Bronchiolitis in children: diagnosis and management

When diagnosing bronchiolitis, take into account that it occurs in babies and children under 2 years of age and most commonly in the first year of life, peaking between 3 and 6 months. [2015]

When diagnosing bronchiolitis, take into account that symptoms usually peak between 3 and 5 days, and that cough resolves in 90% of infants within 3 weeks. [2015]

Diagnose bronchiolitis if the baby or child has a coryzal prodrome lasting 1 to 3 days, followed by:

• persistent cough and

• either tachypnoea or chest recession (or both) and

• either wheeze or crackles on chest auscultation (or both). [2015]

When diagnosing bronchiolitis, take into account that the following symptoms are common in babies and children with this disease:

• fever (in around 30% of cases, usually of less than 39°C)

• poor feeding (typically after 3 to 5 days of illness). [2015]

When diagnosing bronchiolitis, take into account that young infants with this disease (in particular those under 6 weeks of age) may present with apnoea without other clinical signs. [2015]

Consider a diagnosis of pneumonia if the baby or child has:

• high fever (over 39°C) and/or

• persistently focal crackles.
  
  See also the NICE guideline on sepsis and risk stratification tool for sepsis in under 5s. [2015]

Think about a diagnosis of viral‑induced wheeze or early‑onset asthma rather than bronchiolitis in older infants and young children if they have:

• persistent wheeze without crackles or

• recurrent episodic wheeze or

• a personal or family history of atopy.
  
  Take into account that these conditions are unusual in children under 1 year of age. [2015]

Measure oxygen saturation in every baby and child presenting with suspected bronchiolitis, including those presenting to primary care if pulse oximetry is available. [2015]

Ensure healthcare professionals performing pulse oximetry are appropriately trained in its use specifically in babies and young children. [2015]

December 2018: Follow the NHS England Patient Safety Alert on the risk of harm from inappropriate placement of pulse oximeter probes.

Be aware that some pulse oximeters can underestimate or overestimate oxygen saturation levels, especially if the saturation level is borderline. Overestimation has been reported in people with dark skin.

Suspect impending respiratory failure, and take appropriate action as these babies and children may need intensive care (see recommendations 1.2.1 and 1.4.5), if any of the following are present:

• signs of exhaustion, for example listlessness or decreased respiratory effort

• recurrent apnoea

• failure to maintain adequate oxygen saturation despite oxygen supplementation. [2015]

Immediately refer babies and children with bronchiolitis for emergency hospital care (usually by 999 ambulance) if they have any of the following:

• apnoea (observed or reported)

• baby or child looks seriously unwell to a healthcare professional

• severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute

• central cyanosis. [2015]

Consider referring babies and children with bronchiolitis to hospital if they have any of the following:

• a respiratory rate of over 60 breaths/minute [2015]

• difficulty with breastfeeding or inadequate oral fluid intake (50% to 75% of usual volume, taking account of risk factors [see recommendation 1.3.3] and using clinical judgement) [2015]

• clinical dehydration [2015]

• persistent oxygen saturation of less than 92%, when breathing air. [2021]
  
  December 2018: Follow the NHS England Patient Safety Alert on the risk of harm from inappropriate placement of pulse oximeter probes.

When deciding whether to refer a baby or child with bronchiolitis to secondary care, take account of any known risk factors for more severe bronchiolitis such as:

• chronic lung disease (including bronchopulmonary dysplasia)

• haemodynamically significant congenital heart disease

• age in young infants (under 3 months)

• premature birth, particularly under 32 weeks

• neuromuscular disorders

• immunodeficiency. [2015]

When deciding whether to refer a baby or child to secondary care, take into account factors that might affect a carer's ability to look after a child with bronchiolitis, for example:

• social circumstances

• the skill and confidence of the carer in looking after a child with bronchiolitis at home

• confidence in being able to spot red flag symptoms (see recommendation 1.6.1)

• distance to healthcare in case of deterioration. [2015]

Measure oxygen saturation using pulse oximetry in every baby and child presenting to secondary care with clinical evidence of bronchiolitis. [2015]

December 2018: Follow the NHS England Patient Safety Alert on the risk of harm from inappropriate placement of pulse oximeter probes.

Be aware that some pulse oximeters can underestimate or overestimate oxygen saturation levels, especially if the saturation level is borderline. Overestimation has been reported in people with dark skin.

