bronchiolitis in infants and children_ clinical features and diagnosis

7/27/2019 Bronchiolitis in Infants and Children_ Clinical Features and Diagnosis

1/18

28/0 7/13 Bronchiolitis in infants and children: Clinical features and diagnosis

www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis?topicKey=PEDS%2F6018&elapsedTimeMs=11&source=see 1/18

Official reprin t from UpToDate www.uptodate.com 2013 UpToDate

AuthorsPedro A Piedra, MD

Ann R Stark, MD

Section EditorsGregory Redding, MDMorven S Edwards, MD

Deputy Editor Mary M Torchia, MD

Bronchiolitis in infants and children: Clinical features and diagnosis

Discl os ures

All topics are updated as new evidence becomes available and our peer review process is complete.Literature review current through: Jun 2013. | This topic last updated: Mar 13, 2013.

INTRODUCTION Bronchiolitis, a lower respiratory tract infection that primarily affects the sm all airways(bronchioles), is a common caus e o f illness and hospitalization in infants and young children.

The microbiology, epidemiology, clinical features, and diagnosis of bronchiolitis will be presented here. Thetreatment, outcome, and prevention of bronchiolitis in children; respiratory syncytial virus, and the emergentevaluation of c hildren with acute respiratory distress are discussed separately:

(Se e "Bronchiolitis in in fants and children: Treatment; outcome; and prevention" .)

(See "Respiratory syncytial virus infection: Clinical features and dia gnosis" and "Respiratory syncytial virusinfection: Treatment" and "Respiratory syncytial virus infection: Prevention" .)

(See "Emergent evaluation of acute respiratory compromise in children" .)

DEFINITION Bronchiolitis is broadly defined as a clinical syndrome that occurs in children


2/18

28/07/13 Bronchiolitis in infants and children: Clinical features and diagnosis

www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis?topicKey=PEDS%2F6018&elapsedTimeMs=11&source=see 2

'Clinical features' .)

RSV RSV is the most common cause of bronchiolitis and the virus most often detected as the solepathogen. RSV is ubiquitous throughout the world and causes seasonal outbreaks. In temperate climates,late fall and winter epidemics of bronchiolitis usually are linked to RSV. In tropical and semitropical climates,the seasonal outbreaks usually are associated with the rainy season. (See "Respiratory syncytial virusinfection: Clinical features and diagnosis" .)

Rhinovirus Human rhinoviruses are the main cause of the common cold. There are more than 100serotypes. Rhinovirus is associated with lower respiratory tract infection in young children and in individualswith chronic pulmonary disease [ 18 ]. Dual viral infections are often detected. Rhinovirus is often associatedwith bronchiolitis in the spring and fall [ 19 ]. (See "Epidemiology, clinical manifestations, and pathogenesis of rhinovirus infections" .)

Parainfluenza virus Parainfluenza virus type 3, which is associated with epidemics in early spring and fall,is another cause of bronchiolitis. Parainfluenza virus types 1 and 2 also can cause bronchiolitis althoughcroup is the more common presentation [ 20 ]. (See "Parainfluenza viruses in children", section on 'Clinicalpresentation' .)

Human metapneumovirus Human metapneumovirus sometimes occurs in conjunction with other viralinfections and has been identified as an etiology of bronchiolitis and pneumonia in children [ 21,22 ]. (See"Human metapneumovirus infections" .)

Influenza virus The lower respiratory tract manifestations of influenza are clinically indistinguishable fromthose due to RSV or parainfluenza viral infections. (See "Clinical features and diagnosis of seasonalinfluenza in children", section on 'Clinical features' .)

Adenovirus Adenovirus may cause lower respiratory tract infections, including bronchiolitis, bronchiolitisobliterans, and pneumonia, though it more typically causes pharyngitis and coryza. Adenovirus can alsoinfect other organs causing disseminated disease. (See "Epidemiology and clinical manifestations of adenovirus infection", section on 'Clinical presentation' .)

Coronavirus Human coronaviruses are another important cause of the common cold, which can also causelower respiratory tract infection, including bronchiolitis [ 23,24 ]. Severe acute respiratory syndrome (SARS)was caused by a coronavirus that likely originated from the Chinese horseshoe bat [ 25 ]. (See"Coronaviruses" .)

Human bocavirus Human bocavirus 1 causes upper and lower respiratory infections during the fall andwinter months [ 13,26-28 ]. Bronchiolitis and pertussis-like illness can occur. Human bocavirus 2 through 4are primarily enteric viruses [ 29 ].

EPIDEMIOLOGY Bronchiolitis typically affects infants and children younger than two years, principally duringthe fall and winter [ 30 ]. Bronchiolitis hospitalization has a peak incidence between two and six months of age andremains a significant cause of respiratory disease during the first five years of life [ 31 ]. It is a leading cause of hospitalization in infants and young children [ 31,32 ].

The epidemiology of bronchiolitis is similar to that of respiratory syncytial virus (RSV) infection because most casesof bronchiolitis are caused by RSV. (See "Respiratory syncytial virus infection: Clinical features and diagnosis",section on 'Epidemiology' .)

