Bronchiolitis

Bronchiolitis is a common lung infection in young children and infants. It causes congestion in the small airways (bronchioles) of the lung. Bronchiolitis is almost always caused by a virus. Typically, the peak time for bronchiolitis is during the winter months.

Bronchiolitis starts out with symptoms similar to those of a common cold but then progresses to coughing, wheezing and sometimes difficulty breathing. Symptoms of bronchiolitis can last for several days to weeks, even a month.

Most children get better with supportive care at home. A very small percentage of children require hospitalization.

For the first few days, the signs and symptoms of bronchiolitis are similar to those of a common cold:

• Runny nose
• Stuffy nose
• Cough
• Slight fever (not always present)

After this, there may be a week or more of breathing difficulty or a whistling noise when breathing out (wheezing).

Many infants will also have an ear infection (otitis media).

When to see a doctor

If it’s difficult to get your child to eat and his or her breathing becomes more rapid or labored, contact your child’s doctor. This is especially true if your child is younger than 12 weeks old or has other risk factors for bronchiolitis — including premature birth or a heart or lung condition.

The following signs and symptoms are reasons to seek prompt medical attention:

• Vomiting
• Breathing very fast — more than 60 breaths a minute — and shallowly
• Skin turning blue, especially the lips and fingernails (cyanosis)
• Lethargy
• Refusal to drink enough fluids, or breathing too fast to eat or drink
• Audible wheezing sounds
• Ribs seem to suck inward when infant inhales

Bronchiolitis occurs when a virus infects the bronchioles, which are the smallest of the airways branching off the main breathing tubes (bronchi) within your lungs. The viral infection makes the bronchioles swell and become inflamed. Mucus collects in these airways, which can make it difficult for air to flow freely into and out from the lungs.

Most cases of bronchiolitis are caused by the respiratory syncytial virus (RSV). RSV is a common virus which infects just about every child by the age of 2. Seasonal outbreaks of RSV infection occur every winter. Bronchiolitis can also be caused by a variety of other viruses, including those that cause the flu or the common cold.

Bronchiolitis is a contagious condition. You contract the virus just as you would a cold or the flu — through droplets in the air when someone who is sick coughs, sneezes or talks. You can also contract bronchiolitis by touching shared objects — such as utensils, towels or toys — and then touching your eyes, nose or mouth.

One of the greatest risk factors for getting bronchiolitis is being younger than 6 months old, because the lungs and immune system aren’t yet fully developed.

Other factors that have been associated with an increased risk of bronchiolitis in infants, or more severe illness due to bronchiolitis, include:

• Never having been breast-fed — breast-fed babies receive immune benefits from the mother
• Premature birth
• An underlying heart or lung condition
• A depressed immune system
• Exposure to tobacco smoke
• Contact with multiple children, such as in a child care setting
• Living in a crowded environment
• Having siblings who attend school or child care and bring home the infection

Complications of severe bronchiolitis may include:

• Cyanosis, a condition in which the skin appears blue or ashen, especially the lips, caused by lack of oxygen.
• In the youngest infants, acute bronchiolitis can sometimes cause long pauses in breathing (apnea).
• Dehydration.
• Fatigue and respiratory failure.

If these occur, your child may need hospitalization. Severe respiratory failure may require that a tube be inserted into the trachea to help the child’s breathing until the infection has run its course.

If your infant was born prematurely, has a heart or lung condition, or has a compromised immune system, watch closely for beginning signs of bronchiolitis. The infection may rapidly become severe, and signs and symptoms of the underlying condition may become worse. In such cases, your child will usually need hospitalization.

RSV can also cause pneumonia. Sometimes a second infection, such as bacterial pneumonia, can occur at the same time, but this is not common. Reinfections with RSV after the initial episode may occur but typically aren’t as severe.

