Premature babies are vulnerable to RSV infection not only because of their small size, but because their lungs, airways and immune defences are still developing.

KUCHING (Aug 30): For many families of premature babies, birth does not come with the celebration they had imagined.

There may be few congratulatory messages, and there might not even be a chance to hold the baby before he is rushed away to the neonatal intensive care unit (NICU) and placed inside an incubator.

There, the baby will spend what should have been the final weeks or months inside the womb continuing to grow and develop.

And the NICU becomes a second home for both the baby and the family—always beeping, always clinical, and always carrying the quiet tension of one lingering question: “When can baby come home?”

Eventually, the day arrives, but the ordeal may not be over yet.

RSV: A common threat

A premature baby may continue to have vulnerable lungs and a developing immune system, leaving them more susceptible to respiratory infections. And one common virus, the respiratory syncytial virus (RSV), is no pushover.

An RSV infection may become serious enough to require another hospital admission, forcing the entire family to relive the stress and anxiety of a hospital stay all over again.

For one premature baby, this was exactly what happened.

Dr Amita Vivehanantham

Kuching-based consultant neonatologist Dr Amita Vivehanantham recalled reviewing the baby after he was admitted with RSV when he was several months old.

The infection began with poor feeding and nasal congestion. But within about half a day, his mother noticed he was having increasing difficulty breathing and brought him to the hospital.

The baby required oxygen therapy and temporary feeding through a feeding tube. He remained in the hospital for approximately five days.

And while he recovered relatively quickly, the case demonstrated how rapidly a young or premature baby could worsen even when the initial symptoms appeared mild.

RSV is one of the most common respiratory viruses affecting young children, with almost every child expected to encounter it by the age of two.

For adults and older children, RSV may cause little more than a runny nose, cough or mild fever.

Newborns and babies under six months, however, are more vulnerable to severe illness.

Born before the lungs are ready

Dr Wong Ann Cheng, a consultant neonatologist based in Miri, said some of the most important stages of lung and immune development occur during the third trimester of pregnancy.

During the final weeks before birth, a baby’s lungs continue to mature, the airways grow larger and protective antibodies are transferred from the mother to the baby through the placenta.

But when a baby is born prematurely, these processes are interrupted.

As a result, premature babies may enter the world with smaller airways, less mature lungs, weaker immune defences, and lower levels of maternal antibodies to protect them against infection.

Even a small amount of airway swelling and mucus caused by RSV can significantly narrow their already tiny airways, forcing them to work much harder to breathe.

The earlier the baby is born, the greater the degree of immaturity is likely to be. And a premature infant’s vulnerability does not disappear simply because the baby has grown well enough to leave neonatal care.

“Discharge from the NICU is a major milestone, but it does not mean the baby’s lungs and immune system have fully matured,” Dr Wong said.

Those born very prematurely, as well as babies with chronic lung disease, congenital heart disease or other medical conditions, remain at particularly high risk.

When there is little reserve left

Some premature infants need extra help breathing after birth, such as oxygen, CPAP (which uses pressurised air to help keep the lungs open), or a ventilator.

Although such treatments are lifesaving, babies with very immature lungs may later develop bronchopulmonary dysplasia (BPD). Babies with BPD may have less efficient and more reactive lungs, leaving them with less capacity to cope with an infection.

And as RSV causes inflammation, airway swelling and increased mucus production, this additional burden may quickly overwhelm the limited reserve available in an infant whose lungs are already weakened.

“A baby who appears well at home can potentially deteriorate within hours and require oxygen, respiratory support or even intensive care,” said Dr Wong.

Other high-risk groups include babies with congenital heart disease or weakened immune systems.

Ambiguous start that can worsen within hours

Recognising RSV can be especially difficult in newborns because the infection does not always begin as an obvious respiratory illness.

Some babies may initially feed poorly, become unusually sleepy or appear less active. And premature infants may experience pauses in breathing, known as apnoea, because the centres in the brain responsible for regulating their breathing are still developing.

Other early symptoms may include a runny nose, nasal congestion, cough or a low-grade fever that parents could easily dismiss as a mild cold.

And as the infection progresses, parents may notice rapid breathing, chest recessions (where the skin between or below the ribs pulls inward with each breath), flaring of the nostrils, grunting, or noisy breathing.

