CHILD WITH BRONCHIOLITIS

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An acute viral infection of the lower respiratory tract that occurs primarily in children less than 2 years (peaks during the rainy season). It is characterized by airways obstruction and wheezing. Episodes of wheeze may occur for months after an attack of bronchiolitis, but will eventually stop.

Causes and risk factors

  • Respiratory Syncytial Virus (RSV) in 70% of cases
  • Children who were never breastfed
  • Children exposed to secondary tobacco smoke

Signs and symptoms

  • First 24-72 hours, rhinopharyngitis with dry cough
  • Wheezing not relieved by bronchodilators
  • Difficulty in breathing
  • Lower chest wall indrawing
  • Moderate or no fever
  • Difficulty in feeding, breastfeeding or drinking owing to respiratory distress
  • Nasal discharge

Signs of serious illness

  • Rapid breathing, often a respiratory rate of less than 50–60 breaths per minute
  • Cyanosis evident in the lips, buccal membranes, and fingernails
  • Nasal flaring
  • Periods of cessation of breathing, especially in infants <6 weeks
  • Poor feeding or refusal of feedings; difficulty drinking or breastfeeding
  • Seizure as a result of hypoxia
  • Altered level of consciousness
  • Chest indrawing
  • Chest is silent on auscultation

Evaluation

Most children can be treated at home, but those with the following signs of:

  • Severe pneumonia should be treated in hospital:
  • Oxygen saturation < 94% or central cyanosis.
  • Apnoea or history of apnoea
  • Inability to breastfeed or drink, or vomiting everything
  • Convulsions, lethargy or unconsciousness
  • Gasping and grunting (especially in young infants)
  • Age less than 3 months

Treatment objectives

  • Classify severity of illness
  • Alleviate symptoms
  • Treat secondary infections
  • Refer appropriately

Non-pharmacological treatment

  • Position the child in a half-sitting position to make breathing easier
  • Nasal irrigation with 0.9% NaCl before each feeding
  • Small, frequent feedings to reduce vomiting triggered by bouts of coughing
  • Increase fluid intake if fever and/or vomiting are present.
  • Do not sedate the child

Pharmacological treatment

Oxygen therapy

  • Give oxygen to all children with severe respiratory distress or oxygen saturation ≤ 90%
  • Use pulse oximetry to guide oxygen therapy (to keep oxygen saturation > 90%).
  • If a pulse oximeter is not available, continue oxygen until the signs of hypoxia (such as inability to breastfeed or breathing rate ≥ 70/min) are no longer present.

Antibiotic treatment

  • Give an antibiotic only if the child has signs of pneumonia (fast breathing and lower chest wall indrawing)

When infant is treated, give

Amoxicillin oral

90 mg/kg/day in two divided doses for 5 days (children >1-18 yrs)

Ampicillin 50mg/Kg/dose every 6 hours for 5 days

For Newborns, give Intravenous:

Ampicillin 50mg/Kg/dose every 12  hours

 

If child is allergic to Penicillins, you switch to:

Azithromycin 10mg/Kg/day for 3 days (1-18yrs)

OR

Erythromycin 12.5mg/Kg/dose every 6 hours for 5 days

 

If the newborn is allergic to Penicillins, switch to:

Cefuroxime 75mg/Kg/dose every 12 hours x5 days

(if conditions improve, you may switch to oral medication to complete 7 days of treatment)

 

If there are signs of severe pneumonia

(Older Children: 1-18 yrs)  Ampicillin IV 50 mg/kg every 6 hours for at least 5 days

AND

Gentamicin 7.5 mg/kg IM or IV once a day for at least 5 days. (Older Children)

Gentamicin 3.5 mg/kg/dose  IM or IV once a day for at least 5 days (newborns)

 

If the child has fever ≥ 39 °C that appears to be causing distress, give

Paracetamol

10 mg/kg -20mg/Kg every 6 hours (when necessary)

Referral

  • If the child fails to respond to oxygen therapy or the child’s condition worsens suddenly, refer immediately for specialist attention.