Bronchiolitis in children overview

NICE Pathways bring together everything NICE says on a topic in an interactive

flowchart. NICE Pathways are interactive and designed to be used online.

They are updated regularly as new NICE guidance is published. To view the latest
version of this NICE Pathway see:

http://pathways.nice.org.uk/pathways/bronchiolitis-in-children
NICE Pathway last updated: 09 August 2021

This document contains a single flowchart and uses numbering to link the boxes to the
associated recommendations.

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1 Child under 2 with suspected bronchiolitis

No additional information

2 Assessment and diagnosis

When diagnosing bronchiolitis, take into account that it occurs in babies and children under 2
years of age and most commonly in the first year of life, peaking between 3 and 6 months.

When diagnosing bronchiolitis, take into account that symptoms usually peak between 3 and 5
days, and that cough resolves in 90% of infants within 3 weeks.

Diagnose bronchiolitis if the baby or child has a coryzal prodrome lasting 1 to 3 days, followed
by:

persistent cough and

either tachypnoea or chest recession (or both) and
either wheeze or crackles on chest auscultation (or both).

When diagnosing bronchiolitis, take into account that the following symptoms are common in
babies and children with this disease:

fever (in around 30% of cases, usually of less than 39°C)

poor feeding (typically after 3 to 5 days of illness).

When diagnosing bronchiolitis, take into account that young infants with this disease (in
particular those under 6 weeks of age) may present with apnoea without other clinical signs.

3 Symptoms requiring immediate referral

Immediately refer babies and children with bronchiolitis for emergency hospital care (usually by
999 ambulance) if they have any of the following:

apnoea (observed or reported)

baby or child looks seriously unwell to a healthcare professional
severe respiratory distress, for example grunting, marked chest recession, or a respiratory
rate of over 70 breaths/minute
central cyanosis.

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See the NICE guideline to find out why we made this recommendation and how it might affect
practice.

Suspected impending respiratory failure

Suspect impending respiratory failure, and take appropriate action (see above recommendation)
as these babies and children may need intensive care, if any of the following are present:

signs of exhaustion, for example listlessness or decreased respiratory effort

recurrent apnoea
failure to maintain adequate oxygen saturation despite oxygen supplementation.

Consider performing a chest X-ray if intensive care is being proposed for a baby or child.

4 Measuring oxygen saturation

Measure oxygen saturation in every child presenting with suspected bronchiolitis, including
those presenting to primary care if pulse oximetry is available.

Ensure healthcare professionals performing pulse oximetry are appropriately trained in its use
specifically in babies and young children.

Follow the NHS England Patient Safety Alert on the risk of harm from inappropriate placement
of pulse oximeter probes.

5 When to perform chest physiotherapy

Do not perform chest physiotherapy on babies and children with bronchiolitis who do not have
relevant comorbidities (for example spinal muscular atrophy, severe tracheomalacia).

Consider requesting a chest physiotherapy assessment in babies and children who have
relevant comorbidities (for example spinal muscular atrophy, severe tracheomalacia) when there
may be additional difficulty clearing secretions.

6 When to refer

See also symptoms requiring immediate referral [See page 3].

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Consider referring babies and children with bronchiolitis to hospital if they have any of the
following:

a respiratory rate of over 60 breaths/minute

difficulty with breastfeeding or inadequate oral fluid intake (50% to 75% of usual volume,
taking account of risk factors [see risk factors in initial assessment in secondary care [See
page 5]] and using clinical judgement)
clinical dehydration
persistent oxygen saturation of less than 92% when breathing air.

Follow the NHS England Patient Safety Alert on the risk of harm from inappropriate placement
of pulse oximeter probes.

See the NICE guideline to find out why we made this recommendation and how it might affect
practice.

When deciding whether to refer a baby or child with bronchiolitis to secondary care, take
account of any known risk factors for more severe bronchiolitis such as:

chronic lung disease (including bronchopulmonary dysplasia)

haemodynamically significant congenital heart disease
age in young infants (under 3 months)
premature birth, particularly under 32 weeks
neuromuscular disorders
immunodeficiency.

When deciding whether to refer a baby or child to secondary care, take into account factors that
might affect a carer's ability to look after a child with bronchiolitis, for example:

social circumstances
the skill and confidence of the carer in looking after a child with bronchiolitis at home
confidence in being able to spot red flag symptoms (see safety information when looking
after a child at home [See page 7])
distance to healthcare in case of deterioration.

7 Initial assessment in secondary care

Measure oxygen saturation using pulse oximetry in every baby and child presenting to
secondary care with clinical evidence of bronchiolitis.

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Follow the NHS England Patient Safety Alert on the risk of harm from inappropriate placement
of pulse oximeter probes.

Clinically assess the hydration status of babies and children with bronchiolitis.

Do not routinely perform blood tests in the assessment of a baby or child with bronchiolitis.

Do not routinely perform a chest X-ray in babies or children with bronchiolitis, because changes
on X-ray may mimic pneumonia and should not be used to determine the need for antibiotics.

