It’s winter 2022, and COVID-19 is still wreaking havoc on patients and the health care system. When a child comes in with respiratory symptoms, the first thing that may come to your mind is coronavirus; however, it’s important to remember that cases of bronchiolitis, including respiratory syncytial virus (RSV), have also been skyrocketing.
Treating RSV and other forms of bronchiolitis in children
As medical professionals, we’re painfully aware of how much the COVID-19 pandemic has infiltrated our practices. But having a new respiratory virus on the block doesn’t mean other previously existing viruses have gone away. In fact, in late fall of 2021, U.S. pediatric hospitals saw a surge of RSV and other viral bronchiolitis cases.
In their podcast, Guidelines with Gabi: Something Old, Something New, Lots of Kids Needing O2: Update in Bronchiolitis, Drs. Gabi Hester and Nadia Maccabee-Ryaboy discuss the influx of bronchiolitis cases they’ve seen at Children’s Minnesota along with methods of treatment, possible coexisting infections and promising research on the horizon.
Gabrielle (Gabi) Zimbric Hester, MD
Dr. Hester is a pediatric hospitalist at Children’s Minnesota and the medical director of clinical outcomes within the department of quality. She’s interested in quality improvement, patient safety, health equity and health services research.
Nadia Maccabee-Ryaboy, MD
Dr. Maccabee-Ryaboy is a pediatric hospitalist at Children’s Minnesota. She has a passion for public health advocacy and for hospital-wide quality improvement to enhance patients’ health.
In this episode
In this episode, Drs. Hester and Maccabee-Ryaboy discuss:
- The importance of viral testing and screening for coexisting conditions.
- Bronchiolitis treatment.
- Trial interventions.
- New hope for an RSV vaccine.
Bronchiolitis is a viral infection in the lower respiratory tract that is clinically diagnosed in children under the age of 2 years. While its symptoms can be similar to those of influenza or COVID-19, treatment for the three conditions vary. Therefore, viral testing is advised before beginning care.
Any coexisting conditions that can occur alongside bronchiolitis also need to be identified as they may require alternative treatment. However, it’s important to note that infants who have a fever with viral bronchiolitis have only a 3-5% chance of also having a urinary tract infection and an almost 0% risk of having meningitis; although the risks are slightly higher for babies who are younger than 28 days old. When seeing a patient who meets these criteria, it’s advisable to perform urine and blood tests, but if the lab results are reassuring, there may be no need for a lumbar puncture or antibiotics.
Typically, the body fights bronchiolitis on its own; however, some patients require help. It’s important to help parents understand that “less is more” when it comes to treating RSV and other forms of viral bronchiolitis. Antibiotics and many other interventions do not help; however, there are some cases where trialing certain medications or methods — as listed below — may be beneficial.
Parents should also be advised that the average hospital stay for bronchiolitis is two to three days and their child will continue to have symptoms for up to four weeks. After discharge, parents should watch for increased labored breathing, signs of dehydration (less than four wet diapers per day), lethargy or a new high fever, and they should follow up with their child’s pediatrician if new concerns or questions arise.
When trialing a medication or method, it’s vitally important to trial them separately to help determine what is effective for the child and what is not. This helps to avoid giving false diagnoses, unnecessary interventions or ongoing medication that is not needed. Research indicates that certain patients may benefit from trialing some of the following interventions.
There is strong evidence supporting the effectiveness of nasal suctioning for children suffering from bronchiolitis. It may be especially useful for infants before they feed. You should avoid deep suctioning as much as possible, as this can worsen symptoms and airway edema.
If a patient is dehydrated, this will help replenish fluid and electrolytes and often improve their level of comfort. However, it does not seem to shorten the duration of the virus.
High-flow nasal cannula (HFNC).
This method is commonly used in hospital cases. It’s a respiratory support system that provides higher oxygen flow and concentration which washes out dead space and improves the expulsion of carbon dioxide. The heat and humidity also work to improve pulmonary compliance and conductance. It’s also been observed to decrease metabolic demand on respiratory muscles, making it easier for patients to breath. HFNC does not decrease length of hospital stay or of oxygen therapy needed, but it does tend to reduce the risk of needing intensive care unit care.
Medications, such as Albuterol, are typically not effective in treating bronchiolitis. However, some children, including those with food allergies, eczema or a family history of asthma, may be good candidates for a bronchodilator trial. You may want to consider — especially in the height of COVID-19 — using an inhaler instead of a nebulizer whenever possible since nebulizers aerosolize the child’s droplets, which makes viruses spread more easily to others.
RSV vaccine trials are underway
There’s exciting news on the vaccine-front that can have a significant impact for our pediatric population. Both Moderna and Pfeizer have begun Food and Drug Administration review and clinical trials for RSV vaccines for kids and pregnant women. The day may be quickly approaching when we can recommend that our pediatric patients get their RSV shot along with their flu shot in the fall.