A refresher on best interventions for common respiratory disorders in children.
Most respiratory infections present as mild symptoms of the common cold. However, some viruses, such as respiratory syncytial virus (RSV), can cause significant morbidity and mortality, particularly in infants.1 Throughout the United States, respiratory illnesses are a leading cause of hospital admissions in children. It is of utmost importance to discuss prevention strategies with parents and caregivers to mitigate the spread of these infections.
A major strategy in preventing severe infection from respiratory illnesses is immunization, specifically against influenza, COVID-19, and now RSV. In July 2023, the FDA approved the use of nirsevimab-alip (Beyfortus), a monoclonal antibody that protects against RSV lower respiratory tract infections.2 The vaccine, which is for infants and children up to 24 months, is administered as a single dose.3 This is a significant alternative to palivizumab (Synagis), another monoclonal antibody against RSV, that is administered monthly during RSV season and is available only to children deemed high risk.4 In August 2023, the FDA approved Abrysvo (respiratory syncytial virus vaccine), the first vaccine approved for use in pregnant women to prevent lower respiratory tract disease (LRTD) and severe LRTD caused by RSV in infants from birth through 6 months. According to study results, this vaccine reduced the risk of severe LRTD by 81.8% and 69.4% within 90 and 180 days after birth, respectively.5
Like RSV, the influenza virus often causes symptoms similar to the common cold. However, children younger than 5 years and children with chronic health conditions are at especially high risk for developing complications of the flu, such as pneumonia, encephalopathy, and even death. Each year, millions of children get the flu and thousands are hospitalized with complications of the virus. From the 2004-2005 to 2019-2020 flu seasons, pediatric flu-related deaths reported to the CDC ranged from 37 to 199 deaths during the regular flu season. 6 However, during the 2019-2020 flu season, statistical modeling suggests that approximately 434 deaths may have occurred—more than the 199 flu-related pediatric deaths that were reported.6 Notably, among children who died because of flu-related complications, approximately 80% were not fully vaccinated against influenza.6 A 2022 study showed that in children, flu vaccine effectiveness was 75% against life-threatening complications of influenza.7
Annual vaccination against influenza is the best protection against development of serious complications of the virus. It is particularly important that children who are at higher risk of developing complications get vaccinated. This includes children with asthma, cystic fibrosis, chronic lung disease, cerebral palsy, epilepsy, developmental delay, spinal cord injury, muscular dystrophy, congenital heart disease, sickle cell disease, diabetes, kidney or liver disorders, immunocompromised children with HIV/ AIDS or cancer, or obesity. Additionally, vaccinating pregnant women during any trimester of pregnancy helps protect their babies during the first several months of life when they are too young to get vaccinated.
During the 2021-2022 flu season, 65% of children who were hospitalized with influenza had at least 1 preexisting chronic health condition (eg, asthma, obesity). The flu vaccine decreases the risk of developing severe respiratory infections due to the influenza virus by 40% to 60%8 and has been shown to decrease missed school days, flu-related hospitalizations, and death related to influenza. Unfortunately, during the 2022-2023 flu season, only 64% of children aged 6 months to 4 years were vaccinated, 56% of children aged 5 to 12 years were vaccinated, and 47% of adolescents aged 13 to 17 years were vaccinated.9
Each season, the flu vaccine is quadrivalent, protecting against 4 different flu viruses, and is updated to protect against the 4 influenza strains that are predicted to be the most common during the upcoming flu season. There are 2 flu vaccine formulations available: injection or nasal spray. The injectable influenza vaccine is approved for individuals 6 months and older, and the nasal spray is approved for individuals 2 years and older. In general, children 6 months and older are eligible to get the flu vaccine every year, ideally in September or October.
Many studies have looked at the safety of influenza vaccines in children and have shown very good safety profiles and few adverse effects. Results of one such study showed that some common reactions (local and systemic) to the flu vaccine were pain, redness, or tenderness at the injection site, and irritability, fatigue/malaise, headache, and/or myalgias systemically.10 In the United States, another study showed that 1 in 5 children have a parent who reports vaccine hesitancy (“mental state of holding back in doubt or indecision regarding vaccination”), which leads to 26% fewer vaccines administered against influenza in children.11 Therefore, as providers, it is of utmost importance to inform, counsel, and educate parents and caregivers about the benefits of vaccination.
Wearing face masks can reduce the transmission of respiratory infections and is an important public health measure. School districts vary on face mask policies. If a child chooses to wear a face mask in school, it is important to choose one that fits well and is comfortable. Pediatricians may wish to recommend that children be sent to school with an extra mask each day and to label the child’s mask.12
A poll of more than 475 parents of school-aged children found that nearly half of parents felt that having their child wear masks in school negatively impacted their child’s education, social interactions, and mental and emotional health.13 Although it may take several years of data to see the full consequences and effects of wearing masks on children’s language development, early data thus far suggest that masking does not significantly impact social or speech skills.14
Pharmacists and other health care providers should remind families that proper handling of masks is important. When a child touches a contaminated mask on the face with his hands, he contaminates not only his hands but whatever else his hands touch. Masks often are improperly fitted to children’s faces and slide down below the nose, leading children to touch the mask to readjust its position, thereby contaminating their hands, which become vectors for viral spread.
Proper hand hygiene is another key public health measure in reducing the spread of severe respiratory infections. Good hand hygiene is strongly advocated by the World Health Organization. A recent meta-analysis looking at hand-hygiene frequency in decreasing the spread of respiratory infections estimated that even 1 episode of hand washing can reduce the daily probability of acquiring an acute respiratory infection by 3%.15 This risk can be extrapolated to a 28% reduction in daily risk of infection with 10 episodes of handwashing. The CDC advocates promoting hand hygiene in schools, as this leads to fewer respiratory illnesses and fewer missed school days. Proper handwashing involves using soap and water for at least 20 seconds or utilizing a hand sanitizer that is alcohol based (with at least 60% ethyl alcohol or 80% isopropyl alcohol) if soap and water are not available.16,17 Using warm water with soap is more effective than cold water, which does not remove microbes and oils as well as warm water.
According to the CDC, school-aged children are not washing their hands enough—or at all, in fact. One study showed that just 58% of girls and 48% of boys in middle school and high school washed their hands after using the restroom, and only a fraction of those students used soap.18 These data indicate the importance of repeating hand hygiene lessons throughout school curricula.
Finally, social distancing may play a very important role in reducing severe respiratory infections in children. Results of a recent study showed that social distancing as a result of the COVID-19 pandemic has decreased the number of common childhood infections, including otitis media, bronchiolitis, croup, influenza, pneumonia, sinusitis, and streptococcal pharyngitis. These common infections are often spread via respiratory droplets. The biggest decrease was in the rates of diagnoses of influenza, croup, and bronchiolitis infections (99.5%, 96.5%, and 92.9% respectively) per 100,000 children.19 These data show the substantial impact social distancing can have on preventing the spread of infection.
Steven M. Selbst, MD, is a professor and vice chair for education in the Department of Pediatrics at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, Pennsylvania.
Lauren Jonas, MD, is a pediatric resident at Sidney Kimmel Medical College at Thomas Jefferson University/ Nemours Children’s Health in Wilmington, Delaware.