RISK FACTORS FOR SEVERE DISEASE Risk factors for severe or complicated bronchiolitis include [ 33-38 ]:

Prematurity (gestational age


3/18



Chronic pulmonary disease, particularly bronchopulmonary dysplasia (also known as chronic lung disease)Congenital and anatomic defects of the airwaysCongenital heart diseaseImmunodeficiencyNeurologic disease

Environmental and other risk factors, such as passive smoking, crowded household, daycare attendance,concurrent birth siblings, older siblings, and high altitude (>2500 meters) can also contribute to more severedisease [ 38-42 ].

CLINICAL FEATURES

History Infants with moderate to severe bronchiolitis typically present for medical attention three to six days after illness onset. Bronchiolitis often is preceded by a one- to three-day history of upper respiratory tract symptoms,such as nasal congestion and/or discharge and mild cough [ 43 ]. It typically presents with fever (usually 38.3C),cough, and mild respiratory distress (eg, mildly increased respiratory rate, mild retractions).

Compared with other viruses that cause bronchiolitis, fever tends to be lower with respiratory syncytial virus (RSV)and higher with adenovirus [ 44 ]. (See "Respiratory syncytial virus infection: Clinical features and diagnosis", sectionon 'Clinical manifestations' and "Epidemiology and clinical manifestations of adenovirus infection", section on'Clinical presentation' .)

Aspects of the history that help in determining the severity of illness and/or need for hospitalization include (see'Severity assessment' below and "Bronchiolitis in infants and children: Treatment; outcome; and prevention",section on 'Indications for hospitalization' ) [1]:

Assessment of hydration status (eg, fluid intake, urine output)Symptoms of respiratory distress (tachypnea, nasal flaring, retractions, grunting)CyanosisEpisodes of restlessness or lethargy (may indicate hypoxemia and/or impending respiratory failure)

A history of apnea with cyanosis or bradycardia

Examination Characteristic examination findings of bronchiolitis include tachypnea, mild intercostal andsubcostal retractions, and expiratory wheezing. Additional auscultatory findings may include prolonged expiratoryphase and coarse or fine crackles (rales). The chest may appear hyperexpanded with increased anteroposterior diameter and may be hyperresonant to percussion. Mild hypoxemia (oxygen saturation


4/18



Segmental consolidation and alveolar infiltrates are more characteristic of bacterial pneumonia than bronchiolitis,but radiographic findings are poor indicators of the etiologic diagnosis and must be used in conjunction with other clinical features in making decisions about diagnosis and treatment. (See 'Differential diagnosis' below and "Clinicalfeatures and diagnosis of community-acquired pneumonia in children", section on 'Etiologic clues' .)

CLINICAL COURSE The duration of the illness due to bronchiolitis depends upon age, severity of illness,associated high-risk conditions (eg, prematurity, chronic pulmonary disease), and the causative agent [ 10 ].Bronchiolitis usually is a self-limited disease. Most children who do not require hospitalization recover by 28 days[54-56 ].

Typical illness with bronchiolitis begins with upper respiratory tract symptoms, followed by lower respiratory tractsigns and symptoms on days two to three, which peak on days five to seven and then gradually resolve. In a cohortof 181 children, the median duration of caretaker-reported symptoms was 12 days [ 54 ]. Approximately 20 percentcontinued to have symptoms for at least three weeks, and 10 percent had symptoms for at least four weeks.

In previously healthy infants older than six months who require hospitalization, the average length of hospitalizationis three to four days, although it may be longer in children with bronchiolitis due to rhinovirus [ 10,31 ]. Therespiratory status typically improves over two to five days [ 34,57-60 ]. However, wheezing persists in some infantsfor a week or longer.

The course may be prolonged in infants younger than six months (particularly those younger than 12 weeks) andthose with comorbid conditions (eg, bronchopulmonary dysplasia); these children often are severely affected andmay require assisted ventilation [ 33,61 ]. (See 'Risk factors for severe disease' above and 'Respiratory failure' below.)

COMPLICATIONS In most previously healthy infants, bronchiolitis resolves without complications. However,severely affected patients, particularly those born prematurely,


5/18



during hospitalization. No patient classified as low risk subsequently developed apnea.

Respiratory failure Respiratory failure is another serious complication of bronchiolitis. In a multicenter study,respiratory failure occurred in 14 percent of 684 infants younger than 12 months who were hospitalized for management of bronchiolitis [ 62 ]. In another multicenter study, 16 percent of infants hospitalized with RSV requiredintensive care support (with or without mechanical ventilation) [ 34 ]. However, the need for intensive care varieddepending on the presence and type of risk factors for serious disease:

No known risk factors 7 percent

Congenital heart disease, bronchopulmonary dysplasia, or immunosuppression 19 to 37 percent

Age


6/18



unless the results of such testing will alter management of the patient or patients contacts (eg, initiation or continuation/discontinuation of antibiotic therapy, anti-influenza therapy, anti-influenza prophylaxis for high riskcontacts, or cohorting of hospitalized patients or caregivers) [ 2,74 ]. (See "Antiviral drugs for the prevention andtreatment of seasonal influenza in children", section on 'Antiviral therapy' .)

There is debate about whether testing for specific viral agents alters clinical management or outcome, particularly inthe outpatient setting [ 1,2,72,74-77 ]. However, the identification of a viral etiologic agent during emergencydepartment evaluation or in hospitalized patients has been associated with a decreased utilization of antibiotictreatment [ 76,78-80 ].

