It’s deep winter again, and in the PICU that means cases of severe infection from respiratory syncytial virus, or RSV, are starting to come in. This virus is the major cause of periodic outbreaks of lower respiratory tract (meaning in the lungs) illness in young children. It is extremely common and highly infectious: its attack rate, meaning the chances of a susceptible person getting the infection if exposed to a case, is among the highest of any virus. Estimates are that as many as 125,000 infants each year are hospitalized with RSV, with many, many more infected less severely. The peak age for those children needing a hospital is between two and five months. It is so common that by early childhood virtually all of us have been infected at least once.

If it’s so common, why don’t we become immune to it? And we don’t become immune — even adults are frequently reinfected, especially adults who spend time with young children. Immunologists don’t know the answer to that question. For one thing, our immune systems may even be involved somehow in causing some of the manifestations of RSV. The problem is not, as with common cold viruses, that there are so many varieties of RSV; there are only two forms of RSV, and getting infected with either of them doesn’t mean you won’t get infected again within a couple of years. So whatever immunity we get from infection is very short-lived. That being the case, it isn’t surprising that efforts to develop a vaccine have been unsuccessful.

Much of the time RSV causes the symptoms of a cold — cough, runny nose, sometimes a low-grade fever. But in very young children, particularly infants, RSV can cause severe pneumonia or bronchiolitis. The latter disorder is an inflammation of the tiniest of the lung’s air tubes, or bronchioles. This inflammation blocks off the little tubes, making it difficult for air to get in, or most characteristically, to get the air out. Babies with severe RSV often need oxygen, some need mechanical ventilators to breathe for them, and a few die. Over the years I have cared for hundreds of children with severe RSV infection in the PICU. It is so common that, during an outbreak, PICUs often run out of available beds.

As for most viral infections, there is no specific treatment for RSV — therapy is, as we say, “supportive.” This means that we use oxygen, frequent suctioning of the child’s respiratory secretions, and, if needed, a mechanical ventilator to support the child while the disease runs its course.

Nearly all children are equally susceptible to getting RSV, but some children are especially prone to develop severe cases when they get it. Former premature infants and those with significant underlying lung problems are especially at risk. For these infants we do have an injection of an anti-RSV antibody that can help; it doesn’t prevent them from getting it so much as make their cases less severe if they do. Unfortunately the injection doesn’t last very long — it needs to be given every month.

How can you prevent your child from getting RSV? That is a difficult question, and a better one is how to postpone your child’s getting it until they are out of the most high-risk age group for severe disease. The only way is to reduce or eliminate exposure to sick children during the peak season, which is usually winter to early spring. It also helps simply to have everyone wash their hands before holding your child.

You can read much more about RSV here.

In a nutshell — none of the preparations sold over-the-counter to treat upper respiratory infections in children work, and all could be dangerous. That’s the conclusion of a recent report by the Food and Drug Administration. You can read about the details of the decision, as well as the history of how and why these cold remedies were regulated in the past, here.

There is a huge market for these products. Ninety-five million packages of them are sold each year, and drug companies spent over 50 million dollars last year marketing them in various ways. The implication of the advertising is that these preparations (most are mixtures of several things) are safe.

In fact, they are not. Poison control centers have received 750,000 calls about them since 2000, and The Centers for Disease Control found that over 1500 children under two were seen in emergency departments owing to their side-effects. The FDA even found 123 deaths linked to their use. Possible side-effects can include hallucinations, dangerous over-sedation, and serious heart rhythm disturbances. Over the years I myself have cared for several children in the PICU who had serious side-effects from them.

The problem isn’t just over-dosing errors. The problem is we don’t know the correct dose for children, and estimating how much to give from adult doses is misleading and dangerous. The fundamental problem, though, is that they just don’t work. In fact, a total of six carefully randomized studies testing these agents in children under twelve all showed they worked no better than placebo — in other words, a sugar pill worked just as well. So using them puts a child at some risk with no benefit.

If you have questions about cold preparations, by all means talk to your child’s doctor about it. But the growing consensus among physicians is simple – don’t use them in small children.

This is something that doesn’t seem, on the surface, to be directly related to critical care, but it really is. One of Dr. Mike Magee’s recent posts on his excellent blog was about an organization called The Rocking Chair Project. The notion is simple. Parents (and grandparents) have known for generations, probably millennia, that rocking a baby is comforting to the child. But there’s more — now we know something as simple as gentle rocking of infants actually has a positive effect on their brain development.

The project began like this. Doctor Magee and his wife told their daughter, a family practice resident physician, to identify a needy mother who had just given birth, and they would donate a gliding rocker to her and her new baby if a family practice resident would deliver the chair to the home, assemble it as part of a home visit, and continue to give close follow-up to the family. The idea took off, and there is now a foundation to continue the project.

I’ve written in several places — this blog, my first book, an op-ed piece in the Denver Post – that disadvantaged kids have a disproportionately high chance of ending up in the PICU. James Heckman, a Noble Prize-winning economist, has shown that early intervention programs, besides giving kids better outcomes, even save money. So if a rocking chair can keep a child away from my PICU, we’ve saved that child from suffering and we’ve saved society some money. It’s win-win, and incredibly low-tech.

I’ve written before about the radiation risk of x-ray studies. Most of this risk is in the form of increased lifetime cancer risk. This is a particular concern for children because lifetime risk is cumulative, and children have much more of their life before them. Computed tomographic scans, or CT scans, use several hundred times the amount of radiation of ordinary x-rays.

A recent article in the New England Journal of Medicine estimated up to a third of all CT scans ordered in children are not really needed. Why all the unnecessary scans? One reason is poor communication between doctors when, for example, a child is transferred from one hospital to another. Another reason is “defensive medicine,” situations in which doctors order a scan because they fear missing something which, although highly unlikely, could get them sued.

The bottom line for parents? Ask your child’s doctor how crucial the CT scan is for your child’s care. From the article: “From an individual standpoint, when a CT scan is justified by medical need, the associated risk is small relative to the diagnostic information obtained.” The key is to make sure there is a good medical indication.