Bronchiolitis Guideline

S I
GN
Scottish Intercollegiate Guidelines Network
91 Bronchiolitis in children
A national clinical guideline
1 Introduction 1
2 Diagnosis 4
3 Risk factors for severe disease 7
4 Assessment and referral 10
5 Investigations 12
6 Treatment 15
7 Symptom duration and hospital discharge 18
8 Chronic symptoms and follow up 19
9 Limiting disease transmission 21
10 Prophylactic therapies 23
11 Information for parents and carers 26
12 Implementation and audit 31
13 Development of the guideline 33
Abbreviations 37
References 38
November 2006
Copies of all SIGN guidelines are available online at www.sign.ac.uk
KEY TO EVIDENCE STATEMENTS AND GRADES OF RECOMMENDATIONS
LEVELS OF EVIDENCE
1++ High quality meta-analyses, systematic reviews of randomised controlled trials

(RCTs), or RCTs with a very low risk of bias
1 + Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low
risk of bias
1 - Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2 ++
High quality systematic reviews of case control or cohort studies
High quality case control or cohort studies with a very low risk of confounding or
bias and a high probability that the relationship is causal
2 + Well conducted case control or cohort studies with a low risk of confounding or
bias and a moderate probability that the relationship is causal
2 - Case control or cohort studies with a high risk of confounding or bias
and a significant risk that the relationship is not causal
3 Non-analytic studies, eg case reports, case series
4 Expert opinion
GRADES OF RECOMMENDATION
Note: The grade of recommendation relates to the strength of the evidence on which the
recommendation is based. It does not reflect the clinical importance of the recommendation.
A At least one meta-analysis, systematic review of RCTs, or RCT rated as 1++

and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable
to the target population, and demonstrating overall consistency of results
B A body of evidence including studies rated as 2++, directly applicable to the target
population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C A body of evidence including studies rated as 2+, directly applicable to the target
population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good practice points
 Recommended best practice based on the clinical experience of the guideline

development group
This document is produced from elemental chlorine-free material and is sourced from sustainable forests
Bronchiolitis in children
A national clinical guideline
November 2006
© Scottish Intercollegiate Guidelines Network
ISBN 1 (10) 905813 01 5
ISBN (13) 978 1 905813 01 8
First published 2006
SIGN consents to the photocopying of this guideline for the

purpose of implementation in NHSScotland
28 Thistle Street, Edinburgh EH2 1EN
www.sign.ac.uk
1 INTRODUCTION
1 Introduction
1.1 background
Bronchiolitis of infancy is a clinically diagnosed respiratory condition presenting with breathing
difficulties, cough, poor feeding, irritability and, in the very young, apnoea. These clinical
features, together with wheeze and/or crepitations on auscultation combine to make the
diagnosis. Bronchiolitis most commonly presents in infants aged three to six months.1
Bronchiolitis occurs in association with viral infections (respiratory syncytial virus; RSV, in
around 75% of cases)2 and is seasonal, with peak prevalence in the winter months (November
to March) when such viruses are widespread in the community. Re-infection during a single
season is possible.
The burden of disease is significant. Around 70% of all infants will be infected with RSV in
their first year of life and 22% develop symptomatic disease. Since RSV is associated with
only 75% of bronchiolitis cases, it may be estimated that around a third of all infants will
develop bronchiolitis (from all viruses) in their first year of life.3 For Scotland this translates to
approximately 15,000 infants.
Around 3% of all infants younger than one year are admitted to hospital with bronchiolitis.4
Based on Scottish morbidity recording for the years 2001 to 2003 a mean of 1,976 children
per year (aged up to 12 months) were admitted to hospital with bronchiolitis as the principal
diagnosis.5
The rate of admissions to hospital with bronchiolitis has increased over the past 10 years. The
reasons for this are not fully understood and are likely to be multifactorial and include improved
survival of preterm infants.4
In most infants the disease is self limiting, typically lasting between three and seven days.
Most infants are managed at home, often with primary care support. Admission to hospital is
generally to receive supportive care such as nasal suction, supplemental oxygen or nasogastric
tube feeding.
Children with underlying medical problems (prematurity, cardiac disease or underlying respiratory
disease) are more susceptible to severe disease and so have higher rates of hospitalisation.4
In preterm infants less than six months of age, admission rate with acute bronchiolitis is 6.9%
with admission to intensive care more frequent in such patients.4
In a UK study, the RSV-attributed death rate (measured in infants aged one to 12 months) was
8.4 per 100,000 population.6
Twenty percent of infants with bronchiolitis (40-50% of those hospitalised) proceed to a
grumbling, sometimes protracted, respiratory syndrome of persistent cough and recurrent viral-
induced wheeze.7 Ongoing symptoms may relate to continuing inflammation and temporary
cilial dysfunction.8 An association between acute bronchiolitis and later respiratory morbidity
is recognised.9
1.2 need for a guideline

There is widespread variation in the management of infants with bronchiolitis both in hospital
and, anecdotally, in the community.10 The guideline aims to reduce the use of unnecessary
therapies and investigations, particularly in the acute illness, and to guide referral patterns from
primary to secondary and for some, tertiary care.
1

Bronchiolitis in Children
1.3 guideline remit

This guideline provides evidence based recommendations on the prevention, diagnosis,
investigation, treatment and management of bronchiolitis. Specific attention has been given
to the most appropriate use of diagnostic, referral and prognostic tools, particularly for those
in primary care.
The guideline focuses on the clinically diagnosed condition of bronchiolitis in infants less than
12 months of age. This minimises any bias from reporting discrepancies associated with the
diagnosis of bronchiolitis above this age. For example, in the USA the term ‘bronchiolitis’ may
be used to describe any wheeze associated with a viral infection in older children, creating the
risk that studies on children over twelve months of age may include different disease entities.
As infants with significant comorbidities have increased susceptibility to bronchiolitis beyond
twelve months of age, the following specific groups were considered up to 24 months of age:
 those born prematurely (≤37 weeks gestational age)
 infants with congenital heart disease (CHD) or underlying respiratory disease.
Most studies of investigations and treatments for bronchiolitis have been conducted in hospitalised
infants. In addition, the majority of studies which were identified excluded individuals with
significant coexisting conditions. Except where explicitly stated, recommendations apply directly
to previously healthy infants.
Bronchiolitis in immunodeficient infants or those with rare (‘orphan’) lung disease was not
considered, nor was preoperative screening for RSV. Specialist intensive care practice was also
beyond the scope of the guideline. Virological testing for non-RSV causes of bronchiolitis such
as parainfluenza, adenovirus, influenza A and B, metapneumovirus, rhinovirus, enterovirus or
Mycoplasma pneumoniae is outside the scope of this guideline.
1.4 audience
This guideline will be of interest to all health professionals in primary and secondary care
involved in the management of infants with bronchiolitis including:
 general practitioners (GPs)  specialist paediatric nurses
 emergency medicine specialists  paediatric nurses
 general paediatricians  infection control team
 respiratory paediatricians  health visitors
 neonatologists  practice nurses
 paediatric intensivists  paediatric physiotherapists
 public health specialists  pharmacists
The guideline will also be of interest to parents and carers as well as to healthcare managers
and policy makers.

1 INTRODUCTION
1.5 Statement of intent

This guideline is not intended to be construed or to serve as a standard of care. Standards
of care are determined on the basis of all clinical data available for an individual case and
are subject to change as scientific knowledge and technology advance and patterns of care
evolve. Adherence to guideline recommendations will not ensure a successful outcome in
every case, nor should they be construed as including all proper methods of care or excluding
other acceptable methods of care aimed at the same results. The ultimate judgement must be
made by the appropriate healthcare professional(s) responsible for clinical decisions regarding
a particular clinical procedure or treatment plan. This judgement should only be arrived at
following discussion of the options with the patient, covering the diagnostic and treatment
choices available. It is advised, however, that significant departures from the national guideline
or any local guidelines derived from it should be fully documented in the patient’s case notes
at the time the relevant decision is taken.
1.6 review and updating

This guideline was issued in 2006 and will be considered for review in three years. Any updates
to the guideline in the interim period will be noted on the SIGN website: www.sign.ac.uk

2 Diagnosis
2.1 clinical definition
The diagnosis of bronchiolitis is a clinical one based on typical history and findings on
physical examination.11 Clinicians in different countries use different criteria to diagnose acute
bronchiolitis.12
A consensus guideline from the UK developed using a Delphi panel reported a 90% consensus
on the definition of bronchiolitis as ‘a seasonal viral illness characterised by fever, nasal discharge 4
and dry, wheezy cough. On examination there are fine inspiratory crackles and/or high pitched
expiratory wheeze’.12
Bronchiolitis typically has a coryzal phase for two to three days which precedes the onset of 4
other symptoms.1
In the first 72 hours of the illness, infants with bronchiolitis may deteriorate clinically before 4
symptom improvement.1
A number of other conditions can mimic acute bronchiolitis. Pulmonary causes of bronchiolitis-
like symptoms include asthma, pneumonia, congenital lung disease, cystic fibrosis or inhaled 4
foreign body. Non-pulmonary causes include CHD, sepsis or severe metabolic acidosis.13
2.2 diagnostic value of clinical characteristics
2.2.1 Age
Bronchiolitis mainly affects infants under two years of age. Ninety percent of cases requiring
3
hospitalisation occur in infants under twelve months of age.4 Incidence peaks at age three to
4
six months.1
No evidence was identified on the value of age as a specific discriminatory feature in the
diagnosis of bronchiolitis.
2.2.2 Fever
Infants with bronchiolitis may have fever or a history of fever.14-18 High fever is uncommon in
bronchiolitis.1,16 In a prospective study of 90 infants hospitalised with acute bronchiolitis (mean
4
age 4.4 months), only two (2.2%) had a temperature of ≥40°C. Twenty eight infants (31%) had
3
fever as defined by a single axillary temperature recording >38°C or two successive recordings
2+
>37.8°C taken four hours apart during the first 24 hours of admission. A high proportion of
the febrile infants (71%) had a severe disease course requiring oxygen supplementation.19
D The absence of fever should not preclude the diagnosis of acute bronchiolitis.
D In the presence of high fever (axillary temperature ≥39°C) careful evaluation for other
causes should be undertaken before making a diagnosis.
 It is unusual for infants with bronchiolitis to appear ”toxic”. A “toxic” infant who is
drowsy, lethargic or irritable, pale, mottled and tachycardic requires immediate treatment.
Careful evaluation for other causes should be undertaken before making a diagnosis of
bronchiolitis.