When assessing a baby or child in a secondary care setting, admit them to hospital if they have any of the following:

• apnoea (observed or reported) [2015]

• persistent oxygen saturation (when breathing air) of:

  • less than 90%, for children aged 6 weeks and over

  • less than 92%, for babies under 6 weeks or children of any age with underlying health conditions [2021]

• inadequate oral fluid intake (50% to 75% of usual volume, taking account of risk factors [see recommendation 1.3.3] and using clinical judgement) [2015]

• persisting severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute. [2015]

When deciding whether to admit a baby or child with bronchiolitis, take account of any known risk factors for more severe bronchiolitis, such as:

• chronic lung disease (including bronchopulmonary dysplasia)

• haemodynamically significant congenital heart disease

• age in young infants (under 3 months)

• premature birth, particularly under 32 weeks

• neuromuscular disorders

• immunodeficiency. [2015]

When deciding whether to admit a baby or child, take into account factors that might affect a carer's ability to look after a child with bronchiolitis, for example:

• social circumstances

• the skill and confidence of the carer in looking after a child with bronchiolitis at home

• confidence in being able to spot red flag symptoms (see recommendation 1.6.1)

• distance to healthcare in case of deterioration. [2015]

Clinically assess the hydration status of babies and children with bronchiolitis. [2015]

Do not routinely perform blood tests in the assessment of a baby or child with bronchiolitis. [2015]

Do not routinely perform a chest X‑ray in babies or children with bronchiolitis, because changes on X‑ray may mimic pneumonia and should not be used to determine the need for antibiotics. [2015]

Consider performing a chest X‑ray if intensive care is being proposed for a baby or child. [2015]

Provide parents or carers with key safety information (see recommendation 1.6.1) if the baby or child is not admitted. [2015]

Do not perform chest physiotherapy on babies and children with bronchiolitis who do not have relevant comorbidities (for example spinal muscular atrophy, severe tracheomalacia). [2015]

Consider requesting a chest physiotherapy assessment in babies and children who have relevant comorbidities (for example spinal muscular atrophy, severe tracheomalacia) when there may be additional difficulty clearing secretions. [2015]

Do not use any of the following to treat bronchiolitis in babies or children:

• antibiotics

• hypertonic saline

• adrenaline (nebulised)

• salbutamol

• montelukast

• ipratropium bromide

• systemic or inhaled corticosteroids

• a combination of systemic corticosteroids and nebulised adrenaline. [2015]

Give oxygen supplementation to babies and children with bronchiolitis if their oxygen saturation is:

• persistently less than 90%, for children aged 6 weeks and over

• persistently less than 92%, for babies under 6 weeks or children of any age with underlying health conditions. [2021]
  
  December 2018: Follow the NHS England Patient Safety Alert on the risk of harm from inappropriate placement of pulse oximeter probes.

Consider continuous positive airway pressure (CPAP) in babies and children with bronchiolitis who have impending respiratory failure (see recommendation 1.1.10). [2015]

Do not routinely perform upper airway suctioning in babies or children with bronchiolitis. [2015]

Consider upper airway suctioning in babies and children who have respiratory distress or feeding difficulties because of upper airway secretions. [2015]

Perform upper airway suctioning in babies and children with bronchiolitis presenting with apnoea even if there are no obvious upper airway secretions. [2015]

Do not routinely carry out blood gas testing in babies or children with bronchiolitis. [2015]

Consider carrying out capillary blood gas testing in babies and children with severe worsening respiratory distress (when supplemental oxygen concentration is greater than 50%) or suspected impending respiratory failure (see recommendation 1.1.10). [2015]

Give fluids by nasogastric or orogastric tube in babies and children with bronchiolitis if they cannot take enough fluid by mouth. [2015]

Give intravenous isotonic fluids (see the NICE guideline on intravenous fluid therapy in children) to babies and children who:

• do not tolerate nasogastric or orogastric fluids or

• have impending respiratory failure. [2015]

When deciding on the timing of discharge for babies and children admitted to hospital, make sure that they:

• are clinically stable [2015]

• are taking adequate oral fluids [2015]

• have maintained an oxygen saturation in air at the following levels for 4 hours, including a period of sleep:

  • over 90%, for children aged 6 weeks and over

  • over 92%, for babies under 6 weeks or children of any age with underlying health conditions. [2021]
    
    December 2018: Follow the NHS England Patient Safety Alert on the risk of harm from inappropriate placement of pulse oximeter probes.

When deciding whether to discharge a baby or child, take into account factors that might affect a carer's ability to look after a baby or child with bronchiolitis, for example:

• social circumstances

• the skill and confidence of the carer in looking after a baby or child with bronchiolitis at home

• confidence in being able to spot red flag symptoms (see recommendation 1.6.1)

• distance to healthcare in case of deterioration. [2015]

Provide parents or carers with key safety information (see recommendation 1.6.1) when the baby or child is discharged. [2015]

Provide key safety information for parents and carers to take away for reference for babies and children who will be looked after at home. This should cover:

• how to recognise developing 'red flag' symptoms:

  • worsening work of breathing (for example grunting, nasal flaring, marked chest recession)

  • fluid intake is 50% to 75% of normal or no wet nappy for 12 hours

  • apnoea or cyanosis

  • exhaustion (for example, not responding normally to social cues, wakes only with prolonged stimulation).

• that people should not smoke in the baby or child's home because it increases the risk of more severe symptoms in bronchiolitis

• how to get immediate help from an appropriate professional if any red flag symptoms develop

• arrangements for follow‑up if necessary. [2015]