Bronchiolitis (RSV)

Bronchiolitis is a respiratory illness in children less than 24 months old. It is a cold (upper respiratory infection) that also infects the lungs causing wheezing sounds and rapid breathing. It is caused by a virus and cannot be treated with antibiotics. Like all colds, there is no cure but it will go away by itself. Because it causes wheezing, it is a little more serious than a routine cold and children need to be observed more carefully for complications.

What are the symptoms?

  • Runny nose and nasal congestion, which may last 7-10 days
  • Cough, usually starting several days after the runny nose starts.
  • Rapid breathing, may notice some wheezing or raspy sounding breaths.
  • Often not eating or drinking very well.
  • Fever up to 102-103 °F or higher for the first 2-4 days (remember fever itself will not harm your child)
  • Decreased appetite, tiredness, fatigue, fussiness, or crankiness
  • Cough may last up to 3-4 weeks
  • Some children continue to wheeze with colds after having bronchiolitis

What causes bronchiolitis?

Bronchiolitis is caused by a respiratory virus, most commonly RSV (respiratory syncytial virus), although several other viruses can cause the same symptoms. Almost all infants and toddlers will eventually catch RSV, usually by their third birthday. It is more likely to cause wheezing in children 2 years old and younger. Most children with RSV just have cold symptoms and parents never know that it was RSV because the child never had wheezing or trouble breathing. It simply appeared as a cold, perhaps one a little worse than normal.

What should I expect?

It starts with a runny nose then a cough. The cough often worsens and your child may have some rapid breathing and wheezing. Most children have a fever for 2-3 days. Most have a decreased appetite, and some children with bronchiolitis do not drink very well and have to be watched closely for dehydration. The congestion gets thicker and then goes away after about a week. The wheezing does not usually last more than a week, but the cough can last 4-6 weeks. Ear infections are common complications of bronchiolitis.

How is it treated?

  • There is no treatment for the virus itself; the infection has to run its course. Antibiotics will not help.
  • Asthma medications, including albuterol nebulizer treatments and steroids, have been tried repeatedly for bronchiolitis and have little to no effect. They are not currently recommended. Sometimes we try a breathing treatment to see if it will help and if it does, continue them.
  • Treatment for a runny nose: wiping, and suctioning with a soft rubber suction bulb syringe.
  • If the skin around the nose becomes raw and irritated, Vaseline can be put on the skin.
  • Treatment for a congested, stuffed up nose:
    • Suction the nose with a bulb syringe. Use saline drops if necessary.
    • Use nose drops of warm tap water, homemade saline (½ tsp table salt in 8 oz warm water), or saline drops from the drug store. Place 1 drop in each nostril and after 1 minute remove mucous with a soft rubber suction bulb. Children may cry, cough, or sneeze in this process. Repeat until the nose sounds clear. This process will need to be repeated 4 or more times a day.
    • Cool-mist humidifiers may also help at night with congestion.
    • Infants need to breathe through their noses. You may need to clear their noses with saline and suction before each feeding and before putting the child down to sleep.
  • Fever (temperature 100.4º F or higher) should only be treated if it makes your child uncomfortable or fussy.
    • Do not treat fever in infants less than 3 months old without seeing a doctor first.
    • Babies 3-6 months old may use acetaminophen (Tylenol®) for fever.
    • Babies older than 6 months old may use acetaminophen or ibuprofen (Motrin®/ Advil®).
    • Do not alternate medications; choose one and give according to instructions.
  • Cough and cold medicines do not work in children less than 2 years old and can have dangerous side effects in children this age. They should not be used. Diphenhydramine (Benadryl®) should not be used either.

What complications should I look for?

  • Dehydration can occur if fluid intake is inadequate. A poor appetite is normal, but be sure your child is drinking adequate fluids and urinating at least once every 6 hours.
  • Ear infections typically start several days to a week into the cold and are characterized by a return of fever, plus crankiness especially at night and pulling on the ears.
  • Sinus infections start when the cold starts to go away. The congestion will be thick, will worsen after the 7-10th day instead of getting better, and will last longer than 10-14 days.
  • Pneumonia usually starts several days into the cold when the child should be getting better. Usually, a fever develops, along with a worsening cough. The child may have more rapid breathing and shortness of breath.

How can I prevent my child from catching bronchiolitis?

Respiratory viruses are spread from person to person through direct contact, and from toys and other objects contaminated with mucous and saliva containing the virus. Avoiding exposure to adults and children with colds, particularly in daycare and nurseries, can reduce the number of infections. Handwashing is the most effective means of preventing the spread of germs, including cold viruses. Avoid exposure to cigarette smoke. Breastfeeding also helps prevent infections.

When can my child return to daycare?

Your child can return to school when there has been no fever in 24 hours and your child is drinking well and feels well enough.

When should I seek further care?

Call 911 or seek immediate care if your child:

  • Has breathing difficulty or labored breathing, has chest retractions (skin pulling around ribs when breathing), grunts when breathing, has a blue or dark purple color to lips, or stops breathing for more than 10 seconds.
  • Is lethargic and/or barely responds to you or is very weak.

Call your doctor for an appointment the same day or seek after-hours care if your child:

  • Does not smile or play some at least a few minutes every four hours.
  • Has worsening wheezing or working harder to breathe.
  • Is not drinking enough fluid (not having urine/wet diapers at least every 6-8 hours, dry lips and mouth).
  • Is inconsolable and cannot be calmed down at least a few minutes every hour.
  • Looks or acts a lot sicker or the way your child looks or feels concerns you.
  • Is less than 3 months old and has a fever (a rectal temperature greater than 100.4 °F).

Call your doctor for an appointment today or tomorrow if your child:

  • Has a fever that lasts longer than 3 days or has a fever that goes away for 24 hours or more and then returns.
  • Has signs of an ear infection (is cranky or fussy, especially at night, is pulling at the ears, and usually has a fever).
  • Has congestion that lasts more than 10-12 days or that worsens after the 10th day.
  • Has severe cough or a cough that lasts longer than 14-21 days or that worsens after the 14th day.

References

Ralston SL, Lieberthal AS, Meissner HC, et al. American Academy of Pediatrics. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014;134(5). Available at: www.pediatrics.org/cgi/content/full/134/5/e1474.

Skjerven HO, Hunderi JO, Brügmann-Pieper SK, et al. Racemic adrenaline and inhalation strategies in acute bronchiolitis. N Engl J Med. 2013;368(24):2286–2293.

Gadomski AM, Scribani MB. Bronchodilators for bronchiolitis. Cochrane Database Syst Rev. 2014;(6):CD001266.

Quinonez RA, Schroeder AR. Safely Doing Less and the New AAP Bronchiolitis Guideline. Pediatrics 2015; 135(5). http://pediatrics.aappublications.org/content/135/5/793.

Published 1/12/2010. Last updated 2015, 2021.