Croup and Bronchiolitis – PediaCast 447

Show Notes


  • Join us as we explore two respiratory illnesses circulating in the community: croup and bronchiolitis. Discover the cause, symptoms, diagnosis, treatment and natural course of these common viral infections. We also consider the latest AAP Clinical Practice Guidelines for bronchiolitis and what these mean for parents and providers.


  • Croup
  • Bronchiolitis



Announcer 1: This is PediaCast.


Announcer 1: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.

Dr. Mike Patrick: Hello, everyone. And welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital. We are in Columbus, Ohio. 

It is Episode 447 for December 11th, 2019. We are calling this one "Croup and Bronchiolitis". I want to welcome you to the program. 

It is our final installment of PediaCast for the 2019 season, which was our 14th year of production on this longest running pediatric podcast for parents. And, of course, I want to thank each and every one of you for helping make this program a success by listening to our episodes, like you're doing right now, connecting with us on social media -- we're on Facebook, Twitter, LinkedIn and Instagram -- and writing in with your suggestions for show topics. Really do appreciate that.


And since this is our final show of 2019, I also wanted to take a moment to wish each and every one of you the happiest of holidays, the merriest of Christmases, and a wonderful upcoming new year. I really do hope that you're able to spend some quality time with your family and your friends. 

Take a break from work and practice a little bit of self-care. It's good to have work-life balance and this is wonderful time of the year just to take a step back and relax and make some memories. So I hope all of you are able to do that at some point over this holiday season. 


As we approach the new year on our podcast, the plan moving forward is to build upon the foundation that we lay down last week. You will recall the Pediatric in Plain Language Panel joined us and we explored the basics of fever, infections, and over-the-counter medicine.

Today, we're going to dive a little deeper and talk about two specific infections, which are extremely common this time of year, namely croup and bronchiolitis. And then, after we enjoy the holidays and head  into 2020, we're going to start the new year by exploring two additional infections, the common cold and the flu. We'll also cover some pediatric news for you as we head into the new year.

Now, all of these infections -- croup, bronchiolitis, the common cold, the flu -- all of them impact the respiratory tract which starts at the nose, travels down the throat through the voice box and on into the lungs. And although each of this infections is caused by a viruses, the specific viruses that cause each of those are different. And that results in different set of symptoms and different treatment strategies. 


So it is important to distinguish between this common respiratory infections, these viral respiratory infections, and arrive at the correct diagnosis in the most appropriate treatment plan. Of course, it's up to your medical provider in real time, not through social media or a podcast, to make the correct diagnosis and recommend the most up-to-date treatment. 

However, it's also important for parents to understand the difference and to know what this might be, when to see your child's medical provider for each of these conditions. Sort of, for each one know what am I watching for? What do I need to worry about, when do we go in? And to have some working knowledge regarding treatment and the timeline for getting better, so you know what to expect and can ask good questions along the way. 


There's another role that parents play in all of these. It turns out that recommendations for treating various illnesses including viral respiratory tract illnesses, recommendation can change over time as scientific evidence and our understanding of infections and the best treatment as our understanding evolves. 

And sometimes, it can take awhile for medical providers to change their practice when new recommendations are released. Now, there are several reasons for this. We, as providers, tend to continue practicing medicine as we were once taught to practice. 

Sure, we use personal experience as well as evidence and consensus to guide our practice. In other words, we see what appears to have worked for our patients in the past. We see what does not appear to have worked and we allow these observations to impact our practice. 

But with new recommendations come out, or guidelines, some of us are slow to keep up with change. And one big reason for that is we are simply bombarded with information from many different sources, sometimes conflicting information. So it's hard to know which way should I go, how do we change?


And then, sometimes, it's easier just keep doing things the way that we were taught to do them, even though there may be new information out there.

The other thing is medical providers are busy people taking care of you and your kids, which often leaves little time for researching with the new things are and to keep up with that change. So with that said, when an informed parent speaks up and says, "Hey, why are we doing things this way? You know, I read or heard that recommendations have changed. Why are we doing things differently for my child?"

Not in an adversarial way, but simply being inquisitive, wondering, advocating for the best approach for your child. Now, your provider may have a very good reason for doing things differently. You know, the practice of medicine is nuanced, there are many data points to consider, which makes each child and each situation unique. 

But the exceptions are just that, they're exceptions. And your provider should be able to explain why your case is different. Patients and parents deserve thoughtful explanations. 


So your questions as parents sort of force us medical providers to examine ourselves. Are we really still up to date with the latest recommendations? If a parent says, "Hey, I read or heard this," well, you know, did we not read or hear that? Maybe not, and it can get us thinking and wondering and researching better answers to your questions. 

So as a parent, your knowledge and your questions can be the stimulating factor that brings about evidence-based change in practice behavior. 

