Treatment of Bronchitis in Pediatric Patients
The term "bronchitis" in children requires immediate clarification because it encompasses two fundamentally different diseases: acute viral bronchiolitis (infants <24 months) and protracted bacterial bronchitis (chronic wet cough), each requiring completely different management approaches. 1
For Acute Viral Bronchiolitis (Infants and Young Children)
Core Management: Supportive Care ONLY
The cornerstone of bronchiolitis management is supportive care alone—oxygen when SpO2 <90%, hydration support, and gentle nasal suctioning—while avoiding ALL routine pharmacologic interventions. 2, 1
What TO Do:
Oxygen therapy: Administer supplemental oxygen ONLY if SpO2 persistently falls below 90%, maintaining SpO2 ≥90% with standard oxygen delivery 3, 2, 1
Hydration management: Assess ability to take fluids orally; use IV fluids only when oral intake is inadequate 2. When respiratory rate exceeds 60-70 breaths/minute, feeding may be compromised and aspiration risk increases 2. Use isotonic fluids if IV hydration is needed, as infants may develop SIADH 2
Airway clearance: Use gentle nasal suctioning only as needed for symptomatic relief 2. Deep suctioning should be avoided as it is associated with longer hospital stays 2
Continue breastfeeding if possible, as breastfed infants have 72% reduction in hospitalization risk 2
What NOT To Do:
Do NOT use bronchodilators routinely—they lack evidence of benefit 3, 2, 1, 4
Do NOT use corticosteroids routinely—they lack evidence of benefit 3, 2, 1, 4
Do NOT use antibiotics unless there is specific evidence of bacterial coinfection (acute otitis media, documented bacterial pneumonia). The risk of serious bacterial infection in infants with bronchiolitis is <1% 2, 1
Do NOT order routine chest radiographs, viral testing, or laboratory studies—diagnosis is based on history and physical examination alone 2, 1, 4
Do NOT use chest physiotherapy—it provides no benefit 2
Risk Stratification for Severe Disease:
High-risk infants requiring closer monitoring include 2, 1:
- Age <12 weeks
- History of prematurity (especially <32 weeks gestation)
- Hemodynamically significant congenital heart disease
- Chronic lung disease of prematurity
- Immunodeficiency
Hospitalization Criteria:
Admit if the child has 5:
- SpO2 <90% persistently
- Moderate to severe respiratory distress
- Inability to feed or signs of dehydration
- Apnea
Clinical Pitfalls to Avoid:
- Do NOT treat based solely on pulse oximetry without clinical correlation—transient desaturations occur in healthy infants 2, 1
- Do NOT use continuous pulse oximetry in stable infants, as it may lead to less careful clinical monitoring 2
- Fever alone does NOT justify antibiotics 2, 1
For Protracted Bacterial Bronchitis (Chronic Wet Cough)
If a child has chronic wet/productive cough lasting >4 weeks, this is protracted bacterial bronchitis, NOT viral bronchiolitis, and requires antibiotic therapy. 3
Treatment Approach:
Use amoxicillin-clavulanate as first-line antibiotic for 2 weeks initially 3. The most common pathogens are Haemophilus influenzae (nontypeable), Moraxella catarrhalis, and Streptococcus pneumoniae 3
Extend treatment up to 4 weeks if needed in a minority of children who don't respond to the initial 2-week course 3
Early identification and treatment prevents bronchiectasis development—children with chronic wet cough that doesn't resolve after 4 weeks of appropriate antibiotics have 5.9-fold increased likelihood of CT-diagnosed bronchiectasis 3, 5
Key Distinction:
- 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 5
For Post-Bronchiolitis Persistent Cough:
Do NOT use asthma medications (bronchodilators, inhaled corticosteroids) unless there is additional evidence of asthma 5
Do NOT use hypertonic saline for persistent cough post-bronchiolitis 5
Consider a 2-week course of antibiotics targeted to common respiratory bacteria if wet/productive cough persists without specific underlying disease 5, 1
Prevention Strategies:
Palivizumab prophylaxis should be administered during RSV season to high-risk infants: those with hemodynamically significant heart disease, chronic lung disease of prematurity, or history of prematurity ≤35 weeks gestation 5
Avoid tobacco smoke exposure—it significantly increases severity and hospitalization risk 2
Promote breastfeeding and complete immunizations to prevent severe pneumonia that can lead to bronchiectasis 3