Pediatric Bronchiolitis 

  • Author: Lucian Kenneth DeNicola, MS, MD, FAAP, FCCM; Chief Editor: Russell W Steele, MD   more...
 
Updated: Mar 26, 2012
 

Background

Bronchiolitis is an acute, infectious, inflammatory disease of the upper and lower respiratory tract that may result in obstruction of the small airways. Although it may occur in all age groups, the larger airways of older children and adults better accommodate mucosal edema; severe respiratory symptoms are usually limited to young infants. An example of radiographic findings in bronchiolitis is shown in the image below.

A chest radiography revealing lung hyperinflation A chest radiography revealing lung hyperinflation with a flattened diaphragm and bilateral atelectasis in the right apical and left basal regions in a 16-day-old infant with severe bronchiolitis.
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Pathophysiology

Necrosis of the respiratory epithelium is one of the earliest lesions in bronchiolitis and occurs within 24 hours of the acquisition of infection.[1] Proliferation of goblet cells results in excessive mucus production, whereas epithelial regeneration with nonciliated cells impairs elimination of secretions. Lymphocytic infiltration may result in submucosal edema. Cytokines and chemokines, released by infected respiratory epithelial cells, amplify the immune response by increasing cellular recruitment into infected airways. Interferon and interleukin (IL)-4, IL-8, and IL-9 are found in high concentrations in respiratory secretions of infected patients.[2, 3]

Johnson et al analyzed autopsy findings of children who died due to possible respiratory syncytial virus (RSV) from 1925-1959, before modern intensive care, and autopsy findings of a child with RSV bronchiolitis who died in a motor vehicle accident.[4] They found that small bronchiole epithelium was circumferentially infected, but basal cells were spared. Both type 1 and type 2 alveolar pneumocytes were also infected. Airway obstruction was due to epithelial and inflammatory cell debris mixed with fibrin, mucus, and edema fluid but not bronchial smooth muscle constriction. Other research revealed that neutrophil inflammation, but not eosinophil inflammation, is related to the severity of a first infection in infants.[5]

The inflammation, edema, and debris result in obstruction of bronchioles, leading to hyperinflation, increased airway resistance, atelectasis, and ventilation-perfusion mismatching. Bronchoconstriction has not been described.

Infants are affected most often because of their small airways, high closing volumes, and insufficient collateral ventilation. Recovery begins with regeneration of bronchiolar epithelium after 3-4 days; however, cilia do not appear for as long as 2 weeks. Mucus plugs are predominantly removed by macrophages.

Risk factors for developing bronchiolitis include the following[6, 7, 8, 9] :

  • Low birth weight, particularly premature infants[10]
  • Gestational age (independently associated with hospital resource use and outcome among infants hospitalized for RSV)
  • Lower socioeconomic group[11]
  • Crowded living conditions, daycare, or both
  • Parental smoking[12]
  • Chronic lung disease, particularly bronchopulmonary dysplasia
  • Severe congenital or acquired neurologic disease
  • Congenital heart disease (CHD) with pulmonary hypertension[13] : Interestingly, Swiss children with CHD did not show increased risk.[14]
  • Congenital or acquired immune deficiency diseases
  • Age less than 3 months
  • Airway anomalies

One study collected epidemiological, clinical, and virological data on 310 infants to determine the incidence and predisposing factors for severe bronchiolitis in previously healthy term infants younger than 12 months who were experiencing their first episode of bronchiolitis. The results found that infants with severe disease presented with lower birth weight, younger gestational age, lower postnatal weight, younger postnatal age, and a stronger likelihood of having been born by cesarian delivery. Positive C-reactive protein results (>0.8 mg/dL) and pulmonary consolidation on chest radiographs were more common among infants with severe disease, although no significant differences were found between epidemiologic variables. While severe bronchiolitis is uncommon in infants with these characteristics (ie, previously healthy term infants, < 12 mo), severity is predicted by young age and RSV carriage, and, when present, it develops soon after disease onset.[15]

Virtually all children experience RSV infection within the first 3 years of life, but previous infection does not convey complete immunity. Reinfection is common; however, significant antibody titers from previous infection ameliorate the severity of symptoms.[16]

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Epidemiology

Frequency

United States

Respiratory infection is observed in 25% of children younger than 12 months and 13% of children aged 1-2 years.[17] Of these 25%, one-half have wheezing-associated respiratory disease.[18] RSV can be cultured from one third of these outpatients and from 80% of hospitalized children younger than 6 months.[19, 20] Nearly 100% of children experience an RSV infection within 2 RSV seasons, and 1% are hospitalized.[18] Among healthy full-term infants, 80% of hospitalizations occur in the first year, and 50% of hospitalizations occur in children aged 1-3 months.[11]

Descriptive analysis of the US National Hospital Discharge Survey data from 1980-1996 showed that admissions associated with bronchiolitis totaled 1.65 million.[21] The hospitalization rate for children younger than 1 year increased from 12.9 in 1980 to 31.2 per 1000 population in 1996, and the proportion of hospitalizations for lower respiratory tract illnesses among children younger than 1 year associated with bronchiolitis increased from 22.2% in 1980 to 47.4% in 1996.

The increase in hospitalizations is not due to increased pediatrician risk aversion, but rather is attributable to physicians' desire to treat the condition with bronchodilators.[22] The cost of hospitalization for bronchiolitis in children younger than 1 year is estimated to be more than $700 million per year.[23]

Fewer than 5% of hospitalizations occur in the first 30 days of life, presumably because of transplacental transfer of maternal antibody.[24]

In the temperate climates of the northern hemisphere, RSV epidemics generally occur annually in winter and late spring, whereas parainfluenza outbreaks usually occur in the fall. Conversely, in the southern hemisphere, wintertime epidemics occur from May to September. In the United States, the highest RSV activity usually occurs in winter, except in the subtropical areas of the southeastern United States (eg, Florida) where RSV is endemic throughout the year, with peaks from October to February and relative subsidence only from March to July.[25, 26, 27]

Secondary infections occur in 46% of family members, 98% of other children in daycare, 42% of hospital staff, and 45% of previously uninfected hospitalized infants.[28, 29, 30] Infection is spread through self-inoculation of fomites via direct contact and environmental surfaces to nasopharyngeal or ocular mucous membranes. RSV can survive for several hours on hands and surfaces; therefore, handwashing and using disposable gloves and gowns may reduce nosocomial spread.[31, 32]

International

Bronchiolitis is a significant cause of respiratory disease worldwide. Its incidence in developed countries appears similar to that in the United States. Epidemiologic data from underdeveloped countries show RSV is a predominant viral cause of acute lower respiratory tract infections and accounts for about 65% of hospitalizations due to viruses.[33] However, little is known about RSV-associated mortality in developing countries.

Mortality/Morbidity

RSV bronchiolitis accounts for about 50,000-80,000 hospitalizations annually.[21] In a prospective, population-based surveillance of acute respiratory infections, RSV accounted for 20% of hospitalizations, 18% of emergency department visits, and 15% clinic visits in winter.[34] Overall, the mortality rate in children hospitalized for bronchiolitis in different series is 0.2-7%. This large variability is based on investigations of different cohorts with different risk factors and different points in time relative to modern intensive care.