You’re likely to start by seeing your family doctor or your child’s doctor. Here’s some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

• Write down any symptoms your child is experiencing,including any that may seem unrelated to an upper respiratory infection, and when they started.
• Write down key personal information, such as if your child was born prematurely or if he or she has a heart or lung problem.
• Write down questions to ask your doctor.

Questions to ask your doctor

Some basic questions to ask your doctor include:

• What is likely causing my child’s symptoms? Are there other possible causes?
• Does my child need any tests?
• How long do symptoms usually last?
• Is my child’s infection contagious?
• What is the best course of action?
• What are the alternatives to the primary approach that you’re suggesting?
• Does my child need medication? If so, is there a generic alternative to the medicine you’re prescribing me?
• What can I do to make my child feel better?
• Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting?

Don’t hesitate to ask questions during your appointment anytime that you don’t understand something.

What to expect from your doctor

Be ready to answer questions your doctor may ask:

• When did your child first begin experiencing symptoms?
• Have your child’s symptoms been continuous, or intermittent?
• How severe are your child’s symptoms?
• What, if anything, seems to improve your child’s symptoms?
• What, if anything, appears to worsen your child’s symptoms?

What you can do in the meantime

If your child has a fever, you can give him or her acetaminophen (Tylenol, others) or ibuprofen (Children’s Advil, Children’s Motrin) (after age 3 months). Have your child drink plenty of fluids to prevent dehydration. Keeping your child upright and the air moist with a humidifier also may help ease congestion.

Tests and X-rays are not usually needed to diagnose bronchiolitis. The doctor can usually identify the problem by observing your child and listening to his or her lungs with a stethoscope. It may take several visits to distinguish the condition from a cold or flu.

If your child is at greater risk of severe bronchiolitis, if symptoms are worsening or if another problem is suspected, your doctor may order tests, including:

• Chest X-ray. Your doctor may request a chest X-ray to look for signs of pneumonia.
• Mucus sample test. Your doctor may collect a sample of mucus from your child to test for the virus causing bronchiolitis. This is done using a swab or a suction catheter that’s gently inserted into the nose.
• Blood tests. Occasionally, blood tests might be used to check your child’s white blood cell count. An increase in white blood cells is usually a sign that your body is fighting an infection. A blood test can also determine whether the level of oxygen has decreased in your child’s bloodstream. An alternative test for oxygen levels is an oximeter that fits over the finger. Oxygen is necessary to the functioning of the body’s organs, including the brain.

Your doctor may also ask you about signs of dehydration, especially if your child has been refusing to drink or eat or has been vomiting. Signs of dehydration include sunken eyes, dry mouth and skin, sluggishness, and little or no urinary output.

The vast majority of cases of bronchiolitis can be cared for at home with supportive care. Make sure your child is getting adequate liquids. Consider saline nose drops or suctioning with a bulb to relieve nasal congestion. Be alert for changes in breathing difficulty. Expect the condition to last for a week to a month.

Drugs that open the airways (bronchodilators) haven’t been found to be routinely helpful. But your doctor may elect to try a nebulized albuterol treatment to see if it helps.

Because viruses cause bronchiolitis, antibiotics — which are used to treat infections caused by bacteria — aren’t effective against it. If your child has an associated bacterial infection, such as pneumonia, your doctor may prescribe an antibiotic for that.

Use of corticosteroid medications, the antiviral drug ribavirin and pounding on the chest to loosen mucus (chest physiotherapy) have not been shown to be effective treatments for bronchiolitis and are not recommended.

Hospital care

A tiny percentage of children need hospital care to manage their condition. At the hospital, your child will likely receive humidified oxygen to maintain sufficient oxygen in the blood, and perhaps fluids through a vein (intravenously) to prevent dehydration. In severe cases, a tube may be inserted into the windpipe (trachea) to help the child’s breathing.