So as we consider two common infections of the respiratory tract this week, croup and bronchiolitis, and two more after the new year, colds and flu, I'm going to make a point of including how the diagnosis and treatment of these infections has changed over time and why it has changed. Which, I hope will bring about better understanding and empower you as a parent to have a questioning attitude as you engage your child's healthcare provider. Again, not as an adversary but just being inquisitive, wondering and advocating for your child.


All right, before we travel down that road, I do have a couple of quick housekeeping items for you. Don't forget, you can find PediaCast in all sorts of places. We are in the Apple Podcast app, iTunes, Google Play, iHeart Radio, Spotify, SoundCloud and most mobile podcast app for iOS and Android. So there may be an easier way for you to subscribe and keep up and listen to the podcasts.

Also, reviews are helpful wherever you listen to PediaCast. We always appreciate it when you take the time to share your thoughts about the show. And, of course, we love connecting with you on social media. As I mentioned, we are on Facebook, Twitter, LinkedIn and Instagram. Simply search for PediaCast. 


And then, we have a handy contact link over at If you would like to suggest a topic for 2020, please go to and click on that Contact link. We'd love to hear from you. 

Also, I want to remind you the information presented in each and every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to call your doctor and arrange a face-to-face interview and hands-on physical examination.

Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement which you can find at

So, let's take a quick break. And then we will come back to talk about croup and bronchiolitis. That's coming up, right after this.


Dr. Mike Patrick: So let's talk about croup. We have talked about croup before. But when you have a program that's been around as long as we have, it's been long enough that things have changed a little bit in terms of what we think about croup and how we treat croup. 

We first covered it in Episode 9 back in September of 2006. So over 13 years ago and things have definitely changed since then. And I'll explain what has changed as we move through this. We also covered it in Episode 276. That was January of 2014. But again, six years ago, so let's cover it again. This is an important topic because so many kids are affected by croup especially this time of year. 

So as I mentioned in the introduction, croup is caused by a virus. So it's a viral infection. It's what we would consider a clinical syndrome. And that means, it's a set of symptoms that occur together but it can be caused by several different viruses.


So it's more important that you can recognize the set of symptoms so that you can arrive at a diagnosis of croup and then figure out the right treatment plan rather than identifying which specific virus it is since several viruses can cause this constellation of symptoms. 

Now, the most common virus that's involved is the parainfluenza virus, that even though it's got the word influenza in it, it is not the same as influenza, which causes the flu, which we're going to talk about on our next episode, after the new year. 

So parainfluenza virus is different than the flu and is the most common virus associated with croup. However, influenza itself, influenza A and B can cause a croup-like picture in some kids. Measles can cause croup symptoms. Adenovirus and respiratory syncytial virus, which causes primarily bronchiolitis -- which we're going to talk about next -- in other kids, that particular virus could cause more croup-like symptoms. 


So again, it's really important that you recognized what croup looks like as a syndrome, a viral syndrome, rather than identifying a specific virus. It's common, croup is really common. And parents who have older kids and you think back as we describe what croup looks like, you will probably recognize it. Like, "Oh, yeah, I remember, my kids had croup, maybe more than once, maybe more than twice." And the autumn, fall, and into the winter really is when we see this the most. 

Now, the hallmark of croup in kids is going to be a barky cough and stridor, which is a noise that kids make when they breathe. So in the infants and young children is when you're really going to see this the most. And it really has to do just with the fact that their airway is small. And so, it can't really tolerate as much swelling as an older kid or an adult could.


So the older kids and the adults may just have cold-like symptoms, just some nasal congestion, a little bit of a cough. Maybe it's more of a hoarse cough or a little bit of a hoarse voice that goes along with it, but not the full pledge barky cough and stridor, which again, we'll talk about and describe exactly what these things are in more detail in a moment. 

It's most common in children six months to three years. And again, more likely for infants and the young children due to the small airway diameter. But you can see it in older kids as well.

So what is going on that causes the symptoms of croup? Well, like most viral infections, the virus infects cells of the respiratory tract. And basically, it does so because it's turning those cells into virus-producing factories and damaging those cells in the process. 


And your body is going to respond by bringing in white blood cells in your immune system to kills the virus, to kill those damaged cells, and then your body's going to make new cells. Also, there's mucus that's produced which helps to trap the virus and mobilize it and probably also aids in the turnover of cells as cells die and we make new ones. 

So that process is going to create the congestion. The congestion is going to stimulate the cough so that we keep that mucus out of the lungs and mouth bacteria out of the lungs so we don't get pneumonia. So cough is going to be common.

