Introduction

Bronchiolitis is an acute lower respiratory tract infection caused by respiratory syncytial virus. It affects more than a third of children aged less than two years and is the leading cause of hospital admission during the first year of life. 

The condition presents with increased mucus production along with inflammation and oedema in the small airways. After the diagnosis of bronchiolitis, severe complications, such as pneumonia and empyema, may occur which can severely affect a child’s health and may result in hospital admission. Moreover, the parents suffer psychologically and emotionally due to their child’s illness.¹

Understanding bronchiolitis

A major concern of this disease is that the viruses that cause bronchiolitis can be easily transmitted. When a sick person coughs, sneezes, or talks, respiratory droplets might enter the air and spread to others. Additionally, those droplets can land and live on surfaces, infecting anyone who touches those objects and then touches their mouth, nose, or eyes. 

Typically, children under the age of two are affected by bronchiolitis. Since their lungs and immune systems are still developing, infants under three months old are most vulnerable to developing bronchiolitis. Adults rarely develop bronchiolitis.²

Multiple factors increase the risk of bronchiolitis in infants and young children such as premature birth. Having a weakened immune system due to other conditions such as a lung or heart ailment also makes a child prone to this disease. Other factors include being near tobacco smoke and spending time in overcrowded conditions.²

Diagnosis

A thorough history and physical examination are necessary for the diagnosis of bronchiolitis. Typically, children diagnosed with bronchiolitis have a history of upper respiratory tract infection (URTI) lasting one or two days.²

Some typical signs and symptoms comprise:²

• A temperature, typically not exceeding 39°C
• Inadequate nourishment
• A wet cough 
• Pulmonary distress brought on by mucus hypersecretion
• Lower respiratory tract involvement. 

A nasopharyngeal aspirate can be taken from the child to identify the viral infection causing the illness, but a medical professional should decide whether to do the procedure.

Treatments at home for children with bronchiolitis

Parents of children diagnosed with bronchiolitis are often advised to manage the condition at home, as a majority of cases can be effectively handled without the need for hospitalisation. Understanding the typical course of the illness, which tends to peak between the third and fifth days after onset, enables parents to anticipate and respond to changes in their child's condition. Crucially, parents should be educated about identifying 'red flag' symptoms indicative of worsening bronchiolitis which are:^1,3

• Excessive breathing including nasal flaring, grunting, and marked chest recession
• Reduced fluid intake, which can be 50% less than normal
• Absence of wet nappies for almost 12 hours
• Signs of exhaustion such as not being able to respond normally to social cues
• Symptoms of apnoea or cyanosis 

Monitoring the child's feeding ability becomes paramount, serving as a vital marker for disease severity. Consequently, parents are guided on adjusted feeding regimens, which involve offering smaller, more frequent feeds to prevent exhaustion and ensure adequate fluid intake. Moreover, parents are provided with safety netting information, empowering them to recognise signs of clinical decline and seek immediate medical attention when necessary. Recognising the significant emotional toll on parents due to the rapid onset of bronchiolitis and accompanying sleep disturbances, healthcare professionals offer reassurance and support to alleviate anxiety.¹

Additionally, parents are advised on home treatments, such as:

• Administering children's paracetamol (to babies and children over 2 months old) or ibuprofen (to babies and children over 3 months old) for symptom relief - it is not advised to give aspirin to children under 16 years of age
• Utilising saline drops for nasal congestion
• Maintaining upright positioning to facilitate breathing when the child is awake as it helps them to breathe easily
• Providing hydration, more often, through smaller feeds

Emphasising the importance of environmental factors, parents are reminded to avoid tobacco smoke exposure, which elevates bronchiolitis symptoms in children. 

In cases where home management proves insufficient, hospital admission is considered, where supportive care, hydration, airway suction, and close respiratory monitoring are provided. Hypertonic saline nebulisers may also be administered for symptom relief, emphasising the comprehensive approach to managing bronchiolitis across home and hospital settings.^3,4

Prevention

One of the most effective methods to prevent getting sick is to wash your hands frequently because the viruses that cause bronchiolitis are transmittable. Doing this before handling your baby is particularly important if you have a cold, the flu, or any other contagious illness. If you have any of these conditions, wear a face mask.²

A few basic measures can be taken to help avoid infection:²

• Keep your child away from people who are il, especially during the first two months of your baby's life and if they are born prematurely 
• Make sure to clean and disinfect surfaces coming into contact with the child, particularly if a family member is ill
• Frequently wash your hands and your child's hands with soap and water for at least 20 seconds
• Always have hand sanitiser with an alcohol base (at least 60% alcohol concentration) available when you're not at home and are unable to wash your hands with soap and water

Summary

Bronchiolitis, an acute lower respiratory tract infection primarily caused by the respiratory syncytial virus (RSV), affects a significant proportion of children under two years old and stands as the leading cause of hospital admissions during infancy. Characterised by increased mucus production, airway inflammation, and oedema, bronchiolitis can lead to severe complications such as pneumonia and empyema, necessitating hospitalisation and profoundly impacting a child's health. Moreover, the emotional strain on parents is notable. The disease spreads easily through respiratory droplets and contact with contaminated surfaces, making infants under three months most susceptible due to their developing immune systems. Diagnosis relies on a thorough history, and physical examination, and may involve nasopharyngeal aspirate analysis to identify viral pathogens. 

Home management is often recommended, emphasising parental education on identifying 'red flag' symptoms indicative of worsening bronchiolitis, adjusting feeding regimens, administering home treatments, and providing reassurance amidst the emotional toll. Prevention measures, such as frequent handwashing, avoiding contact with sick individuals, and disinfecting surfaces, are crucial in minimising transmission. However, if home management fails, hospital admission may be necessary, where supportive care and monitoring are provided.

FAQ’s 

How common is bronchiolitis in children?

In the first year of life, 11% to 15% of children will get bronchiolitis, and 3% of those infected will need to be hospitalised. Wintertime is the season when bronchiolitis is most common.²

When should my child be admitted to the hospital?

If a child exhibits any of the following symptoms, they must be admitted to the hospital:³

• Observed or reported apnea
• Reduced oral fluid intake (less than 50% of typical volume)
• Persistent oxygen saturation when breathing air of less than 90% for children six weeks and above, and less than 92% for newborns under six weeks or children of any age with underlying health issues
• Prolonged, severe dyspnea, as evidenced by a significant retraction of the chest and grunting

When can my child be discharged from the hospital?

When determining the appropriate time for discharge for hospitalised children, ensure that the child:⁵  

• Demonstrates clinical stability
• Consumes sufficient oral fluids
• Sustains oxygen saturation levels above 92% while breathing in ambient air for a continuous period of four hours, which includes a duration of sleep

How long does bronchiolitis last?

The majority of children with bronchiolitis typically experience a worsening of symptoms during the initial 1-3 days of the illness, followed by gradual improvement over the subsequent two weeks. Although the cough may persist for several more weeks, antibiotics are not necessary. Once the child is well enough, displaying normal feeding habits and no respiratory difficulties, they can return to nursery or daycare. Routine follow-up with a doctor is usually unnecessary if the child is recovering satisfactorily; however, if any concerns arise regarding the child's progress, caregivers are advised to consult their Health Visitor, Practice Nurse, or GP, or contact NHS 111 for guidance.