What is the treatment approach for bronchitis in children?

Treatment of Bronchitis in Children

Bronchiolitis in children requires only supportive care—bronchodilators, corticosteroids, and antibiotics should NOT be used routinely. 1, 2

Critical Distinction: Bronchiolitis vs. Recurrent Wheezing

• Bronchiolitis is a viral lower respiratory tract infection affecting infants 1-23 months, characterized by first-time wheezing with rhinitis, cough, tachypnea, and respiratory distress 1, 2
• Children with recurrent episodes of "bronchiolitis" after the first year of life likely have recurrent wheezing or asthma, NOT viral bronchiolitis, and should not receive bronchiolitis treatment 3
• Wheezy bronchitis in preschool children is treated differently—short-acting beta-2 agonists are first-line, and inhaled corticosteroids may be tried for frequently recurring episodes 4

Diagnosis: Clinical Only

• Diagnosis is based on history and physical examination alone—no routine chest X-rays, viral testing, or laboratory studies needed 2, 5
• Chest radiographs show atelectasis or infiltrates in 25% of cases, often misinterpreted as bacterial pneumonia, but true bacterial pneumonia without consolidation is unusual 1

Supportive Care: What TO Do

Hydration Management

• Assess oral feeding ability and hydration status 2, 5
• Continue oral feeding if the child feeds well without respiratory compromise 5
• When respiratory rate exceeds 60-70 breaths/minute, feeding may be compromised and aspiration risk increases—consider IV or nasogastric hydration 2, 5
• Use isotonic fluids if IV hydration needed, as infants with bronchiolitis may develop SIADH and are at risk for hyponatremia with hypotonic fluids 5

Oxygen Therapy

• Administer supplemental oxygen ONLY if SpO₂ persistently falls below 90% 1, 2, 5
• Goal is to maintain SpO₂ ≥90% 2, 5
• Discontinue oxygen when SpO₂ ≥90%, child feeds well, and has minimal respiratory distress 2, 5
• Avoid continuous pulse oximetry in stable infants—it may lead to less careful clinical monitoring and serial clinical assessments are more important 5

Airway Clearance

• Gentle nasal suctioning may provide temporary relief for symptomatic relief only 2, 5, 3
• Avoid deep suctioning—associated with longer hospital stays in infants 2-12 months of age 5
• Do not use chest physiotherapy—no evidence of benefit 5

Positioning

• Elevate the head of the bed slightly to facilitate breathing 3

What NOT to Do: Avoid These Interventions

Bronchodilators: NOT Recommended

• Do not use bronchodilators routinely (albuterol, salbutamol, epinephrine) 1, 2, 5
• Multiple meta-analyses show bronchodilators may transiently improve clinical scores but do not affect disease resolution, hospitalization need, or length of stay 1, 6
• Clinical scores are not validated measures and do not correlate with objective measures like pulmonary function tests 1
• Potential adverse effects (tachycardia, tremors) and cost outweigh any minimal benefits 1
• The 2006 guideline allowed a "trial" of bronchodilators, but the 2014 AAP guideline removed this option due to stronger evidence of no benefit and lack of validated methods to identify responders 1

Corticosteroids: NOT Recommended

• Do not use corticosteroids routinely 1, 2, 5, 6
• No evidence of benefit for bronchiolitis 2, 6

Antibiotics: Only for Specific Bacterial Coinfection

• Do not use antibiotics routinely 1, 2, 5
• Use antibiotics ONLY when there are specific indications of bacterial coinfection (e.g., acute otitis media, documented bacterial pneumonia) 1, 2, 5
• Risk of serious bacterial infection (SBI) in infants with bronchiolitis is <1% to 3.7% 1, 5
• When SBI occurs, it is more likely to be UTI than bacteremia or meningitis 1
• Fever alone does not justify antibiotics 5
• Cochrane review found minimal evidence supporting antibiotics for bronchiolitis 7

Antiviral Therapy (Ribavirin): NOT Recommended

• Ribavirin shows marginal benefit at best, with cumbersome delivery, potential health risks to caregivers, and high cost 1
• May be considered only in highly selected situations with documented RSV and severe disease or high-risk patients (immunocompromised, hemodynamically significant cardiopulmonary disease) 1

Risk Stratification: Identify High-Risk Patients

High-risk infants require closer monitoring and may have abnormal baseline oxygenation 5, 3:

• Age <12 weeks (especially <28 days) 1, 5, 3
• History of prematurity (especially <32 weeks gestation) 1, 5, 3
• Hemodynamically significant congenital heart disease 1, 5, 3
• Chronic lung disease of prematurity (required >21% oxygen during first 28 days of life) 1, 3
• Immunodeficiency 5, 3

Hospitalization Criteria

Consider hospitalization for 3:

• Moderate to severe respiratory distress 3
• Difficulty feeding or dehydration 3
• Apnea 3
• SpO₂ persistently <90% 2

Prevention

Palivizumab Prophylaxis

• Administer palivizumab to high-risk infants during the first year of life: those with hemodynamically significant heart disease, chronic lung disease of prematurity, or prematurity ≤35 weeks gestation 1, 3
• Give 5 monthly doses (15 mg/kg per dose IM), typically starting November or December 2

General Prevention

• Hand hygiene is the most important step in preventing nosocomial RSV spread—alcohol-based disinfectants preferred 2
• Avoid tobacco smoke exposure—significantly increases severity and hospitalization risk 2, 5
• Recommend breastfeeding—72% reduction in hospitalization risk for respiratory diseases 5

Clinical Course and Expectations

• Bronchiolitis is self-limited in most children, with mean duration of 8-15 days 3
• 90% of children are cough-free by 21 days 3
• Symptoms (cough, congestion, wheezing) lasting 2-3 weeks are normal and do not indicate treatment failure 5

Common Pitfalls to Avoid

• Do not treat based solely on pulse oximetry without clinical correlation—transient desaturations occur in healthy infants 5
• Do not overlook feeding difficulties—aspiration risk increases significantly when respiratory rate exceeds 60-70 breaths/minute 5
• Do not use continuous pulse oximetry in stable infants—serial clinical assessments are more important 5
• Despite clear guidelines, clinicians continue to overprescribe drugs (antibiotics 50%, corticosteroids 85.7%, bronchodilators 91.6% in one study) due to perceived severity, anxiety about not treating acutely ill children, and parental pressure 8

Post-Bronchiolitis Persistent Cough

• Do not use asthma medications for persistent cough after bronchiolitis unless there is additional evidence of asthma 3
• Do not use hypertonic saline for persistent cough after bronchiolitis 3
• For wet/productive cough without underlying disease, consider evaluation for protracted bacterial bronchitis and a 2-week course of antibiotics targeting common respiratory bacteria 3