Quest for Health KC

Bronchiolitis is an infection of the respiratory tract that leads to wheezing and difficulty breathing, most often in infants and children under 2 years of age. It’s often called simply “RSV.” While it’s often caused by a virus called Respiratory Syncytial Virus (RSV), it’s not always. Let’s talk about what it is and what we can do about it.

Symptoms of bronchiolitis

Bronchiolitis often starts off just like a common cold, with a runny nose or congestion. In older children and adults it progresses just like a cold. Because it is.

In infants and young children symptoms can progress to make them more significantly sick. Day 3-5 of illness often is the worst.

Symptoms include (but not everyone has all):

• Rapid heavy breathing (more than 60 breaths per minute – always count for a full minute in babies because they can pant or hold their breath, which throws the count off)
• Wheezing (tight breathing with a whistling sound)
• Retractions (the skin between ribs suck in during inspiration)
• Nasal flaring (where the nostrils widen with breathing)
• Belly breathing (the abdomen moves up and down more than usual)
• Fever
• Cough (which can occasionally cause vomiting)
• Lots of mucus from the nose and mouth (lots!)
• Decreased appetite (which can lead to dehydration, so offer frequent liquid feedings)

If you’re wondering what type of cough your child has, check out The sounds of coughing.

Causes of bronchiolitis

Most cases of bronchiolitis are due to viruses.

RSV is a common cause, which is why the condition is often simply called RSV. Most of us have had RSV by the time we’re 3 years old. It doesn’t always cause the symptoms of bronchiolitis. Sometimes it just looks like a common cold, especially in older kids and adults. This is why it’s really important to protect young infants around people who are just a little sick.

Bronchiolitis can be caused by many of the viruses that cause upper respiratory tract infections. Rhinovirus, metapneumovirus, adenovirus, influenza, parainfluenza, and coronavirus are some of the other culprits.

Who’s at risk?

Symptoms tend to be worst in babies who are higher risk. This includes infants who were born prematurely, those who have certain heart defects, the very young, or those with other chronic conditions.

Infants are more at risk of having simple cold viruses cause the more severe symptoms of bronchiolitis. Their narrow airways contribute to this because they become plugged with mucus more easily than larger airways.

All viral illnesses are more common among infants who are in daycare or around lots of people. The more people, the more likely they’ll be exposed to a person sharing germs. Infants also put their hands and toys in their mouth often, which helps them get germs into their body.

Those who are around cigarette smoke are also more at risk because of the chronic airway irritation caused by smoke. Even babies who are around people who smoke prior to being with the child can get third hand smoke exposure from hair and clothing.

Prevention

Standard infection control protocols can help avoid spread.

Wash hands frequently or use hand sanitizer. Teach kids to get all parts of their hands clean. Wash hands even when you’re not feeling sick… we share germs before we know we have them and we need to protect ourselves from catching new ones!

Avoid being around people who are sick and when you’re sick, stay home! If you’re the one who’s sick, check out Help! I’m sick and have a baby at home.

Have separate towels (or disposable towels) in the bathroom. After brushing your teeth, you don’t want to wipe on a towel that was used by someone who’s brewing germs!

Don’t kiss babies on their face, hands, or feet. The top of the head is best!

Avoid cigarette smoke – even second hand and third hand smoke (on surfaces) can cause airway irritation. This irritation makes it harder to fend off germs, which leads to more infections.

Germs can live on surfaces and objects for 2 or 3 hours or longer. It’s a good idea not to share toys because babies put them in their mouth all the time. Clean your child’s toys often with soap and water.

Cover coughs and sneezes properly.

Testing

Virus testing

There are tests that can be done on mucus from the nose to see which virus is the culprit, but they aren’t usually required.

Knowing if it’s RSV or another virus doesn’t make the symptoms change. We treat symptoms.

Testing can be used for infection control measures when babies are admitted to the hospital, but aren’t always necessary.

Tests are expensive, and unless they change something we’ll do, they aren’t generally recommended. Why waste your money? (Even if you think insurance will cover it, the money comes from somewhere… you’ll pay more in premiums if you spend more.)

Oxygen levels

It is common to check oxygen levels when kids (and adults) are sick. Pulse oximeters are an inexpensive tool to help us assess how well a person is compensating when having trouble breathing.

Chest x-ray

Most infants and children with bronchiolitis do not need a chest x-ray, but they are sometimes used to assess for pneumonia or foreign bodies (such as a swallowed coin) that can cause wheezing.

