Bronchiolitis in Children

 Comments from Expert Advisory Committee

• Bronchiolitis typically occurs in infants <6 months old (but can occur up to 12 months of age)
• It is typically caused by Respiratory Syncytial Virus (RSV) so there is no benefit from antibiotics
• It is a clinical diagnosis
• Children have prodromal coryzal symptoms for 1-3 days followed by:
  • Persistent cough
  • Tachypnoea and/or chest recession
  • Wheeze and/or bilateral crackles on chest auscultation
• Peak of illness is day 3 of lower respiratory tract infection (cough) rather than day 3 of coryzal symptoms.
• Associated symptoms include:
  • Fever (30%, usually low grade)
    • Fever >39°C is unusual so consider alternative diagnosis e.g. pneumonia
  • Poor feeding (most common days 3-5)
    • May need urgent review by secondary care if fluid intake <50% normal
• Cough and wheeze associated with bronchiolitis can persist for up to 4 – 6 weeks.
  • There is still no benefit in giving these infants antibiotics for bronchiolitis as it will not help the cough to resolve sooner

• Risk factors for more severe bronchiolitis
  • Previous admissions with bronchiolitis
  • Born < 32 weeks gestation
  • Chronic lung/heart disease
  • Neuromuscular disorders
  • Immunodeficiency
• Alternative diagnosis:
  • Consider pneumonia as an alternative diagnosis if temperature > 39 and/or persistent focal crackles
  • Consider viral-induced wheeze or early-onset asthma rather than bronchiolitis in older infants (over 1) and young children if they have persistent wheeze without crackles, recurrent episodic wheeze or history of atopy
• Consider referring and transferring for admission to secondary care if any of the following:
  • Apnoea (observed or reported) which may actually be the presenting feature in very young babies (especially <6 weeks old)
  • Grunting
  • Central cyanosis
  • Marked chest/sternal recession
  • Tracheal tug/head bobbing
  • Respiratory rate >70 breaths/minute
  • Poor feeding (fluid intake <50% normal)
  • Dehydration (making no tears when crying, sunken fontanelle, dry lips, poor urine output)
  • Cold peripheries
  • Baby looks sick to a healthcare professional

Treatment

• Bronchiolitis is generally a self-limiting disease usually not requiring investigation or treatment.
• There is no evidence that any pharmacological medications provide benefit including:
  • Antibiotics, salbutamol, ipratropium bromide, montelukast, steroids, adrenaline, antivirals, saline nebs
• Some infants require hospitalisation as they require high flow humidified nasal O2 and support of feeding as required

Patient Information

• HSE A-Z Bronchiolitis

Safe Prescribing (visit the safe prescribing page)

Visit the Health Products Regulatory Authority (HPRA) website for detailed drug information (summary of product characteristics and patient information leaflets). Dosing details, contraindications and drug interactions can also be found in the Irish Medicines Formulary (IMF) or other reference sources such as British National Formulary (BNF) / BNF for children (BNFC).

Reviewed August 2022