Bronchiolitis

Bronchiolitis is a viral inflammation of the smallest airways, the bronchioles. It affects children in their first two years, most often babies under one. The wall of the bronchiole swells, the channel fills with mucus and air moves through with difficulty: breathing speeds up, a wheeze appears and feeding becomes hard work. The same virus in an adult passes off as an ordinary cold; in a baby the airways are simply too narrow for the swelling to go unnoticed. Most children get better at home over two to three weeks, but some have a hard time of it and need hospital care.

How it differs from a cold and from bronchitis

A cold stays in the nose and throat: a runny nose, sneezing, a mild temperature. Breathing stays calm. Bronchitis is inflammation of the large airways, it happens at any age, and its main sign is a cough, often with phlegm.

Bronchiolitis starts like a cold but within two or three days moves down into the finest airways. That is why the cough is not the thing to watch: breathing is. It becomes fast and noisy, and the spaces between and below the ribs pull in with each breath. The distinction matters because it changes what you monitor: with a cold you watch the temperature, with bronchiolitis you watch how the child breathes and feeds.

How the illness unfolds

For the first day or two there is nothing unusual: a blocked nose, sneezing, a little cough and a temperature around 38°C. On day three the cough builds, breathing quickens and a whistle appears on the out-breath. Days three, four and five are usually the hardest; after that a slow turn for the better begins.

The cough is the last thing to go and can last up to three weeks, sometimes longer. That is not a worry as long as the child is feeding, sleeping and breathing steadily.

The most honest measure at home is feeding. A child who is struggling to breathe cannot suck and breathe at the same time: a few swallows, then the breast or bottle is dropped, a rest, and back to it. If a whole day's intake is less than half the usual, that alone is reason to be seen, even without a temperature.

Signs that mean calling an ambulance

• breathing stops in pauses, as though the child forgets to take a breath;
• the skin, lips or tongue turn blue or grey;
• with every breath the spaces between the ribs, the hollow at the base of the neck or the belly under the ribs suck inwards;
• the child grunts on breathing out and the nostrils flare;
• the child is floppy, unresponsive, hard to wake or cannot stay awake;
• the child is under three months old and has a temperature of 38°C or above.

Pauses in breathing deserve to be remembered separately. In babies in their first two months and in those born prematurely, such a pause can be the very first sign of the illness, arriving before any wheeze and before an obvious cough. From the outside the baby simply looks quiet and slightly unwell, and then stops breathing for several seconds. This is not something to wait out.

Do not drive the child in yourself: you would have to watch the road instead of watching them. Let someone else drive, or call an ambulance.

When to be seen the same day

• the cold is not turning the corner and is getting worse day by day;
• the child is taking noticeably less than usual or refusing feeds;
• the nappy stays dry for twelve hours or more, the lips and tongue are dry, crying produces no tears;
• a temperature of 39°C or above in a child over three months;
• the child is unusually sleepy or, the other way round, cannot be settled;
• breathing is fast even at rest, when the child is neither crying nor feeding.

Parents usually sense that something is wrong before they can put it into words. That feeling is reason enough to seek help, and it needs no justification.

Who has the harder time

Severe illness is commoner in children with less breathing reserve:

• under three months old, especially in the first weeks of life;
• born markedly early;
• with a heart condition present from birth or a long-term lung disease;
• with weakened immunity or a serious neurological condition;
• living where people smoke indoors.

This does not mean such a child is bound to end up in hospital. It means watching more closely and asking for help sooner, rather than waiting until things look truly bad.

What helps at home

There is no medicine that kills this virus. Home care is for something else: making breathing easier and keeping the child from becoming dehydrated.

• feed more often and in smaller amounts: a baby copes better with short feeds than long ones;
• before a feed put saline drops in the nose and clear the mucus; a blocked nose gets in the way of feeding far more than it seems;
• hold the child upright while they are awake, it makes breathing easier;
• for fever and discomfort, paracetamol or ibuprofen in a children's formulation, at the dose for the child's age and weight; ibuprofen is not given in the first months of life or when a child is dehydrated, and aspirin is not given to children or teenagers at all;
• air the room and do not smoke indoors: smoke stays on clothing even if you go out to the balcony.

Sponging with cool water or stripping a child bare to bring a temperature down is not worth doing: they start to shiver and the temperature comes back.

What does not work, though it is often suggested

Antibiotics are of no use in bronchiolitis: the cause is a virus, and they have no effect on viruses. A doctor will prescribe them only if a bacterial infection has been added on top.

Inhalers that open the airways, and steroids whether by mouth or inhaled, have been studied many times over and do not change the course of the illness. Expectorant and cough-suppressing syrups are not suitable for young children: here the cough is doing the job of clearing the airway.

In hospital a child may be given oxygen, helped with breathing, fed through a tube or given fluids by drip. That is support while the body deals with the virus itself, not a strike against the infection.

How to lower the risk

The main culprit is respiratory syncytial virus. It spreads in droplets from coughing and sneezing, and also on hands and objects, where it survives for several hours. Almost every child meets it before the age of two; the only question is how hard it hits.

• wash your hands before picking up a baby, and ask visitors to do the same;
• keep a newborn away from anyone with a runny nose or a cough, especially if the baby was born early;
• wipe down toys, dummies, door handles and the surfaces everybody touches;
• do not share cups, spoons or bottles; use disposable tissues and bin them straight away;
• stop smoking in the house and in the car: children breathing tobacco smoke have worse illness.

There is medical protection too. Vaccination against respiratory syncytial virus during pregnancy passes maternal antibodies to the baby for the first months of life. Children in at-risk groups are given ready-made antibodies ahead of the seasonal rise: that is prevention, not treatment for an illness already under way. Who needs it and when is decided case by case, and is a conversation for the child's doctor or the doctor looking after the pregnancy.

Online consultation

In an online appointment a doctor can go through how things have changed day by day, how much the child is feeding and how often the nappy is wet, ask to see the chest uncovered, and judge the breathing rate and any pulling in of the ribs. That is usually enough to decide whether to watch at home or head for hospital, and what should raise alarm over the next few hours.

This material is for information only and does not replace medical advice.