Identification of the responsible virus in hospitalized patients may help to avoid nosocomial transmission bypermitting cohorting of patients and/or caregivers. However, direct evidence that this strategy prevents nosocomialtransmission or respiratory viruses in children is lacking, and it may be more logical to isolate all infants withbronchiolitis [ 2,81 ]. Cohorting has the potential to increase the risk of infection with other respiratory viruses leadingto prolonged hospitalization [ 10 ]. (See "Respiratory syncytial virus infection: Prevention", section on 'Nosocomialinfection' .)

When an etiologic diagnosis is necessary (eg, for cohorting hospitalized patients or caregivers; if the results willaffect other management decisions such as whether to initiate or continue antibiotic therapy), the recommendedapproach is screening by antigen detection or immunofluorescence of respiratory secretions obtained by nasal

wash or nasal aspirate (rather than nasopharyngeal swabs) [ 82,83 ]. Rapid antigen tests are available for respiratorysyncytial virus (RSV), parainfluenza, adenovirus, and influenza viruses. Direct or indirect immunofluorescence testsare available for these and other viruses that cause bronchiolitis. Culture and polymerase chain reaction (PCR) areadditional methods that can be used for viral identification. The laboratory diagnosis depends upon the quality andproper handling of the specimen. The sensitivity of most rapid antigen tests ranges from 80 to 90 percent [ 84 ].

Nasal wash specimens are obtained by holding the infant or child upright at a 45 angle. A bulb syringe or a softplastic catheter attached to suction is used to aspirate nasal secretions after a small amount of normal saline (1 to3 mL) is instilled in each nostril.

Other laboratory tests Laboratory tests are not routinely indicated in the evaluation of infants and youngchildren with suspected bronchiolitis. Data demonstrating the utility of complete blood counts (CBCs) in thediagnosis or management of bronchiolitis are lacking [ 1,2,72,85 ].

However, laboratory and/or radiographic evaluation may be necessary to evaluate the possibility of comorbid or secondary bacterial infection in young infants with suspected bronchiolitis and fever, complications, or other diagnostic considerations in children with an unusual clinical presentation or a severe and/or prolonged course of illness.

Neonates 28 days of age with fever Infants 28 days old with fever (T 38C [100.4F]) and symptomsand signs of bronchiolitis have the same risk for serious bacterial infection as young febrile infants withoutbronchiolitis and should be assessed accordingly [ 49 ]. (See "Evaluation and management of fever in theneonate and young infant (less than three months of age)" .)

Infants 28 to 90 days of age with fever CBC, urinalysis, urine culture, and chest radiograph may bewarranted to exclude comorbid or secondary bacterial infection in febrile (T 38C [100.4F]) infants withsymptoms and signs of bronchiolitis who are between 28 and 90 days of age. However, the yield of thisevaluation is likely to be low. Although the CBC is often used to screen for serious bacterial infection ininfants without bronchiolitis, in a large retrospective study, abnormal white blood cell count was notpredictive of serious bacterial infection in infants and young children who were hospitalized with RSV [ 85 ].(See "Evaluation and management of fever in the neonate and young infant (less than three months of age)",section on 'Evaluation and management' and 'Comorbid serious bacterial infection' above.)

Children of any age with unusual or severe course CBC and chest radiograph may be warranted to
http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis?topicKey=PEDS%2F6018&elapsedTimeMs=11&source=see_link&view=print&displayedView=full&anchor=H7#H317309589http://www.uptodate.com/contents/evaluation-and-management-of-fever-in-the-neonate-and-young-infant-less-than-three-months-of-age?source=see_link&anchor=H12#H12http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/85http://www.uptodate.com/contents/evaluation-and-management-of-fever-in-the-neonate-and-young-infant-less-than-three-months-of-age?source=see_linkhttp://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/49http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/1,2,72,85http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/84http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/82,83http://www.uptodate.com/contents/respiratory-syncytial-virus-infection-prevention?source=see_link&anchor=H104278849#H104278849http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/10http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/2,81http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/76,78-80http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/1,2,72,74-77http://www.uptodate.com/contents/antiviral-drugs-for-the-prevention-and-treatment-of-seasonal-influenza-in-children?source=see_link&anchor=H20#H20http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/2,74


7/18



evaluate secondary bacterial infection and other conditions in the differential diagnosis in infants and youngchildren with an unusual or severe course (eg, failure to improve after two to five days, wheezing that persistsfor more than one week) [ 1,2 ]. (See 'Clinical course' above and 'Differential diagnosis' below.)

Children of any age with severe disease In infants and young children with severe disease, arterial or capillary blood gas measurements may be necessary to evaluate respiratory failure. (See 'Respiratory failure'above.)

Severity assessment Severe bronchiolitis is indicated by persistently increased respiratory effort (tachypnea;nasal flaring; intercostal, subcostal, or suprasternal retractions; accessory muscle use; grunting), hypoxemia,apnea, or acute respiratory failure [ 1,86 ]. Repeated observations are necessary to adequately assess diseaseseverity because examination findings may vary substantially over time. Infants and young children with severedisease usually require hospitalization for frequent observation as well as respiratory and/or fluid support. (See"Bronchiolitis in infants and children: Treatment; outcome; and prevention", section on 'Indications for hospitalization' .)

