Inter-society consensus document on treatment and prevention of bronchiolitis in newborns and infants

Abstract

Acute bronchiolitis is the leading cause of lower respiratory tract infection and hospitalization in children less than 1 year of age worldwide. It is usually a mild disease, but some children may develop severe symptoms, requiring hospital admission and ventilatory support in the ICU. Infants with pre-existing risk factors (prematurity, bronchopulmonary dysplasia, congenital heart diseases and immunodeficiency) may be predisposed to a severe form of the disease.Clinical diagnosis of bronchiolitis is manly based on medical history and physical examination (rhinorrhea, cough, crackles, wheezing and signs of respiratory distress). Etiological diagnosis, with antigen or genome detection to identify viruses involved, may have a role in reducing hospital transmission of the infection.Criteria for hospitalization include low oxygen saturation (<90-92%), moderate-to-severe respiratory distress, dehydration and presence of apnea. Children with pre-existing risk factors should be carefully assessed.To date, there is no specific treatment for viral bronchiolitis, and the mainstay of therapy is supportive care. This consists of nasal suctioning and nebulized 3% hypertonic saline, assisted feeding and hydration, humidified O2 delivery. The possible role of any pharmacological approach is still debated, and till now there is no evidence to support the use of bronchodilators, corticosteroids, chest physiotherapy, antibiotics or antivirals. Nebulized adrenaline may be sometimes useful in the emergency room. Nebulized adrenaline can be useful in the hospital setting for treatment as needed. Lacking a specific etiological treatment, prophylaxis and prevention, especially in children at high risk of severe infection, have a fundamental role. Environmental preventive measures minimize viral transmission in hospital, in the outpatient setting and at home. Pharmacological prophylaxis with palivizumab for RSV bronchiolitis is indicated in specific categories of children at risk during the epidemic period.Viral bronchiolitis, especially in the case of severe form, may correlate with an increased incidence of recurrent wheezing in pre-schooled children and with asthma at school age.The aim of this document is to provide a multidisciplinary update on the current recommendations for the management and prevention of bronchiolitis, in order to share useful indications, identify gaps in knowledge and drive future research.

Uso de broncodilatadores en bronquiolitis: ¿sí o no?

“…Por ejemplo, según el consenso italiano correspondiente, la bronquiolitis se restringe al primer episodio en un niño menor de 12 meses, 6 mientras que las guías norteamericanas no lo limitan al primer año de vida y remarcan la presencia de sibilancias. 2 Más aún, la guía británica de bronquiolitis señala que hay que pensar en un ataque precoz de asma más que en bronquiolitis si el episodio ocurre en niños cercanos a los 12 meses o más, que tengan sibilancias persistentes sin rales crepitantes, episodios de sibilancias recurrentes o historia familiar de asma.…”

Linking childhood allergic asthma phenotypes with endotype through integrated systems biology: current evidence and research needs

“…However, it remains unknown whether the intermittent to persistent wheezing represents the sentinel event for IgE-mediated asthma. The mildly infected infants/children may also develop recurrent wheezing symptoms at older age (66). In a small prospective follow-up study, the children with a history of respiratory syncytial virus-induced bronchiolitis during infancy were significantly more likely to develop current asthma, current asthma/recurrent wheezing, or allergic rhinoconjunctivitis at 13 years of age (67).…”

“…However, within a small subset, the infection spreads to lower respiratory tract, thereby becoming severe enough to require hospitalization (66). Those children who recover from lower respiratory viral infection often experience wheezing symptoms as sequelae (66). However, it remains unknown whether the intermittent to persistent wheezing represents the sentinel event for IgE-mediated asthma.…”

“…In majority of the infected children, infection is contained within the upper respiratory tract, and the corresponding symptoms remain mild (66). However, within a small subset, the infection spreads to lower respiratory tract, thereby becoming severe enough to require hospitalization (66).…”

Bronchodilators in bronchiolitis: Yes or no?

“…For example, according to the Italian consensus, bronchiolitis is restricted to the first episode in a child less than 12 month of age, 6 whereas the AAP guidelines do not limit it to the first year of life, and point out the presence of wheezing. 2 Moreover, the British bronchiolitis guideline states that we should think of an early asthma attack rather than bronchiolitis if the episode occurs in children close to 12 months or older, who have persistent wheezing without crackles, episodes of recurrent wheezing or family history of asthma.…”