Coughs, Colds & RSV: How to Tell When Your Child Is Having Trouble Breathing

What causes coughs and colds?

The common cold is caused by viruses, not bacteria, which is why antibiotics do not treat an ordinary cold.

Many viruses can cause cold or cold-like symptoms.

Rhinoviruses are particularly common. Seasonal coronaviruses and many other respiratory viruses can also cause ordinary colds.

Other viruses—including influenza, parainfluenza, respiratory syncytial virus (RSV), and others—can produce symptoms that initially look very similar to a cold.

Typical symptoms include:

• Runny or stuffy nose
• Sneezing
• Sore throat
• Cough
• Fever
• Fussiness or tiredness
• Decreased appetite

Nasal mucus often starts clear and later becomes thicker, yellow, or green.

Yellow or green mucus does not automatically mean your child has a bacterial infection or needs antibiotics.

Most children begin improving within about a week.

However:

• Nasal drainage may last 7 to 14 days
• A viral cough can commonly last 2 to 3 weeks

A lingering cough by itself does not necessarily mean the infection has become bacterial.

What is RSV?

RSV—respiratory syncytial virus—is an extremely common respiratory virus.

Most children have been infected with RSV by about 2 years of age.

For many children, RSV looks like an ordinary cold.

In babies and young children, however, the infection can sometimes spread into the small airways of the lungs and cause bronchiolitis.

Bronchiolitis can make breathing more difficult and can also interfere with feeding.

What does RSV or bronchiolitis look like?

RSV often begins with symptoms such as:

• Runny nose
• Nasal congestion
• Cough
• Fever
• Decreased appetite

If bronchiolitis develops, you may notice:

• Faster breathing
• Wheezing
• Flaring of the nostrils
• Grunting with breathing
• The skin pulling inward around or between the ribs
• Tugging at the lower neck while breathing
• Belly breathing
• Head bobbing with each breath in a young infant
• Difficulty feeding because breathing is taking too much effort

RSV symptoms are often worst around days 3 to 5 of illness and generally improve over the following days.

In very young infants, RSV may look different.

A young baby may have:

• Irritability
• Decreased activity
• Poor feeding
• Pauses in breathing, called apnea

Some young infants may not have an obvious cough or fever.

What does “working hard to breathe” actually look like?

This is one of the most important things for parents to recognize.

Retractions

Normally, the chest and abdomen move fairly smoothly with each breath.

When breathing becomes difficult, you may see the skin pull inward between the ribs, underneath the ribs, or at the base of the neck with each breath.

These are called retractions.

Retractions mean your child is using extra muscles to move air.

Nasal flaring

The nostrils widen with each breath as your child tries to pull in more air.

Grunting

A short grunting sound may occur with each breath, particularly when breathing out.

Head bobbing

In young infants, the head may move forward slightly with each breath because neck muscles are being recruited to help with breathing.

Difficulty eating, speaking, or crying

A baby who repeatedly stops feeding to breathe—or an older child who cannot comfortably speak or cry because of breathing difficulty—is working too hard.

Color change

Blue, gray, or unusually pale lips, tongue, face, or skin are particularly concerning.

How these changes appear can vary with skin tone.

Which children are at higher risk from RSV?

Severe RSV can occur in any infant, but risk is higher in:

• Babies younger than about 6 months
• Babies born prematurely
• Children with chronic lung disease
• Children with certain congenital heart conditions
• Children with significant immune-system problems
• Some children with conditions affecting their ability to clear respiratory secretions

Parents of higher-risk infants should seek medical advice earlier when breathing or feeding begins to worsen.

Caring for coughs and colds at home

Most uncomplicated viral respiratory illnesses can be managed with supportive care.

Fluids

Encourage fluids to prevent dehydration.

For babies, continue:

• Breast milk
• Formula

If congestion makes feeding difficult, smaller and more frequent feeds may be easier.

Nasal saline and suctioning

Saline nose drops or spray can help loosen thick mucus.

For babies, gentle nasal suctioning can be particularly useful:

• Before feeding
• Before sleep
• When nasal congestion is making breathing uncomfortable

Avoid aggressive or constant suctioning, which can irritate the inside of the nose.

Humidified air

If the air in your home is dry, a cool-mist humidifier may help keep nasal secretions from becoming too thick.

Clean the humidifier regularly according to the manufacturer's instructions.

Fever and discomfort

Acetaminophen or ibuprofen may be used when appropriate for your child's age and weight.

Ibuprofen is generally used in children 6 months and older unless a clinician specifically recommends otherwise.

Use fever medicine for comfort rather than simply because the thermometer shows a particular number.

See our Fever in Children guide for weight-based acetaminophen and ibuprofen dosing tables.

Honey for cough

For children 1 year of age and older, a small amount of honey can help soothe coughing, particularly at night.

Never give honey to a baby younger than 1 year because of the risk of infant botulism.

Over-the-counter cough and cold medicines

For children under 6 years old, avoid routine use of over-the-counter cough and cold medicines unless your child's clinician specifically recommends a particular product.