Other factors that that have been associated with increased illness severity include toxic or ill appearance, oxygensaturation


8/18



some cases, the underlying disorder is unrecognized before the acute episode. The clinical course of bronchiolitis in children with underlying pulmonary disorders tends to be severe and may require prolongedhospitalization.

Foreign body aspiration Clinical features of foreign body aspiration may include a history of choking (notalways present), focal monophonic wheezing, decreased air entry, or regional variation in aeration. A highindex of suspicion should be maintained for foreign body aspiration so that definitive treatment can beprovided. (See "Airway foreign bodies in children" .)

Aspiration pneumonia Aspiration pneumonia may occur secondary to gastroesophageal reflux diseaseand/or swallowing dysfunction. It also may occur as a complication of bronchiolitis; the risk of aspirationincreases during active bronchiolitis and resolves weeks later as tachypnea and the work of breathingsubside. Clinical features associated with aspiration may include coughing with feeds, weak suck reflex,cyanosis during feeding, and recurrent or chronic stridor. (See "Gastroesophageal reflux in infants" and"Aspiration due to swallowing dysfunction in infants and children" .)

Congenital heart disease Associated clinical findings of congenital heart disease may include failure tothrive, poor peripheral perfusion, and abnormalities on cardiac examination (eg, pathologic heart murmur,abnormal second heart sound, gallop, rub, active precordium). (See "Suspected heart disease in infants andchildren: Criteria for referral" .)

Children with underlying cardiac conditions may have a superimposed acute episode of bronchiolitis, and insome cases, the underlying disorder is unrecognized before the acute episode. The clinical course of bronchiolitis in children with underlying cardiac disorders tends to be severe and may require prolongedhospitalization.

Heart failure Associated clinical findings may include exercise intolerance, easy fatigue, hepatomegaly,shortness of breath, peripheral edema. (See "Etiology and diagnosis of heart failure in infants and children",section on 'Clinical manifestations' .)

Vascular rings Although stridor is more common, children with vascular rings may also have wheezing

(typically with pulmonary artery slings). Anterior bowing of the trachea in the lateral chest radiograph may bea clue, but other modalities ( barium contrast esophagogram, bronchoscopy, magnetic resonanceangiography) usually are necessary for definitive diagnosis. (See "Vascular rings", section on 'Clinicalmanifestations' .)

INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and

Beyond the Basics. The Basics patient education pieces are written in plain language, at the 5 th to 6 th gradereading level, and they answer the four or five key questions a patient might have about a given condition. Thesearticles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond theBasics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the

10th

to 12th

grade reading level and are best for patients who want in-depth information and are comfortable withsome medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail thesetopics to your patients. (You can also locate patient education articles on a variety of subjects by searching onpatient info and the keyword(s) of interest.)

Basics topic (see "Patient information: Bronchiolitis (and RSV) (The Basics)" )

Beyond the Basics topic (see "Patient information: Bronchiolitis (and RSV) in infants and children (Beyondthe Basics)" )
http://www.uptodate.com/contents/bronchiolitis-and-rsv-in-infants-and-children-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/bronchiolitis-and-rsv-the-basics?source=see_linkhttp://www.uptodate.com/contents/vascular-rings?source=see_link&anchor=H11#H11http://www.uptodate.com/contents/barium-drug-information?source=see_linkhttp://www.uptodate.com/contents/etiology-and-diagnosis-of-heart-failure-in-infants-and-children?source=see_link&anchor=H23884780#H23884780http://www.uptodate.com/contents/suspected-heart-disease-in-infants-and-children-criteria-for-referral?source=see_linkhttp://www.uptodate.com/contents/aspiration-due-to-swallowing-dysfunction-in-infants-and-children?source=see_linkhttp://www.uptodate.com/contents/gastroesophageal-reflux-in-infants?source=see_linkhttp://www.uptodate.com/contents/airway-foreign-bodies-in-children?source=see_link


9/18



SUMMARY AND RECOMMENDATIONS

Bronchiolitis is broadly defined as a clinical syndrome that occurs in children


10/18


www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis?topicKey=PEDS%2F6018&elapsedTimeMs=11&source=se 10/18

4. Wainwright C, Altamirano L, Cheney M, et al. A multicenter, randomized, double-blind, controlled trial of nebulized epinephrine in infants with acute bronchiolitis. N Engl J Med 2003; 349:27.

5. Plint AC, Johnson DW, Patel H, et al. Epinephrine and dexamethasone in children with bronchiolitis. N Engl JMed 2009; 360:2079.

6. Colby TV. Bronchiolitis. Pathologic considerations. Am J Clin Pathol 1998; 109:101.

7. Aherne W, Bird T, Court SD, et al. Pathological changes in virus infections of the lower respiratory tract inchildren. J Clin Pathol 1970; 23:7.

8. Wohl ME, Chernick V. State of the art: bronchiolitis. Am Rev Respir Dis 1978; 118:759.9. Coffin SE. Bronchiolitis: in-patient focus. Pediatr Clin North Am 2005; 52:1047.

10. Mansbach JM, Piedra PA, Teach SJ, et al. Prospective multicenter study of viral etiology and hospital lengthof stay in children with severe bronchiolitis. Arch Pediatr Adolesc Med 2012; 166:700.

11. Mansbach JM, McAdam AJ, Clark S, et al. Prospective multicenter study of the viral etiology of bronchiolitisin the emergency department. Acad Emerg Med 2008; 15:111.

