Respiratory Syncytial Virus Bronchiolitis in Children

 

Am Fam Physician. 2017 Jan 15;95(2):94-99.

  Patient information: See related handout on respiratory syncytial virus infection, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Bronchiolitis is a common lower respiratory tract infection in infants and young children, and respiratory syncytial virus (RSV) is the most common cause of this infection. RSV is transmitted through contact with respiratory droplets either directly from an infected person or self-inoculation by contaminated secretions on surfaces. Patients with RSV bronchiolitis usually present with two to four days of upper respiratory tract symptoms such as fever, rhinorrhea, and congestion, followed by lower respiratory tract symptoms such as increasing cough, wheezing, and increased respiratory effort. In 2014, the American Academy of Pediatrics updated its clinical practice guideline for diagnosis and management of RSV bronchiolitis to minimize unnecessary diagnostic testing and interventions. Bronchiolitis remains a clinical diagnosis, and diagnostic testing is not routinely recommended. Treatment of RSV infection is mainly supportive, and modalities such as bronchodilators, epinephrine, corticosteroids, hypertonic saline, and antibiotics are generally not useful. Evidence supports using supplemental oxygen to maintain adequate oxygen saturation; however, continuous pulse oximetry is no longer required. The other mainstay of therapy is intravenous or nasogastric administration of fluids for infants who cannot maintain their hydration status with oral fluid intake. Educating parents on reducing the risk of infection is one of the most important things a physician can do to help prevent RSV infection, especially early in life. Children at risk of severe lower respiratory tract infection should receive immunoprophylaxis with palivizumab, a humanized monoclonal antibody, in up to five monthly doses. Prophylaxis guidelines are restricted to infants born before 29 weeks' gestation, infants with chronic lung disease of prematurity, and infants and children with hemodynamically significant heart disease.

Bronchiolitis is a common lower respiratory tract infection in infants and young children, and respiratory syncytial virus (RSV) is the most common cause. Although the exact mechanism is unclear, it is likely that direct viral cytotoxic injury has a role in the pathogenesis of RSV infections. This leads to necrosis of the epithelial cells of the small airways, and the sloughed cells and mucus cause plugging of the bronchioles that leads to hyperinflation and atelectasis.13 RSV bronchiolitis typically affects children in the first two years of life. In 2014, the American Academy of Pediatrics updated its clinical practice guideline on RSV bronchiolitis to minimize unnecessary diagnostic testing and interventions.4 This guideline was accepted by the American Academy of Family Physicians and incorporated in its updated policy.5

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Routine viral testing and chest imaging are not recommended for patients with presumed RSV bronchiolitis.

B

4, 15, 16

Bronchodilators, systemic or inhaled corticosteroids, and epinephrine should not be administered to infants and children with bronchiolitis.

A

4, 24, 28, 30

Antibiotics should not be administered to children with RSV bronchiolitis unless a bacterial infection is confirmed or suspected.

B

4, 37

Palivizumab (Synagis) should be given in the first year of life to infants born before 29 weeks' gestation or to infants born before 32 weeks' gestation who have chronic lung disease.

B

42


RSV = respiratory syncytial virus.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Routine viral testing and chest imaging are not recommended for patients with presumed RSV bronchiolitis.

B

4, 15, 16

Bronchodilators, systemic or inhaled corticosteroids, and epinephrine should not be administered to infants and children with bronchiolitis.

A

4, 24, 28, 30

Antibiotics should not be administered to children with RSV bronchiolitis unless a bacterial infection is confirmed or suspected.

B

4, 37

Palivizumab (Synagis) should be given in the first year of life to infants born before 29 weeks' gestation or to infants born before 32 weeks' gestation who have chronic lung disease.

B

42


RSV = respiratory syncytial virus.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

View/Print Table

BEST PRACTICES IN INFECTIOUS DISEASE: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organization

Do not order chest radiography in children with uncomplicated asthma or bro

The Authors

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DUSTIN K. SMITH, DO, is a faculty member at Naval Hospital Jacksonville (Fla.) Family Medicine Residency Program....

SAJEEWANE SEALES, MD, MPH, is a third-year resident at Naval Hospital Jacksonville Family Medicine Residency Program.

CAROL BUDZIK, MD, is head of the Pediatrics Department at Naval Hospital Jacksonville Family Medicine Residency Program.

Address correspondence to Dustin K. Smith, DO, Naval Hospital Jacksonville, 2080 Child St., Jacksonville, FL 32214 (e-mail: dustin.k.smith16.mil@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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