Dr Amita advised parents that, rather than focusing only on whether their baby had a cough or fever, they should observe the baby as a whole and pay close attention to their usual feeding, sleeping and diaper patterns.

“They should be concerned if the baby does not finish a milk feed, takes much longer to feed, is less interested in milk, has fewer wet diapers or the diapers feel less wet,” she shared.

More severe warning signs include pauses in breathing and bluish discolouration around the lips or skin, but it is imperative for a child to receive medical attention before the illness progresses to such a severe stage.

Dr Amita cautioned that time was of the essence when dealing with newborns, premature babies and other vulnerable infants.

“Even if the baby has only a mild cough, nasal congestion or a runny nose in the morning, significant breathing difficulty may develop within a few hours. The younger the baby, the more quickly the baby can become very ill,” she said.

Reversing hard-earned progress

Once a child is admitted to hospital for RSV, treatment is mainly supportive.

For families of former premature babies, Dr Wong said another hospital admission could be especially traumatic, forcing them to relive the anxiety they experienced during their baby’s initial NICU stay.

And difficulty feeding caused by RSV can affect a baby’s weight gain and growth, while another prolonged admission may interrupt their developmental progress.

“Unfortunately, a severe RSV infection can reverse much of that hard-earned progress,” she said.

And those with chronic lung disease may also remain more vulnerable to subsequent respiratory infections down the line. Recurrent wheezing and reduced lung function are among the concerns that may require continued medical follow-up after RSV.

Protection should begin early

For premature babies and other vulnerable infants, discussions about infection prevention and RSV preventive options should ideally begin before the child even leaves neonatal care.

Dr Wong said discharge planning should prepare families to care for an infant who may still require additional care and monitoring at home.

“Protecting a premature baby requires a family effort,” she stressed.

Protecting a premature baby requires a family effort, with everyone playing a part in reducing exposure to infections such as RSV.

And basic precautions remain important: household members should wash their hands, stay away from the baby when unwell, and keep the home free of cigarette smoke and vaping exposure.

Families may also need to limit crowded visits and unnecessary travel, particularly during periods when respiratory infections are increasing.

Older siblings who attend school or childcare may bring viruses home before developing noticeable symptoms themselves.

Preventing infection should therefore be treated as a shared family responsibility, with household members encouraged to cover coughs and sneezes and avoid close contact with the baby when they are unwell.

Breastfeeding should also be encouraged where possible, as breast milk provides antibodies and other immune factors that can help protect infants from infection.

Keeping up with the routine childhood vaccination programme offered at health clinics is equally important, as these vaccines protect against a range of other potentially serious infections.

“Avoiding a severe RSV infection is not just about preventing a short illness; it is about protecting the remarkable progress premature babies have made since birth and giving them the best opportunity to continue growing and thriving at home,” said Dr Wong.

But precautions alone cannot eliminate every risk.

Immunisation, vaccination programmes

While RSV-specific preventive measures are not currently part of Malaysia’s routine childhood immunisation programme, preventive options may be available outside the public programme and can be discussed with a child’s doctor.

Dr Amita said maternal RSV vaccination during pregnancy is one preventive approach as it allows the mother’s protective antibodies to be transferred to the baby before birth.

However, some premature babies may be born before they have had enough time to receive the full benefit of these transferred antibodies.

For these infants, monoclonal antibodies — lab-made antibodies that provide protection against RSV — can offer another form of protection, particularly for those at higher risk of severe disease, including premature babies and children with certain chronic medical conditions or weakened immune systems.

Within the public healthcare system, RSV monoclonal antibodies are not routinely given to all infants and their use is generally limited to selected high-risk babies.

Parents should speak to their baby’s neonatologist or paediatrician about whether their child may be eligible or whether other preventive options may be appropriate.

For parents, the message is not that every cold will become severe, but that newborns and premature babies have far less room to compensate when breathing becomes difficult.

Their vulnerability lies not only in their small size, but also in lungs, airways and immune defences that are still developing.

“When something can be prevented, it is better to prevent severe complications, particularly because every significant infection can affect a premature baby’s already vulnerable lungs,” Dr Amita said.

And protection is about more than avoiding one hospital admission. It is about preserving the progress these babies have fought to make.

*This special report is powered by Bintulu Lumber Development Sdn Bhd.

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