Studies in pediatric ICUs (PICUs) of children with RSV bronchiolitis without comorbidities show a 2-3% death rate, regardless of whether the children had CHD with pulmonary hypertension.[8] In a cohort study from 1999-2007 in the United Kingdom, RSV bronchiolitis-related mortality was 1.7% with higher risk of death associated with preexisting conditions, especially cardiac anomalies.[35]

Sex

Boys are affected more often than females.[33, 36] Death is 1.5 times more likely in males.[37]

Age

Although RSV bronchiolitis is clearly a significant disease of the young child, immunity has been shown to wane over time;[38] susceptible adults may be asymptomatic or mildly symptomatic and act as carriers. With the increasing use of treatment modalities that compromise cellular immunity, RSV infection may be life threatening to older children and adults undergoing organ and bone marrow transplantation, as well as to the elderly.[39, 40]

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Contributor Information and Disclosures
Author

Lucian Kenneth DeNicola, MS, MD, FAAP, FCCM  Professor, Department of Pediatrics, University of Florida Health Science Center at Jacksonville

Lucian Kenneth DeNicola, MS, MD, FAAP, FCCM is a member of the following medical societies: American Academy of Pediatrics, American College of Critical Care Medicine, Florida Medical Association, Florida Pediatric Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Nizar F Maraqa, MD  Assistant Professor of Pediatrics, Pediatric Infectious Diseases, University of Florida College of Medicine at Jacksonville

Nizar F Maraqa, MD, is a member of the following medical societies: American Academy of Pediatrics, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Haidee T Custodio, MD  Assistant Professor, Department of Pediatrics, Division of Pediatric Infectious Diseases, University of South Alabama College of Medicine

Haidee T Custodio, MD is a member of the following medical societies: American Academy of Pediatrics, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Specialty Editor Board

David Jaimovich, MD  Chief Medical Officer, Joint Commission International and Joint Commission Resources

David Jaimovich, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Mark R Schleiss, MD  American Legion Chair of Pediatrics, Professor of Pediatrics, Division Director, Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Minnesota Medical School

Mark R Schleiss, MD is a member of the following medical societies: American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Robert W Tolan Jr, MD  Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: Novartis Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

The authors gratefully acknowledge Michael Gayle, MBBS, FRCPC, FAAP, FCCM, for his participation in the original production of this review in 2001.

References

  1. Tristram DA, Welliver RC. Bronchiolitis. In: Long SS, Pickering LK, Prober CG. Principles and Practice of pediatric Infectious Diseases. 2nd. New York: Churchill Livingstone; 2003:213.

  2. McNamara PS, Flanagan BF, Baldwin LM, et al. Interleukin 9 production in the lungs of infants with severe respiratory syncytial virus bronchiolitis. Lancet. Mar 27 2004;363(9414):1031-7. [Medline].

  3. McNamara PS, Flanagan BF, Hart CA, Smyth RL. Production of chemokines in the lungs of infants with severe respiratory syncytial virus bronchiolitis. J Infect Dis. Apr 15 2005;191(8):1225-32. [Medline].

  4. Johnson JE, Gonzales RA, Olson SJ, Wright PF, Graham BS. The histopathology of fatal untreated human respiratory syncytial virus infection. Mod Pathol. Jan 2007;20(1):108-19. [Medline].

  5. Marguet C, Bocquel N, Benichou J, et al. Neutrophil but not eosinophil inflammation is related to the severity of a first acute epidemic bronchiolitis in young infants. Pediatr Allergy Immunol. Mar 2008;19(2):157-65. [Medline].

  6. Shaw KN, Bell LM, Sherman NH. Outpatient assessment of infants with bronchiolitis. Am J Dis Child. 1991;145:151-5. [Medline].

  7. Meissner HC. Selected populations at increased risk from respiratory syncytial viral infection. Pediatric Infectious Disease. 2003;22:S40.

  8. 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 syncytial virus lower respiratory tract infections. J Pediatrics. 1995;126:212-19.

  9. Bloemers BL. Down syndrome: A novel risk factor for respiratory syncytial virus bronchiolitis-a prospective birth-cohort study. Pediatr. Oct 2007;120:e1076-81.

  10. Horn SD, Smout RJ. Effect of prematurity on respiratory syncytial virus hospital resource use and outcomes. J Pediatr. Nov 2003;143(5 Suppl):S133-41. [Medline].

  11. Glezen WP, Paredes A, Allison JE, et al. Risk of respiratory syncytial virus infection for infants from low- income families in relationship to age, sex, ethnic group, and maternal antibody level. J Pediatr. May 1981;98(5):708-15. [Medline].

  12. [Best Evidence] Carroll KN, Gebretsadik T, Griffin MR, et al. Maternal asthma and maternal smoking are associated with increased risk of bronchiolitis during infancy. Pediatrics. Jun 2007;119(6):1104-12. [Medline].

  13. Feltes TF, Cabalka AK, Meissner HC, et al. Palivizumab prophylaxis reduces hospitalization due to respiratory syncytial virus in young children with hemodynamically significant congenital heart disease. J Pediatr. Oct 2003;143(4):532-40. [Medline].

  14. Duppenthaler A, Ammann RA, Gorgievski-Hrisoho M, Pfammatter JP, Aebi C. Low incidence of respiratory syncytial virus hospitalisations in haemodynamically significant congenital heart disease. Arch Dis Child. Oct 2004;89(10):961-5. [Medline].

  15. Papoff P, Moretti C, Cangiano G, et al. Incidence and predisposing factors for severe disease in previously healthy term infants experiencing their first episode of bronchiolitis. Acta Paediatr. Jul 2011;100(7):e17-23. [Medline].

  16. Henderson FW, Collier AM, Clyde WA Jr, Denny FW. Respiratory-syncytial-virus infections, reinfections and immunity. A prospective, longitudinal study in young children. N Engl J Med. Mar 8 1979;300(10):530-4. [Medline].

  17. Carlsen KH, Orstavik I, Halvorsen K. Viral infections of the respiratory tract in hospitalized children. Acta Pediatr Scand. 1983;72:53-54.

  18. Henderson FW, Clyde WA Jr, Collier AM, Denny FW, Senior RJ, Sheaffer CI. The etiologic and epidemiologic spectrum of bronchiolitis in pediatric practice. J Pediatr. Aug 1979;95(2):183-90. [Medline].

  19. Denny FW, Clyde WA. Acuet lower respiratory tract infections in non-hospitalized children. J Pediatr. 1986;108:635-646.

  20. Glezen WP, Paredes A, Allison JE, Taber LH, Frank AL. Risk of respiratory syncytial virus infection for infants from low-income families in relationship to age, sex, ethnic group, and maternal antibody level. J Pediatr. May 1981;98(5):708-15. [Medline].

  21. Shay DK, Holman RC, Newman RD, Liu LL, Stout JW, Anderson LJ. Bronchiolitis-associated hospitalizations among US children, 1980-1996. JAMA. Oct 20 1999;282(15):1440-6. [Medline].

  22. Baldwin RL, Green JW, Shaw JL, Simpson DD, Bird TM, Cleves MA, et al. Physician risk attitudes and hospitalization of infants with bronchiolitis. Acad Emerg Med. Feb 2005;12(2):142-6. [Medline].

