It was 7:30 a.m. on September 27, 23 hours into a 24-hour shift in the NICU at Children’s Hospital of Philadelphia, when I received a call from my wife, who was concerned about our 18 month old. Exhausted from a sleepless night, I listened as she explained that he was struggling to breathe. He was panting, breathing fast, and looked tired. I told her to take him to the emergency department right away. When I got there, he was wearing a mask attached to a CPAP machine to help him breathe. He was admitted to the intensive care unit later that day.
As a physician working in the NICU, I am no stranger to ventilators, but it was shocking to experience it first hand. Our son was eventually diagnosed with bronchiolitis, a lower respiratory tract infection unique to young children that can lead to shortness of breath and respiratory failure. Our son was lucky to be released from the hospital after a short stay. What he didn’t know, however, was that he was part of the beginning of a surge in viral respiratory infections in children this fall.
The most common cause of bronchiolitis is respiratory syncytial virus, or RSV. Unlike COVID-19, RSV is not new to us. We’ve known about it as one of the leading causes of respiratory illness in children since the 1950s. Every year in the winter months, there are cyclical outbreaks of RSV that send infants and young children to the emergency department, which historically children’s hospitals have been able to handle.
Many predicted that respiratory viruses in children would make a comeback with the relaxation of pandemic restrictions. What was not clear until now was the magnitude of the return.
Here in Philadelphia, the number of children hospitalized with respiratory failure due to RSV is more than double what it has been in years past over a decade. The number of children testing positive for RSV in our community is four times what it is in a typical RSV season. The sheer volume of illnesses has pushed many hospitals to the limit of their capacity.
In our NICU, we are seeing babies admitted daily who are struggling to breathe and need intensive care. Hospitals are full, emergency department wait times are long, staff are understaffed, and we are struggling to care for all the children and families who come seeking care. If this weren’t enough, we are just beginning to see influenza spread significantly for the first time since before COVID-19. For kids, this is a viral season like no other.
The reasons behind the current rise in pediatric respiratory infections are complex and multifactorial, but one of the leading theories is that children incurred an immunity debt from the prolonged period of isolation and physical distancing during the peak of COVID-19.
Most young children experience an upper respiratory tract infection about once a month during the first few years of life, allowing for a slow buildup of protective immunity. This did not happen with children who were young or were born during the pandemic.
Now that COVID-19 mitigation procedures have been relaxed, masks are largely gone, and daycare centers are back at full capacity, a generation of children ages 0-5 who carry this immunity debt are all getting sick. at once. This has also coincided with a national reduction in the number of pediatric health care facilities, hindering our ability to care for children who need to be hospitalized.
After the experience with COVID-19, our country is unlikely to tolerate a return to full-scale lockdowns and the physical distancing required to mitigate the current viral surge. Children’s hospitals are doing everything they can to accommodate this additional capacity as quickly as possible. Beyond this, more creative and targeted approaches are needed.
Nationally, the Biden administration should declare a public health emergency that broadly encompasses this viral surge: not just RSV, but other respiratory viruses as well. This would make federal resources available to address the current crisis.
The Food and Drug Administration should expedite approval of RSV vaccines and monoclonal antibodies. State medical boards should consider temporarily expanding the scope of practice of certain providers and interns to address hospital staffing shortages.
Hospital networks can be creative in maximizing the care that can be provided in the outpatient setting to open up more inpatient beds. City governments should work with healthcare organizations to establish better testing infrastructure to eliminate costs and improve access to the community to help diagnose infections and enable home isolation. Local municipalities should be given the autonomy to introduce masking policies based on the level of respiratory disease in the community.
Families who are concerned or have questions about their children can talk to their doctors or consult professional resources like chop.edu/sickseason to help make decisions about whether they can safely treat their children at home, go to urgent care, or Go to the emergency department for evaluation.
Vaccination is still the best way to protect children. Although we do not yet have a vaccine against RSV, we do have safe and effective vaccines for COVID-19, influenza, and many other viruses that cause serious illness in children. Pediatricians can help answer questions about vaccination, which is the most effective strategy for keeping children out of the hospital.
We don’t know how long this viral surge in children will last, but with increased public awareness and some targeted strategies, together we can keep as many children safe and at home as possible.
Jonathan Knowlton is a neonatal fellow at the Children’s Hospital of Philadelphia.