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Bronchiolitis in children: diagnosis and management

Assessment and diagnosis

  • When diagnosing bronchiolitis, take into account that it occurs in children under 2 years of age and most commonly in the first year of life, peaking between 3 and 6 months
  • When diagnosing bronchiolitis, take into account that symptoms usually peak between 3 and 5 days, and that cough resolves in 90% of infants within 3 weeks.
  • Diagnose bronchiolitis if the child has a coryzal prodrome lasting 1 to 3 days, followed by:
    • persistent cough and
    • either tachypnoea or chest recession (or both) and
    • either wheeze or crackles on chest auscultation (or both)
  • When diagnosing bronchiolitis, take into account that the following symptoms are common in children with this disease:
    • fever (in around 30% of cases, usually of less than 39°C)
    • poor feeding (typically after 3 to 5 days of illness)
  • When diagnosing bronchiolitis, take into account that young infants with this disease (in particular those under 6 weeks of age) may present with apnoea without other clinical signs
  • Consider a diagnosis of pneumonia if the child has:
    • high fever (over 39°C) and/or
    • persistently focal crackles
  • Think about a diagnosis of viral-induced wheeze or early-onset asthma rather than bronchiolitis in older infants and young children if they have:
    • persistent wheeze without crackles or
    • recurrent episodic wheeze or
    • a personal or family history of atopy
  • Take into account that these conditions are unusual in children under 1 year of age
  • Measure oxygen saturation in every child presenting with suspected bronchiolitis, including those presenting to primary care if pulse oximetry is available
  • Ensure healthcare professionals performing pulse oximetry are appropriately trained in its use specifically in infants and young children
  • Suspect impending respiratory failure, and take appropriate action as these children may need intensive care, if any of the following are present:
    • signs of exhaustion, for example listlessness or decreased respiratory effort
    • recurrent apnoea
    • failure to maintain adequate oxygen saturation despite oxygen supplementation

When to refer

  • Immediately refer children with bronchiolitis for emergency hospital care (usually by 999 ambulance) if they have any of the following:
    • apnoea (observed or reported)
    • child looks seriously unwell to a healthcare professional
    • severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute
    • central cyanosis
    • persistent oxygen saturation of less than 92% when breathing air
  • Consider referring children with bronchiolitis to hospital if they have any of the following:
    • a respiratory rate of over 60 breaths/minute
    • difficulty with breastfeeding or inadequate oral fluid intake (50–75% of usual volume, taking account of risk factors and using clinical judgement)
    • clinical dehydration
  • When deciding whether to refer a child with bronchiolitis to secondary care, take account of the following risk factors for more severe bronchiolitis:
    • chronic lung disease (including bronchopulmonary dysplasia)
    • haemodynamically significant congenital heart disease
    • age in young infants (under 3 months)
    • premature birth, particularly under 32 weeks
    • neuromuscular disorders
    • immunodeficiency
  • When deciding whether to refer a child to secondary care, take into account factors that might affect a carer's ability to look after a child with bronchiolitis, for example:
    • social circumstances
    • the skill and confidence of the carer in looking after a child with bronchiolitis at home
    • confidence in being able to spot red flag symptoms
    • distance to healthcare in case of deterioration

Key safety information for looking after a child at home

  • Provide key safety information for parents and carers to take away for reference for children who will be looked after at home. This should cover:
    • how to recognise developing 'red flag' symptoms:
      • worsening work of breathing (for example grunting, nasal flaring, marked chest recession)
      • fluid intake is 50–75% of normal or no wet nappy for 12 hours
      • apnoea or cyanosis
      • exhaustion (for example, not responding normally to social cues, wakes only with prolonged stimulation)
    • that people should not smoke in the child's home because it increases the risk of more severe symptoms in bronchiolitis
    • how to get immediate help from an appropriate professional if any red flag symptoms develop
    • arrangements for follow-up if necessary

full guideline available from…
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT
www.nice.org.uk/guidance/ng9

National Institute for Health and Care Excellence. Bronchiolitis in children: diagnosis and management.
First included: October 2015.