  23. Stang P, Brandenburg N, Carter B. The economic burden of respiratory syncytial virus-associated bronchiolitis hospitalizations. Arch Pediatr Adolesc Med. Jan 2001;155(1):95-6. [Medline].

  24. La Via WV, Marks MI, Stutman HR. Respiratory syncytial virus puzzle: clinical features, pathophysiology, treatment, and prevention. J Pediatr. Oct 1992;121(4):503-10. [Medline].

  25. Brief report: respiratory syncytial virus activity--United States, 2005-2006. MMWR Morb Mortal Wkly Rep. Dec 1 2006;55(47):1277-9. [Medline].

  26. Halstead DC, Jenkins SG. Continuous non-seasonal epidemic of respiratory syncytial virus infection in the southeast United States. South Med J. May 1998;91(5):433-6. [Medline].

  27. Panozzo CA, Fowlkes AL, Anderson LJ. Variation in timing of respiratory syncytial virus outbreaks: lessons from national surveillance. Pediatr Infect Dis J. Nov 2007;26(11 Suppl):S41-5. [Medline].

  28. Hall CB, Geiman JM, Biggar R, Kotok DI, Hogan PM, Douglas GR Jr. Respiratory syncytial virus infections within families. N Engl J Med. Feb 19 1976;294(8):414-9. [Medline].

  29. Henderson FW, Collier AM, Clyde WA Jr, Denny FW. Respiratory-syncytial-virus infections, reinfections and immunity. A prospective, longitudinal study in young children. N Engl J Med. Mar 8 1979;300(10):530-4. [Medline].

  30. Hall CB, Douglas RG Jr, Geiman JM, Messner MK. Nosocomial respiratory syncytial virus infections. N Engl J Med. Dec 25 1975;293(26):1343-6. [Medline].

  31. Leclair JM, Freeman J, Sullivan BF, Crowley CM, Goldmann DA. Prevention of nosocomial respiratory syncytial virus infections through compliance with glove and gown isolation precautions. N Engl J Med. Aug 6 1987;317(6):329-34. [Medline].

  32. Isaacs D, Dickson H, O'Callaghan C, Sheaves R, Winter A, Moxon ER. Handwashing and cohorting in prevention of hospital acquired infections with respiratory syncytial virus. Arch Dis Child. Feb 1991;66(2):227-31. [Medline].

  33. Weber MW, Mulholland EK, Greenwood BM. Respiratory syncytial virus infection in tropical and developing countries. Trop Med Int Health. Apr 1998;3(4):268-80. [Medline].

  34. Hall CB, Weinberg GA, Iwane MK, et al. The burden of respiratory syncytial virus infection in young children. N Engl J Med. Feb 5 2009;360(6):588-98. [Medline].

  35. Thorburn K. Pre-existing disease is associated with a significantly higher risk of death in severe respiratory syncytial virus infection. Arch Dis Child. Feb 2009;94(2):99-103. [Medline].

  36. Iwane MK, Edwards KM, Szilagyi PG, Walker FJ, Griffin MR, Weinberg GA. Population-based surveillance for hospitalizations associated with respiratory syncytial virus, influenza virus, and parainfluenza viruses among young children. Pediatrics. Jun 2004;113(6):1758-64. [Medline].

  37. Mage DT, Donner EM. The fifty percent male excess of infant respiratory mortality. Acta Paediatr. Sep 2004;93(9):1210-5. [Medline].

  38. Terrosi C, Di Genova G, Martorelli B, Valentini M, Cusi MG. Humoral immunity to respiratory syncytial virus in young and elderly adults. Epidemiol Infect. Dec 2009;137(12):1684-6. [Medline].

  39. Falsey AR, Hennessey PA, Formica MA, Cox C, Walsh EE. Respiratory syncytial virus infection in elderly and high-risk adults. N Engl J Med. Apr 28 2005;352(17):1749-59. [Medline].

  40. Ebbert JO, Limper AH. Respiratory syncytial virus pneumonitis in immunocompromised adults: clinical features and outcome. Respiration. May-Jun 2005;72(3):263-9. [Medline].

  41. Edelson PJ. Respiratory syncytial virus pneumonia. In: Pediatric Emergency Casebook. New York: World Health Communications Inc.; 1985:1-15.

  42. Becker S, Soukup J, Yankaskas JR. Respiratory syncytial virus infection of human primary nasal and bronchial epithelial cell cultures and bronchoalveolar macrophages. Am J Respir Cell Mol Biol. Apr 1992;6(4):369-74. [Medline].

  43. Njoku DB, Kliegman RM. Atypical extrapulmonary presentations of severe respiratory syncytial virus infection requiring intensive care. Clin Pediatr (Phila). Aug 1993;32(8):455-60. [Medline].

  44. Thomas JA, Raroque S, Scott WA, Toro-Figueroa LO, Levin DL. Successful treatment of severe dysrhythmias in infants with respiratory syncytial virus infections: two cases and a literature review. Crit Care Med. May 1997;25(5):880-6. [Medline].

  45. Rivers RP, Forsling ML, Olver RP. Inappropriate secretion of antidiuretic hormone in infants with respiratory infections. Arch Dis Child. May 1981;56(5):358-63. [Medline].

  46. Ralston S, Hill V. Incidence of apnea in infants hospitalized with respiratory syncytial virus bronchiolitis: a systematic review. J Pediatr. Nov 2009;155(5):728-33. [Medline].

  47. Kneyber MC, Brandenburg AH, de Groot R, Joosten KF, Rothbarth PH, Ott A. Risk factors for respiratory syncytial virus associated apnoea. Eur J Pediatr. Apr 1998;157(4):331-5. [Medline].

  48. Willwerth BM, Harper MB, Greenes DS. Identifying hospitalized infants who have bronchiolitis and are at high risk for apnea. Ann Emerg Med. Oct 2006;48(4):441-7. [Medline].

  49. Abreu e Silva FA, Brezinova V, Simpson H. Sleep apnoea in acute bronchiolitis. Arch Dis Child. Jun 1982;57(6):467-72. [Medline].

  50. Al-balkhi A, Klonin H, Marinaki K, Southall DP, Thomas DA, Jones P. Review of treatment of bronchiolitis related apnoea in two centres. Arch Dis Child. Mar 2005;90(3):288-91. [Medline].

  51. Bruhn FW, Mokrohisky ST, McIntosh K. Apnea associated with respiratory syncytial virus infection in young infants. J Pediatr. Mar 1977;90(3):382-6. [Medline].

  52. Church NR, Anas NG, Hall CB, Brooks JG. Respiratory syncytial virus-related apnea in infants. Demographics and outcome. Am J Dis Child. Mar 1984;138(3):247-50. [Medline].

  53. Mansbach JM, McAdam AJ, Clark S, Hain PD, Flood RG, Acholonu U. Prospective multicenter study of the viral etiology of bronchiolitis in the emergency department. Acad Emerg Med. Feb 2008;15(2):111-8. [Medline].

  54. Fodha I, Vabret A, Ghedira L, et al. Respiratory syncytial virus infections in hospitalized infants: association between viral load, virus subgroup, and disease severity. J Med Virol. Dec 2007;79(12):1951-8. [Medline].