2 DIAGNOSIS
2.2.3 Rhinorrhoea
Nasal discharge often precedes the onset of other symptoms such as cough, tachypnoea, 4
respiratory distress and feeding difficulties.13,14
2.2.4 Cough
Expert opinion suggests that a dry, wheezy cough is characteristic of bronchiolitis.12,13 Cough,
4
along with nasal symptoms, is one of the earliest symptoms to occur in bronchiolitis.17
2.2.5 respiratory rate

Increased respiratory rate is an important symptom in lower respiratory tract infection (LRTI) 3
and particularly in bronchiolitis and pneumonia.1,15,16,18 4
D Increased respiratory rate should arouse suspicion of lower respiratory tract infection,
particularly bronchiolitis or pneumonia.
It is not possible to provide specific definitions of tachypnoea since the range of rates varies
by age with rates particularly difficult to interpret in infants less than six months of age.12 The 3
World Health Organisation cut offs for defining tachypnoea, although widely used, have not 4
been fully validated.12,18,20
2.2.6 poor feeding

Many infants with bronchiolitis have feeding difficulties due to dyspnoea but poor feeding
is not essential for the diagnosis of bronchiolitis. Feeding problems are often the reason for 4
hospital admission.1,14
2.2.7 increased work of breathing and recession

Dyspnoea and subcostal, intercostal and supraclavicular recessions are commonly seen in 3
infants with acute bronchiolitis.11-14,16 4
The chest may be visibly hyperinflated in bronchiolitis.1,13,16 The presence of a hyperinflated 3

chest may help to distinguish bronchiolitis from pneumonia.16 4
2.2.8 crackles/crepitations
Fine inspiratory crackles in all lung fields are a common (but not universal) finding in acute
bronchiolitis.1,12,15,16 In the UK, crackles on chest auscultation are regarded as the hallmark of 3
bronchiolitis. Infants with no crackles and only transient early wheezing are usually classified 4
as having viral-induced wheeze rather than bronchiolitis.14
2.2.9 wheeze
UK definitions of bronchiolitis describe high pitched expiratory wheeze as a common but not
universal examination finding.1,12,15,18 American definitions of bronchiolitis place much more 3
emphasis on the inclusion of wheeze in the diagnosis.16 This presents difficulties in extrapolating 4
data from American research.
2.2.10 apnoea
Apnoea can be the presenting feature of bronchiolitis, especially in the very young and in
4
premature or low birthweight infants.13,14,20
2.3 summary of diagnostic characteristics

D A diagnosis of acute bronchiolitis should be considered in an infant with nasal discharge
and a wheezy cough, in the presence of fine inspiratory crackles and/or high pitched
expiratory wheeze. Apnoea may be a presenting feature.

2.4 seasonality
Both bronchiolitis and RSV infection demonstrate winter seasonality in temperate climates.7 4
This is less true in other parts of the world,21 and a recent history of international travel may be 3
significant. In Scotland, RSV infection peaks between November and March (see Figure 1).
The generation of epidemiological information is dependent on virological testing and disease
surveillance. In Scotland, weekly surveillance information is based on the numbers of laboratory 3
reports to Health Protection Scotland, which come mainly from hospitalised patients.22
Figure 1: RSV laboratory reports to Health Protection Scotland by four-week period
D Healthcare professionals should take seasonality into account when considering the
possible diagnosis of acute bronchiolitis.

3 RISK FACTORS FOR SEVERE DISEASE
3 Risk factors for severe disease

Almost all studies relating to bronchiolitis are performed on those attending or admitted to
hospital. The disease severity status triggering attendance at or admission to hospital will depend
on local levels of supportive care provided through both primary and secondary care within
the community. Decisions to admit or to discharge from hospital are multifactorial, taking into
consideration factors such as comorbidities, geography and the perceived ability of carers to
respond appropriately if an infant’s condition deteriorates.
3.1 age
Younger infants have a higher risk of hospital admission with bronchiolitis than older 2+
infants.23-26
3.2 significant comorbidities
3.2.1 Prematurity
Infants born prematurely have a modestly higher rate of RSV-associated hospitalisation compared
with full-term healthy babies. 23,25-33 Table 1 presents the results of a study to determine the rates
2+
of hospital admission (in children up to two years of age) for RSV infection among infants born
at different gestational ages over a ten year period.27
Table 1: Association of gestational age with RSV hospital admission rate27
Gestational age (weeks) ≤28 29-32 33-35 ≥36

Number of infants observed 168 498 1,133 33,983
RSV hospital admission rate (%) 7 7 4 2
Relative risk of hospital admission 3.6 1.9
1
(95% Confidence Intervals) (2.7 to 4.8) (1.4 to 2.6)
3.2.2 Congenital heart disease

In a retrospective observational study of infants born at term, the hospital admission rate for
children under three years of age with bronchiolitis was higher for those with congenital
2+
heart disease (9.2%) than those with no underlying medical condition (3%).26 In three further 2-
observational studies infants with CHD accounted for 6.4% to 12% of all RSV associated
hospital admissions.28,32,34
3.2.3 Chronic lung disease of prematurity

A prospective study of the use of healthcare resources in infants with chronic lung disease
(CLD) born at 32 weeks gestation or less found that during the first two years after birth 45
infants (19%) had at least one hospital admission for a proven RSV infection and 24 (10%) had 2+
at least one admission for probable bronchiolitis.35
This increased rate of hospitalisation (with RSV infection) in those with underlying CLD is also 2+
shown in five retrospective cohort studies, some of which included full-term infants.26-28,31,32 2-

3.2.4 Summary of effect of comorbidity

Infants born prematurely or who have congenital heart disease or chronic lung disease are at
increased risk of severe RSV disease.
C Healthcare professionals should be aware of the increased need for hospital admission
in infants born at less than 35 weeks gestation and in infants who have congenital heart
disease or chronic lung disease of prematurity.
No evidence was identified on the risk of hospitalisation with bronchiolitis in infants with
chronic lung disease not associated with prematurity.
3.3 atopy
No evidence was identified on personal atopy as a risk factor for severe disease course in
bronchiolitis. There is conflicting evidence as to whether a family history of atopy is associated
with acute bronchiolitis requiring hospitalisation. In two studies, different markers of atopy 2-
demonstrated both association and lack of association with severe disease within the same 2+
study.25,36 A further study demonstrated an association between maternal asthma and less severe
hospitalised disease as measured by oxygen saturation and length of stay.37
3.4 Social factors
3.4.1 breast feeding

In a prospective case control study of infants born at 33-35 weeks gestation or who were less
than six months of age at the start of the RSV season, breast feeding for more than two months
had a protective effect.38 There was a greater likelihood of RSV hospitalisation if breast feeding 2-
duration was less than two months (odds ratio; OR 3.25, 95% confidence intervals; CI 1.96 2+
to 5.42). In another case control study, breast feeding was associated with a lower risk of RSV
hospitalisation in infants under and over six months of age.39
C Breast feeding reduces the risk of RSV-related hospitalisation and should be encouraged
and supported.
3.4.2 Parental smoking

Parental smoking is associated with an increased risk of RSV-related hospitalisation of infants
when compared with non-smoking families (with adjusted odds ratios ranging from 1.3 to 3.4 2+
with broad confidence intervals).23,26,40 There is evidence of a weak association between RSV 2-
hospitalisation and smoking in pregnancy.25,33,40
One study in premature infants found no significant association between hospitalisation for
RSV-related LRTI and maternal smoking, although maternal smoking was associated with 2-
hospitalisation for any LRTI.30
C Healthcare professionals should inform families that parental smoking is associated

with increased risk of RSV-related hospitalisation.
3.4.3 Number of siblings and nursery or day-care attendance

Observational studies indicate an association between having siblings at home (particularly of
school age or attending day care) and increased risk of hospitalisation of infants with clinically 2-
2+
diagnosed bronchiolitis or RSV infection.23,25,26,28,33,39,41 This effect is seen in infants previously
healthy, born prematurely or with CLD.28

3 RISK FACTORS FOR SEVERE DISEASE
3.4.4 socioeconomic deprivation

Only one study was identified that examined the association between severe bronchiolitis and
deprivation score. A small case control study in infants under 12 months of age found that
the risk of admission with clinically suspected bronchiolitis and with bronchiolitis requiring 2+
medical intervention rose with increasing level of deprivation score based on electoral ward
of residence.42
Overcrowding and fuel poverty are other markers of socioeconomic deprivation. Observational
studies show associations between both overcrowding and bedroom sharing and increased
risk of hospitalisation with RSV in infants born at term and prematurely.23,24,33,39 No studies 2-
were identified on the influence of domestic heating on incidence or severity of acute
bronchiolitis.