Now, with croup, the cells in the airway, in the vicinity of the voice box, so the vocal cords, the larynx, the trachea -- so from the back of the throat, we pass through the voice box -- the trachea goes on down to the lungs, and then the bronchi are where the trachea divides and goes down into each lung. 


So these big air tubes in the voice box are primarily what gets inflamed with croup. So we really have more upper airway compared to lower airway, which we'll see with bronchiolitis, you get a little more lower airway involvement.

This is more upper and in particular swelling around the vocal cords which is why you get that hoarse voice and a distinctive barky cough. You know, like a seal bark or a dog bark. It can be difficult to understand, what does that sound like? And I wanted to be able to play those for you, but because of copyright and permissions, it's not an easy thing to do.


So instead, what I've done is I went to YouTube and I found the best videos that really described what this cough and stridor, which we're going to talk about more in a minute, what they sound like. So head over to the show notes at, Episode 447, and I have a link for you about this cough. 

So we will have some examples of what this croup cough sounds like. What do we mean when we say it sounds like a seal barking or a dog barking? And what's the stridor business? So head over there once you're done listening and you can see those real-life examples of what these things sound like. 

So when this inflammation, in the beginning, you get the inflammation around the vocal cords and you get this, again, this forced barky sound cough. But then, as the inflammation gets worse and you start to block off more of the airway, then that's when stridor kind of kicks in. And this is a high pitch sound that occurs with inspiration primarily.


So when air is breathe in, it's flowing across inflammation and narrowing of that passage and you get almost a high pitch whistle kind of in a noise, which is different than wheezing. But wheezing is going to be more when you breathe out primarily as opposed to when you're breathing in. So when you hear noisy breathing, when kids are breathing in and they have that barky cough, that makes you start thinking about croup. 

The stridor tends to be worse when kids are upset, when they're crying. And the reason for that is when you're crying, you are sucking in air more forcefully. And so, you're more likely to create sound because of that inflammation that's there. And then you're upset and breathing in really forcefully against that inflammation and that narrowing. 


So oftentimes, stridor will be there when kids are crying. Yeah, I guess you could call it cry-dor. It's there when they're crying and then when they calm down and start breathing slower and with less force, then that stridor goes away. We get more concerned when we hear that noise with every breath of breathing even when kids are at rest. 

So that would definitely be a warning when you hear stridor continuously. You want to get your kid seen right away if they have that. 

Now wheezing can also happen with each breath. So if you have questions about is it stridor that goes along with croup or is it wheezing that goes along with asthma and bronchiolitis, you know, it may take a trained ear really to tell the difference. Your child's healthcare provider is there for that reason. They're on call or someone is on call for them. 

Don't be afraid to pick up the phone and let them listen over the phone to what your child sounds like. Or if you can share a video, that can be helpful. 


If you can't get a hold of your provider and you're worried, absolutely go see someone, hopefully, with some pediatric expertise, whether that be in an emergency department or an urgent care center. It is important when your child's having any noisy breathing that you're uncomfortable with. And if it's with every breath, you really should be uncomfortable with that. It's important that your child be seen. 

Now, one thing that's interesting with croup is oftentimes the symptoms improve during the day and then they get worse at night. That's really common with croup.

Fever is also very common with the viruses that cause croup. So fever that's there for a day or two, sometimes a very high fever. And sore throat can go along with that, too, because again, this virus is infecting the throat, the voice box, and the upper air tubes. And so, sore throat is definitely possible. 

Now, the good news with croup is it usually doesn't last too long. It's usually just a few days, the worst of it, like two or three days. And then, symptoms can kind of linger for a few more days after that. But we're generally talking less than a week of illness. Sort of seven to ten days would be long.

But the barky cough and the stridor usually are just going to last two or three days. So much shorter lived infection compared to the flu, real influenza, or bronchiolitis, we're going to talk about next which tend to be more long-lasting illnesses. 


One other thing I mentioned, call your doctor if you have a question. Go to the emergency room or an urgent care center if your child's making a noise or struggling to breathe.

And also, if your child's really in a lot of distress, like they are really working hard to breathe and you're worried, call 911. Have a little threshold for getting emergency medical services involved when there are breathing issues at play. So that's going to be really important. 

Also, if your child is lethargic, literally, just like limp and laying around or they're drooling, like they can't handle their secretions, these are all going to be reasons to get help right away and including calling 911.


Now, in terms of what else can cause a hoarse, barky cough and stridor, there are some other things that can be quite serious than can obstruct the airway and cause similar symptoms. So it's important that you do have your child seen if these symptoms are severe or they are persisting. 

Foreign body, for example. If your child puts something in their mouth and it enters into the airway, now you have a foreign object in the airway that's obstructing, that could potentially cause a stridor, sometimes a barky cough. 