  55. Hall CB, Walsh EE, Schnabel KC, et al. Occurrence of groups A and B of respiratory syncytial virus over 15 years: associated epidemiologic and clinical characteristics in hospitalized and ambulatory children. J Infect Dis. Dec 1990;162(6):1283-90. [Medline].

  56. McConnochie KM, Hall CB, Walsh EE, Roghmann KJ. Variation in severity of respiratory syncytial virus infections with subtype. J Pediatr. Jul 1990;117(1 Pt 1):52-62. [Medline].

  57. Papadopoulos NG, Gourgiotis D, Javadyan A, et al. Does respiratory syncytial virus subtype influences the severity of acute bronchiolitis in hospitalized infants?. Respir Med. Sep 2004;98(9):879-82. [Medline].

  58. Hall CB, Douglas RG Jr, Geiman JM. Respiratory syncytial virus infections in infants: quantitation and duration of shedding. J Pediatr. Jul 1976;89(1):11-5. [Medline].

  59. Counihan ME, Shay DK, Holman RC, Lowther SA, Anderson LJ. Human parainfluenza virus-associated hospitalizations among children less than five years of age in the United States. Pediatr Infect Dis J. Jul 2001;20(7):646-53. [Medline].

  60. Bosis S, Esposito S, Niesters HG, Crovari P, Osterhaus AD, Principi N. Impact of human metapneumovirus in childhood: comparison with respiratory syncytial virus and influenza viruses. J Med Virol. Jan 2005;75(1):101-4. [Medline].

  61. Caracciolo S, Minini C, Colombrita D, Rossi D, Miglietti N, Vettore E. Human metapneumovirus infection in young children hospitalized with acute respiratory tract disease: virologic and clinical features. Pediatr Infect Dis J. May 2008;27(5):406-12. [Medline].

  62. Risnes KR, Radtke A, Nordbø SA, Grammeltvedt AT, Døllner H. [Human metapneumovirus--occurrence and clinical significance]. Tidsskr Nor Laegeforen. Oct 20 2005;125(20):2769-72. [Medline].

  63. Werno AM, Anderson TP, Jennings LC, Jackson PM, Murdoch DR. Human metapneumovirus in children with bronchiolitis or pneumonia in New Zealand. J Paediatr Child Health. Sep-Oct 2004;40(9-10):549-51. [Medline].

  64. Williams JV, Harris PA, Tollefson SJ, Halburnt-Rush LL, Pingsterhaus JM, Edwards KM. Human metapneumovirus and lower respiratory tract disease in otherwise healthy infants and children. N Engl J Med. Jan 29 2004;350(5):443-50. [Medline].

  65. van den Hoogen BG, de Jong JC, Groen J, et al. A newly discovered human pneumovirus isolated from young children with respiratory tract disease. Nat Med. Jun 2001;7(6):719-24. [Medline].

  66. van den Hoogen BG, Osterhaus DM, Fouchier RA. Clinical impact and diagnosis of human metapneumovirus infection. Pediatr Infect Dis J. Jan 2004;23(1 Suppl):S25-32. [Medline].

  67. Garcia-Garcia ML, Calvo C, Casas I, et al. Human metapneumovirus bronchiolitis in infancy is an important risk factor for asthma at age 5. Pediatr Pulmonol. May 2007;42(5):458-64. [Medline].

  68. Dollner H, Risnes K, Radtke A, Nordbo SA. Outbreak of human metapneumovirus infection in norwegian children. Pediatr Infect Dis J. May 2004;23(5):436-40. [Medline].

  69. Garcia Garcia ML, Calvo Rey C, Martin del Valle F, et al. [Respiratory infections due to metapneumovirus in hospitalized infants]. An Pediatr (Barc). Sep 2004;61(3):213-8. [Medline].

  70. McNamara PS, Flanagan BF, Smyth RL, Hart CA. Impact of human metapneumovirus and respiratory syncytial virus co-infection in severe bronchiolitis. Pediatr Pulmonol. Aug 2007;42(8):740-3. [Medline].

  71. Semple MG, Cowell A, Dove W, et al. Dual infection of infants by human metapneumovirus and human respiratory syncytial virus is strongly associated with severe bronchiolitis. J Infect Dis. Feb 1 2005;191(3):382-6. [Medline].

  72. Serafino RL, Gurgel RQ, Dove W, Hart CA, Cuevas LE. Respiratory syncytial virus and metapneumovirus in children over two seasons with a high incidence of respiratory infections in Brazil. Ann Trop Paediatr. Sep 2004;24(3):213-7. [Medline].

  73. Arnold JC, Singh KK, Spector SA, Sawyer MH. Human bocavirus: prevalence and clinical spectrum at a children's hospital. Clin Infect Dis. Aug 1 2006;43(3):283-8. [Medline].

  74. Dornelles CT, Piva JP, Marostica PJ. Nutritional status, breastfeeding, and evolution of Infants with acute viral bronchiolitis. J Health Popul Nutr. Sep 2007;25(3):336-43. [Medline].

  75. Downham MA, Scott R, Sims DG, Webb JK, Gardner PS. Breast-feeding protects against respiratory syncytial virus infections. Br Med J. Jul 31 1976;2(6030):274-6. [Medline].

  76. Titus MO, Wright SW. Prevalence of serious bacterial infections in febrile infants with respiratory syncytial virus infection. Pediatrics. Aug 2003;112(2):282-4. [Medline].

  77. Kuppermann N, Bank DE, Walton EA, Senac MO Jr, McCaslin I. Risks for bacteremia and urinary tract infections in young febrile children with bronchiolitis. Arch Pediatr Adolesc Med. Dec 1997;151(12):1207-14. [Medline].

  78. Levine DA, Platt SL, Dayan PS, Macias CG, Zorc JJ, Krief W, et al. Risk of serious bacterial infection in young febrile infants with respiratory syncytial virus infections. Pediatrics. Jun 2004;113(6):1728-34. [Medline].

  79. Purcell K, Fergie J. Concurrent serious bacterial infections in 2396 infants and children hospitalized with respiratory syncytial virus lower respiratory tract infections. Arch Pediatr Adolesc Med. Apr 2002;156(4):322-4. [Medline].

  80. Greenes DS, Harper MB. Low risk of bacteremia in febrile children with recognizable viral syndromes. Pediatr Infect Dis J. Mar 1999;18(3):258-61. [Medline].

  81. Macfarlane P, Denham J, Assous J, Hughes C. RSV testing in bronchiolitis: which nasal sampling method is best?. Arch Dis Child. Jun 2005;90(6):634-5. [Medline].

  82. Templeton KE, Scheltinga SA, Beersma MF, Kroes AC, Claas EC. Rapid and sensitive method using multiplex real-time PCR for diagnosis of infections by influenza a and influenza B viruses, respiratory syncytial virus, and parainfluenza viruses 1, 2, 3, and 4. J Clin Microbiol. Apr 2004;42(4):1564-9. [Medline].

  83. Casiano-Colon AE, Hulbert BB, Mayer TK, Walsh EE, Falsey AR. Lack of sensitivity of rapid antigen tests for the diagnosis of respiratory syncytial virus infection in adults. J Clin Virol. Oct 2003;28(2):169-74. [Medline].

