Viral Bronchiolitis in Children 2016 (1).pdf

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n e w e ng l a n d j o u r na l

tion was not found to extend to young children
with severe RSV infection indicates that there is
a complex interaction between genetic and environmental factors in the development of asthma.
Results from a Danish study involving twins
suggested that severe RSV bronchiolitis is an
indicator of a genetic predisposition to asthma
and that, in the absence of this predisposition,
asthma is less likely to develop even if they had
previously had bronchiolitis.61
Whether the prevention of severe RSV bronchiolitis will reduce the number of episodes of
recurrent wheezing has been studied, but the
answer remains elusive. A randomized, doubleblind, placebo-controlled trial conducted in the
Netherlands involving preterm infants born at
33 to 35 weeks of gestation addressed the possible benefit of prophylaxis with palivizumab
(a humanized anti-RSV antibody) in preventing
wheezing during the first year of life.62 Recipients of RSV immunoprophylaxis had a significant relative reduction of 61% in the number of
days of wheezing; this difference resulted in
their having 2.7 fewer days of wheezing per 100
patient-days than did participants who received
placebo. Because the viral cause of wheezing
episodes was determined inconsistently and the
primary end point of the study was audible
wheezing as reported by a parent, rather than a
medically verified event, the small reduction in
the number of days with wheezing is of uncertain clinical significance.
A prospective randomized, placebo-controlled
trial with motavizumab (a second-generation
monoclonal antibody with greater potency against
RSV than palivizumab) that involved 2696 healthy,
full-term Native American infants showed a significant between-group difference (in favor of
motavizumab) in both inpatient and outpatient
medically attended RSV lower tract disease.63
However, no reduction in wheezing occurred
among prophylaxis recipients during 3 years of
careful follow-up. This result is consistent with
the concept that prevention of RSV infection
with immunoprophylaxis does not have a measurable effect on subsequent episodes of wheezing.


m e dic i n e

possible care for a young child with this illness
because of the lack of curative therapy. No
available treatment shortens the course of
bronchiolitis or hastens the resolution of symptoms. Therapy is supportive, and the vast majority of children with bronchiolitis do well regardless of how it is managed. The intensity of
therapy among hospitalized children has been
shown to have little relationship to the severity
of illness.64,65
To improve the standardization of the diagnosis and management of bronchiolitis in children, the American Academy of Pediatrics published a clinical practice guideline, which was
based on a Grading of Recommendations, Assessment, Development and Evaluation (GRADE)
analysis, to clarify the level of evidence required
for diagnosis and to assess the relationship of
benefit to harm and the strength of recommendations regarding various aspects of the diagnosis, treatment, and prevention of bronchiolitis.9,10,66 The evidence-based guidelines emphasize
that a diagnosis of bronchiolitis should be based
on the history and physical examination and
that radiographic and laboratory studies should
not be obtained routinely (Table 2). Short-acting
β2-agonists, epinephrine, and systemic glucocorticoids are not recommended for the treatment
of children with bronchiolitis. Clinicians may
elect not to administer supplemental oxygen
when oxyhemoglobin saturation exceeds 90%.
Intravenous or nasogastric fluids may be used
for children with bronchiolitis who cannot maintain hydration orally. A complete discussion
regarding the management of bronchiolitis is
available in the clinical practice guidelines.9

Im munoproph y l a x is

Palivizumab, a humanized mouse IgG1 monoclonal antibody directed against a conserved
epitope on the surface fusion protein of RSV,
was licensed by the Food and Drug Administration in June 1998 for monthly prophylaxis for
infants at high risk for RSV infection.10 Licensure was based largely on the results of a randomized, double-blind, placebo-controlled trial
conducted during the 1996–1997 RSV season,
Supp or t i v e M a nagemen t
which showed a reduction of 5.8% in the rate of
Despite the high burden of disease due to bron- hospitalization attributable to RSV among prechiolitis, it has been difficult to define the best term infants (10.6% in the placebo group vs.


n engl j med 374;1  January 7, 2016

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