What is the treatment for bronchiolitis in children?

Treatment of Bronchiolitis in Children

Bronchiolitis in children should be managed primarily with supportive care, avoiding routine use of bronchodilators, corticosteroids, antibiotics, and diagnostic tests as recommended by the American Academy of Pediatrics. 1

Diagnosis

• Diagnosis is based on clinical findings including:
  • Rhinorrhea, cough, wheezing, crackles
  • Signs of respiratory distress (tachypnea, nasal flaring, accessory muscle use)
  • Most common in infants under 2 years, particularly during winter months
• Routine laboratory tests and chest radiographs are NOT recommended 1, 2
• Viral testing is only indicated if results would change management 1

Risk Assessment

• Identify high-risk infants who may require closer monitoring:
  • Age less than 12 weeks
  • History of prematurity
  • Underlying cardiopulmonary disease
  • Immunodeficiency
  • Severe respiratory distress
  • Oxygen saturation <90% 1

Treatment Recommendations

First-line: Supportive Care

1. Oxygen Therapy

   • Provide supplemental oxygen if SpO₂ <90% 1
   • Consider high-flow nasal cannula if respiratory distress worsens 1
   • Continuous SpO₂ monitoring not routinely needed as clinical course improves 1

2. Hydration and Nutrition

   • Assess hydration status and ability to take fluids orally
   • Provide IV or nasogastric fluids if oral intake is compromised
   • Be cautious of fluid retention related to antidiuretic hormone production 1

3. Airway Management

   • Nasal suctioning to clear secretions 1, 3
   • Frequent reassessment of respiratory status 1

Interventions NOT Routinely Recommended

1. Bronchodilators (including albuterol and nebulized epinephrine)

   • Not recommended for routine use 1, 3
   • May consider trial of nebulized epinephrine in emergency room setting with objective evaluation of response 1, 4

2. Corticosteroids

   • Not recommended for routine use 1, 3

3. Antibiotics

   • Only indicated when specific bacterial co-infection is suspected:
     • High fever persisting >3 days
     • Associated purulent acute otitis media
     • Confirmed pneumonia 1

4. Hypertonic Saline

   • 3% nebulized hypertonic saline may be considered in hospitalized infants 4
   • Evidence for benefit remains limited 1

5. Ribavirin

   • Not recommended for routine use
   • May be considered only for severe RSV infection in high-risk patients 1, 5

Prevention Strategies

1. Infection Control

   • Hand decontamination before and after patient contact
   • Alcohol-based hand rubs preferred, antimicrobial soap as alternative 1
   • Education of staff and family on hand hygiene 1

2. Risk Reduction

   • Avoid exposure to tobacco smoke
   • Encourage breastfeeding to reduce risk of lower respiratory tract disease 1

3. RSV Prophylaxis

   • Palivizumab (15 mg/kg IM) in 5 monthly doses starting before RSV season for high-risk infants:
     • Premature infants
     • Children with congenital heart disease
     • Children with chronic lung disease 1, 4

Hospitalization Criteria

• Oxygen saturation <90-92%
• Moderate-to-severe respiratory distress
• Dehydration
• Presence of apnea
• Inability to maintain adequate oral hydration
• Children with pre-existing risk factors requiring closer assessment 1, 4

Caution

• Heart rate >200/min in a 6-month-old with minimal respiratory distress warrants cardiac evaluation 1
• Infants under 6 months are at highest risk for major medical interventions within the first 5 days of illness 1
• Monitor high-risk infants more closely during oxygen weaning 1

The evidence consistently shows that bronchiolitis is primarily a self-limited viral illness requiring supportive care, and that most pharmacologic interventions have not demonstrated significant benefit in improving outcomes related to morbidity, mortality, or quality of life.