4 Assessment and referral

4.1 assessment
4.1.1 severe disease

Previous guidelines identify a number of clinical features of severe disease in
bronchiolitis:12,43
 poor feeding (<50% of usual fluid intake in preceding 24 hours)
 lethargy
4
 history of apnoea
 respiratory rate >70/min
 presence of nasal flaring and/or grunting
 severe chest wall recession
 cyanosis.
Risk factors for severe disease are discussed in section 3.
4.1.2 clinical scoring systems

No good quality evidence on the use of formal clinical scoring systems in infants with acute
bronchiolitis was identified.
4.2 referral
No good quality studies were identified regarding the effectiveness of indicators for referral
from primary to secondary care or for admission to intensive care. Good practice guidance
based on the clinical experience of the guideline development group is presented. This takes
into account risk factors for, and clinical predictors of, severe disease as well as a previous
consensus guideline on breathing difficulty in children, a New Zealand guideline on wheeze
and chest infection in children less than one year and the British Thoracic Society guidelines
on the management of community acquired pneumonia in childhood.1,12,44
 Most infants with acute bronchiolitis will have mild disease and can be managed at home

with primary care support. Parents/care givers should be given information on how
to recognise any deterioration in their infant’s condition and asked to bring them back
for reassessment should this occur.
 Any of the following indications should prompt hospital referral/acute paediatric

assessment in an infant with acute bronchiolitis or suspected acute bronchiolitis:
 poor feeding (<50% of usual fluid intake in preceding 24 hours)
 lethargy
 history of apnoea
 respiratory rate >70/min
 presence of nasal flaring and/or grunting
 severe chest wall recession
 cyanosis
 oxygen saturation ≤94%
 uncertainty regarding diagnosis.
Clinicians assessing the need to refer (or review in primary care) should also take
account of whether the illness is at an early (and perhaps worsening) stage, or at a
later (improving) stage.
10
4 ASSESSMENT AND REFERRAL
 The threshold for hospital referral should be lowered in patients with significant
comorbidities, those less than three months of age or infants born at less than 35 weeks
gestation. Geographical factors/transport difficulties and social factors should also be
taken into consideration.
 Indications for high dependency/intensive care unit consultation include:

 failure to maintain oxygen saturations of greater than 92% with increasing oxygen
therapy
 deteriorating respiratory status with signs of increasing respiratory distress and/or
exhaustion
 recurrent apnoea.
11
5 Investigations
Acute bronchiolitis is a clinical diagnosis. Clinicians assessing infants with possible acute
bronchiolitis may perform investigations when diagnostic uncertainty exists or to aid decision
making regarding subsequent management. These investigations may include oxygen saturation
recording, blood gas analysis, chest X-ray, virological or bacteriological testing, haematology
and biochemistry. This section considers the evidence supporting the role of these investigations
in the management of an infant with acute bronchiolitis.
5.1 oxygen saturation

In an emergency department study, clinical assessment alone was poor at predicting associated
hypoxaemia in infants presenting with a respiratory illness.45 A survey described how small
2+
differences in oxygen saturation level (92% compared to 94%) within the theoretical clinical
3
vignette of an infant with acute bronchiolitis significantly influenced the recommendation of
paediatric emergency physicians to admit or discharge patients.46
Lower oxygen saturation levels on hospital admission predict more severe disease and longer 2+
lengths of stay.47-49 2-
C Pulse oximetry should be performed in every child who attends hospital with acute
bronchiolitis.
  Infants with oxygen saturation ≤92% require inpatient care.
 Decision making around hospitalisation of infants with oxygen saturations between
92% and 94% should be supported by detailed clinical assessment, consideration
of the phase of the illness and take into account social and geographical factors.
 Infants with oxygen saturations >94% in room air may be considered for
discharge.
5.2 Blood Gases

An observational study attempted to correlate clinical respiratory features, arterial blood gases
and oxygen saturation with illness severity (measured as the maximum fraction of inspired
oxygen; FiO2, required during admission). Oxygen saturation and arterial carbon dioxide
tension (PaCO2) best predicted the need for high concentration oxygen therapy. Oxygen tension 2-
(PaO2) levels were less useful. There is a risk of confounding in the study in that the degree
of hypoxaemia or hypercarbia may have influenced both the decision to use oxygen and the
concentration used.50
Blood gas analysis (capillary or arterial) is not usually indicated in acute bronchiolitis.

It may have a role in the assessment of infants with severe respiratory distress or
who are tiring and may be entering respiratory failure. Knowledge of arterialised
carbon dioxide values may guide referral to high dependency or intensive care.
5.3 chest x-ray

In a systematic review of the use of chest X-ray in acute bronchiolitis it was concluded that, in
2+
mild disease, chest X-ray provides no information that is likely to affect treatment.11
An observational study identified a range of independent predictive factors for a normal chest
X-ray in infants with virologically confirmed RSV attending or admitted to hospital: increased
postnatal age in months, larger birth weight, presence of rhinitis, absence of retractions and 3
higher transcutaneously measured oxygen saturation.51 These studies suggest that chest X-ray
need only be performed in selected cases.
12
5 INVESTIGATIONS
C Chest X-ray should not be performed in infants with typical acute bronchiolitis.
 Chest X-ray should be considered in those infants where there is diagnostic uncertainty
or an atypical disease course.
5.4 virological testing

Strategies for limiting disease transmission are discussed in section 9.
Rapid virological testing can be of benefit in relation to guiding isolation and allocating patients
into cohorts in hospital.52 Rapid testing for RSV, which can be performed at the point of care
in order to facilitate this, has been shown to have acceptable performance in comparison to
laboratory based tests despite reduced diagnostic sensitivity.53,54 A case control study found that 2+
rapid diagnosis of respiratory viral infections in infants was cost effective by reducing length
of hospital stay, antibiotic use and number of microbiological tests performed compared to a
matched group of patients from the previous year who were diagnosed by virus culture.55
There may be a reduction in unnecessary interventions associated with knowledge of RSV
2+
status.53,56 In a postal survey, physicians reported that a definitive viral diagnosis was important 3
to patients.57
D Unless adequate isolation facilities are available, rapid testing for RSV is recommended
in infants who require admission to hospital with acute bronchiolitis, in order to guide
cohort arrangements.
5.5 bacteriological testing

In a prospective cohort study of 156 previously healthy febrile infants with bronchiolitis, none
and 1.9% had bacteraemia or urinary tract infection (UTI) respectively, in comparison with 2.7% 2+
and 13.6% of 261 febrile controls.58 This study concluded that previously healthy febrile infants
aged 24 months or younger with bronchiolitis are unlikely to have bacteraemia or UTI.
A cross-sectional study found that 6.5% of febrile infants up to 60 days old with bronchiolitis had
a UTI and none had bacteraemia or meningitis in comparison with 10% (UTI), 2.3% (bacteraemia) 3
and 0.8% (meningitis) in febrile non-bronchiolitic infants in the same age range.59
C Routine bacteriological testing (of blood and urine) is not indicated in infants with
typical acute bronchiolitis. Bacteriological testing of urine should be considered in
febrile infants less than 60 days old.
5.6 haematology
A well conducted systematic review did not identify any studies directly addressing the value of
full blood count in the management of infants with bronchiolitis. Extrapolation of data comparing
1+
full blood count at baseline in interventional studies suggests that full blood count does not aid
diagnosis or guide therapeutic intervention in infants with acute bronchiolitis.11
D Full blood count is not indicated in assessment and management of infants with typical
acute bronchiolitis.
13
5.7 biochemistry
5.7.1 Urea and Electrolytes

No studies were identified on the use of urea and electrolytes (U&E) measurement in infants
with acute bronchiolitis. Expert opinion considers that electrolyte disturbances are unlikely 4
unless there is severe disease.13
D Measurement of urea and electrolytes is not indicated in the routine assessment and
management of infants with typical acute bronchiolitis but should be considered in
those with severe disease.
5.7.2 c-reactive protein

There has been limited investigation into the role of C-reactive protein (CRP) measurement
in distinguishing bacterial from viral lower respiratory tract infections. Existing studies are 2-
retrospective or of poor quality and do not provide sufficient evidence upon which to base a 3
recommendation in relation to bronchiolitis.60-62
14
6 TREATMENT
6 Treatment
Outcomes examined include short term clinical benefits, development of subsequent chronic
respiratory symptoms, attendance at medical services, length of hospital stay and readmissions
rate and admission to a paediatric intensive care unit (PICU). Evidence from primary care,
accident and emergency (A&E), hospital and PICU environments has been considered. Studies
are reported on the basis of their primary outcome measures unless otherwise stated.
6.1 antivirals
A Cochrane systematic review examined the effectiveness of nebulised ribavirin in infants
and children with lower respiratory disease attributable to RSV infection.63 Many studies in
the review excluded children with significant comorbidities. There was a conflict within the
review with regard to the acute infection phase. One study, which used a nebulised water
placebo, suggested that nebulised ribavirin reduced length of hospital stay and the number of 1+
days of mechanical ventilation. Nebulised water, however, may have a detrimental effect on
pulmonary mechanics.64 If this study is excluded, two randomised controlled trials (RCTs) using
saline placebo suggest there is no effect in the ribavirin group.
B Nebulised ribavirin is not recommended for treatment of acute bronchiolitis in

infants.
Three RCTs examined the effect of nebulised ribavirin on chronic respiratory symptoms. All
trials were of poor quality with lack of blinding to treatment allocation, no placebo control,
short follow up period or very small numbers.65-67 There is insufficient evidence to make 1-
a recommendation on the use of nebulised ribavirin for treatment of long term respiratory
symptoms in bronchiolitis.
6.2 antibiotics
No contemporary studies were identified on the use of antibiotics in infants with acute
bronchiolitis. Bacteraemia is infrequent in RSV infection (see section 5.5).
 Antibiotic therapy is not recommended in the treatment of acute bronchiolitis in infants.
6.3 inhaled bronchodilators
6.3.1 Beta 2 agonists

