What is the treatment for bronchitis in children?

Treatment for Bronchitis in Children

Critical Distinction: Bronchiolitis vs. Bronchitis

The term "bronchitis" in children requires immediate clarification, as acute viral bronchiolitis (infants <2 years) and acute bronchitis (older children) are fundamentally different diseases requiring distinct management approaches. 1, 2

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For Infants with Acute Viral Bronchiolitis (<2 years)

What TO Do: Evidence-Based Supportive Care Only

The cornerstone of bronchiolitis management is supportive care alone—oxygen supplementation when SpO2 <90%, hydration support, and gentle nasal suctioning—while avoiding all routine pharmacologic interventions. 1, 2

Oxygen Therapy

• Administer supplemental oxygen only if SpO2 persistently falls below 90% 1, 2
• Maintain SpO2 ≥90% with standard oxygen delivery 1
• Discontinue oxygen when SpO2 ≥90%, infant feeds well, and has minimal respiratory distress 1, 2
• Avoid continuous pulse oximetry in stable infants, as it leads to less careful clinical monitoring 1

Hydration Management

• Continue oral feeding if the infant feeds well without respiratory compromise 1
• When respiratory rate exceeds 60-70 breaths/minute, feeding may be compromised and aspiration risk increases 1
• Use IV fluids only when oral intake is inadequate 1, 2
• Use isotonic fluids if IV hydration needed, as infants may develop SIADH and are at risk for hyponatremia with hypotonic fluids 1

Airway Clearance

• Use gentle nasal suctioning only as needed for symptomatic relief 1, 2
• Avoid deep suctioning, as it is associated with longer hospital stays in infants 2-12 months of age 1
• Do not use chest physiotherapy—it lacks evidence of benefit 1

What NOT to Do: Avoid These Interventions

Bronchodilators, corticosteroids, and antibiotics should not be used routinely in bronchiolitis, as they lack evidence of benefit and represent inappropriate overtreatment. 1, 2, 3, 4

Bronchodilators

• Do not use bronchodilators routinely 1, 2, 3
• A carefully monitored trial may be considered, but continue only if there is documented positive clinical response 2

Corticosteroids

• Do not use corticosteroids routinely—they lack evidence of benefit 1, 2, 3, 5

Antibiotics

• Use antibacterial medications only with specific indications of bacterial coinfection (acute otitis media, documented bacterial pneumonia) 1, 2, 4
• The risk of serious bacterial infection in infants with bronchiolitis is <1% 1
• Fever alone does not justify antibiotics 1
• Antibiotics are used at rates of 34-99% in uncomplicated cases despite lack of evidence, representing significant overtreatment 4

Diagnostic Testing

• Do not routinely order chest radiographs, viral testing, or laboratory studies 1, 2
• Diagnosis is clinical, based on history and physical examination alone 1, 2

High-Risk Infants Requiring Closer Monitoring

• Age <12 weeks 1, 2
• History of prematurity 1, 2
• Hemodynamically significant congenital heart disease 1, 2
• Chronic lung disease 1, 2
• Immunodeficiency 1, 2

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For Older Children with Acute Bronchitis

Management Approach

In older children with acute bronchitis (typically viral), treatment focuses on symptomatic relief while avoiding antibiotics unless bacterial infection is specifically indicated. 6, 5

Symptomatic Treatment

• Short-acting beta-2 agonists are first choice for wheezy bronchitis 5
• Inhaled corticosteroids may be tried to control symptoms in children with frequently recurring and/or severe episodes of wheezy bronchitis 5
• Antibiotics should not be used routinely, as acute bronchitis is mainly viral-caused 6

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For Children with Chronic Cough Post-Bronchiolitis (>4 weeks)

Manage chronic cough following acute viral bronchiolitis according to pediatric chronic cough guidelines, using 2 weeks of antibiotics targeted to common respiratory bacteria for wet/productive cough without specific cough pointers. 7

Management Strategy

• Evaluate for presence of cough pointers (coughing with feeding, digital clubbing) 7
• For wet or productive cough unrelated to underlying disease and without specific cough pointers: use 2 weeks of antibiotics targeted to Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis based on local antibiotic sensitivities 7
• Do not use asthma medications unless other evidence of asthma is present (recurrent wheeze and/or dyspnea) 7
• Do not use inhaled osmotic agents 7

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For Children with Bronchiectasis

In children with bronchiectasis, interventions that reverse and/or prevent bronchiectasis should be undertaken wherever possible, including early identification and treatment of inhaled foreign bodies, preventing recurrent protracted bacterial bronchitis, and treating primary immunodeficiency disorders. 7

Key Management Principles

• Do not use inhaled corticosteroids with or without LABA routinely in either short- or long-term, irrespective of stability or exacerbation 7
• ICS may be beneficial in those with eosinophilic airway inflammation 7
• SABA may be beneficial as pre-airway clearance therapies 7
• Resolution or improvement rates after appropriate treatment may be as great as 64% 7

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Critical Clinical Pitfalls to Avoid

• Do not treat based solely on pulse oximetry readings without clinical correlation, as transient desaturations can occur in healthy infants 1
• Do not overlook feeding difficulties, as aspiration risk increases significantly when respiratory rate exceeds 60-70 breaths/minute 1
• Do not prescribe drugs due to anxiety about acutely ill children or parental pressure—this represents the main reason for inappropriate overtreatment 8
• Do not apply pediatric bronchiolitis treatment paradigms to adults, as adult bronchiolitis is fundamentally different and requires cause-specific treatment 9