PEDIATRIC BRONCHIOLITIS

Major Risk
Respiratory infection (most likely RSV, but could also be caused by rhinovirus, influenza or
Factors coronavirus)
Age <12 weeks
Prematurity
Underlying cardiopulmonary disease
Immunodeficiency
Epidemiolog 90% of children are infected with RSV in the first 2 years of life 40% will experience LRTI during the
y initial infection
100,000 admissions occur annually in the US and bronchiolitis is the most common cause of
hospitalization among infants during the first 12 months of life
Highest age-specific rate of RSV hospitalization occurs between 30 and 60 days of age
Highest incidence of RSV infection occurs between December and March in North America (can be as
long as May in California)
Presentation Characterized by:
acute inflammation
edema
necrosis of epithelial cells lining small airways
increased mucus production
Signs and symptoms typically begin with rhinitis and cough, which may progress to tachypnea (defined as RR
> 70), wheezing, rales, use of accessory muscles, and/or nasal flaring
Diagnosis Assessed by a combination of:
Respiratory rate/presence of apnea
Increased respiratory effort
Underlying risk factors as mentioned above
RSV PCR assays when receiving monthly prophylaxis (routine testing not recommended)
Chest radiography is NOT recommended as a routine diagnostic
Non- Wash hands or used alcohol-based rubs if in direct contact with infant or children with bronchiolitis
pharmacolog Avoid exposure to environmental airborne irritants like smoke, fumes, etc.
ical Breastfeeding is encouraged for at least 6 months to decrease morbidity of respiratory infections
Recommend
ations

TREATMENT STRATEGIES
Treatment - Nebulized hypertonic saline while hospitalized increases mucociliary clearance
Recommended Supplemental O2 with pulse oximetry if needed to maintain oxygen saturation
Nasogastric or intravenous fluids to maintain hydration if oral route is not possible

Prepared by Duy-Anh Dang, Mar 2017

Treatment- NOT Albuterol/Salbutamol subgroup in which clear benefit is demonstrated is poorly defined
Recommended Epinephrine no difference in efficacy compared with placebo and may extend LOS, may be
used as rescue agent
Nebulized hypertonic saline in the ER
Systemic corticosteroids no difference in benefit compared with placebo and may prolong
viral shedding
Chest physiotherapy such as suctioning
Antibacterial medications unless bacterial infection is strongly suspect or confirmed
Prevention Palivizumab (Synagis)
Indicated during first year of life to infants with acyanotic congenital heart disease chronic
lung disease of prematurity (born before 29 weeks, 0 days) requiring >21% O2 for first 28
days of life, or in children < 2 years old with chronic lung disease requiring oxygen or on
chronic corticosteroid therapy
Not recommended in children with Downs syndrome, cystic fibrosis, or congenital heart
disease with cyanosis
Given in 5 monthly doses during RSV season, and discontinued if patient has an active RSV
infection
Dosed 15 mg/kg/dose IM in anterolateral thigh muscle monthly for maximum of 5 doses
PEDIATRIC PNEUMONIA
Major Risk Respiratory infections (viral and bacteria)
Factors Bacterial: S. pneumoniae, with M. pneumoniae, C. pneumoniae, and H. influenza more common in
school-aged children
Viral: RSV, Influenza, Rhinovirus
Prematurity
Malnutrition
Low socioeconomic status
Exposure to tobacco smoke
Epidemiolog CAP is the leading cause of death in children younger than 5 years worldwide
y Mixed viral and bacterial infections account for 30-50% of CAP infections in children
7.8% of childhood hospitalizations with average LOS of three days
Presentation Signs and symptoms typically begin with fever, tachypnea, increasingly labored breathing, rhonchi, crackles,
and wheezing.
Diagnosis Assessed by a combination of:
Tachypnea assessed over the course of a full minute (RR >50 for age 2-12 months, RR > 40 for age 1-5
years)
Chest radiography for evidence of infiltrates
Antigenic tests for Influenza A and B and RSV when diagnosis is unclear
Blood and sputum cultures are not always reliable and often do not yield a pathogen
Prepared by Duy-Anh Dang, Mar 2017
 Criteria for Infants
Hospitalizati Apnea or grunting
on O2 saturation < 92%
Poor feeding
RR > 70
Older children
Grunting
Inability to tolerate PO intake
O2 saturation < 92%
RR > 50
All age groups
Chronic heart or lung disease
Other comorbidities (DM, neuromuscular disease)
TREATMENT STRATEGIES
Outpatient Most treatment is empiric as pathogen is not known at time of diagnosis
Treatment Age 60 days to 5 years:
Options Amoxicillin (80-90 mg/kg/day in 2-3 divided doses for 7-10 days)
Azithromycin (10 mg/kg/day on day 1, 5 mg/kg/day on days 2-5)
Clarithromycin (15 mg/kg/day in 2 divided doses for 7-10 days)
Age 5 16 years:
Azithromycin (10 mg/kg/day on day 1, 5 mg/kg/day on days 2-5)
Inpatient Most treatment is empiric as pathogen is not known at time of diagnosis
Treatment Age 60 days to 5 years:
Options Amoxicillin (80-90 mg/kg/day in 2-3 divided doses for 7-10 days)
Azithromycin (10 mg/kg/day on day 1, 5 mg/kg/day on days 2-5)
Clarithromycin (15 mg/kg/day in 2 divided doses for 7-10 days)
Cefuroxime (150 mg/kg/day IV in divided doses q8h, for 10-14 days)
Add erythromycin (40 mg/kg/day IV or PO in divided doses q6h for 10-14 days for severe illness
Age 5 16 years:
Azithromycin (10 mg/kg/day on day 1, 5 mg/kg/day on days 2-5)
Cefuroxime (150 mg/kg/day IV in divided doses q8h, for 10-14 days)
Add erythromycin (40 mg/kg/day IV or PO in divided doses q6h for 10-14 days for severe illness

MRSA: Vancomycin 15 mg/kg IV q6h or Zyvox (10 mg/kg PO or IV q8h if less than 12 years old or 600 mg IV
BID if 12 years or older)

Prepared by Duy-Anh Dang, Mar 2017