In a systematic review of 12 small placebo controlled trials, eight reported no clinical benefit
for inhaled beta 2 agonist bronchodilators in infants with acute bronchiolitis. Three studies
demonstrated short term (30 to 60 minutes) clinical benefit as measured by various indicators
such as clinical scores, respiratory rate, heart rate and oxygen saturation. One study measured 1+
a worse clinical outcome in the treatment group. The use of bronchodilators had no effect on
rate of hospitalisation or time to hospital discharge. Chronic symptoms and reattendance at
hospital were not considered.68
B Inhaled beta 2 agonist bronchodilators are not recommended for the treatment of
acute bronchiolitis in infants.
6.3.2 anticholinergics
Two underpowered studies demonstrate no benefit in the use of nebulised ipratropium in
1-
infants with bronchiolitis.69,70
 Nebulised ipratropium is not recommended for the treatment of acute bronchiolitis in

infants.
15
6.4 nebulised epinephrine

In a high quality multicentre RCT, nebulised epinephrine did not affect overall clinical status,
oxygen requirement, time to hospital discharge or rate of hospital readmission within one month, 1++
for infants hospitalised with acute bronchiolitis.71 Although additional RCTs were identified,
none were of sufficient quality for inclusion.
A Nebulised epinephrine is not recommended for the treatment of acute bronchiolitis

in infants.
6.5 anti-inflammatories
6.5.1 inhaled corticosteroids

Two RCTs in infants with bronchiolitis have demonstrated that inhaled corticosteroids have
no effect on length of hospital stay, time to becoming asymptomatic or rate of respiratory 1+
readmission to hospital within 12 months.72,73
A Inhaled corticosteroids are not recommended for the treatment of acute bronchiolitis
in infants.
6.5.2 systemic corticosteroids

A Cochrane systematic review concluded that oral systemic corticosteroids did not reduce
length of hospital stay in previously well infants less than 12 months of age with acute 1++
bronchiolitis.74
A Oral systemic corticosteroids are not recommended for the treatment of acute
bronchiolitis in infants.
Long term effects of oral corticosteroids were investigated in a small RCT (n=54) with follow-up
at age five years. Oral prednisolone given for the first seven days of acute bronchiolitis did not
prevent wheeze or the development of asthma up to a mean age of five years.75 The applicability
of this study is limited by its recruitment of children up to two years of age.
6.5.3 leukotriene receptor antagonist (montelukast)

Only one study on the use of montelukast in children with bronchiolitis was identified. For
children aged three to 36 months (median age nine months) admitted to hospital with acute
bronchiolitis/acute wheeze, daily treatment with montelukast for 28 days (starting within seven
days of symptom onset) significantly increased the number of symptom free days over a 56 2+
day period (22% v 4% placebo, p=0.015). Day-time (but not night-time) cough scores were
reduced.76 The results of this study cannot be generalised to infants in the UK with bronchiolitis
where median age at diagnosis is 4.6 months.72 There is therefore insufficient evidence on
which to base a recommendation.
6.6 hospital based supplementary therapies
6.6.1 physiotherapy
A Cochrane systematic review examined three RCTs of chest physiotherapy in infants with acute
bronchiolitis not undergoing mechanical ventilation, and without comorbidities. Percussion 1+
and vibration techniques did not reduce length of hospital stay or oxygen requirements, nor
did they improve the clinical severity score.77
A Chest physiotherapy using vibration and percussion is not recommended in infants

hospitalised with acute bronchiolitis who are not admitted to intensive care.
16
6 TREATMENT
6.6.2 Nasal suction

There are no clinical trials assessing the benefit of nasal suction in acute bronchiolitis. Expert
4
consensus is that nasal suction may improve respiratory status in infants with bronchiolitis.43
D Nasal suction should be used to clear secretions in infants hospitalised with acute
bronchiolitis who exhibit respiratory distress due to nasal blockage.
6.6.3 maintaining fluid balance/hydration

Infants in respiratory distress may have difficulty feeding due to increased work of breathing,
nasal secretions and exhaustion. This makes it difficult for them to maintain adequate input and
hydration. Common strategies are to commence small frequent feeds, nasogastric or orogastric
4
feeding or intravenous fluids. In a review there was no good quality evidence that rehydration
by the nasogastric route is more or less safe than via the intravenous route.78 Expert opinion
considers that nasogastric feeding may be an option where infants are at risk of dehydration.1
D Nasogastric feeding should be considered in infants with acute bronchiolitis who cannot
maintain oral intake or hydration.
6.6.4 oxygen
No studies on the use of oxygen in infants with acute bronchiolitis were identified. The
4
recommendation is based on expert opinion.79
D Infants with oxygen saturation levels ≤92% or who have severe respiratory distress
or cyanosis should receive supplemental oxygen by nasal cannulae or facemask.
6.6.5 Continuous Positive Airway Pressure and Negative Pressure Ventilation

No studies were identified that provided evidence about the location or timing of ventilatory
support for infants with acute bronchiolitis.
 Early discussion with a paediatric intensive care unit and introduction of respiratory
support should be considered in all patients with severe respiratory distress or
apnoeas.
6.7 hospital based treatment guidelines

Three studies on the effect of treatment guideline implementation on length of hospital stay in
infants with acute bronchiolitis were identified. The small numbers included in these studies and 2-
significant methodological problems with confounding factors mean that no recommendation 3
can be made.80-82
6.8 community based supplementary therapies

No studies were identified on the effectiveness of steam, nasal decongestion, homeopathic
remedies or any complementary therapies in the treatment of infants with acute bronchiolitis.
17
7 Symptom duration and hospital discharge

7.1 duration of symptoms following acute BRONCHIOLITIS
In an RCT of inhaled corticosteroid treatment in infants with acute bronchiolitis, time taken
for half of the infants in the placebo arm to become asymptomatic for 48 hours was 12 days 2+
(95% CI 10 to 16).72
Two cohort studies provided information on the duration of symptoms following acute
bronchiolitis. The first, employing twice-weekly structured telephone interviews found that the
median duration of illness was 12 days (95% CI 11 to 14 days), with 39% of infants reportedly
‘not completely well’ after 14 days, 18% after 21 days and 9% after 28 days.83 This study 2-
also suggested that subsequent contacts with healthcare professionals may be reduced when 2+
parents/carers are fully aware of the potential duration of acute symptoms. The second study
further subdivided symptoms and reported median duration of cough was 12 days (interquartile
range 8-20 days); wheeze was seven days, difficulty breathing was six days and poor feeding
was seven days.16
B Parents and carers should be informed that, from the onset of acute bronchiolitis,
around half of infants without comorbidity are asymptomatic by two weeks but that
a small proportion will still have symptoms after four weeks.
Following acute bronchiolitis, cilial damage persists for 13-17 weeks.8 3
7.2 hospital discharge criteria
7.2.1 oxygen saturation

Two studies provide evidence that, in infants who attend hospital with bronchiolitis, pulse
3
oximetry has a significant influence on the decision to admit to hospital or to discharge.84,85
No good quality evidence was identified for specific thresholds on which to base decisions about
discharge or whether these should be based on continuous or intermittent oxygen saturation
monitoring.
Previous guidelines offer various lower limits for acceptable oxygen saturation levels in air in
infants with acute bronchiolitis, ranging from 90-94%. An acceptable duration of desaturation 4
is not defined.11,12
 Infants who have required supplemental oxygen therapy should have oxygen saturation

monitoring for a period of 8-12 hours after therapy is discontinued (including a period of
sleep) to ensure clinical stability before being considered for discharge.
 Infants with oxygen saturations >94% in room air may be considered for discharge.

7.2.2 feeding
Although a history of reduced feeding is one of the main factors in deciding whether to admit
an infant to hospital, no studies were identified on the use of feeding as an indicator for safe
hospital discharge.86 In hospitalised infants with bronchiolitis, oral feed volumes have been
reported as less than half that of well infants.87
 Hospitalised infants should not be discharged until they can maintain an adequate daily

oral intake (>75% of usual intake).
18
8 CHRONIC SYMPTOMS AND FOLLOW UP
8 Chronic symptoms and follow up

8.1 chronic symptoms
An association between acute bronchiolitis and later respiratory morbidity is recognised. The
mechanisms for this are poorly understood. There is debate as to whether the primary insult
to the lung is the acute bronchiolitic illness, or whether there is prior genetic/environmental 4
predisposition to respiratory morbidity. The severity of acute bronchiolitis may be the best
predictor of chronic respiratory symptoms.88
8.1.1 one year

Two small prospective cohort studies confirm high rates of recurrent wheeze episodes in the 12
months following hospitalisation for RSV bronchiolitis.89,90 A Dutch study (n=130) reported a
recurrent wheeze rate of 61% in those with, compared with 21% in those infants without, signs
of airflow limitation at presentation.89 A German study (n=126) reported recurrent wheeze in 2+
31% of infants hospitalised with RSV bronchiolitis compared with 3.6% in controls.89 In extended
follow up the Dutch study measured an overall decline in the number of wheeze episodes over
three years but with seasonal increases in wheeze episodes in the winter months.91
8.1.2 up to age six years

A quantitative review of six case control studies identified wheeze in 40% of children compared
with 11% of controls (OR 3.8, 95% CI 1.6 to 9.3, p<0.001) at five years after hospitalisation 2+
with RSV infection.92 No significant differences between the RSV bronchiolitis group and controls
were found regarding a personal history of atopy, a family history of atopy and/or asthma.
8.1.3 Up to age 13 years

Long term morbidity into early adolescence has been studied by two groups who report
conflicting results which may relate to differences in patient recruitment, including genetic
influences, and study size. The Tucson Children’s Respiratory Study which recruited a large
2+
cohort of hospitalised and non-hospitalised infants, showed an increase in wheeze up to age
11 but this was no longer significant at age 13 (OR 1.4, 95% CI 0.7 to 2.6, see Table 2). There
was no association with allergic sensitisation.93
Table 2: Frequent wheeze in children following RSV infection in first three years of life.93
Age 6 Age 8 Age 11 Age 13