With foreign body issue, usually, there's not going to be a fever present or nasal congestion. However, you can have an upper respiratory tract infection from a virus and the foreign body. Kids can have viruses and foreign body. 

So it is possible that your child has a fever and nasal congestion from a cold, but maybe they put something in their mouth. And that's what causing the breathing problem. So something that we always keep in the back of our minds and another reason not to just ignore this if they have a noise with breathing. 


The other thing in the differential is something that is not as common as it was once, thanks to routine childhood vaccinations. But there was  a disease process, and it still is possible, called epiglottitis, that killed many kids. And the epiglottis, you remember from high school biology class, is a flap in the back of the throat that covers the entrance to the trachea when you swallow. 

So it sort of keeps things out of the airway and guides them into the esophagus, so they go down the right tube, so they go down the stomach and not down to the lungs and this prevents choking. 

Well, epiglottitis is an infection of that flap, usually caused by a bacteria and requiring antibiotics. And it's a very dangerous condition because the swelling can become severe quickly and completely obstruct the airway leading to death. 


The symptoms of early epiglottitis can be similar to croup with sort of hoarse sounding cough and stridor that's there, noisy breathing. But they progress quickly and these kids are often sitting upright, keeping still to maintain their own airway, they're often drooling. They may be working hard to breathe. 

And they usually will end up needing a breathing tube placed, oftentimes in the operating room under very controlled conditions until that swelling goes away. And that's usually best inserted by a pediatric ear nose and throat specialist in the operating room. So this is serious business.

Now, again, fortunately, we do not see much epiglottitis these days because the bacteria that caused the majority of these cases is rare today. Thanks to the Hib, Hib vaccine which protects against Haemophilus influenzae type B, which is a bacteria. And that immunization was introduced in the late 1980s. And so, we've seen much less epiglottitis. 

But it's still one of those things, if you're going to pediatrics, when you're an intern, like one of your first days on the job, it's like, "This is what epiglottitis looks like, you do not want to mistake this. It's important to diagnose it and treat it right away."


Incidentally, that same bacteria once caused many cases of meningitis in toddlers, which also lead to many deaths, which is also rare now. Again, thanks to that Hib vaccine. So that's a particularly important, all are important, but the Hib vaccine particularly important for young kids. 

And since a lot of parents are skipping vaccines for their children, we still have to be in our toes and think about these once rare diseases in the back of our heads and look out for them because they can easily make a comeback if current vaccination trends continue.

All right, so how do you diagnose croup then from a medical provider's standpoint? It's really a clinical diagnosis. You got a kid with a fever, runny nose, they start to have a barky cough, and then they have the stridor. We may need to do X-rays if we suspect a foreign body could be there.

Parainfluenza virus can be detected with a nasal swab, but again, there's really not a reason to do that in a kid, unless they're so sick they have to be in the hospital. And then, you want to know, well, could it be a different virus that maybe we could do something else for to help them because the symptoms are so severe. 


Or it could be bacteria. We mentioned measles is one of those things that could cause croup-like symptoms, usually with other symptoms present as well. But by identifying the parainfluenza virus in a kid that's sick enough to be in the hospital kind of gives you some reassurance that, yeah, it's just severe croup and not something else. 

But that test is expensive. It's what we'd called a PCR, polymerase chain reaction type test. And those are expensive, so again, not routinely done. This is primarily diagnosed clinically when we see the right set of symptoms. 

In terms of treatment, because it's a virus, antibiotics do not help. We do not have antiviral medications for the viruses that typically cause croup, unless it's influenza. But again, even though influenza can cause a croup-like picture, that's rare. And we'll talk more on our next episode of what influenza looks like to remind you of that.


So the hallmark, the main stay of treatment is really going to be supportive care at home. And by supportive care, we mean rest, fluids. For the fever or the sore throat, we can use some Tylenol or acetaminophen, brand name Tylenol or ibuprofen with brand names like Advil and Motrin.

So really, just support care, comfort care. Now this is where things have changed a little bit. When I trained, we really would only give Decadron which is a steroid medication as a shot to kids who had stridor, not just a barky cough.

So if they just had a barky cough, comfort care, you go home. If they had stridor that was there when they were upset, but they got better at rest -- or stridor was continuously there, either one of those -- you would give a dose of dexamethasone which is a long-acting steroid medicine, and you would give this as an injection or shot. 


And that would help reduce the swelling because steroids reduce swelling. And so, that would help in the airway, oftentimes, it would buy you a little bit of time as your body's immune system fights the virus off and reduces the swelling. And then, you're better in a couple of days. And the effect of that Decadron would last for two or three days. 

What we found over more recent years is that you can actually give the Decadron instead of as a shot, you can give it orally. And in fact, you can even give orally the same solution that you used to give with the shot. But there had to be studies done to show, "Hey, this is just as effective," because when you're talking about a sick kid in the airway and the potential for obstruction of breathing, it's more difficult to design a study because you want to give kids what you know works.


