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A cold virus is creating crises for pediatric hospitals

In the United States, respiratory syncytial virus, or RSV, is creating a health care crisis in the pediatric system, which already has smaller capacity than the adult health system, placing the youngest and most vulnerable children at risk.

RSV, which usually peaks in late fall and continues through the winter, has presented early this year, with dramatically rising cases in recent weeks, creating undue strain on hospital emergency rooms, inpatient units and critical care services.

After nearly two years of masking, physical distancing and rigorous hygiene practices to curb the spread of COVID-19, other respiratory viruses sharply declined in prevalence, but have returned this year with detrimental impact on pediatric hospital systems.

RSV causes the common cold in many people but can cause deleterious and sometimes life-threatening complications in young children. The virus can cause inflammation in the lower airways, causing a condition called bronchiolitis, or inflammation deeper in the airspaces of the lung, causing pneumonia.

Infection in young children often results in difficulty breathing, eating and drinking, risking a need for hospitalization to provide support for breathing or rehydration. Children sometimes need support with a breathing tube and a mechanical ventilator, requiring critical care services to be available.

Yet, the recent surge in RSV cases, combined with hospital shortages in staffing across clinical units, has placed some hospitals back into what could be considered crisis states. Even in non-crisis states, some children may have poorer access to specialized regional pediatric critical care services. This could worsen when regional resources are strained.

Pediatric critical care doctors see the rapidity with which babies with respiratory illness can decline. There are sometimes literally minutes between a baby whose tiny body is able to keep up with breathing with support to a baby who quickly decompensates, requiring swift and skilled intervention to place a tiny tube through the mouth into the airway so that a machine can take over and the body can rest. Without such intervention, a baby whose body becomes overwhelmed may not breathe effectively enough such that their heart and lungs may stop from the strain of the illness.

Currently, pediatric emergency departments are filled with patients needing care but are unable to move patients to inpatient general medicine or critical care beds, leaving children in the emergency department, which is not intended to provide longer-term inpatient care.

Many emergency departments, then, are already in contingency status, utilizing resources in non-traditional ways in order to try to maintain standard of care. In other cases, children are being cared for in emergency departments in predominantly adult facilities or being transferred to distant but available pediatric resources. Some children who are denied transfer to regional pediatric centers that are at capacity are receiving care at adult facilities, which are again stretching resources in non-traditional ways.

Many hospitals are operating at 70 percent or greater bed capacity, sometimes higher in specialized intensive care units, where doctors are specially trained to provide the increasingly intensive therapies that children who are very sick from RSV may require.

We learned fromCOVID that stretching to more than 75 percent capacity resulted in increased mortality for patients. Already, 100 to 300 children die annually from RSV, and approximately 58,000 children younger than 5 require hospitalization.

Although it is too early to know what the impact of this early presentation and increased rate of disease will be, it is reasonable to predict that mortality may increase due to more cases alone, but also because of the strains placed on the pediatric system. For the sake of children, it is imperative to return to the basic principles that helped curb the strain on the health system during the COVID pandemic.

Those basic principles are that preventing spread of the virus will lower the number of children presenting with the disease at one time, reducing the strain on hospital systems. RSV spreads from direct contact with respiratory secretions from infected children. Avoiding transmission can be accomplished by limiting children infected with respiratory viruses from coming into contact with other children. Parents of children with such illnesses should not send children to daycare or school. Schools and daycare centers should continue rigorous hygiene practices and have policies to ensure that infected children are not in these settings. While masking is not generally required to prevent spread of RSV in particular, the virus often co-occurs with others that do spread more easily via droplets, for which masking can be useful. 

We also need regional coordination for availability of pediatric resources to create a separate resource pool. Recent expansion of a pediatric pandemic preparedness network will help. It’s crucial to continue funding and focus on public health preparedness. Health care providers need clear guidance for procedures when there is a risk of entering crisis standards of care. A central database and coordination of bed availability would ensure that a sick child gets the necessary care at a hospital able to provide that level of care.

Policymakers must work with hospital and medical care administrators, as well as health care foundations focusing on children’s health, to ensure enough funding for development of the pediatric workforce. That way, more pediatric resources can become available at more hospitals. Employers should provide families with time off work to care for children who must remain home, or offer resources for child care in the setting of illness.

Ensuring that a sick child is in the right place, with the resources to support them, is the best way to prevent a devastating outcome. The pandemic showed us the tools available and it’s time to use them for the children.