  84. Falsey AR, McCann RM, Hall WJ, Criddle MM. Evaluation of four methods for the diagnosis of respiratory syncytial virus infection in older adults. J Am Geriatr Soc. Jan 1996;44(1):71-3. [Medline].

  85. Bada C, Carreazo NY, Chalco JP, Huicho L. Inter-observer agreement in interpreting chest X-rays on children with acute lower respiratory tract infections and concurrent wheezing. Sao Paulo Med J. May 3 2007;125(3):150-4. [Medline].

  86. Counihan ME, Shay DK, Holman RC, Lowther SA, Anderson LJ. Human parainfluenza virus-associated hospitalizations among children less than five years of age in the United States. Pediatr Infect Dis J. Jul 2001;20(7):646-53. [Medline].

  87. Dawson KP, Long A, Kennedy J, Mogridge N. The chest radiograph in acute bronchiolitis. J Paediatr Child Health. Aug 1990;26(4):209-11. [Medline].

  88. Schuh S, Lalani A, Allen U, Manson D, Babyn P, Stephens D. Evaluation of the utility of radiography in acute bronchiolitis. J Pediatr. Apr 2007;150(4):429-33. [Medline].

  89. Leer JA Jr, Green JL, Heimlich EM, Hyde JS, Moffet HL, Young GA. Corticosteroid treatment in bronchiolitis. A controlled, collaborative study in 297 infants and children. Am J Dis Child. May 1969;117(5):495-503. [Medline].

  90. Kellner JD, Ohlsson A, Gadomski AM, Wang EE. Efficacy of bronchodilator therapy in bronchiolitis. A meta-analysis. Arch Pediatr Adolesc Med. Nov 1996;150(11):1166-72. [Medline].

  91. Flores G, Horwitz RI. Efficacy of beta2-agonists in bronchiolitis: a reappraisal and meta-analysis. Pediatrics. Aug 1997;100(2 Pt 1):233-9. [Medline].

  92. Dobson JV, Stephens-Groff SM, McMahon SR, Stemmler MM, Brallier SL, Bay C. The use of albuterol in hospitalized infants with bronchiolitis. Pediatrics. Mar 1998;101(3 Pt 1):361-8. [Medline].

  93. Prendiville A, Green S, Silverman M. Ipratropium bromide and airways function in wheezy infants. Arch Dis Child. Apr 1987;62(4):397-400. [Medline].

  94. Everard ML, Bara A, Kurian M, Elliott TM, Ducharme F, Mayowe V. Anticholinergic drugs for wheeze in children under the age of two years. Cochrane Database Syst Rev. Jul 20 2005;CD001279. [Medline].

  95. Unger S, Cunningham S. Effect of oxygen supplementation on length of stay for infants hospitalized with acute viral bronchiolitis. Pediatrics. Mar 2008;121(3):470-5. [Medline].

  96. Boogaard R, Hulsmann AR, van Veen L, Vaessen-Verberne AA, Yap YN, Sprij AJ. Recombinant human deoxyribonuclease in infants with respiratory syncytial virus bronchiolitis. Chest. Mar 2007;131(3):788-95. [Medline].

  97. Chapman J, Abbott E, Alber DG, Baxter RC, Bithell SK, Henderson EA. RSV604, a novel inhibitor of respiratory syncytial virus replication. Antimicrob Agents Chemother. Sep 2007;51(9):3346-53. [Medline].

  98. Chavez-Bueno S, Mejias A, Jafri HS, Ramilo O. Respiratory syncytial virus: old challenges and new approaches. Pediatr Ann. Jan 2005;34(1):62-8. [Medline].

  99. Davis IC, Lazarowski ER, Chen FP, Hickman-Davis JM, Sullender WM, Matalon S. Post-infection A77-1726 blocks pathophysiologic sequelae of respiratory syncytial virus infection. Am J Respir Cell Mol Biol. Oct 2007;37(4):379-86. [Medline].

  100. Maggon K, Barik S. New drugs and treatment for respiratory syncytial virus. Rev Med Virol. May-Jun 2004;14(3):149-68. [Medline].

  101. Kellner JD, Ohlsson A, Gadomski AM, Wang EE. Bronchodilators for bronchiolitis. Cochrane Database Syst Rev. 2000;CD001266. [Medline].

  102. Gadomski AM, Brower M. Bronchodilators for bronchiolitis. Cochrane Database Syst Rev. Dec 8 2010;CD001266. [Medline].

  103. Schuh S, Johnson D, Canny G, Reisman J, Shields M, Kovesi T. Efficacy of adding nebulized ipratropium bromide to nebulized albuterol therapy in acute bronchiolitis. Pediatrics. Dec 1992;90(6):920-3. [Medline].

  104. Hammer J, Numa A, Newth CJ. Albuterol responsiveness in infants with respiratory failure caused by respiratory syncytial virus infection. J Pediatr. Sep 1995;127(3):485-90. [Medline].

  105. Derish M, Hodge G, Dunn C, Ariagno R. Aerosolized albuterol improves airway reactivity in infants with acute respiratory failure from respiratory syncytial virus. Pediatr Pulmonol. Jul 1998;26(1):12-20. [Medline].

  106. Langley JM, Smith MB, LeBlanc JC, Joudrey H, Ojah CR, Pianosi P. Racemic epinephrine compared to salbutamol in hospitalized young children with bronchiolitis; a randomized controlled clinical trial [ISRCTN46561076]. BMC Pediatr. 2005;5(1):7. [Medline].

  107. Menon K, Sutcliffe T, Klassen TP. A randomized trial comparing the efficacy of epinephrine with salbutamol in the treatment of acute bronchiolitis. J Pediatr. Jun 1995;126(6):1004-7. [Medline].

  108. Wainwright C, Altamirano L, Cheney M, Cheney J, Barber S, Price D. A multicenter, randomized, double-blind, controlled trial of nebulized epinephrine in infants with acute bronchiolitis. N Engl J Med. Jul 3 2003;349(1):27-35. [Medline].

  109. Lowell DI, Lister G, Von Koss H, McCarthy P. Wheezing in infants: the response to epinephrine. Pediatrics. Jun 1987;79(6):939-45. [Medline].

  110. Henderson AJ, Arnott J, Young S, Warshawski T, Landau LI, LeSouef PN. The effect of inhaled adrenaline on lung function of recurrently wheezy infants less than 18 months old. Pediatr Pulmonol. Jul 1995;20(1):9-15. [Medline].

  111. Kristjansson S, Lodrup Carlsen KC, Wennergren G, Strannegard IL, Carlsen KH. Nebulised racemic adrenaline in the treatment of acute bronchiolitis in infants and toddlers. Arch Dis Child. Dec 1993;69(6):650-4. [Medline].

  112. Langley JM, Smith MB, LeBlanc JC, Joudrey H, Ojah CR, Pianosi P. Racemic epinephrine compared to salbutamol in hospitalized young children with bronchiolitis; a randomized controlled clinical trial [ISRCTN46561076]. BMC Pediatr. 2005;5(1):7. [Medline].

  113. Ralston S, Hartenberger C, Anaya T, Qualls C, Kelly HW. Randomized, placebo-controlled trial of albuterol and epinephrine at equipotent beta-2 agonist doses in acute bronchiolitis. Pediatr Pulmonol. Oct 2005;40(4):292-9. [Medline].