But they were able to give some kids oral Decadron and monitor them very closely. And what we discovered is that oral dexamethasone, so given by mouth as a single dose, is just as effective as the shot form. 

Now that we have an easier way to give Decadron, sort of the practice has morph into now, anytime a kid has symptom of croup, barky cough, we give them Decadron. So we don't just reserve it for medium to severe cases. Even a barky cough without stridor now, we typically give Decadron. Because it's easy to give and it can help prevent worsening to the point where kids have stridor and difficulty breathing, especially the younger kids who have smaller airways. 


So that's one practice change. Now, we use Decadron more widely. We use it orally instead of as an injection.

And then, another thing that we do is for severe persistent stridor is we give epinephrine as a breathing treatment. So this is different than the breathing treatments that we give for asthma. This is epinephrine that's aerosolized and this greatly reduces airway swelling and can make the stridor and the barky cough really much better very quickly. 

The problem with racemic epinephrine or epinephrine aerosol is that the effect of it can be short-lived. And in many cases, kids, once the effect of the epinephrine goes away, the swelling returns, the symptoms return. And every now and then, you have a kid that has what we would call a rebound effect, where it's actually the swelling is worse afterward than it was to begin with.

And so because of that concern for inflammation coming back and perhaps even being worse, we don't do these treatments at home. If they're done in the doctor's office or an urgent care setting, or an emergency department, usually your child will get one of these breathing treatments and then be watched for a few hours to make sure that as the epinephrine wears off, things are going to get worse. 


If they do get worse, then we would use a second dose of the epinephrine aerosol. And then if you need a second one, oftentimes when that one wears off, you're going to need a third one and maybe a fourth one. And so, at that point, usually kid get admitted to the hospital. 

And if the epinephrine doesn't work at all, there are some other things that can be done, but usually at that point, you're thinking about, first, is it croup? Could it be something else like a foreign body? And then, they often get admitted to a pediatric intensive care unit at that point. Because again, airway inflammation, if it gets severe can be life-threatening.

Now, I also want to mention a word about humidification. So having more moisture in the air can help air flow a little bit easier through narrow swollen passages. And so, you may have heard, like if you turn the shower on hot and take your child into the steamy bathroom, not necessarily under the hot shower, but just let them breathe the steamy air, that sometimes that will help stridor go away and ease the cough a little bit.


Also, humidifier in the bedroom can have a similar effect. Also, if you open up your freezer, that cold air that sort of comes rolling out, that tends to have more moisture in it. And even just walking outside, our heaters in the winter time, the furnaces tend to dry out the air, and so the air outside often has more moisture in it. 

And that's why a lot of kids sound terrible at home. And you take them into the doctor's office or an urgent care or an emergency department, by the time you get there, they're breathing fine and the barky cough is much better. Again, because of more moisture in the air.

However, this is not really a primary way of treating this. It helps great but you want to have a low threshold for getting help and doing more like the Decadron and the racemic epinephrine aerosol if your child's persisting in having noisy breathing or any difficulty breathing. So it doesn't hurt to try it, but you don't want to waste your time if your child has severe symptoms. You want to seek medical care right away. 


So anyway, that's really where we are in terms of treatment. Oh, one other thing with the Decadron. So I mentioned that lasts a couple of days. For most kids, they just need that one dose. But there's going to be a small number of kids who they get the Decadron, they're better but their bodies are not quite done fighting off the virus and the inflammation can return as the Decadron wears off. 

It wears off much slower than the epinephrine does. So maybe a couple of days, your child's barky coughs are its worst again. Maybe the stridor returns, then they might need a second dose of Decadron. But most kids only need one but if things aren't getting better, you do want to see your doctor.


Another interesting thing is when kids aren't getting better, they're needing frequent epinephrine aerosols. And so now, they needed more than a couple, they end going into the intensive care unit. There is another thing that's kind of interesting called Heliox which is a mixture of oxygen and helium. So it's still 21% oxygen just like room air but the helium replaces a lot of the nitrogen. 

It turns out helium flows smoothly in tight areas through laminar laminar flow. So the helium can exist as single atoms that line up nicely and flow smoothly in tight areas and are less prone to turbulent flow from tissue resistance. 

o Heliox is one of the things that can also help. Now, it does not mean that you should take a helium balloon and let your kid breath in that air when they're having trouble. Not to mention balloons can be choking hazards, but not a good idea. But something of interest, that's another tool that doctors have in their pocket for treating with really severe cases of croup. 