(n=68/669) (n=56/545) (n=79/634) (n=49/469)
Frequent wheeze
4.3 1.9 2.4 1.4
Adjusted odds ratio*
(2.2 to 8.7) (0.9 to 4.2) (1.3 to 4.6) (0.7 to 2.6)
(95% CI)
* Results adjusted for sex, maternal education, family history of asthma, allergy skin tests at year 6,
birthweight, and current maternal smoking.
In contrast, a small case control study of hospitalised infants with RSV bronchiolitis demonstrated
an increase in current asthma/recurrent wheezing (relative risk; RR 5.7, 95% CI 2.6 to 12.5,
2+
p<0.001), allergic rhinoconjunctivitis (RR 2.6, 95% CI 1.4 to 4.7, p=0.004) and allergic
sensitisation at age 13 (serum IgE: RR 1.8, 95% CI 1.1 to 2.9, p=0.038).94
8.1.4 ADulthood
One small cohort study (n=81) on respiratory morbidity at age 18-20 years, following RSV
infection, found that RSV infection in infancy was not a significant risk factor for asthma or
bronchial reactivity. In logistic regression adjusted for atopy, there were minor differences for 2-
lung function abnormality (one or more abnormal result in flow-volume spirometry; OR 5.27,
95% CI 1.6 to 17.35), indicating that lung function abnormalities may be associated with RSV
infection which required hospitalisation in infancy.95
19
8.2 referral to secondary care

No reliable, valid published evidence was identified that explored when infants should be
referred to secondary care because of post-bronchiolitic cough/wheeze.
8.3 routine follow up

No published evidence was identified that explored whether or not routine follow up affected
parental anxiety, hospital readmission rates, rates of unplanned primary care contact or
attendance at an emergency department.
20
9 LIMITING DISEASE TRANSMISSION
9 Limiting disease transmission

The role of virological testing is discussed in section 5.4
In examining the evidence around reducing disease transmission, a number of characteristics
of the RSV virus have been considered in relation to the need for an integrated approach.96
RSV:
 is highly infectious
 is transmitted mainly through contagious secretions or via environmental surfaces (skin,
cloth and other objects) 4
 in respiratory droplets produced during coughing or sneezing can spread up to two
metres
 enters the body via the mucous membranes of the eyes, nose or mouth
 can survive 6-12 hours on environmental surfaces
 may be transferred on the hands to the eyes or nose
 is destroyed by soap and water/alcohol gel
 may be shed for up to three weeks and longer if a child is immuno-compromised.
9.1 IN the community

No studies were identified which examined the effectiveness of measures to reduce bronchiolitis
transmission in the community setting.
9.2 In Hospital
Only one contemporary study was identified which examined the effectiveness of infection
control measures in RSV transmission.97 This before and after study measured RSV healthcare
associated infection (HAI) rate before and after intervention with an infection control programme
based on expert opinion from the Centers for Disease Control and Prevention.98 The primary
outcome of the study was incidence density of RSV HAI and there was no attempt to disentangle
the contribution of the various components of the control of infection policy. Implementation 3
of the programme prevented 10 RSV HAIs per season in a 304 bed paediatric hospital. The 2+
infection control intervention was also deemed to be cost effective with a cost benefit ratio of
1:6. This is in agreement with a controlled study that compared four infection control strategies
in general paediatric wards and found that a regimen including rapid laboratory diagnosis,
cohort nursing and the wearing of gowns and gloves for all contacts with RSV infected infants
can significantly reduce the risk of RSV HAI.52
Recommendations are derived from the key aspects of the interventions implemented in these
studies. The use of masks and eye goggles was not investigated.
9.2.1 education
D Healthcare professionals should be educated about the epidemiology and control of

RSV where appropriate.
21
9.2.2 ward based strategies

D  Staff should decontaminate their hands (with soap and water or alcohol gel) before
and after caring for patients with viral respiratory symptoms.
 Gloves and plastic aprons (or gowns) should be used for any direct contact with the
patient or their immediate environment.
 Infected patients should be placed in single rooms. If adequate isolation facilities
are unavailable, the allocation of patients into cohorts should be based on laboratory
confirmation of infection in all inpatients less than two years of age with respiratory
symptoms.
 Both service providers and staff should be aware of the risk that those with upper
respiratory tract infections pose for high-risk infants.
 Local policies should restrict hospital visiting by those with symptoms of respiratory
infections.
 There should be ongoing surveillance by control of infection staff to monitor
compliance with infection control procedures.
22
10 PROPHYLACTIC THERAPIES
10 Prophylactic therapies
10.1 palivizumab
10.1.1 clinical effectiveness

Palivizumab is a humanised monoclonal RSV antibody licensed for prophylaxis of development
of severe pathology arising from an RSV infection. It does not prevent infection.
A well constructed RCT in infants who were born at or less than 35 weeks gestation and six
months of age or younger, or children 24 months of age or younger with a clinical diagnosis
of bronchopulmonary dysplasia (BPD) and requiring ongoing treatment, examined the
effectiveness of five injections of palivizumab (15 mg/kg at 30 day intervals during the winter) 1++
in preventing hospitalisation for a respiratory illness with confirmed RSV. Palivizumab reduced
RSV hospitalisation in infants with the specific comorbidities (relative RR 55%, absolute RR
5.8%) as described in Table 3. The effect in the BPD group was less than in pre-term infants
who did not have BPD.99
In a subgroup analysis, there was no clear difference in the effectiveness in infants ≤32 weeks
1++
gestation when compared with those >32 weeks gestation.100
The results of a similar RCT in infants aged less than two years with haemodynamically significant
CHD are also shown in Table 3. Palivizumab was effective for prophylaxis of serious RSV disease
(as measured by statistically significant reduction in RSV hospitalisation rates).101 There was no
impact on mortality, PICU admission rate or the need for mechanical ventilation. On subgroup 1++
analysis, the beneficial effect was only statistically significant in infants with acyanotic heart
disease leading to the positive overall results of the study.
Palivizumab was shown to be safe over the short term follow up period (150 days) adopted
in each study.
Table 3: The effectiveness of palivizumab in preventing RSV hospitalisation in specific
populations of infants with significant comorbidities.
Event rate NNT to

(RSV hospitalisation) ARR* RRR* prevent one
Population
Palivizumab (95%CI) (95%CI) hospitalisation*
Placebo (95%CI)
group
IMPACT study
population99 5.8% 54.8% 18
4.8% 10.6%
(≤35 weeks or (2.8 to 8.8) (34 to 69) (11 to 36)
BPD) n=1502
Prematurity99
(≤35 weeks
6.3% 78.1% 16
gestation and 1.8% 8.1%
(2.7 to 10) (52 to 90) (10 to 37)
≤6 months of
age) n=740
BPD 99 (and 24
months of age 4.9% 38.5% 21
7.9% 12.8%
or younger) (0.3 to 9.6) (5 to 60) (10 to 333)
n= 762
Congenital
4.4% 45.3% 23
heart disease101 5.3% 9.7%
(1.5 to 7.3) (18 to 63) (14 to 67)
n=1287
*Calculated using University of Toronto Stats Calculator for Evidence Based Medicine102
23
The clinical benefit of palivizumab in individual infants remains inconclusive. There is evidence
that it produces a reduction in RSV associated hospitalisation for routine care in previously
premature infants. There is no evidence that it prevents infection and there is no beneficial
impact on length of stay (once hospitalised), need for increased oxygen or for mechanical
ventilation (see Table 4) or on mortality.100
Table 4: RSV Hospital course in the subset of RSV hospitalised subjects100
Placebo* Palivizumab*
RSV hospital outcome Measure
n=53 n=48
Days of hospitalisation Total days/subject 5.9 7.6
Days of increased oxygen Total days/subject 4.8 6.3
Days with lower respiratory

Total days/subject 4.5 6.2
infection/ illness (LRI) score≥3
Yes 15(28%) 13(27%)
ICU admission
No 38 35
Days ICU stay Total days/subject 1.2 2.8
Yes 1(2%) 7(14.6%)

Mechanical ventilation
No 52 41
Days of mechanical ventilation Total days/subject 0.2 1.7
*Statistical comparison data not available
Long term effects have not been investigated. The true biological benefit is uncertain and must
be balanced against the need to treat a large number of infants. This involves multiple medical
contacts during the winter months, parental inconvenience in arranging for and travelling to these
appointments and discomfort for the treated infants, in addition to staff time and drug costs.
The consensus-based guidance of the Joint Committee on Vaccination and Immunisation (JCVI),
which advises UK health departments, recommends use of palivizumab in high risk groups, as
defined by the committee (children under two years of age with chronic lung disease, on home 4
oxygen or who have had prolonged use of oxygen; infants less than six months of age who
have left to right shunt haemodynamically significant congenital heart disease and/or pulmonary
hypertension; children under two years of age with severe congenital immuno-deficiency).103
10.1.2 cost effectiveness

A well conducted systematic review identified seven United Kingdom RSV related cost
studies.104 The studies consistently concluded that the costs of palivizumab prophylaxis were
far in excess of any likely savings achieved by decreasing hospital admission rates. One of the
studies performed a sensitivity analysis and found that the probability of hospital admission
would have to be >31% for palivizumab to be cost effective.105 The non-societal perspective
of most studies was acknowledged.
Another systematic review encompassing UK and non-UK studies reported diverse results ranging
from cost savings to considerable incremental costs per hospitalisation avoided. The diversity
was attributed to the range of different infant groups, study methods and assumptions and also
to the poor quality of some of the studies.106 In general palivizumab was not cost effective if
administered to all infants for whom it was approved.
24
10 PROPHYLACTIC THERAPIES
10.1.3 summary of use of palivizumb

On a population basis, palivizumab use in preterm infants and patients with congenital heart
disease demonstrates benefit although this is unlikely to be cost effective. The potential clinical
benefit for an individual patient is limited. Palivizumab prevents hospital admission with RSV
for some infants, but it does not decrease length of stay or oxygen requirement for those who
are admitted. Trials to date have not directly addressed the use of palivizumab in the highest
risk groups of infants (extreme prematurity, complex cardiorespiratory disease).
The guideline development group consider that palivizumab cannot be recommended for
routine use in the groups defined by the JCVI as the current evidence suggests that overall
clinical benefits in these groups are limited.
Evidence to date is equivocal and no evidence based recommendation can be made.
For some individual patients the degree of respiratory and/or cardiac instability may provide
justification for attempting to minimise the effect of RSV disease where the potential for admission
to intensive care or death is considered to be extremely high.
The guideline development group consider that palivizumab use may be appropriate in
individuals less than 12 months old with significant comorbidity (defined as extreme prematurity,
acyanotic congenital heart disease and immune deficiency) where the risk of severe sequelae
of RSV disease may be expected to carry significant immediate and long term consequences.
Local expert groups should consider cases on an individual basis.
 Routine use of palivizumab is not recommended.

