An early respiratory virus season overwhelms children's hospitals

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Children’s hospitals are overwhelmed by an early respiratory virus season. Their troubles may just be starting.

Since mid-August, the intensive-care unit at Duke Children’s Hospital in Durham, North Carolina, has been nearly full of children sick with respiratory illnesses that normally strike only in the fall and winter.


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“There has not been a day where we can decompress down to, say, 50 percent capacity of our ICU to get a breather,” said Sameer Kamath, a pediatric critical care medicine specialist. “We’ve been at or above 90 percent capacity consistently for the past two months.”

Across the country, children’s hospitals have been grappling with a surge of respiratory illnesses — including respiratory syncytial virus (RSV), rhinoviruses and enteroviruses — that’s hit earlier and harder than recent memory. The demand for beds has been so great that some facilities may set up tents to expand capacity.

While the viruses themselves are part of the mix that pops up in kids every fall and winter, their behavior this year is unusual, stirred up by the pandemic. Social distancing to fight covid stemmed the spread of many of these better-known viruses, which are now exploiting a more susceptible population that has largely abandoned protective measures.

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“The volume [of cases] has been unusual, and they’re causing somewhat worse illness than we would expect,” said Sarah Combs, an emergency medicine physician at Children’s National Hospital in Washington, D.C. “We’re seeing otherwise healthy children who we wouldn’t expect to get more than a sniffle ending up needing help breathing,” she said. “I think that’s why a lot of hospitals are getting to capacity nationwide, it’s both volume and severity.”

Relief may not come for some time. As some of the earlier surging viruses start to wane, others are picking up steam ahead of what could be the worst flu season in several years. Add the possibility of another covid surge into the mix, and the picture becomes even more worrisome for a healthcare workforce worn thin after nearly three years of fighting covid.

“My peers at other institutions and I are trying to figure out the best way to stretch and stretch,” said Kamath, “but we’re afraid we’re reaching a breaking point where something’s gotta give.”

Summer surprise

Most years, cases of common respiratory viruses in kids follow a predictable pattern: Cases start in mid- to late fall and last through the winter. But as much of the nation donned masks and socially distanced to fight covid, these viruses all but disappeared.

From fall 2020 into that winter, “we essentially flatlined, we saw virtually no flu, no RSV,” Combs said. During the 2021-2022 season, as most kids returned to school, these viruses started returning, “but what we’re seeing now feels like a vicious rebound,” Combs said.

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A combination of factors is likely causing that rebound. First, kids are mingling in day cares and schools with much less masking and other protective measures than in the past couple years, providing ample opportunity for viruses to spread. Second, many young kids are getting exposed to these viruses for the very first time because of covid precautions, and older kids may have less immune protection against these viruses than they would have if the pandemic hadn’t happened.

RSV in particular can be dangerous, especially for young kids. It impacts the bronchioles, “the teeniest, tiniest branches of airways,” said Combs. “Block these off with even a little bit of mucus, and you’re in trouble.”

Typically, RSV is riskiest for weeks-old infants, Combs said. But this year, she’s seeing healthy school-age children coming in with RSV and needing low-flow oxygen. “At the more severe end, I think all of my colleagues and I have intubated a higher number of patients,” she said.

Without better national data, it’s difficult to say whether these anecdotes add up to an actual increase in the severity of the average case of RSV or rhinovirus. “As you see more cases, you’re going to see more of those patients who were previously healthy that come in really sick,” said Annabelle M. de St. Maurice, a pediatric infectious disease physician at UCLA Health.

Kids might also be getting sicker because they’re getting infected by more than one virus. “We’re seeing a lot of kids coming in with multiple viruses at the same time, which is part of the reason why we’re seeing more severe illnesses,” said Russell McCulloh, a pediatric infectious disease specialist at Children’s Hospital and Medical Center in Omaha, Nebraska.

Bad news for hospitals

The precise mixture of viruses at play differs region by region, but the result has been the same — stretched hospital capacity, said Mary Beth Miotto, a pediatrician and president of the Massachusetts chapter of the American Academy of Pediatrics.

That’s especially dangerous because there are fewer hospitals for children than for adults, and those kids who need those facilities can’t always get the care they need from adult hospitals if children’s facilities are overwhelmed. Kids’ smaller bodies often need specialized equipment and expertise. At one point this month, a colleague in Boston told Miotto that the closest pediatric ICU bed was in Washington, D.C.

With so many hospitals at or near capacity, some hospitals are cutting back on routine care. “Some hospitals won’t do procedures on kids who would have to go to the pediatric ICU just for a day afterward [to recover],” Miotto said. “So you have kids with chronic or very severe diseases not being able to get their regular care because of this huge backup.”

The backlog also reduces a hospital’s capacity to see new patients. “In the last week, we’ve had children wait so long that they left without being seen by the emergency department or have been hospitalized at another institution,” said McCulloh. Community hospitals, which may not have the capacity to treat really sick kids, are also having more trouble finding open beds nearby to send patients, he said.

Shortages of key health personnel, especially nurses, are compounding the problem, said Miotto. Throughout the pandemic, many hospitals have leaned on travel nurses as a stopgap, but “ones who are trained for pediatrics are scarcer,” she said. School nurses play a crucial role in easing the burden on hospitals, said Miotto, but are also facing high levels of burnout. Nearly 50 percent report mental health conditions, according to a recent survey, including post-traumatic stress disorder, depression and anxiety.


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“These respiratory viruses are driving us crazy,” said Miotto, “But I think it’s just the straw that broke the camel’s back; the whole system is stressed.”

No end in sight

All of this has been happening with two major players — covid and flu — largely out of the picture. But there are signs that may be changing, and hospitals are bracing for what could be a very rough winter.

At the University of Mississippi’s children’s hospital, “influenza, which we had feared was coming in like a lion this year, has arrived,” said Charlotte Hobbs, a pediatric infectious disease specialist. And the hospital continues to see a mix of other respiratory viruses. Nationwide, the flu season is getting an early start across many age groups, and a swell of new omicron variants could drive another surge of covid this winter.

Vaccines could help blunt spikes in covid and flu, giving hospitals a break. But only 9 percent of kids aged 6 months to 4 years have gotten at least one dose of a covid vaccine, according to the Centers for Disease Control and Prevention, and some experts worry flu vaccine uptake could lag this year, too. Other basic measures, like handwashing, staying home when sick and wearing a mask can also ease pressure on hospitals.

“It feels like we’re back to that idea at the beginning of the pandemic, where we were told to do all these good things to flatten the curve, the curve being all those hospitalizations,” Miotto said. “I know the public is tired, but the hospital system doesn’t have much wiggle room, it doesn’t have any fat left.”

Thanks to Lillian Barkley for copy editing this article.

  • Jonathan Lambert
    Jonathan Lambert

    Public Health Reporter

    Jonathan Lambert is a public health reporter for Grid focused on how science, policy and the environment shape our collective well-being.