By Damian Ternullo, M.D., F.A.A.P. — Pediatric Alliance, St. Clair Division
Let’s Talk About Bronchiolitis
A topic that is foremost in many pediatricians’ minds during this time of year is bronchiolitis. It is a common illness which accounts for a significant percentage of pediatrician visits during the late fall and winter time period. Bronchiolitis is caused by RSV (respiratory syncytial virus) and results in the inflammation of the tiny airways in children’s lungs, which are called bronchioles. As the inflammation in these airways progresses, swelling and excess mucous production causes a lot of coughing and can make breathing difficult. One of the most common signs of this illness is wheezing. A child can be infected more than once (sometimes even in the same season) but subsequent infections are usually less severe. Bronchiolitis typically affects children younger than 2 years of age with peak incidence between 3-6 months. For an older child or adult, the symptoms may simply be cough, runny nose and congestion, but to many younger children these symptoms can be more significant and cause significant illness. Pretty much everyone has been exposed to this virus by age 3 years.
Contagiousness of RSV
Similar to how other viruses (like influenza) spread, RSV spreads when an infected person coughs or sneezes out tiny respiratory droplets that contain the virus. These particles then travel to another person either directly into someone else’s eyes, nose, or mouth, or indirectly, by way of touching the infected droplets (where one touch from contaminated fingers to the eyes, nose, or mouth results in infection).
Symptoms of Bronchiolitis
- Copious runny nose, with nasal congestion.
- Fever (temp >100.4).
- Cough (which may be slightly productive, with a wheezy character to it) – can last 14 days or more.
- Wheeze and increased work of breathing (severe signs include rib retractions, nasal flaring, and rapid rate of breathing).
- Apnea (a pause in breathing lasting more than 20 seconds) may be the first sign in infants <2 months of age.
This can be very frustrating to both parents and pediatricians alike. In general, there isn’t much that we do to help with this. The mainstay of treatment is supportive care.
- Ensuring their nostrils are clear from the copious nasal secretions (nasal saline, bulb syringe, and humidifier). Keeping the nasal discharge loose and the nostrils clear helps the child not only breathe better, but feed better as well. This will help prevent dehydration.
- Fever control –acetaminophen can be given to children over 3 months of age (discuss with your pediatrician) to provide comfort. (While fever, in and of itself, is not dangerous, it can raise the heart rate and respiratory rate.)
- Knowing the signs and symptoms of respiratory distress, including grunting, nasal flaring, rib and clavicular (collarbone) retractions, bluish color change to lips or nail beds, head bobbing, or poor feeding. Call your pediatrician’s office if you notice any of these signs of breathing difficulties.
What doesn’t work?
- Albuterol – numerous studies demonstrate that this common inhaled medicine used for children who wheeze with asthma doesn’t work with kids who wheeze with bronchiolitis.
- Antibiotics – remember that bronchiolitis is caused by a virus, not a bacteria.
For many children, bronchiolitis will be like a bad cold and cough, and visiting the pediatrician’s office won’t be necessary. Other children who have more severe symptoms will need to be seen in the office. We’ll watch and listen to your child’s breathing (measuring an oxygen level with a pulse oximeter if needed), get a sense of their hydration status, and check the ears to make sure a secondary bacterial ear infection hasn’t started. Approximately 3% of children who get bronchiolitis require hospitalization. Most of these children will need oxygen, hydration, observation for worsening symptoms, and time to get better. While there is some data showing that inhaled epinephrine may be helpful, this is not a medication that can be given by parents to children at home.
What can parents and families do to limit this illness?
- Avoid smoking, which increases the risk and severity of respiratory disease in children.
- We say this all the time but its true: Wash hands with soap and water for 30 seconds!
- Alcohol-based hand rubs have also been proven effective in preventing spread.
- Avoid sending your child to daycare or school when they are sick. This simply gets other children sick.
- Infants born prematurely (usually less than 32 weeks gestation), or those infants with chronic lung disease (often a complication of severe prematurity) or congenital heart disorders may qualify to receive the medication Palivizumab (Synagis), an antibody treatment that is given by injection in the pediatrician’s office once a month for 5 months, beginning at the start of RSV season.
To summarize: Bronchiolitis is caused by RSV, a common virus seen in late fall and winter. While it causes a bad cold and cough in most people, requiring supportive care like fluids, Tylenol, and rest, young children usually have more severe symptoms. Some kids get sick enough to come into the office, and others require more vigorous supportive care (usually oxygen) in a hospital setting. There are no medicines that specifically treat bronchiolitis, but there are several things we all can do to avoid illness and limit its spread.
As I indicated on Monday’s PediaBlog, more detailed notes from the American Academy of Pediatrics national convention have been shared with my colleagues at Pediatric Alliance, including the latest research into the evaluation and treatment of bronchiolitis. I am pleased to share this information with you!