 Palivizumab may be considered for use, on a case by case basis, in infants less than 12
months old with;
 extreme prematurity
 acyanotic congenital heart disease
 congenital or acquired significant orphan lung diseases
 immune deficiency.
 A local lead specialist should work with the appropriate clinical teams to identify those
infants who may benefit from palivizumab.
10.2 immunoglobulin
Three RCTs found that RSV hyperimmune globulin (RSVIG) is effective in reducing the incidence
of RSV hospitalisations in premature infants and children with bronchopulmonary dysplasia or 1+
1-
congenital heart disease.107-109 RSVIG therapy is not licensed for use in the UK.
25
11 Information for parents and carers

11.1 Information provision
No studies were identified on the provision of information about bronchiolitis to parents and
carers or on the effects this information may have on levels of anxiety and utilisation of healthcare 4
services. General Medical Council guidance states that parents have a right to information about
their child’s condition, its treatment and its prognosis.110
D Parents and carers should receive information about their child’s condition, its treatment
and prognosis.
11.2 sources of further information

British Lung Foundation
73-75 Goswell Road
London EC1V 7ER
Tel: 08458 50 50 20
www.lunguk.org
Baby Breathe Easy groups provide support to parents and carers.
Contact a Family Scotland

Norton Park
57 Albion Road
Edinburgh EH7 5QY
Tel: 0131 475 2608 • Helpline Tel: 0808 808 3555.

Freephone for parents and families (10am-4pm, weekdays).
www.cafamily.org.uk
Contact a Family is a UK-wide charity providing advice, information and support to the
parents of all disabled children - no matter what their health condition.
NHS 24
Tel: 08454 242424
www.nhs24.com
Provides health advice and information.
11.3 Information leaflet

The following information leaflet for parents and carers has been produced by the guideline
development group based on the findings of two small focus groups with a total of seven
mothers of infants who had been hospitalised with bronchiolitis. The focus groups, run by an
experienced facilitator in March 2005, explored information needs at the time of the illness.
The leaflet is also informed by the evidence base as well as by the clinical experience of the
multidisciplinary group.
26
11 INFORMATION FOR PARENTS AND CARERS
Information about bronchiolitis for

parents and carers
What is bronchiolitis?
Bronchiolitis is when the tiniest air passages in your baby’s lungs become swollen. This
can make it more difficult for your baby to breathe. Usually, bronchiolitis is caused by a
virus called respiratory syncytial virus (known as RSV).
Healthy bronchiole
Windpipe
Airways
Lungs
Obstructed bronchiole
Almost all children will have had an infection caused by RSV by the time they are two. It
is most common in the winter months and usually only causes mild ‘cold-like’ symptoms.
Most children get better on their own.
Some babies, especially very young ones, can have difficulty with breathing or feeding and
may need to go to hospital.
Can I prevent bronchiolitis?

No. The virus that causes bronchiolitis in babies also causes coughs and colds in older
children and adults so it is very difficult to prevent.
What are the symptoms?

• Bronchiolitis starts like a simple cold. Your baby may have a runny nose and sometimes
a temperature and a cough.
• After a few days your baby’s cough may become worse.
• Your baby’s breathing may be faster than normal and it may become noisy. He or she
may need to make more effort to breathe.
27
• Sometimes, in very young babies, bronchiolitis may cause them to have brief pauses in
their breathing.
• As breathing becomes more difficult, your baby may not be able to take the usual amount
of milk by breast or bottle. You may notice fewer wet nappies than usual.
• Your baby may be sick after feeding and become irritable.
How can I help my baby?

• If feeding is difficult, try breastfeeding more often or offering smaller bottle feeds more
often.
• If your baby has a temperature, you can give him or her paracetamol (for example,
Calpol or Disprol). You must follow the instructions that come with the paracetamol
carefully. If you are not sure, ask your community pharmacist if paracetamol is suitable
for your baby, and what dose you should give.
• If your baby is already taking any medicines or inhalers, you should carry on using
these. If you find it difficult to get your baby to take them, ask your doctor for advice.
• Bronchiolitis is caused by a virus so antibiotics won’t help.
Make sure your baby is not exposed to tobacco smoke. Passive smoking can seriously
damage your baby’s health. It makes breathing problems like bronchiolitis worse.
How long does bronchiolitis last?

• Most babies with bronchiolitis get better within about two weeks. They may still have a
cough for a few more weeks.
• Your baby can go back to nursery or daycare as soon as he or she is well enough (that
is feeding normally and with no difficulty breathing).
• There is usually no need to see your doctor if your baby is recovering well. If you are
worried about your baby’s progress, discuss this with your doctor or health visitor.
When should I get advice?

Contact your GP if :
• you are worried about your baby;
• your baby is having difficulty breathing;
• your baby is taking less than half his or her usual feeds over two to three feeds, or has
no wet nappy for 12 hours;
• your baby has a high temperature; or
• your baby seems very tired or irritable.
28
11 INFORMATION FOR PARENTS AND CARERS
Dial 999 for an ambulance if:

Your baby is having a lot of difficulty breathing and is pale or sweaty;
Your baby’s tongue and lips are turning blue; or
There are long pauses in your baby’s breathing.
What will happen if I have to take my baby to hospital?

• At hospital, a doctor or nurse will examine your baby.
• The doctor or nurse will check your baby’s breathing using a special machine called
a pulse oximeter. This is a light-probe which will usually be wrapped around your baby’s
finger or toe. It measures the oxygen in your baby’s blood, and helps doctors and nurses
to assess your baby’s breathing.
• If your baby needs oxygen, it will be given through fine tubes into the nose or through
a mask.
• If your baby needs help to breathe or feed, he or she may need to stay in hospital.
• You will be able to stay with your baby while he or she is in hospital.
• Your baby will probably only need to stay in hospital for a few days. You will be able to
take your baby home when he or she is able to feed and doesn’t need oxygen any
more.
• To confirm the cause of the bronchiolitis, some of the mucous from your baby’s nose
may be tested for RSV. In hospital, it is important to separate babies with and without
the virus to stop the virus spreading.
• You will need to clean your hands with alcohol gel or wash and dry them carefully before
and after caring for your baby.
• Visitors may be restricted to prevent the spread of infection.
• If your baby needs help with feeding, he or she may be given milk through a feeding
tube. This is a small plastic tube which is passed through your baby’s nose or mouth
and down into his or her stomach. It is kept in place by taping the tube to your baby’s
cheek. The tube will be removed when your baby is able to feed again.
• Some babies may need to be given fluids through a drip to make sure they are getting
enough fluids.
• A few babies become seriously ill and need to go into intensive care (perhaps in a
different hospital) for specialist help with their breathing.
29
After leaving hospital

Remember, you can ask your GP or health visitor for advice or contact them if you become
worried about your baby.
Will it happen again?

Your baby is not likely to get bronchiolitis again, although occasionally it can happen.
Are there any long-term effects?

Your baby may still have a cough and remain chesty and wheezy for some time but this will
settle down gradually.
Bronchiolitis does not usually cause long-term breathing problems.
Useful contacts
NHS 24
Tel: 08454 242424 • www.nhs24.com
Provides health advice and information.
30
12 IMPLEMENTATION AND AUDIT
12 Implementation and audit

12.1 local implementation
Implementation of national clinical guidelines is the responsibility of each NHS Board and is
an essential part of clinical governance. It is acknowledged that every Board cannot implement
every guideline immediately on publication, but mechanisms should be in place to ensure
that the care provided is reviewed against the guideline recommendations and the reasons for
any differences assessed and, where appropriate, addressed. These discussions should involve
both clinical staff and management. Local arrangements may then be made to implement the
national guideline in individual hospitals, units and practices, and to monitor compliance. This
may be done by a variety of means including patient-specific reminders, continuing education
and training, and clinical audit.
12.2 resource implications

It is likely that implementation of the guideline recommendations will result in decreased use
of unnecessary diagnostic studies, decreased use of medications (including palivizumab) and
a reduction in the use of physiotherapy in infants with bronchiolitis. These factors need to be
balanced against the introduction of rapid RSV testing in those centres which do not currently
have this facility.
12.3 key points for audit

 Number of emergency referrals from primary care
 admissions rate following attendance at accident and emergency
 percentage of infants given chest X-ray
 use of drug therapies
 palivizumab use
 use of chest physiotherapy
 number of centres with access to rapid RSV testing facilities
 urinary tract infection in those aged <60 days with bronchiolitis
 length of hospital stay
 healthcare associated infection rates
 use of isolation facilities
 re-attendance rates following hospital discharge
 readmission rates.
12.4 recommendations for research

