The SIGN guideline on bronchiolitis in infants will help GPs identify symptoms and know when to refer, explains Dr Alan Woodley

Most GPs expect to see infants who have a cough or wheeze, possibly some crepitations or rhonchi on listening to their lungs, who are feeding less well than usual, and who may continue coughing or wheezing for some time during the winter months. This is a fairly typical presentation of bronchiolitis and approximately one-third of all infants will develop bronchiolitis in their first year of life.1

So how do we diagnose this condition and how should we treat infants with bronchiolitis? The SIGN guideline on bronchiolitis in children, published in November 2006, should help GPs to manage this common condition appropriately.2

Presentation

Bronchiolitis is a clinical diagnosis usually made in those under 1 year of age. Infants may present with cough, breathing difficulties, and poor feeding –— and in the very young, apnoea.2 Typical findings include fine inspiratory crackles in all lung fields and/or high pitched expiratory wheeze. Such a presentation can be alarming for parents and GPs, and can be mimicked by other pulmonary causes (asthma, pneumonia, cystic fibrosis) and non-pulmonary causes (congenital heart disease, sepsis).2 If there is doubt about the diagnosis the infant should be referred for a paediatric assessment.
Management

Although most cases of bronchiolitis are mild and can be managed at home,2 infants should also be referred if there is evidence of severe disease. The guideline states that severe disease is indicated by any of the following:2

  • poor feeding (less than 50% of usual fluid intake in preceding 24 hours is suggested as a guide)
  • lethargy
  • history of apnoea
  • respiratory rate >70/min
  • nasal flaring and/or grunting
  • severe chest wall recession
  • cyanosis oxygen saturation ?94% (although many GPs may not yet be measuring oxygen saturation in infants).

Drug therapy

GPs may be tempted to prescribe antibiotics for children who have a respiratory illness and crackles or wheeze in their chest, but these are not recommended and seem to be of no benefit in uncomplicated acute bronchiolitis.2 Similarly, some GPs may prescribe beta2 agonists, anticholinergics (ipratropium), or corticosteroids in infants who are wheezing. However, studies indicate that the child does not benefit from these drugs, and neither inhaled nor systemic corticosteroids are recommended for the treatment of acute bronchiolitis.3–5

In practice, the best treatment is an explanation to the parents or carers of the course of the illness, and encouraging maintenance of fluid intake with smaller more frequent feeds. Children with more severe disease need to be referred to hospital.

Hospitalisation

Whether admitted to hospital or not, a number of these infants will be brought back to see the GP, possibly on a few occasions, with cough or wheeze. This commonly settles without treatment within a few weeks. Currently, there is no good evidence on whether bronchiolitis predisposes to asthma in later life and whether any treatment of acute bronchiolitis affects the long-term outcome in terms of later respiratory morbidity.

The hospital admission rate for bronchiolitis has increased over the past 10 years.2 The reasons are not clear but may be partly related to the increased survival of premature infants. Children with prematurity, cardiac disease, or underlying lung disease are prone to more serious illness and, therefore, have a higher rate of hospitalisation.2

Summary

This new guideline from SIGN should help GPs to avoid unnecessary treatment and to know when to refer patients for a paediatric assessment.

  1. Glezen W, Taber L, Frank A, Kasel J. Risk of primary infection and reinfection with respiratory syncytial virus. Am J Dis Child 1986; 140 (6): 543–546.
  2. Scottish Intercollegiate Guidelines Network (SIGN 91). Bronchiolitis in children: a national clinical guideline. Edinburgh: SIGN, 2006.
  3. King V, Viswanathan M, Bordley et al. Pharmacologic treatment of bronchiolitis in infants and children: a systematic review. Arch Pediatr Adolesc Med 2004; 158 (2): 127–137.
  4. Chowdhury D, al Howasi M, Khalil M et al. The role of bronchodilators in the management of bronchiolitis: a clinical trial. Ann Trop Paediatr 1995; 15 (1): 77–84.
  5. Patel H, Platt R, Loranzo J, Wang E. Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Database Syst Rev 2004; (3): CD004878G