  114. Sanchez I, De Koster J, Powell RE, Wolstein R, Chernick V. Effect of racemic epinephrine and salbutamol on clinical score and pulmonary mechanics in infants with bronchiolitis. J Pediatr. Jan 1993;122(1):145-51. [Medline].

  115. Wohl ME, Chernick V. Treatment of acute bronchiolitis. N Engl J Med. Jul 3 2003;349(1):82-3. [Medline].

  116. Hartling L, Fernandes RM, Bialy L, Milne A, Johnson D, Plint A, et al. Steroids and bronchodilators for acute bronchiolitis in the first two years of life: systematic review and meta-analysis. BMJ. Apr 6 2011;342:d1714. [Medline].

  117. Plint AC, Johnson DW, Patel H, Wiebe N, Correll R, Brant R, et al. Epinephrine and dexamethasone in children with bronchiolitis. N Engl J Med. May 14 2009;360(20):2079-89. [Medline].

  118. Livni G, Rachmel A, Marom D, Yaari A, Tirosh N, Ashkenazi S. A randomized, double-blind study examining the comparative efficacies and safety of inhaled epinephrine and nasal decongestant in hospitalized infants with acute bronchiolitis. Pediatr Infect Dis J. Jan 2010;29(1):71-3. [Medline].

  119. Corneli HM, Zorc JJ, Mahajan P, et al. A multicenter, randomized, controlled trial of dexamethasone for bronchiolitis. N Engl J Med. Jul 26 2007;357(4):331-9. [Medline].

  120. Daugbjerg P, Brenøe E, Forchhammer H, Frederiksen B, Glazowski MJ, Ibsen KK. A comparison between nebulized terbutaline, nebulized corticosteroid and systemic corticosteroid for acute wheezing in children up to 18 months of age. Acta Paediatr. Jun-Jul 1993;82(6-7):547-51. [Medline].

  121. Davison C, Ventre KM, Luchetti M, Randolph AG. Efficacy of interventions for bronchiolitis in critically ill infants: a systematic review and meta-analysis. Pediatr Crit Care Med. Sep 2004;5(5):482-9. [Medline].

  122. De Boeck K, Van der Aa N, Van Lierde S, Corbeel L, Eeckels R. Respiratory syncytial virus bronchiolitis: a double-blind dexamethasone efficacy study. J Pediatr. Dec 1997;131(6):919-21. [Medline].

  123. Springer C, Bar-Yishay E, Uwayyed K, Avital A, Vilozni D, Godfrey S. Corticosteroids do not affect the clinical or physiological status of infants with bronchiolitis. Pediatr Pulmonol. 1990;9(3):181-5. [Medline].

  124. Tal A, Bavilski C, Yohai D, Bearman JE, Gorodischer R, Moses SW. Dexamethasone and salbutamol in the treatment of acute wheezing in infants. Pediatrics. Jan 1983;71(1):13-8. [Medline].

  125. Zwerdling RG, O'Sullivan BP. Treatment of bronchiolitis. N Engl J Med. Oct 2 2003;349(14):1384-5; author reply 1384-5. [Medline].

  126. Patel H, Platt R, Lozano JM. WITHDRAWN: Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Database Syst Rev. 2008;(1):CD004878. [Medline].

  127. Weinberger MM. High-dose systemic corticosteroids may be effective early in the course of bronchiolitis. Pediatrics. Apr 2007;119(4):864-5; discussion 865-6. [Medline].

  128. Troe JW, Versteegh FG, Mooi-Kokenberg EA, Van den Broeck J. No effect of cromoglycate treatment in hospitalized infants with respiratory syncytial virus bronchiolitis. Pediatr Pulmonol. Nov 2003;36(5):455. [Medline].

  129. Bisgaard H. A randomized trial of montelukast in respiratory syncytial virus postbronchiolitis. Am J Respir Crit Care Med. Feb 1 2003;167(3):379-83. [Medline].

  130. Perrotta C, Ortiz Z, Roque M. Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old. Cochrane Database Syst Rev. Apr 18 2005;CD004873. [Medline].

  131. Roqué I Figuls M, Giné-Garriga M, Granados Rugeles C, Perrotta C. Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old. Cochrane Database Syst Rev. Feb 15 2012;2:CD004873. [Medline].

  132. Johnson DW, Adair C, Brant R, Holmwood J, Mitchell I. Differences in admission rates of children with bronchiolitis by pediatric and general emergency departments. Pediatrics. Oct 2002;110(4):e49. [Medline].

  133. Leclerc F, Riou Y, Martinot A, Storme L, Hue V, Flurin V. Inhaled nitric oxide for a severe respiratory syncytial virus infection in an infant with bronchopulmonary dysplasia. Intensive Care Med. Aug 1994;20(7):511-2. [Medline].

  134. Langley JM, LeBlanc JC, Wang EE, Law BJ, MacDonald NE, Mitchell I. Nosocomial respiratory syncytial virus infection in Canadian pediatric hospitals: a Pediatric Investigators Collaborative Network on Infections in Canada Study. Pediatrics. Dec 1997;100(6):943-6. [Medline].

  135. [Guideline] Diagnosis and management of bronchiolitis. Pediatrics. Oct 2006;118(4):1774-93. [Medline].

  136. Christakis DA, Cowan CA, Garrison MM, Molteni R, Marcuse E, Zerr DM. Variation in inpatient diagnostic testing and management of bronchiolitis. Pediatrics. Apr 2005;115(4):878-84. [Medline].

  137. Cincinnati Children's Hospital Medical Center. Evidence based clinical practice guideline for medical management of bronchiolitis in infants less than 1 year of age presenting with a first time episode. National Guideline Clearinghouse. Available at http://guideline.gov/summary/summary.aspx?doc_id=9528. Accessed February 28, 2010.

  138. Perlstein PH, Kotagal UR, Bolling C, et al. Evaluation of an evidence-based guideline for bronchiolitis. Pediatrics. Dec 1999;104(6):1334-41. [Medline].

  139. Perlstein PH, Kotagal UR, Schoettker PJ, Atherton HD, Farrell MK, Gerhardt WE. Sustaining the implementation of an evidence-based guideline for bronchiolitis. Arch Pediatr Adolesc Med. Oct 2000;154(10):1001-7. [Medline].

  140. Voets S, van Berlaer G, Hachimi-Idrissi S. Clinical predictors of the severity of bronchiolitis. Eur J Emerg Med. Jun 2006;13(3):134-8. [Medline].

  141. Mallory MD, Shay DK, Garrett J, Bordley WC. Bronchiolitis management preferences and the influence of pulse oximetry and respiratory rate on the decision to admit. Pediatrics. Jan 2003;111(1):e45-51. [Medline].

  142. Unger S, Cunningham S. Effect of oxygen supplementation on length of stay for infants hospitalized with acute viral bronchiolitis. Pediatrics. Mar 2008;121(3):470-5. [Medline].

  143. Rivers RP, Forsling ML, Olver RP. Inappropriate secretion of antidiuretic hormone in infants with respiratory infections. Arch Dis Child. May 1981;56(5):358-63. [Medline].

