Acute Bronchiolitis: A common infection of infancy

It starts with symptoms similar to those of the common cold, but then progresses to coughing, wheezing and sometimes shortness of breath. Symptoms of bronchiolitis can last for several days to weeks.

Most children are treated with care at home and only a small percentage need hospitalisation.

Symptoms
In the first few days, the signs and symptoms of bronchiolitis are similar to those of the common cold:
• Runny nose and congestion
• Cough
• Low fever

This is usually followed by a week or more of shortness of breath or noisy exhalation (wheezing).
Some infants may develop acute otitis media.

When is a pediatric evaluation required?
If the child has difficulty eating and drinking and his breathing becomes faster or more labored, he needs to be evaluated by a pediatrician. This is especially important if the child is less than three months old and has other risk factors for severe bronchiolitis (prematurity, congenital heart disease or other respiratory condition).

The following signs and symptoms are grounds for immediate pediatric assessment:
• Noisy breathing on exhalation (wheezing)
• Tachypnea (>60 breaths/minute)
• Labored breathing (ribs appear to be drawn in when the infant inhales – intercostal retractions)
• Lethargy, drowsiness
• Refusal to take liquids and food
• Cyanosis

Rationale
Acute bronchiolitis occurs when a virus infects the bronchioles, which are the smallest airways in the lungs. The infection causes inflammation and swelling of the bronchioles. Mucus builds up in these airways and makes it difficult for air to move freely in and out of the lungs.
Most cases of acute bronchiolitis are caused by respiratory syncytial virus (RSV). It is a common virus that infects almost all children up to the age of 2 years. RSV epidemics occur every winter, and re-infection with this virus is common, as previous infection does not seem to induce immunity for a long time. Bronchiolitis can also be caused by other respiratory viruses, such as rhinovirus, influenza virus, adenovirus, etc.

Risk factors
Acute bronchiolitis mainly affects children under 2 years of age. Infants younger than 3 months are at greater risk of bronchiolitis because their lungs and immune systems are not fully developed.
Other factors associated with increased risk of bronchiolitis in infants and more severe disease include:
• Prematurity
• Underlying cardiovascular or respiratory disease
• Immunosuppression
• Exposure to cigarette smoke
• Artificial nutrition
• Grouping with many children, such as in daycare
• Siblings attending school or daycare

Complications
Complications of acute bronchiolitis include:
• Cyanosis (blue lips or skin) caused by lack of oxygen
• Apnea (stoppage of breathing), which most often occurs in premature infants and infants in the first two months of life
• Dehydration
• Low oxygen levels and respiratory failure
Hospital admission is required in these cases.

Prevention
Because the viruses that cause bronchiolitis are spread from person to person, one of the best ways to prevent it is to wash your hands frequently, especially before handling the infant if they have symptoms of a common cold. The use of a mask in these cases is also necessary.

Vaccines and medication
There are no vaccines for the most common causes of bronchiolitis (RSV and rhinosinusitis).
Infants who are at increased risk for RSV infection are indicated for a drug called Synagis to reduce the chance of RSV infection.

Management of acute bronchiolitis is mainly supportive (oxygen therapy, hydration and mechanical ventilation if necessary). Administration of bronchodilators or corticosteroids does not seem to have an effect and is not recommended.

She writes:
Monica Tsartsali
Pediatrician-Pulmonologist
Deputy Director of MITERA Pediatric Clinic

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