Children’s hospitals in major U.S. cities around the country are reaching capacity due to an unprecedented spike in respiratory illnesses, and COVID-19 is not the main culprit. Common respiratory viruses that typically cause mild, cold-like symptoms in children — such as RSV (respiratory syncytial virus), rhinovirus and enterovirus — are hitting harder and earlier than expected, multiple experts told TODAY, prompting concern ahead of the winter season.
As hospitals report unusually high pediatric case numbers for this time of year, many physicians are sharing anecdotes about packed emergency rooms and intensive care units on social media. Dr. Maya Maxym, a pediatric hospitalist at Kapi‘olani Medical Center for Women and Children in Hawaii, posted a tweet on Sept. 27, 2022, that went viral.
“We are inundated with multiple simultaneous respiratory viruses (lots of RSV, rhino/enterovirus, others). Kids can not breathe,” Maxym wrote in a reply to her original tweet.
RSV is a common respiratory virus that usually causes mild, cold-like symptoms, per the CDC, but it can lead to more serious complications like bronchiolitis (a type of lung infection) or pneumonia. It causes close to 60,000 hospitalizations in kids every year, NBC News medical contributor Dr. Natalie Azar told TODAY.
Rhinoviruses typically cause the common cold, and enteroviruses often cause mild, respiratory symptoms, but in rare cases, they can both cause severe illness, according to the CDC.
“Many children are visiting the emergency department and being admitted to the medical center with respiratory illnesses. ... Some of them are sicker than what we usually see,” Maxym told TODAY via email. “Cases appear to be higher than ‘busy seasons’ prior to the COVID-19 pandemic.”
Before the emergence of SARS-CoV-2, these viruses followed seasonal trends, peaking each year during the fall and winter, according to a recent CDC report on respiratory virus surveillance among children in the U.S. from 2016 to 2021.
“Although Hawai‘i overall has less seasonality than other states, it is very early in the season to be seeing this much respiratory disease,” Mayxm added.
On the mainland, the same trends are holding true in major cities in the Northeast.
“The children’s hospitals, at least in our area, are very full right now,” Dr. Thomas Murray, associate medical director for infection prevention at Yale New Haven Children’s Hospital in Connecticut, told TODAY.
Last week, RSV numbers (in adults and kids) almost doubled compared to the week before, and rhinovirus cases also increased over the same period, Murray said, referencing Yale’s clinical virology seasonal virus reporting website. “And rhinovirus is making kids quite sick,” he added. “We have seen more children in our intensive care unit with rhinovirus than we typically see.”
He pointed out that prior to COVID, this increase would usually start in November, but “the seasonality is kind of gone at the moment."
“Our hospital and others are really preparing for a surge that could get much worse … but the other thing I’ve learned over the past few years is the unpredictability of things that used to be predictable,” Murray added.
Farther north in Boston, two major hospitals — Boston Children’s Hospital and MassGeneral Hospital for Children — are full right now, according to Boston-area pediatrician Dr. Daniel Summers.
“I’m doing all I can to keep my patients out of the emergency department unless it’s absolutely necessary because I know, no matter where they go, it’s going to be hours before they’re going to be seen,” Summers told TODAY.
Connecticut Children's hospital has also had to rely on temporary units to accommodate all of its RSV cases, and it may need support from state and federal agencies to address the surge, NBC Connecticut reported.
Another children’s hospital in Indiana has been experiencing a surge of RSV cases and hospitalizations since the summer.
“RSV is notorious for causing infections in young infants, especially those under 6 months, and in children that have bad lungs or a bad heart,” Dr. John Christenson, associate medical director of infection prevention at Riley Children’s Health in Indianapolis, told TODAY.
Although RSV usually peaks in the middle of January or in February, Christenson explained, cases have tripled in the last three weeks. “We have tons of kids with bronchiolitis, a respiratory condition you tend to see caused by this virus,” he continued.
“Our numbers of rhinovirus and enterovirus are probably double what we usually (see),” Christenson said, adding that the hospital's also dealing with kids in the ICU due to COVID-19 complications.
“It’s putting stress on health care systems, and this is problematic because … what happens if we have RSV, rhinovirus, enterovirus, and then we have influenza season on top of it?” Christenson said.
Nebraska is also experiencing a steep increase in positive RSV tests much sooner than anticipated — this comes after the state saw RSV cases all summer long, which is "unheard of," according to Dr. Stephen Dolter, chief medical informatics officer at Children's Hospital & Medical Center in Omaha.
Across the South, children’s hospitals are either at capacity or close to capacity right now, Dr. Mark W. Kline, infectious disease specialist, physician-in-chief and chief academic officer at Children’s Hospital of New Orleans, told TODAY. “That’s just the tip of the iceberg of what’s happening in the community,” said Kline.
“We’re being inundated with several viruses that typically we only see in large numbers during the winter,” said Kline. Among these is influenza A. “Our test positivity rate over the past week for influenza A has been 30%. … It’s very unusual to see that in September or October,” said Kline, adding that this may be an early indication that the flu will hit hard this year.
“We have a lot of adenovirus right now. Our test positivity for adenovirus is 17% ... but maybe the biggest concern to us at the moment is enterovirus,” said Kline, adding that the test positivity rate for enterovirus at Children’s Hospital New Orleans is an unusually high 37%. (Adenovirus is another family of viruses that typically cause mild, flu-like symptoms, but the CDC is currently investigating if a type of adenovirus, adenovirus 41, is linked to a recent swath of kids developing hepatitis with an unknown cause.)