  144. AHRQ Publication Number 03-E009, January 2003. Agency for Healthcare Research and Quality, Rockville, MD. Management of Bronchiolitis in Infants and Children. Summary, Evidence Report/Technology Assessment: Number 69. US Department of Health and Human Services. Available at http://www.ahrq.gov/clinic/epcsums/broncsum.htm. Accessed February 28, 2010.

  145. Sarrell EM, Tal G, Witzling M, Someck E, Houri S, Cohen HA. Nebulized 3% hypertonic saline solution treatment in ambulatory children with viral bronchiolitis decreases symptoms. Chest. Dec 2002;122(6):2015-20. [Medline].

  146. Mandelberg A, Tal G, Witzling M, et al. Nebulized 3% hypertonic saline solution treatment in hospitalized infants with viral bronchiolitis. Chest. Feb 2003;123(2):481-7. [Medline].

  147. Kuzik BA, Al-Qadhi SA, Kent S, et al. Nebulized hypertonic saline in the treatment of viral bronchiolitis in infants. J Pediatr. Sep 2007;151(3):266-70, 270.e1. [Medline].

  148. Al-Ansari K, Sakran M, Davidson BL, El Sayyed R, Mahjoub H, Ibrahim K. Nebulized 5% or 3% hypertonic or 0.9% saline for treating acute bronchiolitis in infants. J Pediatr. Oct 2010;157(4):630-4, 634.e1. [Medline].

  149. Arnold JH, Hanson JH, Toro-Figuero LO, Gutierrez J, Berens RJ, Anglin DL. Prospective, randomized comparison of high-frequency oscillatory ventilation and conventional mechanical ventilation in pediatric respiratory failure. Crit Care Med. Oct 1994;22(10):1530-9. [Medline].

  150. Arensman RM, Statter MB, Bastawrous AL, Madonna MB. Modern treatment modalities for neonatal and pediatric respiratory failure. Am J Surg. Jul 1996;172(1):41-7. [Medline].

  151. Beasley JM, Jones SE. Continuous positive airway pressure in bronchiolitis. Br Med J (Clin Res Ed). Dec 5 1981;283(6305):1506-8. [Medline].

  152. Gavin R, Anderson B, Percival T. Management of severe bronchiolitis: indications for ventilator support. N Z Med J. Apr 26 1996;109(1020):137-9. [Medline].

  153. Khan JY, Kerr SJ, Tometzki A, Tyszczuk L, West J, Sosnowski A. Role of ECMO in the treatment of respiratory syncytial virus bronchiolitis: a collaborative report. Arch Dis Child Fetal Neonatal Ed. Sep 1995;73(2):F91-4. [Medline].

  154. Möller JC, Schaible TF, Reiss I, Artlich A, Gortner L. Treatment of severe non-neonatal ARDS in children with surfactant and nitric oxide in a "pre-ECMO"-situation. Int J Artif Organs. Oct 1995;18(10):598-602. [Medline].

  155. Leclerc F, Riou Y, Martinot A, Storme L, Hue V, Flurin V. Inhaled nitric oxide for a severe respiratory syncytial virus infection in an infant with bronchopulmonary dysplasia. Intensive Care Med. Aug 1994;20(7):511-2. [Medline].

  156. Ventre K, Haroon M, Davison C. Surfactant therapy for bronchiolitis in critically ill infants. Cochrane Database Syst Rev. 2006;3:CD005150. [Medline].

  157. Cambonie G, Milesi C, Fournier-Favre S, Counil F, Jaber S, Picaud JC. Clinical effects of heliox administration for acute bronchiolitis in young infants. Chest. Mar 2006;129(3):676-82. [Medline].

  158. Hollman G, Shen G, Zeng L, Yngsdal-Krenz R, Perloff W, Zimmerman J. Helium-oxygen improves Clinical Asthma Scores in children with acute bronchiolitis. Crit Care Med. Oct 1998;26(10):1731-6. [Medline].

  159. Liet JM, Millotte B, Tucci M, Laflammme S, Hutchison J, Creery D. Noninvasive therapy with helium-oxygen for severe bronchiolitis. J Pediatr. Dec 2005;147(6):812-7. [Medline].

  160. Martinon-Torres F, Rodriguez-Nunez A, Martinon-Sanchez JM. Heliox therapy in infants with acute bronchiolitis. Pediatrics. Jan 2002;109(1):68-73. [Medline].

  161. Martinon-Torres F, Rodriguez-Nunez A, Martinon-Sanchez JM. Nasal continuous positive airway pressure with heliox in infants with acute bronchiolitis. Respir Med. Aug 2006;100(8):1458-62. [Medline].

  162. Martinon-Torres F, Rodriguez-Nunez A, Martinon-Sanchez JM. Nasal continuous positive airway pressure with heliox versus air oxygen in infants with acute bronchiolitis: a crossover study. Pediatrics. May 2008;121(5):e1190-5. [Medline].

  163. Paret G, Dekel B, Vardi A, Szeinberg A, Lotan D, Barzilay Z. Heliox in respiratory failure secondary to bronchiolitis: a new therapy. Pediatr Pulmonol. Nov 1996;22(5):322-3. [Medline].

  164. Tie SW, Hall GL, Peter S, Vine J, Verheggen M, Pascoe EM, et al. Home oxygen for children with acute bronchiolitis. Arch Dis Child. Aug 2009;94(8):641-3. [Medline].

  165. Weiss J, Annamalai VR. Discharge criteria for bronchiolitis patients. Pediatrics. Feb 2003;111(2):445; author reply 445. [Medline].

  166. Mansbach JM, Clark S, Christopher NC, LoVecchio F, Kunz S, Acholonu U. Prospective multicenter study of bronchiolitis: predicting safe discharges from the emergency department. Pediatrics. Apr 2008;121(4):680-8. [Medline].

  167. Smith RA. Background and mechanism of action of ribavirin. In: Smith RA, Knight V, Smith JA. Clinical Applications of Ribavirin. Orlando, FL: Academic Press Inc; 1984:18.

  168. Reassessment of the indications for ribavirin therapy in respiratory syncytial virus infections. American Academy of Pediatrics Committee on Infectious Diseases. Pediatrics. Jan 1996;97(1):137-40. [Medline].

  169. Ventre K, Randolph AG. Ribavirin for respiratory syncytial virus infection of the lower respiratory tract in infants and young children. Cochrane Database Syst Rev. Jan 24 2007;CD000181. [Medline].

  170. Krilov LR, Mandel FS, Barone SR, Fagin JC. Follow-up of children with respiratory syncytial virus bronchiolitis in 1986 and 1987: potential effect of ribavirin on long term pulmonary function. The Bronchiolitis Study Group. Pediatr Infect Dis J. Mar 1997;16(3):273-6. [Medline].

  171. Randolph AG, Wang EE. Ribavirin for respiratory syncytial virus lower respiratory tract infection. A systematic overview. Arch Pediatr Adolesc Med. Sep 1996;150(9):942-7. [Medline].

  172. Hall CB. Respiratory syncytial virus. In: Feigin RD, Cherry JD. Textbook of Pediatric Infectious Diseases. Philadelphia, Pa: WB Saunders; 1992:1653-75.