In terms of preventing croup, it's a viral upper respiratory infection. And so, avoiding those who have upper respiratory tract infection symptoms is going to be one way to prevent it. Remember, the viruses that cause croup-like symptoms in younger kids may just show up like an adult who has a cold. 

An adult may just have a runny nose and an occasional cough, but that same virus in a little kid could cause croup. And so, if you have young children, sort of keep them away from even adults who have colds. So that's going to be important. 

And then, of course, hand washing frequently. After going to the bathroom, after touching things, keep kids from touching their faces and putting their hands in their mouth and rubbing their eyes and all those things.

Hand washing, by the way, best practices for that. Alcohol-based hand sanitizer is going to be fine. Although it kills most viruses, some of the hardy GI viruses that can cause vomiting and diarrhea, it may not kill quite as well. The mainstay is going to be hand washing. And you want to wash with soap and water for at least 20 seconds, sing the ABC song, and then dry those.


I did write a blog post called All About Croup. So if you'd like just some written information or you want to share that in your own social media channels, there is a written blog post about croup. And I will put a link to that in the show notes for this episode, 447, over at



Dr. Mike Patrick: Our next viral respiratory infection that we're going to cover is bronchiolitis. And this is another one that we have covered before on this podcast, back in Episode 276, which was January of 2014. But that was six years ago. Also, on PediaCast 355 in October of 2016, but that was three years ago. So I guess we're on every three-year pattern to talk about bronchiolitis.

But I do want to cover it again. It is important. It's an important one to talk about because lots and lots and lots of babies are affected by this. And treatment has changed, even more so than with croup over the last few years. And so it is important to discuss this. 

So first of all, what is bronchiolitis? It's not bronchitis. So bronchitis is different than bronchiolitis. Bronchitis are bigger tubes, bronchiolitis, bronchioles are the little air tubes, way down deep in the lungs. 


So that's why it's bronchiolitis because kids do get obstruction primarily through mucus and cellular debris as the virus destroys some cells, and there's turnover and you're making new cells. So of course, some inflammation as well. So these little air tubes become obstructed. 

But it's not the same kind of obstruction that we see with asthma, where there's inflammation and bronchospasms. Where the muscles inside that line the airways are contracted and using something like a bronchodilator or albuterol can relax those muscles and make the airway bigger. 

Bronchospasm of those muscles is not as much of an issue with bronchiolitis. And so, the sort of things that we do to treat asthma like steroids and bronchodilators and albuterol do not help bronchiolitis because this is a different animal. 


It is caused by a virus. That's why we're talking about it with viral respiratory infections. It's also a clinical syndrome. It's typically little babies or kids up to about two years of age who have lots of nasal congestion, and noisy breathing, difficulty breathing, and noise in their chest that would go along with wheezing and hoarse noises from the upper airway and also from the lower airway.

So this is a pretty classic presentation of what a baby with bronchiolitis looks like, having trouble breathing, noisy breathing in a previously healthy baby and lots and lots of nasal mucus being made. And it's this time of the year. 

Now, the most common virus that is associated with bronchiolitis is respiratory syncytial virus or RSV, that's the virus that most commonly will do this. However, other viruses can cause a bronchiolitis sort of picture with lots of nasal congestion and noisy breathing, including influenza virus. So the flu can do this, too. 


Rhinovirus, coronavirus, human metapneumovirus, really, the viruses that's the cause of the common cold also can cause bronchiolitis. 

But respiratory syncytial virus or RSV is the most common one. This again, is very common. Lots and lots and lots of babies, in fact, nearly all children will have bronchiolitis by the age of two. Now, that doesn't mean that all of them have severe bronchiolitis. You know, infections can be mild, 

And in fact, the kids that we see with severe bronchiolitis are just sort of the tip of the iceberg. There's lots and lots and lots more kids who do not get severe symptoms with respiratory syncytial virus. And they just have a lot of nasal congestion and then they're better in a few days. 

So mild infections are possible. However, long lasting, more moderate to severe infections are also very common. And the kids over the age of two, so older kids and even adults, can also be infected with these viruses. 


And as we talked about with the croup, it may just show up as a cold for older kids and adult. But if you give that same virus to a baby, they could have very severe bronchiolitis with the same virus. So even though it just seems it's just like a mild cold for you, you still want to avoid handling babies and passing this on to them because it could show up as a whole different thing that's much more severe in the little babies.

So something to keep in mind, especially with the holidays here, and you're gathering together with family and friends. There's going to be babies there, and if you have a cold, this may not be the time to introduce yourself to those little ones. 

And bronchiolitis, as it turns out, is particularly dangerous for those with really small airways, like the babies, premature babies in particular, infants with underlying health conditions. So if you have a baby, they're premature and now they have bronchopulmonary dysplasia or BPD. Maybe they do have asthma or heart disease or metabolic problems. Kids with diabetes, heart disease as I mentioned.