These medicines have limited benefit in young children and can cause side effects or accidental overdosing, especially because many products contain several active ingredients.

For children 6 years and older, some over-the-counter cough and cold medicines may be used according to the package directions, but check the ingredients carefully and avoid giving more than one medicine containing the same drug.

Always read the Drug Facts label and use the measuring device that comes with the medicine.

Codeine

Do not give codeine-containing cough medicine to a child.

Prescription opioid cough and cold medicines containing codeine or hydrocodone are restricted to adults because of the risk of serious breathing problems.

Antibiotics

Antibiotics do not treat:

• Ordinary colds
• RSV
• Viral bronchitis
• Most viral coughs

They may be needed if a clinician diagnoses a separate bacterial infection such as certain ear infections, pneumonia, or bacterial sinusitis.

Preventing coughs, colds, and RSV

No strategy prevents every respiratory infection, but several steps reduce risk.

Wash hands

Wash hands regularly with soap and water, particularly:

• After coughing or sneezing
• After wiping noses
• Before eating
• Before feeding a baby

Cover coughs and sneezes

Cough or sneeze into a tissue or the elbow rather than into the hands.

Avoid sick contacts around young infants

When possible, keep people who are actively ill away from young babies, particularly during respiratory-virus season.

Avoid tobacco smoke and vaping exposure

Secondhand smoke can worsen respiratory symptoms and increases children's risk of respiratory illness.

Children and infants should not be exposed to tobacco smoke or vaping aerosols.

Keep routine immunizations current

Keep your child's recommended vaccines up to date, including seasonal influenza vaccination when eligible.

RSV protection for babies

There are now highly effective ways to reduce the risk of severe RSV disease in infants.

For most babies, protection is provided through either maternal RSV vaccination during pregnancy or a long-acting RSV antibody given to the infant.

Most babies do not need both.

Maternal RSV vaccination

The maternal RSV vaccine Abrysvo may be given during 32 through 36 weeks of pregnancy during the recommended seasonal window.

Antibodies produced by the mother cross the placenta and help protect the newborn during the first months after birth.

Infant RSV antibodies

Infants who are not adequately protected through maternal vaccination may receive a long-acting RSV monoclonal antibody.

Current options include:

• Nirsevimab (Beyfortus)
• Clesrovimab (Enflonsia)

These are antibodies, not traditional vaccines.

They provide immediate passive protection against severe RSV disease during the baby's first RSV season.

For infants younger than 8 months entering their first RSV season, an RSV antibody is generally recommended when:

• The mother did not receive maternal RSV vaccination during pregnancy
• Maternal vaccination status is unknown
• The baby was born less than 14 days after maternal RSV vaccination

Some children at increased risk of severe RSV disease may also qualify for nirsevimab during their second RSV season.

Clesrovimab is currently used for protection during the first RSV season.

Your child's pediatrician can help determine which option and timing are appropriate.

When should I go to the emergency department?

Seek emergency medical care if your child has:

• Blue, gray, or markedly abnormal color of the lips, tongue, or face
• Severe difficulty breathing or struggling for each breath
• Deep or persistent retractions with each breath
• An inability to comfortably cry, speak, drink, or feed because breathing is too difficult
• Pauses in breathing, especially in an infant
• Extreme sleepiness, confusion, or difficulty waking normally
• Severe respiratory distress or rapidly worsening breathing
• A very ill appearance

For a possible life-threatening emergency, call 911.

When should I call the pediatrician or consider urgent care?

Contact your child's pediatrician or seek same-day medical evaluation for:

• Breathing that is noticeably faster than normal
• Mild or moderate retractions
• Nasal flaring
• Grunting
• Head bobbing in an infant
• New wheezing
• Persistent noisy breathing
• Poor feeding, especially in a baby
• Fewer wet diapers or other signs of dehydration
• A baby younger than 3 months with a fever
• Fever lasting more than about 3 days
• Symptoms that improve and then become significantly worse
• Symptoms that are not beginning to improve after about a week
• Ear pain or drainage
• A cough lasting longer than about 3 weeks
• A child with heart, lung, or immune-system disease whose respiratory illness is worsening
• Any time your child simply appears much sicker than you expect from an ordinary cold

Trust your instincts.

If your child's breathing worries you, it is reasonable to have them evaluated.

The bottom line

Most childhood coughs and colds are caused by viruses and improve without antibiotics.

Runny noses may last up to 1 to 2 weeks, and a viral cough can commonly last 2 to 3 weeks.

At home, focus on:

• Fluids
• Nasal saline
• Gentle suctioning for babies
• Comfort
• Honey for children over 1 year
• Rest

The most important thing is watching how your child is breathing.

Retractions, nasal flaring, grunting, head bobbing, difficulty feeding, or significant changes in breathing deserve attention.

Blue or gray color, apnea, severe breathing difficulty, or a child who is difficult to wake needs emergency evaluation.

When you are unsure, contacting your child's pediatrician is always reasonable.