Blood work

Blood tests are not usually needed to diagnose or treat bronchiolitis but they can help to identify if there’s a need for antibiotics due to a bacterial infection. Sometimes we check blood if we’re worried about dehydration.

Treatments

The virus must run its course and symptoms can last several weeks, so what can you do to help ease symptoms?

Home treatments

Comfort measures

You can use fever reducers if your baby is uncomfortable. These include acetaminophen if your baby is over 2-3 months and ibuprofen or acetaminophen if your baby is over 6 months. I don’t recommend fever reducers before babies get their 2 month vaccines because you can mask symptoms of serious disease. See your physician if your unimmunized child has a fever!

Remember that a fever is the body’s immune system at work, so your goal is comfort, not getting rid of the fever.

More on how to recognize if a fever is too high and the scary facts of fever.

Suck out the snot!

Babies with bronchiolitis often seem as if their nose is a faucet. All that mucus interferes with breathing and feeding. They can’t blow their nose, but you can suck it out!

I’m not a fan of bulb syringes as a nasal aspirator. I find that they have too narrow of a tip to get an effective seal in the nostril until you force it up so far that it causes trauma in the nose. They also run out of suction power before the mucus is all out, which means you must break the seal, empty it out, and resume. This gives your child a chance to suck back some of the mucus you brought forward. Not to mention some of the really gross photos I’ve seen of what grows inside those things!

Here’s a review of various nasal aspirator types and brands. I like the review in general and have no ties to it. She does link to sales, but you can buy from your favorite retailer.

Use one of the aspirators to suction your infant’s nose as they need it. It’s especially helpful before feeding and before they go to sleep, but think of how often you blow your nose when you’re sick. It can be helpful quite often!

Use saline

Saline can help thin out mucus and decrease the swelling of nasal tissues.

It can be used with or without sucking afterward. I talk a bit more about the benefits of saline in How to use nose sprays correctly.

Elevate the head

Raise the head of the bed to help with drainage of mucus. Don’t put your infant on a pillow because that can obstruct breathing. Raise the head of the bed by putting something solid under the legs of the bed or roll a blanket or towel and place it under the mattress at the head of the bed.

I remember many nights of sitting up holding my children when they were sick so they could be upright and sleep. That doesn’t mean I slept well, but that’s what moms do sometimes. You do need to be careful with this – babies can be dropped if a parent falls asleep holding them.

Fluids

Encourage your child to drink fluids in small amounts. This can be breast milk or formula, or water for older infants and children.

Many babies tire out drinking, so they need to drink more frequently than normal to get in a decent volume.

If your baby isn’t drinking well and looks dehydrated, talk to your physician.

Humidify the air

A cool mist vaporizer or humidifier can help your child breathe easier.

Change the water every day.

Clean the machine per the manufacturer recommendations to prevent it being a source of germs.

Things to avoid

Never use menthol products around infants. They have been shown to increase mucus production and worsen symptoms, especially in children under 2 years.

Don’t demand antibiotics. It cannot be cured with antibiotics. No viral illness can.

Decongestants thicken mucus and can lead to more difficulty breathing, sleep disturbances and irritability.

Hospital treatments

Historically we have tried medical treatments when infants present with bronchiolitis. These include breathing treatments with bronchodilators, steroids, and more.

A single treatment with a bronchodilator can be used to see if there’s response to decrease wheezing, but should not be continued if there’s no benefit.

Steroids have not been shown to help unless there’s a history of asthma.

Oxygen is a standard treatment that can help if the oxygen level is low or to ease the work of breathing.

Intravenous (iv) fluids are often required if hydration from feedings is not successful.

Suctioning is a primary treatment in the hospital setting, much like at home.

When should kids be seen?

Infants and children should be seen relatively quickly if the following criteria are met:

• Infants under 2 months of age should be assessed by a physician. They often require hospitalization because of the risk of apnea. Apnea is when they stop breathing and is a risk of very young infants with bronchiolitis.
• Respiratory rate over 60 breaths/minute consistently. It’s common to breathe faster with a fever, so if you can bring it down and their breathing is less labored, that’s okay. They also temporarily breathe faster after eating or crying. Again, if it slows within a few minutes, that’s okay.
• Dehydration. Signs of dehydration include no tears, thick/pasty or no saliva, or fewer than 3 wet diapers in 24 hours.
• The color of the child’s lips or skin looks blue.
• The infant looks uncomfortable or is inconsolable.
• Infants under 3 months (or an under-vaccinated child) with a temperature over 100.4F.

If your child simply isn’t getting better after several days or if earache develops, make an appointment during regular office hours.