What’s alarming pediatricians about the surge in children’s respiratory infections, the flu and COVID-19

BUFFALO, N.Y. – The request by children’s hospitals nationwide this month that the federal government declare a formal state of emergency given the surge in respiratory syncytial virus (RSV) and flu cases was no surprise to Oscar G. Gómez-Duarte, MD, PhD.

As chief of the Division of Infectious Diseases, Department of Pediatrics in the Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo and director of the Pediatric Infectious Diseases Service, John R. Oishei Children’s Hospital, Gómez has seen firsthand the jump in cases of both RSV and flu, and the resulting increase in hospitalizations of children.

By September, Oishei Children’s Hospital reported having seen more patients admitted to the hospital with RSV than it had seen during the entire 2019-20 respiratory season, along with higher rates of flu infections, some requiring hospitalization.

Gómez says the surge this early in the season is unusual and especially concerning since there are very low vaccination rates for COVID-19 and flu in children; cases may rise this winter, especially among unvaccinated children in addition to the rise in RSV cases.

How would you characterize this season so far for RSV and flu in kids?

“What’s concerning to us are not only the number of infections, but the severity of these infections leading to a high number of emergency room visits and hospitalizations. The surge in cases is putting pressure on hospitals nationwide. This is a very dramatic increase over what we normally see, especially at this point in the season. This year, we have been seeing significant increases in cases and this is even before the winter season has begun. We saw RSV cases peak over the summer this year and then another peak was reported in October. This RSV infections pattern is quite different from what we normally saw pre-COVID-19 pandemic.”

How do you think COVID-19 has influenced this increase in other respiratory viruses?

“It’s very possible that this jump in respiratory viruses that we are seeing now is related to the dramatic changes in community behavior during the past two years due to the COVID-19 pandemic.

“Those behaviors significantly limited the normal exchange of viruses that people typically have through interactions with each other. That’s especially true of young children, who exchange different viruses with each other at day care, at school and public gatherings. That exposure allows children to develop a natural immunity to common respiratory viruses at a young age.

“During much of the pandemic, that exchange of viruses wasn’t happening, and there was a gap in natural protective immunity. Now that children are again attending day care and school and other gatherings, getting exposed to these viruses that they haven’t been exposed to in the past two years has resulted in a high peak of infections and an overwhelming number of ER visits and hospital admissions. We are seeing increases especially in RSV, and some of these cases are severe.”

What factors make children especially susceptible to developing RSV?

“RSV tends to affect the very young, those under 2 years of age. Infants at the highest risk are those who were born prematurely or who are immune-compromised.”

Is it mostly children with underlying conditions who are being hospitalized with RSV and/or flu?

“We are seeing hospital admissions for RSV and/or flu among previously healthy children with RSV who have no comorbidities; but we are also seeing it in children with underlying conditions, such as asthma, cardiac conditions, neurological disorders, among other chronic conditions.”  

Are you seeing cases where a child gets infected with two viruses at once?

“Yes, some children are getting what we call coinfections, where they become infected with more than one virus at a time. In some instances, a child becomes initially infected with flu, begins to recover and subsequently comes down with rhinovirus (a common cold virus), RSV or any other respiratory virus. These coinfections tend to be more severe than when the child just has one infection. Different viruses can attack different receptors and use different mechanisms to damage respiratory cells, and this can worsen the disease and, in some cases, may require that the child be admitted to the intensive care unit for management.”

What kinds of treatments are available for children hospitalized with either RSV or the flu?

“While we do have specific treatments for flu and COVID-19, there is no specific treatment for RSV or other respiratory viruses. The mainstay management of respiratory infections is supportive care, such as hydration, control of fever and supplemental oxygen if needed. When the child’s breathing is very compromised, we will put the child on oxygen and, depending on the severity of the respiratory compromise, they may even require more intense measures such as mechanical ventilation.”

Can children be immunized against RSV?

“Passive immunity in the form of monoclonal antibodies is available for premature infants during RSV season. This FDA-approved monoclonal antibody named palivizumab has the ability to block RSV and decrease the severity of the RSV infections.

“There is no approved active vaccine against RSV in the U.S. for children or adults. There is evidence, however, that pregnant mothers do transmit antibodies against RSV to their babies. It was recently reported that pregnant mothers who received an experimental vaccine against RSV did pass those antibodies onto their babies and these infants were at lower risk of developing RSV infections. These developments are very good news for the future, so that maybe pregnant women who are immunized can pass this protection to their babies.”

How concerned are you that along with RSV and the flu, children may begin to get sick from COVID-19 this winter?

“COVID-19 will stay among us in the same way as RSV, influenza and any other respiratory virus. Accordingly, we expect to continue to have COVID-19 infections in children, along with RSV and the flu. Current variants of the COVID-19 virus are becoming resistant to preventive measures such as monoclonal antibodies, although vaccines remain protective.

“It is concerning that the vaccine coverage for COVID-19 and flu vaccine among children in our community is low. Nationally, only 4% of children younger than 5 and fewer than a third of children ages 5 to 11 have had any COVID vaccine series. There is strong evidence that vaccines prevent infection, prevent hospitalizations, and prevent deaths due to COVID-19.

What should parents watch for?

“The first and most important way to protect children is to make sure they get vaccinated against the diseases where vaccines are available, among them the flu and COVID-19.

“If a child acquires a respiratory infection, the child will likely experience upper respiratory symptoms, such as fever, sore throat, cough and nasal congestion.

“Parents should be vigilant for more concerning symptoms, such as shortness of breath. If a parent notices that the child’s breathing is labored and difficult, this is an emergency situation that requires immediate attention, such as taking the child to the closest emergency room or calling 911.

“Most respiratory infections in children, though, are self-limited, and are not associated with shortness of breath. In most cases, a call to the pediatrician for advice is the best measure to take.”