Although it may not be possible to shorten the duration of your child’s illness, you may be able to relieve some of the symptoms and make your child more comfortable. Here are some tips to consider:

• Humidify the air. If the air in your child’s room is dry, a cool-mist humidifier or vaporizer can moisten the air and help ease congestion and coughing. Be sure to keep the humidifier clean to prevent the growth of bacteria and molds. Keep the room warm but not overheated — too much heat can make the air drier. Another way to humidify the air is to run a hot shower or bath in the bathroom and let it steam up the room. Sitting in the room holding your child for about 15 minutes may help ease a fit of coughing.
• Keep your child upright. Being in an upright position usually makes breathing easier. Placing your infant in a car seat may help. If you plan to leave your child in a car seat for an extended period of time, such as for a nap, make sure your child’s head won’t fall forward, which can prevent proper breathing. To do this, place foam wedges or a rolled up blanket on each side of your child’s head to keep it safely in place. Also check that the seat has an appropriate slope. This varies with the child’s size and age.
• Have your child drink clear fluids. To prevent dehydration, give your child plenty of clear fluids to drink, such as water, juice or gelatin water. Your child may drink more slowly than usual, due to congestion.
• Try saline nose drops to ease congestion. You can purchase these drops over-the-counter (OTC). They’re effective, safe and nonirritating, even for children. To use them, instill several drops into one nostril, then immediately bulb suction that nostril (but don’t push the bulb too far in). Repeat the process in the other nostril. If your child is old enough, you might teach your child how to blow his or her nose.
• Use OTC pain relievers. OTC pain relievers such as acetaminophen (Tylenol, others) may help relieve a sore throat and improve your child’s ability to drink fluids. Don’t give acetaminophen to children under 3 months of age. And never give your child aspirin. It’s associated with a rare but serious illness called Reye’s syndrome. OTC cold preparations aren’t appropriate for bronchiolitis, either.
• Maintain a smoke-free environment. Smoke can aggravate symptoms of respiratory infections. If a family member smokes, ask him or her to smoke outside of the house and outside of the car.

Because bronchiolitis spreads from person to person, one of the best ways to prevent it is to wash your hands frequently — especially before touching your baby when you have a cold. Wearing a face mask at this time is appropriate. If your child has bronchiolitis, keep him or her at home until the illness is past to avoid spreading it to others.

Other effective ways that can help curb spread of the infection include:

• Limit your child’s contact with people who have a fever or cold. If your child is a newborn, especially a premature newborn, avoid exposure to people with colds in the first two months of life.
• Get a flu shot. An annual influenza vaccination is recommended for everyone older than 6 months. Although it will not prevent the commonest cause of bronchiolitis (respiratory syncytial virus), a flu shot will spare your child from a severe influenza infection.
• Keep bathroom and kitchen countertops in your home clean. Be especially careful if another family member has a cold. To disinfect the area, you can use a solution of bleach and water made with a tablespoon of bleach per gallon of cool water (14.8 milliliters per 3.8 liters). Don’t mix in any other chemicals, as this can create a toxic chemical reaction. Always store homemade mixtures in a labeled container out of the reach of young children or, better, discard unused mixtures.
• Use a tissue only once. Discard used tissues promptly, then wash your hands or use alcohol hand sanitizer.
• Use your own drinking glass. Don’t share glasses with others.
• Be prepared away from home. Keep a waterless hand sanitizer handy for yourself and for your child when you’re away from home.
• Wash hands. Frequently wash your own hands and those of your child.
• Breast-feed. Breast-fed babies receive immunities from their mother.

No vaccine available

There’s no vaccine for bronchiolitis. But the medication palivizumab (Synagis) can help decrease the likelihood of RSV infections in infants with high risk of severe disease, as well as decrease the need for hospitalization and limit severity of the illness. Palivizumab is typically given through a single injection into a large muscle, such as the thigh, once a month during the peak RSV season — from November through March.

Palivizumab doesn’t interfere with childhood vaccines. Its expense generally limits its use to infants at particularly high risk of RSV infection, such as those born very prematurely or with a heart-lung condition or a depressed immune system.

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