12. Midulla F, Scagnolari C, Bonci E, et al. Respiratory syncytial virus, human bocavirus and rhinovirusbronchiolitis in infants. Arch Dis Child 2010; 95:35.

13. Allander T, Tammi MT, Eriksson M, et al. Cloning of a human parvovirus by molecular screening of respiratorytract samples. Proc Natl Acad Sci U S A 2005; 102:12891.

14. Calvo C, Garca-Garca ML, Pozo F, et al. Clinical characteristics of human bocavirus infections comparedwith other respiratory viruses in Spanish children. Pediatr Infect Dis J 2008; 27:677.

15. Richard N, Komurian-Pradel F, Javouhey E, et al. The impact of dual viral infection in infants admitted to apediatric intensive care unit associated with severe bronchiolitis. Pediatr Infect Dis J 2008; 27:213.

16. Stempel HE, Martin ET, Kuypers J, et al. Multiple viral respiratory pathogens in children with bronchiolitis. Acta Paediatr 2009; 98:123.

17. Miron D, Srugo I, Kra-Oz Z, et al. Sole pathogen in acute bronchiolitis: is there a role for other organismsapart from respiratory syncytial virus? Pediatr Infect Dis J 2010; 29:e7.

18. Piotrowska Z, Vzquez M, Shapiro ED, et al. Rhinoviruses are a major cause of wheezing and hospitalizationin children less than 2 years of age. Pediatr Infect Dis J 2009; 28:25.

19. Jacques J, Bouscambert-Duchamp M, Moret H, et al. Association of respiratory picornaviruses with acutebronchiolitis in French infants. J Clin Virol 2006; 35:463.

20. Counihan ME, Shay DK, Holman RC, et al. Human parainfluenza virus-associated hospitalizations amongchildren less than five years of age in the United States. Pediatr Infect Dis J 2001; 20:646.

21. Greensill J, McNamara PS, Dove W, et al. Human metapneumovirus in severe respiratory syncytial virusbronchiolitis. Emerg Infect Dis 2003; 9:372.

22. Edwards KM, Zhu Y, Griffin MR, et al. Burden of human metapneumovirus infection in young children. N EnglJ Med 2013; 368:633.

23. Kuypers J, Martin ET, Heugel J, et al. Clinical disease in children associated with newly describedcoronavirus subtypes. Pediatrics 2007; 119:e70.

24. Kristoffersen AW, Nordb SA, Rognlien AG, et al. Coronavirus causes lower respiratory tract infections lessfrequently than RSV in hospitalized Norwegian children. Pediatr Infect Dis J 2011; 30:279.

25. Lau SK, Woo PC, Li KS, et al. Severe acute respiratory syndrome coronavirus-like virus in Chinesehorseshoe bats. Proc Natl Acad Sci U S A 2005; 102:14040.

26. Arnold JC, Singh KK, Spector SA, Sawyer MH. Human bocavirus: prevalence and clinical spectrum at achildren's hospital. Clin Infect Dis 2006; 43:283.

27. Allander T, Jartti T, Gupta S, et al. Human bocavirus and acute wheezing in children. Clin Infect Dis 2007;44:904.

28. Regamey N, Frey U, Deffernez C, et al. Isolation of human bocavirus from Swiss infants with respiratoryinfections. Pediatr Infect Dis J 2007; 26:177.
http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/28http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/27http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/26http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/25http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/24http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/23http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/22http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/21http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/20http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/19http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/18http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/17http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/16http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/15http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/14http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/13http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/12http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/11http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/10http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/9http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/8http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/7http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/6http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/5http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/4


11/18



29. Kapoor A, Simmonds P, Slikas E, et al. Human bocaviruses are highly diverse, dispersed, recombinationprone, and prevalent in enteric infections. J Infect Dis 2010; 201:1633.

30. Mansbach JM, Pelletier AJ, Camargo CA Jr. US outpatient office visits for bronchiolitis, 1993-2004. AmbulPediatr 2007; 7:304.

31. Shay DK, Holman RC, Newman RD, et al. Bronchiolitis-associated hospitalizations among US children,1980-1996. JAMA 1999; 282:1440.

32. Pelletier AJ, Mansbach JM, Camargo CA Jr. Direct medical costs of bronchiolitis hospitalizations in theUnited States. Pediatrics 2006; 118:2418.

33. Shaw KN, Bell LM, Sherman NH. Outpatient assessment of infants with bronchiolitis. Am J Dis Child 1991;145:151.

34. Wang EE, Law BJ, Stephens D. Pediatric Investigators Collaborative Network on Infections in Canada(PICNIC) prospective study of risk factors and outcomes in patients hospitalized with respiratory syncytialviral lower respiratory tract infection. J Pediatr 1995; 126:212.

35. MacDonald NE, Hall CB, Suffin SC, et al. Respiratory syncytial viral infection in infants with congenital heartdisease. N Engl J Med 1982; 307:397.

36. Hall CB, Powell KR, MacDonald NE, et al. Respiratory syncytial viral infection in children with compromisedimmune function. N Engl J Med 1986; 315:77.

37. Meissner HC. Selected populations at increased risk from respiratory syncytial virus infection. Pediatr InfectDis J 2003; 22:S40.

38. Mansbach JM, Piedra PA, Stevenson MD, et al. Prospective multicenter study of children with bronchiolitisrequiring mechanical ventilation. Pediatrics 2012; 130:e492.