 Prospective study examining prevalence of bronchiolitis in primary care and current
treatment practice in the community
 repeat study of incidence of UTI in infants with bronchiolitis compared with standard
hospital cohort
 large placebo controlled RCTs on ipratropium and montelukast
 prospective study of effects of systemic corticosteroids on long term respiratory outcomes
 systematic review of the prognostic factors for hospital admission to identify the most
appropriate infants to be treated with palivizumab105
 study of the value of oxygen saturation measurement at initial assessment as an independent
predictor of need for hospital admission
 prospective investigation into the role of C-reactive protein measurement in distinguishing
bacterial from viral lower respiratory tract infections
 assessment of value of the stage of the illness in predicting possible worsening before
recovery as a means of guiding decisions to admit to hospital
31
 evaluation of when to stop oxygen therapy and how soon after cessation it is safe to discharge
infants from in-patient care
 investigation of the risks and benefits of nasogastric fluids compared with intravenous
fluids
 investigation of whether the use of oxygen therapy at borderline saturation levels is effective
in reducing duration of illness or improving long term outcome
 robust studies around effectiveness of infection control measures
 further economic studies into palivizumab
 study of the range of non-RSV viruses in bronchiolitis and their healthcare associated
transmission rates
 definition of characteristics most likely to identify those who may have future respiratory
symptoms
 assessment of value of planned follow up of hospitalised infants on resource use
outcomes
 assessment of the duration of post-bronchiolitic wheeze/cough which should be considered
an indication for referral to secondary care
 study of effectiveness of parent/carer information leaflets.
32
13 DEVELOPMENT OF THE GUIDELINE
13 Development of the guideline

13.1 introduction
SIGN is a collaborative network of clinicians, other healthcare professionals and patient
organisations and is part of NHS Quality Improvement Scotland. SIGN guidelines are developed
by multidisciplinary groups of practising clinicians using a standard methodology based on a
systematic review of the evidence. Further details about SIGN and the guideline development
methodology are contained in “SIGN 50: A Guideline Developer’s Handbook”, available at
www.sign.ac.uk
13.2 the guideline development group
Dr Steve Cunningham Consultant Respiratory Paediatrician,

(Chair) Royal Hospital for Sick Children, Edinburgh
Dr Peter W Fowlie Consultant Paediatrician, Ninewells Hospital, Dundee
(Secretary)
Dr Jack Beattie Consultant Paediatrician,
Royal Hospital for Sick Children, Glasgow
Dr Richard Brooker Consultant Paediatrician,
Royal Aberdeen Children’s Hospital
Dr Donna Corrigan Consultant Paediatrician, Wishaw General Hospital
Dr Jonathan Coutts Consultant Paediatrician,
Ms Sue Danby Nursing Sister, Paediatrics,
Royal Aberdeen Children’s Hospital
Ms Elaine Dhouieb Senior Respiratory Physiotherapist,
Royal Hospital for Sick Children, Edinburgh
Ms Jeanette Fitzgerald Senior Paediatric Nurse, Ninewells Hospital, Dundee
Ms June Grant Pharmacist, Princess Royal Maternity Hospital, Glasgow
Dr Nick Hallam Consultant Virologist, Royal Infirmary of Edinburgh
Ms Mareth Irvine Lay Representative, Dumfries and Galloway
Ms Pamela Joannidis Senior Nurse, Infection Control,
Dr Andrew MacIntyre Consultant in Paediatric Intensive Care Medicine,
Dr Peter Mackie Consultant Clinical Scientist (Virology),
Aberdeen Royal Infirmary
Dr Jillian McFadzean Consultant in Anaesthesia and Intensive Care,
Dr Maeve McPhillips Consultant Paediatric Radiologist,
Dr Angela Oglesby Consultant in Accident and Emergency,
Dr Ronald Seiler Retired General Practitioner, Edinburgh
Ms Ailsa Stein Information Officer, SIGN
Dr Caroline Stimpson General Practitioner and Clinical Assistant in Accident
and Emergency, Edinburgh
Dr Lorna Thompson Programme Manager, SIGN
Ms Moira Walls Case Manager, Neonatal Unit, Ninewells Hospital, Dundee
Dr Louise Wilson Specialist Registrar in Public Health, NHS Lanarkshire
Dr Alan Woodley General Practitioner, Dundee
33
The membership of the guideline development group was confirmed following consultation
with the member organisations of SIGN. All members of the guideline development group
made declarations of interest and further details of these are available on request from the SIGN
Executive. Guideline development and literature review expertise, support and facilitation were
provided by the SIGN Executive.
13.3 systematic literature review

The evidence base for this guideline was synthesised in accordance with SIGN methodology.
A systematic literature review was carried out using an explicit search strategy devised by the
SIGN Information Officer in collaboration with members of the guideline development group.
Literature searches were initially conducted in Medline, Embase, Cinahl and the Cochrane
Library, using the year range 2000-2005. The main searches were supplemented by material
identified by individual members of the development group. All selected papers were evaluated
using standard methodological checklists. The Medline version of the main search strategies
can be found on the SIGN website.
13.4 consultation and peer review
13.4.1 national open meeting

A national open meeting is the main consultative phase of SIGN guideline development, at
which the guideline development group present its draft recommendations for the first time.
The national open meeting for this guideline was held on 9th December 2005 and was attended
by150 representatives of all the key specialties relevant to the guideline. The draft guideline
was also available on the SIGN website for a limited period at this stage to allow those unable
to attend the meeting to contribute to the development of the guideline.
13.4.2 specialist review

This guideline was also reviewed in draft form by the following independent expert referees,
who were asked to comment primarily on the comprehensiveness and accuracy of interpretation
of the evidence base supporting the recommendations in the guideline. SIGN is very grateful
to all of these experts for their contribution to the guideline.
Dr Laurence Abernethy Consultant Paediatric Radiologist,
Royal Liverpool Children’s Hospital
Dr Tom Beattie Consultant in Paediatric Emergency Medicine,
Ms Emma Dear Physiotherapist, Ninewells Hospital, Dundee
Dr Anne Devenny Consultant Respiratory Paediatrician,
Dr Martin Donaghy Consultant in Public Health, Health Protection Scotland
Dr George Farmer Consultant Paediatrician, Raigmore Hospital, Inverness
Ms Hazel Fisher Senior Clinical Pharmacist, Wishaw General Hospital
Dr Julie Freeman Consultant in Paediatric Intensive Care,
Dr Neil Gibson Consultant Respiratory Paediatrician,
Professor Colin A Graham Associate Professor, Accident and Emergency Medicine
Academic Unit, Chinese University of Hong Kong
Dr Rosie Hague Consultant in Paediatric Infectious Diseases and
Immunology, Royal Hospital for Sick Children, Glasgow
Ms Louise Holliday Clinical Educator, Royal Aberdeen Children’s Hospital
Dr Julian Legg Consultant Respiratory Paediatrician,
Southampton General Hospital
Dr Paul Leonard Locum Consultant,
34
13 DEVELOPMENT OF THE GUIDELINE
Professor Warren Lenny Professor of Respiratory Child Health, Keele University

Dr Una MacFadyen Consultant Paediatrician, Stirling Royal Infirmary
Ms Lynsay McAuley Paediatric Pharmacist, Wishaw General Hospital
Professor Neil McIntosh Professor of Child and Life Health,
Dr Mike McKean Consultant Respiratory Paediatrician,
Royal Victoria Infirmary, Newcastle Upon Tyne
Dr Pamela J Molyneaux Consultant Virologist, Aberdeen Royal Infirmary
Dr Somnath Mukhopadhyay Consultant Paediatrician, Ninewells Hospital, Dundee
Ms S Ammani Prasad Research Physiotherapist, Great Ormond Street
Hospital for Children, London
Dr Rob Primhak Consultant Respiratory Paediatrician,
The Children’s Hospital, Sheffield
Mr Neil Richardson Pharmacist, Royal Hospital for Sick Children, Edinburgh
Dr Margrid Schindler Consultant Senior Lecturer in Paediatric Intensive Care,
Bristol Royal Hospital for Children, Avon
Dr Rajendran Shyam Specialist Paediatric Registrar,
Royal Victoria Infirmary, Newcastle Upon Tyne
Dr Charles Skeoch Consultant in Neonatal Intensive Care,
Princess Royal Maternity Hospital, Glasgow
Dr Iain Small General Practitioner, Links Terrace Health Centre, Peterhead
Dr Ben Stenson Consultant in Neonatology, Royal Infirmary of Edinburgh
Mrs Sue Stobie Medicines Management Pharmacist,
Royal Edinburgh Hospital
Dr Robert Tasker Consultant in Paediatrics,
Addenbrooke’s Hospital, Cambridge
Mr Steve Tomlin Principal Paediatric Pharmacist, Guy’s Hospital, London
Dr Tom Turner Neonatology Consultant, Queen Mothers Hospital, Glasgow
Dr Clair Wainwright Paediatric Respiratory Specialist,
Royal Children’s Hospital, Brisbane, Australia
Mr James Wallace Director of Pharmacy Services, Yorkhill Hospital, Glasgow
Dr Peter Weller Consultant Paediatrician in Respiratory
Medicine – Retired, Birmingham
Dr Craig Williams Consultant Microbiologist, Yorkhill Hospital, Glasgow
Dr Job Van Woensel Pediatric-Intensivist, Emma Children’s Hospital, Amsterdam
13.4.3 sign editorial group

