A pediatrician in Mount Zion, Illinois, sent a video of a 6-month-old named Natalie to a colleague for advice: The infant's belly was puffing and retracting with every pant as she struggled to breathe, her nostrils flaring and bubbles forming on her lips.
Like dozens of Dr. Caitlyn Berg's patients in recent weeks, Natalie was infected with respiratory syncytial virus, known as RSV. But the nearest hospital had no pediatric intensive care unit, and the one in Springfield - almost an hour west - was completely full.
For Berg, this case was personal: Natalie is her daughter.
"I try to separate my doctor brain from my mom brain," she said. "But watching her breathe, I was terrified."
A drastic and unusually early spike in RSV, a respiratory infection that impedes airways, is overwhelming pediatric units across the United States, bringing long waits for treatment and prompting hospital systems to rearrange staffing and resources to meet the demand.
"Every children's hospital that I'm aware of is absolutely swamped," said Dr. Coleen Cunningham, the pediatrician in chief at Children's Hospital of Orange County, a 334-bed facility in Southern California that is so full that children are being treated right in the emergency room as they wait for inpatient beds - sometimes for more than 24 hours.
RSV is a common seasonal infection, and the vast majority of cases are very mild. But this year, the number of children falling ill - and seriously ill - is significantly greater than usual. Doctors suspect that those who would ordinarily have been exposed to RSV over the past couple of years were insulated from it by social distancing measures and are now driving up the numbers.
"The immune system works by recognition and repetition," said Dr. Sarah Combs, an emergency medicine physician at Children's National Hospital in Washington, D.C., where more than 1,000 children tested positive for RSV between July and early October of this year. "And when you give it a bit of a rest, like we did during the pandemic - and for good reason - we now have a generation of immune-naive children."
The onslaught of cases is coinciding with the seasonal burst of other respiratory viruses like rhinoviruses and influenza, plus the ongoing burden of COVID. It is particularly challenging in regions where pediatric units have shrunk or have even been shuttered in recent years, creating bottlenecks in emergency rooms and shifting the strain to children's hospitals that focus on specialized services like cancer treatment or heart surgery.
Doctors and public health experts are encouraging parents to do whatever they can to protect their children's health in other ways (such as getting flu shots and COVID boosters) since there is no vaccine available for RSV.
Close to 1 in every 500 babies 6 months and younger were hospitalized with RSV since the beginning of October, according to preliminary estimates from the Centers for Disease Control and Prevention. The agency said the true numbers are most likely higher, as many people infected with the virus - even those who have been hospitalized - never undergo testing.
Johns Hopkins Children's Center in Baltimore, which has also reached capacity, is deploying floor nurses to the pediatric emergency department and will soon have children being treated by doctors who normally care for adults - a reversal from two years ago, when the pediatric staff helped treat adult COVID patients.
"It all has a very COVID-esque feel to it," said Dr. Meghan Bernier, the medical director of the pediatric intensive care unit at the children's center. "This is the pediatrician's COVID. This is our March 2020."
RSV predominantly affects the small airways, called bronchioles, that branch off from bronchi in the lungs. Those tiny, strawlike tubules can become blocked by even minuscule amounts of mucus, particularly in infants and young children.
"The smaller you are, the smaller your airways are; it's just physics," Combs said.
Older adults and immunocompromised people are also at increased risk of severe illness from RSV, which even in a typical year kills about 14,000 adults 65 and older and up to 300 children younger than 5.
The infection can be "somewhat unpredictable," said Dr. Meredith Volle, the Springfield, Illinois, pediatrician whom Berg consulted, because what looks like a few days of a bad cold for some patients "very quickly leads to respiratory failure" in others.
Experts in the disease say there is no evidence that a more severe strain of RSV has emerged. Instead, hospitalization numbers are up because in most regions, more children are being infected overall, and "a small percentage of a high number is still a high number," said Dr. Buddy Creech, professor of pediatric infectious diseases at Vanderbilt University Medical Center.
Virtual learning during the COVID pandemic halted the spread of many respiratory viruses that land children in hospitals. RSV became so rare that some second-year residents at Vanderbilt who joined the staff during the pandemic are only now seeing their first pediatric RSV cases, Creech said.
As a result, older children are being admitted with RSV for longer and with more severe illness than usual. Many of them had never contracted the virus before or had been shielded from reexposure as their immunity waned, doctors say.
"When I first saw a 7-year-old with no asthma who needed breathing support in August, I thought, 'What is going on?'" Combs said.
At the height of the pandemic, hospital administrators across the country transformed empty pediatric floors into adult COVID ones. Without a financial incentive to revert them back to pediatrics, some have made the changes permanent.
Now, with virus-prone children back in classrooms and activities, the demand for pediatric beds falls largely on children's hospitals that take transfers from increasingly distant emergency rooms.
Boston Children's Hospital has postponed some elective surgeries to make room for more patients with respiratory illnesses, according to Dr. Daniel Rauch, a hospitalist there.
Doctors in Illinois received a list from the state's Department of Public Health of 36 pediatric intensive care units in eight other states that doctors should call with patient transfer requests. The document, which was reviewed by The New York Times, lists facilities spread over a range of 1,000 miles, from Minneapolis to Chattanooga, Tennessee.
Johns Hopkins Children's Center has received transfer requests from upstate New York, hundreds of miles away, and West Virginia, among other places. But it - like other pediatric specialty hospitals in Orange County; Seattle; and Lubbock, Texas - is already at capacity. It has been shuttling its own overflow of patients to places like Richmond, Virginia, and Philadelphia.
Bringing doctors who treat adults onto pediatric units to assist with the surge there will be complicated, according to Bernier, given the expertise required for high-quality children's care. The reassignment can also be stressful.
"Watching a baby breathe 90 or 100 times a minute and struggle - that can be very disturbing," she said.
About 2,800 miles away from Johns Hopkins, at Seattle Children's Hospital, several patients are now boarded together in single-patient rooms, and areas typically used for procedures have been transformed into bed space, according to Dr. Surabhi Bhargava Vora, an infectious disease physician. Doctors are being prodded to expedite tests and discharge patients as quickly as possible to free up space, she said, in a season "worse than any other RSV season I've ever seen."
Berg, the pediatrician in Mount Zion, ultimately drove 6-month-old Natalie almost an hour to Springfield, where a line had formed just to check into the waiting room at HSHS St. John's Children's Hospital. After they had spent eight hours in the emergency room, a pediatric bed opened up, and by evening, Natalie was moved to the intensive care unit, where she remained for four nights. She is back home now and mostly recovered, though she still has some congestion and an intermittent cough.
One side effect of the surge in respiratory infections, doctors and hospital officials said, is that children who visit emergency rooms for non-life-threatening conditions like broken legs or dog bites will have longer wait times because they rank lower on the triage scale. Parents should, for the sake of both their children and the hospitals, do what they can to help flatten the curve, they said.
For COVID and influenza - unlike RSV - that means getting the available vaccines. (No vaccine for RSV has been authorized in the United States, but candidates made by Pfizer and GSK have both wrapped up late-stage clinical trials. Cunningham, the pediatrician in chief at Children's Hospital of Orange County, is a leader of another trial for a nasal-drop vaccine for children younger than 2.)
"I don't want to say to parents, 'Be scared,' or 'Hide away,' because RSV is not new, and I think stoking that pandemic-era anxiety is damaging," Combs said. "But get your shots, and if your kid bikes, put a helmet on him. This is not the time to go wild at the trampoline park."
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