39. Holman RC, Curns AT, Cheek JE, et al. Respiratory syncytial virus hospitalizations among American Indianand Alaska Native infants and the general United States infant population. Pediatrics 2004; 114:e437.

40. McConnochie KM, Roghmann KJ. Parental smoking, presence of older siblings, and family history of asthmaincrease risk of bronchiolitis. Am J Dis Child 1986; 140:806.

41. Figueras-Aloy J, Carbonell-Estrany X, Quero J, IRIS Study Group. Case-control study of the risk factorslinked to respiratory syncytial virus infection requiring hospitalization in premature infants born at agestational age of 33-35 weeks in Spain. Pediatr Infect Dis J 2004; 23:815.

42. Choudhuri JA, Ogden LG, Ruttenber AJ, et al. Effect of altitude on hospitalizations for respiratory syncytialvirus infection. Pediatrics 2006; 117:349.

43. Turcios NL. Gauging the severity of bronchiolitis. J Respir Dis 1994; 15:875.

44. Lina B, Valette M, Foray S, et al. Surveillance of community-acquired viral infections due to respiratoryviruses in Rhone-Alpes (France) during winter 1994 to 1995. J Clin Microbiol 1996; 34:3007.

45. Welliver RC. Bronchiolitis and infectious asthma. In: Feigin and Cherry's Textbook of Pediatric InfectiousDiseases, 6th ed, Feigin RD, Cherry JD, Demmler-Harrison GJ, Kaplan SL (Eds), Saunders, Philadelphia2009.

46. Shazberg G, Revel-Vilk S, Shoseyov D, et al. The clinical course of bronchiolitis associated with acute otitismedia. Arch Dis Child 2000; 83:317.

47. Andrade MA, Hoberman A, Glustein J, et al. Acute otitis media in children with bronchiolitis. Pediatrics 1998;101:617.

48. Kuppermann N, Bank DE, Walton EA, et al. Risks for bacteremia and urinary tract infections in young febrilechildren with bronchiolitis. Arch Pediatr Adolesc Med 1997; 151:1207.

49. Levine DA, Platt SL, Dayan PS, et al. Risk of serious bacterial infection in young febrile infants withrespiratory syncytial virus infections. Pediatrics 2004; 113:1728.

50. Bilavsky E, Shouval DS, Yarden-Bilavsky H, et al. A prospective study of the risk for serious bacterialinfections in hospitalized febrile infants with or without bronchiolitis. Pediatr Infect Dis J 2008; 27:269.

51. Ralston S, Hill V, Waters A. Occult serious bacterial infection in infants younger than 60 to 90 days withbronchiolitis: a systematic review. Arch Pediatr Adolesc Med 2011; 165:951.
http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/51http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/50http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/49http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/48http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/47http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/46http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/44http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/43http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/42http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/41http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/40http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/39http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/38http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/37http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/36http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/35http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/34http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/33http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/32http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/31http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/30http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/29


12/18



52. Swingler GH, Hussey GD, Zwarenstein M. Randomised controlled trial of clinical outcome after chestradiograph in ambulatory acute lower-respiratory infection in children. Lancet 1998; 351:404.

53. Dawson KP, Long A, Kennedy J, Mogridge N. The chest radiograph in acute bronchiolitis. J Paediatr ChildHealth 1990; 26:209.

54. Swingler GH, Hussey GD, Zwarenstein M. Duration of illness in ambulatory children diagnosed withbronchiolitis. Arch Pediatr Adolesc Med 2000; 154:997.

55. Patel H, Gouin S, Platt RW. Randomized, double-blind, placebo-controlled trial of oral albuterol in infants withmild-to-moderate acute viral bronchiolitis. J Pediatr 2003; 142:509.

56. Petruzella FD, Gorelick MH. Duration of illness in infants with bronchiolitis evaluated in the emergencydepartment. Pediatrics 2010; 126:285.

57. McMillan JA, Tristram DA, Weiner LB, et al. Prediction of the duration of hospitalization in patients withrespiratory syncytial virus infection: use of clinical parameters. Pediatrics 1988; 81:22.

58. Green M, Brayer AF, Schenkman KA, Wald ER. Duration of hospitalization in previously well infants withrespiratory syncytial virus infection. Pediatr Infect Dis J 1989; 8:601.

59. Dawson KP, Mogridge N. Acute bronchiolitis: a three year study. N Z Med J 1989; 102:528.

60. Robbins JM, Kotagal UR, Kini NM, et al. At-home recovery following hospitalization for bronchiolitis. AmbulPediatr 2006; 6:8.

61. Wright PF, Gruber WC, Peters M, et al. Illness severity, viral shedding, and antibody responses in infantshospitalized with bronchiolitis caused by respiratory syncytial virus. J Infect Dis 2002; 185:1011.

62. Willson DF, Landrigan CP, Horn SD, Smout RJ. Complications in infants hospitalized for bronchiolitis or respiratory syncytial virus pneumonia. J Pediatr 2003; 143:S142.

63. Pinnington LL, Smith CM, Ellis RE, Morton RE. Feeding efficiency and respiratory integration in infants withacute viral bronchiolitis. J Pediatr 2000; 137:523.

