How to manage moderate to severe cough in bronchiolitis in infants and children?

Management of Moderate to Severe Cough in Bronchiolitis in Infants and Children

Supportive care is the mainstay of treatment for moderate to severe cough in bronchiolitis, with no pharmacological interventions routinely recommended for cough management. 1

Assessment and Initial Management

• Evaluate for risk factors for severe disease:

  • Age less than 12 weeks
  • History of prematurity
  • Underlying cardiopulmonary disease
  • Immunodeficiency 1

• Assess respiratory status:

  • Respiratory rate
  • Work of breathing
  • Oxygen saturation
  • Presence of wheezing or crackles
  • Ability to feed and maintain hydration 1

Recommended Supportive Interventions

1. Nasal Suctioning

   • Perform gentle nasal suctioning to clear secretions
   • Avoid deep suctioning as it may prolong hospital stays 1

2. Oxygen Supplementation

   • Provide supplemental oxygen if oxygen saturation is less than 90% 1
   • Consider high-flow nasal cannula if respiratory distress worsens 1

3. 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, 2
   • Note: Nasogastric hydration may require fewer attempts and have higher success rates of insertion than intravenous hydration 2

Non-Recommended Interventions

1. Bronchodilators

   • Albuterol and other bronchodilators are not recommended for routine use 1, 3

2. Corticosteroids

   • Not recommended for routine cough management in bronchiolitis 1, 3

3. Antibiotics

   • Should not be used unless specific bacterial co-infection is suspected
   • Consider only with high fever persisting more than 3 days, purulent acute otitis media, or confirmed pneumonia 1

4. Cough Suppressants

   • Medications like dextromethorphan are not recommended for bronchiolitis 4

5. Inhaled Osmotic Agents

   • Hypertonic saline is not recommended for chronic cough after bronchiolitis 5, 1
   • Note: While some research suggests potential benefits of nebulized 3% hypertonic saline in reducing symptoms and hospital length of stay 6, current guidelines do not recommend its routine use

Management of Persistent Cough (>4 weeks)

For infants with persistent cough more than 4 weeks after acute bronchiolitis:

• Manage according to pediatric chronic cough guidelines 5
• Consider a 2-week course of antibiotics targeted to common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) only if wet or productive cough persists without other specific cough pointers 5
• Do not use asthma medications unless other evidence of asthma is present (recurrent wheeze or dyspnea) 5, 1

Prevention of Complications

• Avoid unnecessary diagnostic tests:

  • Routine chest radiographs and laboratory tests do not improve outcomes 1, 3
  • Viral testing should only be performed if results would change management 1

• Monitor high-risk infants closely:

  • Infants under 6 months are at highest risk for major medical interventions within the first 5 days of illness 1
  • Provide more intensive monitoring when weaning oxygen in high-risk infants 1

• Educate caregivers about warning signs requiring return evaluation:

  • Increased work of breathing
  • Poor feeding
  • Lethargy
  • Apnea 1

Prevention Strategies

• Hand decontamination before and after patient contact
• Avoid exposure to tobacco smoke
• Encourage breastfeeding to reduce risk of lower respiratory tract disease
• Consider RSV prophylaxis for high-risk infants 1, 7