Bronchiolitis in Infants
Scope of the guidance
This item is based on the SIGN Guideline with information from
the reviews in http://clinicalevidence.bmj.com/ceweb/index.jsp
and Clinical Knowledge Summaries
www.cks.library.nhs.uk/cough_acute_with_chest_signs_in_children/view_whole_topic_review.
The recommendations focus on the prevention, diagnosis, treatment
and management of bronchiolitis in children less than 12 months
old. The Guideline does not cover chronic asthma, viral
induced wheeze upper respiratory tract infections, hospital
acquired nor community acquired forms of pneumonia. We have
included this item in the EGP Update 1 as it is linked into the
other EGP Update item focused on the NICE recommendation for
Feverish illness in children
Source
Scottish Intercollegiate Guidelines Network.
Bronchiolitis in children: a national clinical
guideline. Edinburgh: SIGN; 2006.
www.sign.ac.uk/pdf/sign91.pdf
Key Points
1. Background
- Bronchiolitis is a virally-induced acute
respiratory condition which affects infants, typically below the
age of two years, and most commonly between 3-6 months of
age.
- It is usually caused by respiratory syncytial
virus (RSV); peak incidence is during the winter months.
- Children with bronchiolitis typically
deteriorate clinically in the first 72 hours, before symptoms
improve.
- Approximately 70% of infants are infected
with RSV during the first year of their life, but only 3% are
admitted to hospital.
2. Diagnosis
- Bronchiolitis is a clinical diagnosis, based
on a typical history and findings on
examination.
- It is ‘a seasonal viral illness characterized
by fever, nasal discharge, and dry, wheezy cough. On
examination there are fine inspiratory crackles and / or high
pitched expiratory wheeze.’
- There are often symptoms of an upper
respiratory infection for two to three days before the onset of the
other symptoms.
- High fever is uncommon, but being you can
still make a diagnosis of bronchiolitis in a feverish child.
3. Differential diagnosis
- The differential diagnosis includes:
o
Pneumonia
o
Asthma
o
Congenital lung diseases e.g. cystic fibrosis
o
Inhaled foreign body
o
Coronary heart disease
o
Sepsis
o
Severe metabolic acidosis
o
Acute epiglottitis
4. Risk factors for severe disease
- Younger infants have a higher admission rate
to hospital than older infants.
- Infants who were born prematurely have a
higher hospital admission rate, as do infants with other
co-morbidities such as congenital heart disease, chronic lung
disease, immune deficiency etc.
- Environmental factors: parental smoking
increases the risk of hospital admission for bronchiolitis, and.
breast feeding reduces it.
- Any of the following features indicate severe
disease (see red flags in
traffic light system on EGP Update item Feverish illness in
children and asscoiated NICE Guidance www.nice.org.uk/nicemedia/pdf/CG47NICEGuideline.pdf
:
o Poor feeding
o Lethargy
o History of apnoea
o Respiratory rate > 60
breaths / minute
o Presence of nasal flaring and
/ or grunting
o Moderate or severe chest wall
indrawing
o Grunting
o Cyanosis
o Oxygen saturations ≤ 95%
5. Where to treat
o Most can be managed at
home.
o Tell parents how to recognize
any deterioration in their child’s condition, and provide them with
a ‘safety net’ – to seek medical advice if the child gets
worse.
o Consider referral to hospital
if the parents / carers are unable to cope with the ill child.
o If the child has any of the
features of severe disease (listed above), or the diagnosis is
uncertain, you should refer immediately to a hospital
paediatrician.
o The threshold for hospital
referral should be lowered for children with significant
co-morbidities, or infants born at < 35 weeks gestation.
6. Investigations in hospital
- Investigations that may be carried out
if the diagnosis is in doubt or if the child
is seriously unwell are:
o Chest Xray
o Infants with ≤ 92% oxygen
saturation require inpatient care
o Blood gas analysis
o Virology tests – to determine
whether the child should be isolated to prevent spread of RSV to
other children on the ward.
o Blood and urine cultures –
usually not indicated, but important in infants < two months
old
o Blood tests – usually only
indicated if severe disease
7. Treatment
- Community based treatment for mild bronchiolitis. The
following have been found to be ineffective in treating
bronchiolitis, and are not recommended:
o Nebulised ribavirin
o Antibiotics
o Inhaled beta 2 agonists
o Nebulised ipratropium
o Nebulised adrenaline
o Inhaled or systemic
corticosteroids
- Treatments recommended at home are:
o Paracetamol to alleviate
symptoms of distress from fever
o Maintain fluid intake
o Reassurance that
bronchiolitis is a self-limiting condition, whilst providing a
‘safety net’ if the child deteriorates
- Hospital based treatment for severe
bronchiolitis. This is essentially supportive treatment:
o Nasal suction for nasal
blockage
o Nasogastric feeding to
maintain fluid intake if the child is not feeding well
o Supplemental oxygen if
necessary
o Artificial ventilation if
required
o Chest physiotherapy in the
intensive care setting only
EGP 1. May 2008