As a final quality control check, the guideline is reviewed by an editorial group comprising
the relevant specialty representatives on SIGN Council to ensure that the specialist reviewers’
comments have been addressed adequately and that any risk of bias in the guideline
development process as a whole has been minimised. The editorial group for this guideline
was as follows.
Dr Bernard Higgins Royal College of Physicians of London
Professor Gordon Lowe Chair of SIGN; Co-Editor
Professor Chris Kelnar Royal College of Paediatrics and Child Health,
Vice Chair of SIGN
Ms Anne Matthew Royal College of Midwives
Mrs Fiona McMillan Royal Pharmaceutical Society of Great Britain (Scottish Dept)
Dr Safia Qureshi SIGN Programme Director; Co-Editor
Dr Bill Reith Royal College of General Practitioners
Dr Sara Twaddle Director of SIGN; Co-Editor
35
13.5 acknowledgements
SIGN is grateful to the following former members of the guideline development group and
others who have contributed to the development of this guideline. In particular, appreciation
is expressed to the parents who contributed to the focus group discussions which formed the
basis of the parent/carer information leaflet and to the members of the SIGN Patient Network
who reviewed the leaflet in draft form.
Dr Jim Beattie Consultant Paediatrician,
Ms Carol Prentice Lay Representative
Dr Alison Ting Specialist Registrar in Respiratory Medicine,
Mrs Jenni Washington Information Officer, SIGN
Dr Sarah Wheeler Project Development Officer, Health Rights Information
Scotland, Scottish Consumer Council
36
ABBREVIATIONS
Abbreviations
A&E Accident and emergency
ARR Absolute risk reduction
BPD Bronchopulmonary dysplasia
CI Confidence interval
CHD Congenital heart disease
CLD Chronic lung disease
CRP C-reactive protein
FiO2 Fraction of inspired oxygen (%)
GP General practitioner
HAI Healthcare associated infection
ICU Intensive care unit
JCVI Joint Committee on Vaccination and Immunisation
LRI Lower respiratory illness/infection
LRTI Lower respiratory tract infection
NNT Number needed to treat
OR Odds ratio
PaCO2 Partial pressure of arterial carbon dioxide
PaO2 Partial pressure of arterial oxygen
PICU Paediatric intensive care unit
RCT Randomised controlled trial
RR Relative risk
RRR Relative risk reduction
RSV Respiratory syncytial virus
RSVIG Respiratory syncytial virus hyperimmune globulin
U&E Urea and electrolytes
UK United Kingdom
USA United States of America
UTI Urinary tract infection
37
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40
REFERENCES
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91
Information about bronchiolitis for parents and carers
What is bronchiolitis? Make sure your baby is not exposed to tobacco smoke. Passive • Your baby will probably only need to stay in hospital for a few
smoking can seriously damage your baby’s health. It makes days. You will be able to take your baby home when he or she
Bronchiolitis is when the tiniest air passages in your baby’s lungs breathing problems like bronchiolitis worse. is able to feed and doesn’t need oxygen any more.
become swollen. This can make it more difficult for your baby to • To confirm the cause of the bronchiolitis, some of the mucous
breathe. Usually, bronchiolitis is caused by a virus called respiratory How long does bronchiolitis last?
from your baby’s nose may be tested for RSV. In hospital, it is
syncytial virus (known as RSV). • Most babies with bronchiolitis get better within about two important to separate babies with and without the virus to
weeks. They may still have a cough for a few more weeks. stop the virus spreading.
Almost all children will have had an infection caused by RSV by
the time they are two. It is most common in the winter months and • Your baby can go back to nursery or daycare as soon as he or • You will need to clean your hands with alcohol gel or wash and
usually only causes mild ‘cold-like’ symptoms. Most children get she is well enough (that is feeding normally and with no dry them carefully before and after caring for your baby.
better on their own. difficulty breathing). • Visitors may be restricted to prevent the spread of infection.
• There is usually no need to see your doctor if your baby is • If your baby needs help with feeding, he or she may be given
Some babies, especially very young ones, can have difficulty with recovering well. If you are worried about your baby’s progress, milk through a feeding tube. This is a small plastic tube
breathing or feeding and may need to go to hospital. discuss this with your doctor or health visitor. which is passed through your baby’s nose or mouth and down
into his or her stomach. It is kept in place by taping the tube to
Can I prevent bronchiolitis? When should I get advice?
your baby’s cheek. The tube will be removed when your baby
No. The virus that causes bronchiolitis in babies also causes coughs Contact your GP if : is able to feed again.
and colds in older children and adults so it is very difficult to prevent. • you are worried about your baby; • Some babies may need to be given fluids through a drip to
make sure they are getting enough fluids.
• your baby is having difficulty breathing;
What are the symptoms? • A few babies become seriously ill and need to go into
• your baby is taking less than half his or her usual feeds intensive care (perhaps in a different hospital) for specialist
• Bronchiolitis starts like a simple cold. Your baby may have over two to three feeds, or has no wet nappy for 12 hours;
a runny nose and sometimes a temperature and a cough. help with their breathing.
• your baby has a high temperature; or
• After a few days your baby’s cough may become worse. After leaving hospital
• your baby seems very tired or irritable.
• Your baby’s breathing may be faster than normal and it may Remember, you can ask your GP or health visitor for advice or
become noisy. He or she may need to make more effort to contact them if you become worried about your baby.
breathe. Dial 999 for an ambulance if:
• Sometimes, in very young babies, bronchiolitis may cause Your baby is having a lot of difficulty breathing and is pale or sweaty; Will it happen again?
them to have brief pauses in their breathing.
Your baby’s tongue and lips are turning blue; or Your baby is not likely to get bronchiolitis again, although occasionally
• As breathing becomes more difficult, your baby may not be
it can happen.
able to take the usual amount of milk by breast or bottle. There are long pauses in your baby’s breathing.
You may notice fewer wet nappies than usual. Are there any long-term effects?
• Your baby may be sick after feeding and become irritable.
What will happen if I have to take my baby to hospital? Your baby may still have a cough and remain chesty and wheezy for
How can I help my baby? • At hospital, a doctor or nurse will examine your baby. some time but this will settle down gradually.
• If feeding is difficult, try breastfeeding more often or offering • The doctor or nurse will check your baby’s breathing using a Bronchiolitis does not usually cause long-term breathing problems.
smaller bottle feeds more often. special machine called a pulse oximeter. This is a light-probe
• If your baby has a temperature, you can give him or her which will usually be wrapped around your baby’s finger Useful contacts
paracetamol (for example, Calpol or Disprol). You must follow or toe. It measures the oxygen in your baby’s blood, and helps
doctors and nurses to assess your baby’s breathing. NHS 24
the instructions that come with the paracetamol carefully. If you
Phone: 08454 242424 • www.nhs24.com
are not sure, ask your community pharmacist if paracetamol is • If your baby needs oxygen, it will be given through fine tubes Provides health advice and information.
suitable for your baby, and what dose you should give. into the nose or through a mask.
• If your baby is already taking any medicines or inhalers, you • If your baby needs help to breathe or feed, he or she may
should carry on using these. If you find it difficult to get need to stay in hospital.
your baby to take them, ask your doctor for advice.
• You will be able to stay with your baby while he or she is in
• Bronchiolitis is caused by a virus so antibiotics won’t help. hospital.

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S I

1++ High quality meta-analyses, systematic reviews of randomised controlled trials

A At least one meta-analysis, systematic review of RCTs, or RCT rated as 1++

Good practice points

 Recommended best practice based on the clinical experience of the guideline

SIGN consents to the photocopying of this guideline for the

1.2 need for a guideline

1.3 guideline remit

1.5 Statement of intent

1.6 review and updating

2.2 diagnostic value of clinical characteristics

2.2.5 respiratory rate

2.2.6 poor feeding

2.2.7 increased work of breathing and recession

The chest may be visibly hyperinflated in bronchiolitis.1,13,16 The presence of a hyperinflated 3

2.3 summary of diagnostic characteristics

3 Risk factors for severe disease

3.2 significant comorbidities

Gestational age (weeks) ≤28 29-32 33-35 ≥36

3.2.2 Congenital heart disease

3.2.3 Chronic lung disease of prematurity

3.2.4 Summary of effect of comorbidity

3.4 Social factors

3.4.1 breast feeding

3.4.2 Parental smoking

C Healthcare professionals should inform families that parental smoking is associated

3.4.3 Number of siblings and nursery or day-care attendance

3.4.4 socioeconomic deprivation

4 Assessment and referral

4.1.1 severe disease

4.1.2 clinical scoring systems

 Any of the following indications should prompt hospital referral/acute paediatric

 Indications for high dependency/intensive care unit consultation include:

5.1 oxygen saturation

5.2 Blood Gases

5.3 chest x-ray

5.4 virological testing

5.5 bacteriological testing

5.7.1 Urea and Electrolytes

5.7.2 c-reactive protein

B Nebulised ribavirin is not recommended for treatment of acute bronchiolitis in

 Antibiotic therapy is not recommended in the treatment of acute bronchiolitis in infants.

6.3 inhaled bronchodilators

6.3.1 Beta 2 agonists

 Nebulised ipratropium is not recommended for the treatment of acute bronchiolitis in

6.4 nebulised epinephrine

A Nebulised epinephrine is not recommended for the treatment of acute bronchiolitis

6.5.1 inhaled corticosteroids

6.5.2 systemic corticosteroids

6.5.3 leukotriene receptor antagonist (montelukast)

6.6 hospital based supplementary therapies

A Chest physiotherapy using vibration and percussion is not recommended in infants

6.6.2 Nasal suction

6.6.3 maintaining fluid balance/hydration

6.6.5 Continuous Positive Airway Pressure and Negative Pressure Ventilation

6.7 hospital based treatment guidelines

6.8 community based supplementary therapies

7 Symptom duration and hospital discharge

Following acute bronchiolitis, cilial damage persists for 13-17 weeks.8 3

7.2 hospital discharge criteria