When to admit

When assessing a baby or child in a secondary care setting, admit them to hospital if they have
any of the following:

apnoea (observed or reported)

persistent oxygen saturation (when breathing air) of:
less than 90%, for children aged 6 weeks and over
less than 92%, for babies under 6 weeks or children of any age with underlying
health conditions.

inadequate oral fluid intake (50% to 75% of usual volume, taking account of risk factors
[see below] and using clinical judgement)
persisting severe respiratory distress, for example grunting, marked chest recession, or a
respiratory rate of over 70 breaths/minute.

See the NICE guideline to find out why we made this recommendation and how it might affect
practice.

Risk factors

When deciding whether to admit a baby or child with bronchiolitis, take account of any known
risk factors for more severe bronchiolitis such as:

chronic lung disease (including bronchopulmonary dysplasia)

haemodynamically significant congenital heart disease
age in young infants (under 3 months)
premature birth, particularly under 32 weeks
neuromuscular disorders
immunodeficiency.

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Carer's ability to look after child at home

When deciding whether to admit a baby or child, take into account factors that might affect a
carer's ability to look after a child with bronchiolitis, for example:

social circumstances
the skill and confidence of the carer in looking after a child with bronchiolitis at home
confidence in being able to spot red flag symptoms (see safety information when looking
after a child at home [See page 7])
distance to healthcare in case of deterioration.

Provide parents or carers with key safety information (see safety information when looking after
a child at home [See page 7]) if the baby or child is not admitted.

[See page 7]

8 Child not admitted to hospital

No additional information

9 Safety information when looking after a child at home

Provide key safety information for parents and carers to take away for reference for babies and
children who will be looked after at home. This should cover:

how to recognise developing 'red flag' symptoms:

worsening work of breathing (for example grunting, nasal flaring, marked chest
recession)
fluid intake is 50% to 75% of normal or no wet nappy for 12 hours
apnoea or cyanosis
exhaustion (for example, not responding normally to social cues, wakes only with
prolonged stimulation)

that people should not smoke in the child's home because it increases the risk of more
severe symptoms in bronchiolitis
how to get immediate help from an appropriate professional if any red flag symptoms
develop
arrangements for follow-up if necessary.

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Quality standards

The following quality statement is relevant to this part of the interactive flowchart.

3. Key safety information

10 Child admitted to hospital

No additional information

11 Management in hospital

See Bronchiolitis in children / Managing bronchiolitis in children in hospital

12 Medicines that should not be used

Do not use any of the following to treat bronchiolitis in babies or children:

antibiotics
hypertonic saline
adrenaline (nebulised)
salbutamol
montelukast
ipratropium bromide
systemic or inhaled corticosteroids
a combination of systemic corticosteroids and nebulised adrenaline.

Quality standards

The following quality statements are relevant to this part of the interactive flowchart.

1. Antibiotic use

2. Bronchiolitis management

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13 Alternative diagnoses

Consider a diagnosis of pneumonia if the baby or child has:

high fever (over 39°C) and/or

persistently focal crackles.

See also the NICE Pathway on sepsis and how to evaluate the level of risk for a child under 5
years.

Think about a diagnosis of viral-induced wheeze or early-onset asthma rather than bronchiolitis
in older infants and young children if they have:

persistent wheeze without crackles or

recurrent episodic wheeze or
a personal or family history of atopy.

Take into account that these conditions are unusual in children under 1 year of age.

See also the NICE Pathways on:

assessing and diagnosing asthma in under 17s

bacterial meningitis and meningococcal septicaemia in under 16s
neonatal infection: antibiotics for prevention and treatment
fever in under 5s
self-limiting respiratory tract and ear infections – antibiotic prescribing.

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Sources

Bronchiolitis in children: diagnosis and management (2015, updated 2021) NICE guideline NG9

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful
consideration of the evidence available. When exercising their judgement, professionals and
practitioners are expected to take this guideline fully into account, alongside the individual
needs, preferences and values of their patients or the people using their service. It is not
mandatory to apply the recommendations, and the guideline does not override the responsibility
to make decisions appropriate to the circumstances of the individual, in consultation with them
and their families and carers or guardian.

Local commissioners and providers of healthcare have a responsibility to enable the guideline
to be applied when individual professionals and people using services wish to use it. They
should do so in the context of local and national priorities for funding and developing services,
and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to
advance equality of opportunity and to reduce health inequalities. Nothing in this guideline
should be interpreted in a way that would be inconsistent with complying with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, health
professionals are expected to take these recommendations fully into account, alongside the
individual needs, preferences and values of their patients. The application of the
recommendations in this interactive flowchart is at the discretion of health professionals and

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their individual patients and do not override the responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or their carer or guardian.

Commissioners and/or providers have a responsibility to provide the funding required to enable
the recommendations to be applied when individual health professionals and their patients wish
to use it, in accordance with the NHS Constitution. They should do so in light of their duties to
have due regard to the need to eliminate unlawful discrimination, to advance equality of
opportunity and to reduce health inequalities.

Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures

guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, healthcare
professionals are expected to take these recommendations fully into account. However, the
interactive flowchart does not override the individual responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or guardian or carer.

Commissioners and/or providers have a responsibility to implement the recommendations, in

their local context, in light of their duties to have due regard to the need to eliminate unlawful
discrimination, advance equality of opportunity, and foster good relations. Nothing in this
interactive flowchart should be interpreted in a way that would be inconsistent with compliance
with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.

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