And even older kids and adults, if you have a compromised immune system, if you have a problem with your immune system or you have cancer and you're on chemotherapy, any of these viruses can be much more severe for you and lead to more possible complications.

Now, how did these viruses make you sick with bronchiolitis? Just like with croup and with all viral infections, the virus infect cells and turns those cells into virus-producing factories and damage the cells in the process. Your immune system comes in, there's inflammation. There's cell turnover and it takes some time to make things right again.


With bronchiolitis, you can have mild short-lived illness for sure. But when there's more viral load, there's more cell damage, there's more cell turnover, more mucus production, then it can last a lot longer. 

And in particular, with RSV and bronchiolitis, there tends to be tons of mucus production. They just clogs the nasal passages, which is a problem for babies because babies are what we call obligate nose breathers. That means they only know how to breathe through their nose. 

And if their nose is stuffy, they're going to still try to breathe through that really stuffy nose, and that can cause difficulty breathing, struggling. They need to use more force to get the air through and around that mucus, so you can see them sucking in between their ribs with each breath.

Their nose might flare. Their belly's bouncing up and down. They're really working hard to breathe because they're trying to move air through a lot of mucus that's in their nose, because they do not know how to regulate their breathing and just start breathing through their mouth.


The tubes are there to do it, they just don't really know how to self-regulate and sort of change their breathing pattern from through their nose to through their mouth. 

So that's one reason that babies can get into trouble with this. And it's easier said than done, but getting that mucus out is going to be just so important for these babies. And a lot of them, that difficulty breathing, that respiratory distress when you really get all of that mucus out of there and they're able to breathe through their nose, they look like a completely different baby and they sound completely different. 

And so, for a lot of these kids, just getting rid of that nasal mucus is going to make a big big difference. Now, depending on how much small airways, so those bronchioles, how much inflammation and mucus and cell debris and turnover is down on those little airways, they can still have a lot of problems even when you get their nose cleared out. So when the virus sort of invades deeper into the bronchioles, then we have classic bronchiolitis. And those are the cases where it can really result in some severe symptoms. 


The typical symptoms of bronchiolitis are going to be, like we mentioned, the nasal congestion, coughing. Older kids will report a little bit of a sore throat sometimes, a headache. Wheezing can occur. And it may just sound like wheezing but it's really upper airway noise. Or there can be really wheezing from obstruction down deep in the lungs and difficulty with air moving out. 
Compared to stridor, which we talked about with croup, wheezing is typically more at least in the initial stages, with expiration, rather than when you breathe in. But you can have wheezing with breathing in and with breathing out. 

Rapid breathing -- and then, actually, once a baby is breathing rapidly for a long period of time, you get that respiratory rate up above 70 and keep it going for a long time, you start to get tired of breathing. And so, then kids can stop breathing or have periods of apnea and their blood oxygen level can go down. They can have what we call cyanosis. They can turn blue. 


We want to try to avoid getting to that stage. And so, if you have a baby who looks like they're having difficulty breathing, struggling to breathe, difficulty eating because they're working so hard to breathe, these are kids that you want to have seen right away. 

And call your doctor, get them in to a pediatric emergency department or urgent care, and if you're really worried, call 911. Have a low threshold in a baby who's having difficulty breathing of getting emergency medical services involved. 

Now, for the kids who, it's not quite as severe, there are some other reasons that maybe you would call your doctor or get your child seen. Maybe they're not having difficulty breathing but they have a fever that's lasting more than a couple of days. Or the fever comes back after it had gone away. 


Kids with bronchiolitis can often then get mouth bacteria that go up into the Eustachian tube and up into the middle ear and cause an ear infection. Bacteria from the mouth that's normally there can invade down into the lungs and cause a bacterial pneumonia. 

So in babies who they had the fever for a day or two with the onset of symptoms, they've had lots of nasal congestion, maybe some wheezing. And now they had a new fever, maybe they got a second virus and that's what's causing the new fever. But we do worry more about the possibility of ear infection or pneumonia. 

And so, it's important to have your child checked out. If they're really making a lot of noise when they're breathing and you can't tell, is it just nasal congestion? Or is there wheezing or is there stridor? Maybe you still don't really understand the difference between the two. Any noisy breathing that you're worried about, have your child seen. 

And, of course, if they're struggling or working hard to breathe or if they're not eating well because of their breathing or not making wet diapers, signs of dehydration, those kids need to be seen right away.

So how do we treat bronchiolitis? Well, so these viruses that caused it, there's no medicine to take care of killing the virus itself. So there's no antiviral for things like respiratory syncytial virus.


However, I mentioned, in some cases, the flu can cause a bronchiolitis-like picture. So if it is the flu, then that's a little bit different. But otherwise, it's really supportive care. 

