What is the recommended treatment for a pediatric patient with bronchitis, considering age and potential underlying conditions such as asthma or cystic fibrosis?

Pediatric Bronchitis Treatment

For acute bronchitis in children, provide supportive care only—no antibiotics, bronchodilators, or corticosteroids are indicated unless there is a documented bacterial superinfection or underlying asthma. 1

Distinguishing Bronchitis from Bronchiolitis

The term "bronchitis" in pediatrics requires clarification, as bronchiolitis (viral lower respiratory tract infection in infants <2 years) is far more common than true bacterial bronchitis in this age group. 1

• Bronchiolitis presents with rhinitis, cough progressing to tachypnea, wheezing, rales, and respiratory distress in children 1-23 months old 1
• Acute bronchitis in older children typically follows an upper respiratory infection with persistent cough but without the severe lower airway obstruction seen in bronchiolitis 2
• Chronic wet/productive cough (>4 weeks) suggests protracted bacterial bronchitis (PBB), which requires different management 3

Management Algorithm for Acute Bronchitis/Bronchiolitis

For Children <2 Years (Bronchiolitis)

Supportive care is the only evidence-based treatment: 1

• Hydration assessment: Monitor ability to take oral fluids; provide nasogastric or IV hydration if unable to maintain adequate intake 1
• Oxygen supplementation: Administer only if SpO2 persistently falls below 90% in previously healthy infants; discontinue when SpO2 ≥90%, infant feeds well, and has minimal respiratory distress 1
• Minimal handling: Reduce unnecessary interventions to decrease oxygen demand 4, 5

Do NOT use routinely: 1

• Bronchodilators (albuterol, epinephrine) 1, 4
• Corticosteroids 1, 4
• Chest physiotherapy 1
• Antibiotics (unless documented bacterial coinfection) 1
• Hypertonic saline 4, 5
• Chest radiographs or viral testing 1, 4

For Children >2 Years (Acute Bronchitis)

Supportive care remains the mainstay: 6, 2

• Adequate hydration and rest 6
• Fever management with acetaminophen or ibuprofen 6
• Avoid over-the-counter cough suppressants, expectorants, and antihistamines—they lack efficacy and may cause harm 3

Consider short-acting beta-2 agonists ONLY if wheezing is present (suggesting wheezy bronchitis or underlying asthma) 6

When to Use Antibiotics

Antibiotics are indicated ONLY in these specific scenarios:

Chronic Wet/Productive Cough (>4 weeks)

• Prescribe amoxicillin-clavulanate for 2 weeks targeting Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 3, 7
• If cough resolves, diagnosis is protracted bacterial bronchitis (PBB) 3
• If cough persists after 2 weeks, extend antibiotics to 4 weeks total 3
• If cough persists after 4 weeks of antibiotics, refer for bronchoscopy, chest CT, and evaluation for underlying disease (bronchiectasis, cystic fibrosis, immunodeficiency) 3

Documented Bacterial Superinfection

• Treat bacterial coinfection (e.g., pneumonia, otitis media) as you would in the absence of bronchitis 1
• High fever ≥39°C persisting >3 days may indicate bacterial infection requiring antibiotics 7

Special Populations Requiring Closer Monitoring

High-risk groups need more intensive observation: 1

• Age <12 weeks 1
• History of prematurity (<35 weeks gestation) 1
• Hemodynamically significant congenital heart disease 1
• Chronic lung disease of prematurity 1
• Immunodeficiency 1

These children require close monitoring during oxygen weaning and may need hospitalization at lower thresholds. 1

Underlying Conditions: Asthma and Cystic Fibrosis

Asthma

• If asthma coexists, treat the asthma according to standard guidelines with inhaled corticosteroids and bronchodilators as indicated by asthma severity 1
• A trial of bronchodilators may be considered in bronchiolitis if there is documented positive clinical response using objective evaluation, but continue only if beneficial 1
• Distinguish "wheezy bronchitis" (recurrent viral-triggered wheezing) from true asthma—short-acting beta-2 agonists are first-line for wheezy bronchitis episodes 6

Cystic Fibrosis or Bronchiectasis

• These children are excluded from standard bronchiolitis management and require specialized care 1, 8
• All children with bronchiectasis must receive regular airway clearance techniques taught by pediatric-trained physiotherapists 1, 8
• Treat acute exacerbations with 14 days of systemic antibiotics (amoxicillin-clavulanate empirically, guided by previous cultures) 1, 8
• Long-term macrolide antibiotics are indicated for recurrent exacerbations 1, 8
• Do NOT routinely use inhaled corticosteroids in bronchiectasis alone (use only if asthma coexists) 1, 8

Red Flags Requiring Immediate Evaluation

Refer immediately or hospitalize if: 3, 7

• Respiratory rate >70 breaths/minute in infants 3
• Severe respiratory distress with retractions, nasal flaring, grunting 1, 5
• SpO2 <90% on room air 1
• Inability to maintain hydration 1
• Apnea episodes 1
• Digital clubbing (suggests chronic lung disease) 7
• Hemoptysis 7
• Failure to thrive 7
• Coughing with feeding (suggests aspiration) 7

Prevention

Palivizumab prophylaxis should be administered during RSV season to: 1

• Infants <32 weeks gestation in their first year of life 1
• Infants with hemodynamically significant heart disease 1
• Infants with chronic lung disease of prematurity requiring >21% oxygen for ≥28 days 1

Environmental interventions: 3

• Address tobacco smoke exposure and counsel parents on smoking cessation 3
• Standard hand hygiene and cough hygiene measures 1
• Avoid contact with individuals with respiratory infections 1

Common Pitfalls to Avoid

• Do not prescribe antibiotics for acute viral bronchitis (<4 weeks duration)—this contributes to antibiotic resistance without benefit 3, 7
• Never give honey to children <1 year due to infant botulism risk 3
• Do not use the vague term "reactive airway disease" instead of making a proper diagnosis (bronchiolitis, asthma, or PBB) 1
• Do not routinely order chest X-rays or viral testing in uncomplicated bronchiolitis—diagnosis is clinical 1, 4
• Do not continue bronchodilators without documented objective improvement 1