Bronchiolitis is a respiratory infection that affects the smaller branches of the bronchial tree. There is a characteristic moist cough and profuse secretions, and often a low grade fever. In many babies, there will be faint whistle-y, wheezing sounds. In more severe cases, there can be marked wheezing and fast breathing.
Bronchiolitis can be caused by several viruses, but the major culprit is Respiratory Synctial Virus (RSV). It circulates through the community every year, especially December to March. RSV comes from the word “synctia” which means web. After the virus attaches to the respiratory tract, it travels sideways from one cell to another, giving a frothy layer of phlegm.
Most children get exposed to RSV during their first or second winter. It is spread through droplet and hand contact, with the infant usually catching it from an another child or adult who has a simple cold or scratchy throat. It is spread primarily through hand contact and by respiratory droplet. It can cling to surfaces for hours and can be inactivated by alcohol based wipes and hand sanitizers.
Over half of babies will experience congestion with cold/cough symptoms. However, about 40% of babies will develop lower respiratory disease, with a deeper cough, whistling/wheezy sounds. In more severe cases, there can be audible wheezing, as if the child had asthma. Some babies can also develop bronchopneumonia.
Some babies with RSV have to be hospitalized. Any baby who is having excessively fast breathing (over 70 times per minute) should be admitted because this could signal that the illness is progressing into pneumonia. Also, any baby who is having marked wheezing, or difficulty feeding should be hospitalized. Babies with mild or intermittent wheezing are managed at home. Most babies with wheezing can stay at home if they are feeding well, acting normal and breathing comfortably.
Infants less than 12 weeks old are at risk for more serious disease and are routinely admitted to the hospital. Other babies who are usually hospitalized are those who had been premature, or had respiratory distress syndrome, those with congenital heart disease, cystic fibrosis or other pulmonary disease. These infants are given a special preventive medicine called Synagis. It is a monoclonal antibody against RSV and is given as an injection once a month for five months starting in November or December to help protect them during their first winter.
There are no specific medicines to hasten the recovery from bronchiolitis. The respiratory lining heals as the immune system drives away the virus. Hospitalized infants are given oxygen, IV fluids and supportive care. Some babies benefit from nebulized asthma medications, even though they don’t shorten the length of stay. It is thought that babies with a predisposition to asthma experience their first episode when they have RSV. There is also debate that those babies who experience a more severe case of RSV will set the stage for subsequent asthma.
For the majority of infants with bronchiolitis – the mainstay of treatment is helping the baby handle his/her secretions, with tender loving care, suctioning and positioning. Many babies will spend the duration of the cough sleeping in an infant seat or stroller. Excessively dry air can make secretions harder to mobilize so a wet towel can be placed on a radiator, or the parents can run the shower, or use a cool mist humidifier in the room. Infants who have started solid foods can be given baby food pears (used in France to help “cut” the phlegm the baby swallows). White grape and cranberry juice can be given. Also rose hip tea, available in supermarkets and health food stores. There have been no studies on homeopathic, herbal or dietary therapy that have shown a significant benefit. However, giving an older infant a vitamin C containing juice and baby food pears won’t be harmful. The parents can also try applying a little Vicks Vapo rub or similar eucalyptus/mentholated product designed for babies on the chest. However, these products should never be left at the bedside – they are poisonous if eaten.
Breastfeeding doesn’t completely block the virus, but helps protect and lessen the severity of illness. It contains immune substances and antibodies directed against RSV. Even if a mom has to go back to work, it’s worth trying to maintain a partial supply of breast milk. She can also take some extra vitamin C.
Cigarette smoke can worsen bronchiolitis. Also, passive smoke is a known risk factor for infants to develop lower tract disease if they get exposed to RSV.
In a typical case of bronchiolitis, the cough can build over the first couple of days, plateau, and then start to improve. In a lecture on RSV to pediatricians, the pediatric pulmonologist, Steven La Rossa of Beth Israel Hospital in New York City, emphasized that the cough can easily last more than a week. Most babies are symptomatic for about 12 days. However 18% will take 21 days, and 9% will take 28 days to improve. When children get re-exposed to RSV the next year, they can still get re-infected, but typically are not as sick. After a few winters, children become more immune, and RSV becomes a regular cough and cold. However, this is the age when these children can pass the dreaded virus to an infant.
As a child is recovering from bronchiolitis, his/her respiratory lining can be more reactive to allergens and irritants such as cigarette smoke. Avoid visiting relatives whose homes have lots of animal dander, smoke, or mold and try to shield the baby from new respiratory viruses. If he/she gets exposed to another cold within a short period of time, there can be a rebound of wheezing and fever as the immune cells from the RSV infection, which are still encamped along the bronchial tree, gear up to fight the new virus. Parents can get the feeling that their child is “always sick”, or has a weakened immune system.
The take home message with RSV is that it is a commonly encountered virus, and that most children will not be seriously ill with it. However, it is a powerful pathogen and can make many infants very, very sick. Don’t let anyone touch your baby, and don’t touch someone else’s baby, without first washing your hands, and try to shield your baby especially during the holiday season. Sooner or later, every child will encounter RSV, but you want to delay it until the child is older and stronger.