64. Kneyber MC, Brandenburg AH, de Groot R, et al. Risk factors for respiratory syncytial virus associatedapnoea. Eur J Pediatr 1998; 157:331.

65. Bruhn FW, Mokrohisky ST, McIntosh K. Apnea associated with respiratory syncytial virus infection in younginfants. J Pediatr 1977; 90:382.

66. Hall CB, Kopelman AE, Douglas RG Jr, et al. Neonatal respiratory syncytial virus infection. N Engl J Med1979; 300:393.

67. Willwerth BM, Harper MB, Greenes DS. Identifying hospitalized infants who have bronchiolitis and are at highrisk for apnea. Ann Emerg Med 2006; 48:441.

68. Ralston S, Hill V. Incidence of apnea in infants hospitalized with respiratory syncytial virus bronchiolitis: asystematic review. J Pediatr 2009; 155:728.

69. Hall CB, Powell KR, Schnabel KC, et al. Risk of secondary bacterial infection in infants hospitalized withrespiratory syncytial viral infection. J Pediatr 1988; 113:266.

70. Thorburn K, Harigopal S, Reddy V, et al. High incidence of pulmonary bacterial co-infection in children withsevere respiratory syncytial virus (RSV) bronchiolitis. Thorax 2006; 61:611.

71. Duttweiler L, Nadal D, Frey B. Pulmonary and systemic bacterial co-infections in severe RSV bronchiolitis. Arch Dis Child 2004; 89:1155.

72. Viswanthan M, King V, Bordley C, et al. Management of bronchiolitis in infants and children. EvidenceReport/Technology Assessment No. 69. ARHQ Publication No. 03-E014, Agency for Healthcare Researchand Quality; US Department for Health and Human Services, Rockville, MD 2003.

73. Schuh S, Lalani A, Allen U, et al. Evaluation of the utility of radiography in acute bronchiolitis. J Pediatr 2007;150:429.

74. Harris JA, Huskins WC, Langley JM, et al. Health care epidemiology perspective on the October 2006recommendations of the Subcommittee on Diagnosis and Management of Bronchiolitis. Pediatrics 2007;120:890.

75. Antonow JA, Byington CL. Use of respiratory syncytial virus testing could safely eliminate many sepsis
http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/75http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/75http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/74http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/73http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/71http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/70http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/69http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/68http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/67http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/66http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/65http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/64http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/63http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/62http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/61http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/60http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/59http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/58http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/57http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/56http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/55http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/54http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/53http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/52


13/18


www.uptodat e.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis?topicKey=PEDS%2F6018&elapsedTimeMs=11&source= se 13/

evaluations. Arch Pediatr Adolesc Med 1999; 153:1310.

76. Smyth RL, Openshaw PJ. Bronchiolitis. Lancet 2006; 368:312.

77. Hall CB. Diagnosis and testing in bronchiolitis: a systematic review. J Pediatr 2004; 145:417.

78. Vogel AM, Lennon DR, Harding JE, et al. Variations in bronchiolitis management between five New Zealandhospitals: can we do better? J Paediatr Child Health 2003; 39:40.

79. Adcock PM, Stout GG, Hauck MA, Marshall GS. Effect of rapid viral diagnosis on the management of children hospitalized with lower respiratory tract infection. Pediatr Infect Dis J 1997; 16:842.

80. Doan QH, Kissoon N, Dobson S, et al. A randomized, controlled trial of the impact of early and rapiddiagnosis of viral infections in children brought to an emergency department with febrile respiratory tractillnesses. J Pediatr 2009; 154:91.

81. Bourke T, Shields M. Bronchiolitis. Clin Evid (Online) 2011; 2011.

82. Ahluwalia G, Embree J, McNicol P, et al. Comparison of nasopharyngeal aspirate and nasopharyngeal swabspecimens for respiratory syncytial virus diagnosis by cell culture, indirect immunofluorescence assay, andenzyme-linked immunosorbent assay. J Clin Microbiol 1987; 25:763.

83. Macfarlane P, Denham J, Assous J, Hughes C. RSV testing in bronchiolitis: which nasal sampling method isbest? Arch Dis Child 2005; 90:634.

84. American Academy of Pediatrics. Respiratory syncytial virus. In: Red Book: 2012 Report of the Committeeon Infectious Diseases, 29th, Pickering LK. (Ed), American Academy of Pediatrics, Elk Grove Village, IL2012. p.609.

85. Purcell K, Fergie J. Lack of usefulness of an abnormal white blood cell count for predicting a concurrentserious bacterial infection in infants and young children hospitalized with respiratory syncytial virus lower respiratory tract infection. Pediatr Infect Dis J 2007; 26:311.

86. Scottish Intercollegiate Guidelines Network. Bronchiolitis in children. A national clinical guideline. 2006.http://www.sign.ac.uk/pdf/sign91.pdf.

87. Mulholland EK, Olinsky A, Shann FA. Clinical findings and severity of acute bronchiolitis. Lancet 1990;335:1259.

88. Brooks AM, McBride JT, McConnochie KM, et al. Predicting deterioration in previously healthy infantshospitalized with respiratory syncytial virus infection. Pediatrics 1999; 104:463.

89. Roback MG, Baskin MN. Failure of oxygen saturation and clinical assessment to predict which patients withbronchiolitis discharged from the emergency department will return requiring admission. Pediatr Emerg Care1997; 13:9.