  173. Hall CB, Douglas RG Jr. Modes of transmission of respiratory syncytial virus. J Pediatr. Jul 1981;99(1):100-3. [Medline].

  174. Hall CB, Douglas RG Jr, Geiman JM, Messner MK. Nosocomial respiratory syncytial virus infections. N Engl J Med. Dec 25 1975;293(26):1343-6. [Medline].

  175. Hall CB, Geiman JM, Biggar R, Kotok DI, Hogan PM, Douglas GR Jr. Respiratory syncytial virus infections within families. N Engl J Med. Feb 19 1976;294(8):414-9. [Medline].

  176. Hall CB, Geiman JM, Douglas RG Jr, Meagher MP. Control of nosocomial respiratory syncytial viral infections. Pediatrics. Nov 1978;62(5):728-32. [Medline].

  177. Holman RC, Shay DK, Curns AT, Lingappa JR, Anderson LJ. Risk factors for bronchiolitis-associated deaths among infants in the United States. Pediatr Infect Dis J. Jun 2003;22(6):483-90. [Medline].

  178. Englund J. In search of a vaccine for respiratory syncytial virus: the saga continues. J Infect Dis. Apr 1 2005;191(7):1036-9. [Medline].

  179. Groothuis JR, Simoes EA, Levin MJ, et al. Prophylactic administration of respiratory syncytial virus immune globulin to high-risk infants and young children. The Respiratory Syncytial Virus Immune Globulin Study Group. N Engl J Med. Nov 18 1993;329(21):1524-30. [Medline].

  180. [Guideline] From the American Academy of Pediatrics: Policy statements--Modified recommendations for use of palivizumab for prevention of respiratory syncytial virus infections. Pediatrics. Dec 2009;124(6):1694-701. [Medline].

  181. Palivizumab, a Humanized Respiratory Syncytial Virus Monoclonal Antibody, Reduces Hospitalization From Respiratory Syncytial Virus Infection in High-risk Infants. Pediatrics. Sep 1998;102(3):531-7. [Medline].

  182. Romero JR. Palivizumab prophylaxis of respiratory syncytial virus disease from 1998 to 2002: results from four years of palivizumab usage. Pediatr Infect Dis J. Feb 2003;22(2 Suppl):S46-54. [Medline].

  183. Prais D, Danino D, Schonfeld T, Amir J. Impact of palivizumab on admission to the ICU for respiratory syncytial virus bronchiolitis: a national survey. Chest. Oct 2005;128(4):2765-71. [Medline].

  184. Stevens TP, Hall CB. Controversies in palivizumab use. Pediatr Infect Dis J. Nov 2004;23(11):1051-2. [Medline].

  185. Simoes EA, Groothuis JR, Carbonell-Estrany X, Rieger CH, Mitchell I, Fredrick LM. Palivizumab prophylaxis, respiratory syncytial virus, and subsequent recurrent wheezing. J Pediatr. Jul 2007;151(1):34-42, 42.e1. [Medline].

  186. Meissner HC, Long SS. Respiratory syncytial virus infection and recurrent wheezing: a complex relationship. J Pediatr. Jul 2007;151(1):6-7. [Medline].

  187. Resch B, Gusenleitner W, Nuijten MJ, Lebmeier M, Wittenberg W. Cost-effectiveness of palivizumab against respiratory syncytial viral infection in high-risk children in Austria. Clin Ther. Apr 2008;30(4):749-60. [Medline].

  188. Wegner S, Vann JJ, Liu G, Byrns P, Cypra C, Campbell W. Direct cost analyses of palivizumab treatment in a cohort of at-risk children: evidence from the North Carolina Medicaid Program. Pediatrics. Dec 2004;114(6):1612-9. [Medline].

  189. Elhassan NO, Sorbero ME, Hall CB, Stevens TP, Dick AW. Cost-effectiveness analysis of palivizumab in premature infants without chronic lung disease. Arch Pediatr Adolesc Med. Oct 2006;160(10):1070-6. [Medline].

  190. Carbonell-Estrany X, Simões EA, Dagan R, Hall CB, Harris B, Hultquist M. Motavizumab for prophylaxis of respiratory syncytial virus in high-risk children: a noninferiority trial. Pediatrics. Jan 2010;125(1):e35-51. [Medline].

  191. Stretton M, Ajizian SJ, Mitchell I, Newth CJ. Intensive care course and outcome of patients infected with respiratory syncytial virus. Pediatr Pulmonol. Jul 1992;13(3):143-50. [Medline].

  192. Thomas JA, Raroque S, Scott WA, Toro-Figueroa LO, Levin DL. Successful treatment of severe dysrhythmias in infants with respiratory syncytial virus infections: two cases and a literature review. Crit Care Med. May 1997;25(5):880-6. [Medline].

  193. Piastra M, Caresta E, Tempera A, Langer A, Zorzi G, Pulitano S. Sharing features of uncommon respiratory syncytial virus complications in infants. Pediatr Emerg Care. Aug 2006;22(8):574-8. [Medline].

  194. Hyvarinen MK, Kotaniemi-Syrjanen A, Reijonen TM, Korhonen K, Korppi MO. Lung function and bronchial hyper-responsiveness 11 years after hospitalization for bronchiolitis. Acta Paediatr. Oct 2007;96(10):1464-9. [Medline].

  195. Fjaerli HO, Farstad T, Rod G, Ufert GK, Gulbrandsen P, Nakstad B. Acute bronchiolitis in infancy as risk factor for wheezing and reduced pulmonary function by seven years in Akershus County, Norway. BMC Pediatr. 2005;5:31. [Medline].

  196. Piippo-Savolainen E, Korppi M. Wheezy babies--wheezy adults? Review on long-term outcome until adulthood after early childhood wheezing. Acta Paediatr. Jan 2008;97(1):5-11. [Medline].

  197. Openshaw PJ, Dean GS, Culley FJ. Links between respiratory syncytial virus bronchiolitis and childhood asthma: clinical and research approaches. Pediatr Infect Dis J. Feb 2003;22(2 Suppl):S58-64; discussion S64-5. [Medline].

  198. Goetghebuer T, Isles K, Moore C, Thomson A, Kwiatkowski D, Hull J. Genetic predisposition to wheeze following respiratory syncytial virus bronchiolitis. Clin Exp Allergy. May 2004;34(5):801-3. [Medline].

  199. Sweetman LL, Ng YT, Butler IJ, Bodensteiner JB. Neurologic complications associated with respiratory syncytial virus. Pediatr Neurol. May 2005;32(5):307-10. [Medline].

  200. Welliver RC, Wong DT, Sun M, Middleton E Jr, Vaughan RS, Ogra PL. The development of respiratory syncytial virus-specific IgE and the release of histamine in nasopharyngeal secretions after infection. N Engl J Med. Oct 8 1981;305(15):841-6. [Medline].

  201. Stein RT, Sherrill D, Morgan WJ, et al. Respiratory syncytial virus in early life and risk of wheeze and allergy by age 13 years. Lancet. Aug 14 1999;354(9178):541-5. [Medline].

 
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A chest radiography revealing lung hyperinflation with a flattened diaphragm and bilateral atelectasis in the right apical and left basal regions in a 16-day-old infant with severe bronchiolitis.
 
 
 
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