The positive tests Kline's been seeing include enterovirus D68, which can lead to severe respiratory disease that can land a child in the hospital or ICU, he said. “Enterovirus D68 is associated with acute flaccid myelitis, an immune reaction to the virus that affects the spinal cord, and that can lead to paralysis."
In a report issued last week, the CDC warned about increased circulation of enterovirus D68 in kids.
Texas Children's, the largest children's hospital in the U.S., is also seeing cases surge across the state ahead of schedule. “We are certainly seeing a high volume of respiratory illnesses in our patients coming into our offices — and earlier,” Dr. Stan Spinner, vice president and chief medical officer at Texas Children’s Pediatrics and Texas Children’s Urgent Care in Houston, told TODAY.
“We’ve seen (RSV) all through the summer, and it’s increased even more since school has started ... and it continues to increase our hospital census for sick kids,” Spinner added.
“We’re (also) seeing a lot of rhinovirus that started this summer, and some of the kids get sick enough to be hospitalized,” said Spinner.
Although COVID-19 numbers have leveled off in Texas, Spinner said the flu is already spreading in Texas and other states. "It's only going to get worse,” Spinner said.
Why are these respiratory viruses surging now?
There are several possible reasons, according to the experts. “One is the SARS-CoV-2 virus itself being introduced into the environment and how that’s affected the circulation of other respiratory viruses,” said Murray.
As Kline explained it, “COVID has has changed a lot of things, and one of the things is what we thought we knew about the epidemiology and the seasonality of respiratory viruses. I think we’re going to have to relearn how these viruses manifest themselves in the era of COVID."
Mitigation measures like masking and social distancing have also suppressed these respiratory viruses for the last few years, leaving many children vulnerable, Christenson said.
According to a recent report from the CDC, many of these seasonal respiratory viruses circulated at lower-than-expected levels between April 2020 and May 2021.
Kline noted that prior to the pandemic, "these viruses would come through every winter, and lots of kids would experience them, so they’d have some degree of immunity that would persist and help protect them in subsequent seasons. This time around, we haven’t had as many of those exposures." He added that there is now a "big susceptible pool of hosts."
Children being back in school without mask mandates and "being exposed to this barrage of viruses that they weren’t getting these past two years" also plays a role, Spinner said, adding that kids often get sick a lot more frequently until their immune system builds up their defenses.
Fortunately, Murray had some words of reassurance: “I think in due time, everybody is going to get their regular immunity back, but there’s just a lot of things circulating right now."
What are the symptoms to look out for?
The symptoms of RSV, rhinovirus, enterovirus (and even COVID-19) are often indistinguishable, said Murray, and typically include a runny nose, cough or a fever. “The majority of kids will be sick for a few days with a cold and then get better,” he added. The treatment for these viruses is largely "supportive," meaning lots of hydrating and managing the airway, Azar explained. For RSV specifically, there's also an antibody treatment available to high-risk groups.
If a child has influenza A, they may experience more body aches and a medium or high-grade fever, said Kline.
Rapid tests can be used at home to rule out COVID-19, but beyond that you would need to go to a doctor’s office or a hospital that can test for the other viruses, said Kline.
“When your child gets sick, just keep a close eye on them and make sure you’re reaching out to your health care provider to get instructions,” said Murray, adding that parents should be extra vigilant with infants, young children and children who are immunocompromised or have underlying health conditions.
Things to watch out for include a fever that does not get better after a few days or does not respond to over-the-counter fever reducers, said Murray, as well as signs of respiratory distress (rapid breathing, wheezing, bluish lips), refusal to eat or drink, persistent vomiting and lethargy. Azar also suggested looking out for irritability and shortness of breath, especially for caregivers of kids who can't communicate yet.
If you've got a sick child on your hands, you may also want to be on alert for signs of AFM, as a child with AFM needs to be hospitalized right away, per the CDC. The main AFM symptoms include sudden onset of arm or leg weakness or loss of muscle tone and reflexes. Some people also develop pain in the legs, neck or back; facial drooping or weakness, including in the eyes; and difficulty swallowing or slurred speech.
“If a child is really just looking or acting worse than they typically would in previous types of similar situations … be sure that your child gets checked out,” said Spinner.
Although most children will recover from these respiratory viruses, a portion will end up in the hospital, and some will end up in an intensive care unit, Kline said.
“Most of the time, it’s a relatively short hospitalization to give them a little bit of extra support (such as oxygen or fluids),” said Murray, adding that children who end up in intensive care may require a breathing tube.
“Hospitalization can happen even in a very healthy kid, and there’s no way of predicting that,” said Spinner, which is why all parents should take steps to keep their child safe.
How to prevent these respiratory illnesses
There is no vaccine for RSV, rhinovirus or enterovirus. So, “protect your kids against what you can protect them from, so vaccinate them against COVID and the flu,” said Spinner, adding that these help prevent serious illness and keep people out of the hospital.
The COVID-19 and seasonal flu vaccine are both recommended for children aged 6 months and older, the experts noted. And some children may need multiple flu shots this year.
Other preventive actions include frequent hand-washing, sanitizing frequently touched surfaces and wearing a mask, said Christenson.
Maxym said she's continuing “to recommend using a high-quality mask in crowded, indoor spaces to minimize exposure to all respiratory viruses, not just COVID-19."
Additionally, try to keep your children away from other kids who have respiratory symptoms, said Murray. “For younger babies, you know they’re at the highest vulnerability, so you really want to keep them away from sick individuals.”
And of course, sick children should stay home.
"Kids going to school with respiratory infections perpetuates and exacerbates these outbreaks," said Kline. “Unfortunately, the viruses are not relenting … so to the extent that parents can continue to give this some attention and do some simple things to help keep their kids safe, I think it will be very beneficial.”