90. Walsh EE, McConnochie KM, Long CE, Hall CB. Severity of respiratory syncytial virus infection is related tovirus strain. J Infect Dis 1997; 175:814.

91. Martinello RA, Chen MD, Weibel C, Kahn JS. Correlation between respiratory syncytial virus genotype andseverity of illness. J Infect Dis 2002; 186:839.

92. Klassen TP, Rowe PC, Sutcliffe T, et al. Randomized trial of salbutamol in acute bronchiolitis. J Pediatr 1991;118:807.

93. Groothuis JR, Woodin KA, Katz R, et al. Early ribavirin treatment of respiratory syncytial viral infection in

high-risk children. J Pediatr 1990; 117:792.94. Englund JA, Piedra PA, Ahn YM, et al. High-dose, short-duration ribavirin aerosol therapy compared with

standard ribavirin therapy in children with suspected respiratory syncytial virus infection. J Pediatr 1994;125:635.

95. Wang EE, Law BJ, Stephens D, et al. Study of interobserver reliability in clinical assessment of RSV lower respiratory illness: a Pediatric Investigators Collaborative Network for Infections in Canada (PICNIC) study.Pediatr Pulmonol 1996; 22:23.

96. Willson DF, Horn SD, Hendley JO, et al. Effect of practice variation on resource utilization in infantshospitalized for viral lower respiratory illness. Pediatrics 2001; 108:851.

97. Landau LI. Bronchiolitis and asthma: are they related? Thorax 1994; 49:293.
http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/75http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/97http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/96http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/95http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/94http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/93http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/92http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/91http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/90http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/89http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/88http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/87http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/85http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/83http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/82http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/81http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/80http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/79http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/78http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/77http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/76http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis/abstract/75


14/18



Topic 6018 Version 14.0


15/18



GRAPHICS

Bronchiolitis radiographs

The above radiographs demonstrate the following findings that areconsistent with bronchiolitis:1) Patchy atelectasis, in particular of the right middle lobe2) Bilateral peribronchial infiltrations with air bronchograms3) Hyper-inflation of the lungs with flattening of the diaphragms


16/18



Physical findings of volume depletion in infants and children

Finding Mild (3-5percent)

Moderate (6-9percent)

Severe (10 percent)

Pulse Full, normal rate Rapid Rapid and weak OR absent

Systolic

pressure

Normal Normal to low Low

Respirations Normal Deep, rate may beincreased

Deep, tachypnea OR decreasedto absent

Buccalmucosa

Tacky or slightlydry

Dry Parched

Anteriorfontanelle

Normal Sunken Markedly sunken

Eyes Normal Sunken Markedly sunken

Skin turgor Normal Reduced Tenting

Skin Normal Cool Cool, mottled, acrocyanosis

Urine output Normal or mildlyreduced

Markedly reduced Anuria

Systemicsigns

Incre as ed thirs t Lis tle ss ne ss ,irritability

Grunting, lethargy, coma


17/18



Clinical and radiographic clues to the etiology of pneumonia in children*

Etiology Clinical features Radiographicfeatures

Bacteria(most commonlyStreptococcus

pneumoniae )

Children o f all agesAbrupt onset

Ill-appearanceChillsModerate to s evere respiratorydistressFocal auscultatory findingsLocalized chest painWBC count >15,000/microL (if obtained)Elevated acute phase reactants (if obtained)

Alveo lar infiltratesSegmental

consolidationLobarconsolidation"Round"pneumonia

Complications:Pleuraleffusion/empyemaLung abscessNecrotizingpneumonia

Pneumatocele

Atypical bacterial(Mycoplasma

pneumoniae ,Chlamydophila

pneumoniae )

Children of all ages (most common inchildren >5 years)Abrupt onset w ith constitutionalfindings (malaise, myalgia,headache, conjunctivitis,photophobia, sore throat, headache)Gradua lly worsen ing nonproductivecoughWheezingExtrapulmonary manifestations or

complications (eg, Stevens-Johnsonsyndrome, hemolytic anemia,hepa titis, etc)

Interstitial infiltrates

Viral Usua lly children


18/18


Mycobacteriumtuberculosis

Children o f any ageChronic coughCons titutional symptomsExposure history

Mediastinal or hilaradenopathy

WBC: white blood cell; CBC: complete blood count.* The clinical features frequently overlap and canno t reliably distinguish betw ee n bacterial,

atypical bacterial, and viral etiologies; up to one-half of community-acquired pneumonias in

children may be mixed bacterial/viral infections. Chest radiography generally is not helpful indete rmining the pote ntial causative agent of pneumonia. None theless , these features mayfacilitate decisions regarding empiric therapy.Data from:

1. Bartlett JG, Mundy LM. Community-acquired pneumonia. N Engl J Med 1995; 333:1618.2. Boyer KM. Nonbacterial pneumonia. In: Textbook of Pediatric Infectious Diseases, 6th ed, Feigin

RD, Cherry JD, Demmler-Harrison GJ, Kaplan SL (Eds), Saunders, Philadelphia 2009. p.289.3. Broughton RA. Infections due to Mycoplasma pneumoniae in childhood. Pediatr Infect Dis 1986 ;

5:71.4. McIntosh K. Community-acquired pneumonia in children. N Engl J Med 2002; 346:429.

bronchiolitis in infants and children_ clinical features and diagnosis

Documents