The mainstays of treatment are ensuring adequate rest, hydration, and oxygenation. A humidifier can be used to help loosen sticky mucus.

The decision to admit a child to the hospital is made on the basis of the clinical assessment. Previously healthy children with mild disease typically do not require hospitalization. Those with moderate disease may be managed at home if there is no oxygen requirement. However, younger patients, patients with pre-existing medical conditions, or those with a concerning social situation may require inpatient disease management (Table 3).


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Because of increased respiratory rate, poor feeding, and fever, children with bronchiolitis may become dehydrated. In cases of mild-to-moderate disease, nasal obstruction and mucus plugging may cause difficulty feeding. Nasal suctioning can easily be performed by parents using a bulb syringe and may help to clear secretions. Intravenous fluids may be needed for children who tire quickly or are unable to feed due to respiratory distress. In such cases, hospitalization is indicated.

Oxygen supplementation should be used in children with oxygen saturations persistently <90%.2 Once oxygen therapy has been started, spot checks for oxygen saturation are adequate for monitoring. Supplemental oxygen may be discontinued once saturation rises above 90%, there is only mild respiratory distress, and the infant is feeding well. Continuous pulse oximetry is not needed and may contribute to longer hospital stays.11

Following a period of careful observation, home oxygen therapy is a reasonable alternative to hospitalization in cases of uncomplicated bronchiolitis. Home therapy could decrease the economic burden of disease in low-risk children.12

Bronchodilator use has not been shown to improve clinical outcomes in children with bronchiolitis. The American Academy of Pediatrics does not recommend the routine use of bronchodilators in the treatment of this condition. Only one in four children at most may have transient improvement in symptoms with albuterol (Proventil, Ventolin, Volmax, Vospire) or epinephrine.

A review of 29 studies showed that most bronchodilators do not improve oxygen saturation, reduce hospital stay, or decrease length of disease.13 However, a recent review of racemic epinephrine (Micronefrin, VapoNefrin, Nephron) provided preliminary evidence of reduced hospitalization for children with mild-to-moderate disease, provided a dose was received within the first 24 hours of symptoms.14 Although further research is needed, this may show promise for the future. Short-term adverse effects of bronchodilators are common and must be weighed against the benefit of their use. Bronchodilators may be considered in a child with moderate or severe disease.

Inhaled and systemic corticosteroids have not been shown to reduce clinical symptoms, hospitalizations, or length of hospital stays in children with bronchiolitis.15,16 Epinephrine combined with dexamethasone (Decadron, Dexamethasone Intensol, Dexpak) may reduce the number of hospital admissions and shorten stays, but additional study is needed.14 There is no evidence that epinephrine or corticosteroids alone improve clinical outcomes for inpatients with bronchiolitis.

Although the cause of bronchiolitis is viral, antibiotics are commonly prescribed for children with uncomplicated disease.17 Antibiotic use may be appropriate for children at high risk of complications or those with proven bacterial infection, but this modality has no role in healthy children with uncomplicated bronchiolitis. Judicious use of antibiotics in the treatment of bronchiolitis will help reduce the risk of developing resistant bacteria.

Prognosis

Children with bronchiolitis generally recover without complications or wheezing episodes. The average length of illness is 12 days, but some children may continue to cough for weeks. Children who are hospitalized are usually discharged in fewer than five days. Following severe bronchiolitis infection, subsequent asthma has been reported in 30% of children hospitalized with the disease.

Increased severity of infant bronchiolitis may be associated with increased chances of developing childhood asthma, but this relationship is not well understood.18 It is unclear whether bronchiolitis causes or triggers asthma or if children who are prone to asthma are more likely to develop the illness as infants. Further research is needed to clarify the relationship between bronchiolitis and the development of asthma later in childhood.

Prevention

Although there is currently no vaccine against bronchiolitis, the monoclonal antibody palivizumab (Synagis) can be given to high-risk infants to help prevent RSV during respiratory season. Given in once-monthly intramuscular doses, palivizumab may reduce the incidence rate of RSV bronchiolitis by 39% to 82% in high-risk infants.19 If hospitalized during RSV season, eligible children should receive a dose prior to discharge. The specific indications for palivizumab administration are listed in Table 4.