.