So nasal saline and suctioning the... And you want to not be too invasive or suction too often in an invasive way because that can actually cause more nasal inflammation. 

One of the suction methods that worked really well is those human-powered suckers. One of the trade names is NoseFriday, there are others. And you just take some saline drops -- sterile saline, non-medicated -- that you can buy at any pharmacy. So it's just salt water and made as a nose spray. 


Those sprays, nose sprays, if you push the bottle hard upright, it sprays. But if you turn it upside down and push it a little more gently, the saline will drop out. And you put a few drops in one nostril at a time, let that sort of loosen up the mucus and suck it back out with your bulb syringe or one of those human-powered suckers, which has a filter. So the boogers are not going to get in your mouth. 

But those work really well in terms of really getting that mucus out of there, which is what you have to do with these little babies since they do not know how to breathe through their mouth. 

And then, if they have a fever, they just seem fussy and achy, giving babies acetaminophen. If they are from three months to at least six months of age, only use the acetaminophen or Tylenol. Once kids hit six months, then you can also use ibuprofen, trade names, Motrin and Advil and others.


So just helping kids feel more comfortable taking care of the fever, the aches can really perk them up, and sometimes, even eat better when they have those medications on board. Again, any baby less than two months of age who has a fever needs to be seen right away. Any difficulty breathing in young babies needs to be seen right away. 

And then, of course, pushing fluid -- breastfeeding still fantastic if they'll do it. Or expressed breast milk in a bottle, infant formula, Pedialyte, just whatever you can get in them from a fluid standpoint is going to be important. 

And then, just really close observation for worsening symptoms. 

Now, when I trained, so this is 25 years ago, we knew you do not give steroids for bronchiolitis. If you're sure it's bronchiolitis, it's not asthma, we don't use steroids for that because it's really more of a mucus issue than a straight inflammation issue. So steroids tend to not make it much better. And in fact, steroids do decrease your immune system's ability to fight infection and so they can actually works against you a little bit. 


Now, there's going to be some exceptions to that. There's kids who are going to have what we call reactive airway disease. Or they do have some bronchospasm when they have these viruses, especially if they were premature, if they have bronchopulmonary dysplasia, if there's a really strong family history of asthma. There may be more of a component of asthma in these little kids. 

And so, there are situations, again, this is where medicines is nuanced, where a steroid might be something to think about in a kid who you're not sure, is this really bronchiolitis or is this reactive airway disease or asthma? And you have some pretty good reasons to believe that it could be asthma, then some exceptions are going to be made.


So, as a general rule though, for a long time now, we've known you don't use steroids for bronchiolitis. Now, we have kids who are having difficulty breathing and they're wheezing and so we do think about albuterol and bronchodilators. When I learned to practice medicine, all of these babies would get albuterol. 

And then, it kind of morphed into, well, let's try it and see if it works. Well, you try something and it's got saline as part of the breathing treatment. I mean, there's also moisture in the... You see the mist as the medicine's delivered. And so, is that moisture loosening up mucus and that's why they sound better? Or is it really helping them? 

And for most of these kids, when you give them a breathing treatment, you listen again, they don't sound that much better. You can fool yourself into thinking they sound better. So we try it and it helps, keep doing it. If it doesn't help, then not do it. 

And now, the recommendations are really changing to if you're convinced it's bronchiolitis, don't use albuterol at all. It's just going to cause babies' heart rates to be elevated and make them anxious and have little tremor. And really, at that point, the side effects and the effects of the medications sort of outweigh any benefit that you get. 


Now, where am I getting this information? I think this is important because as practicing physicians, we all have different experiences. We learn to do things differently, as I mentioned in the show intro.

But in the case of bronchiolitis, we actually have a group of folks who have looked at all of the evidence that is in the scientific literature regarding bronchiolitis and sort of take all of that data from different studies and come up with one conclusion. So one guideline based on all the data that's out there.


And this is published by the American Academy of Pediatrics. It's called Clinical Practice Guidelines: The Diagnosis Management and Prevention of Bronchiolitis. And I'm going to put a link to it in the show notes. It was published in November of 2014.

And for the sake of transparency, I'm going to mention that when the American Academy of Pediatrics publishes policy statements, practice guidelines, any of their things, they technically are good for five years. And then in five years, they expire. 

And typically at that point, if there's nothing new said about it, most folks would still use those guidelines even though they'd expired because the evaluation process is still ongoing. And likely soon, there will be an updated version of the clinical practice guidelines, which may just reaffirm what was already said or there may be some changes. But in this case, we haven't heard anything yet.

And so, the most recent practice guidelines, they are slightly more than five years old, but it's all that we have to go on. And hopefully, we will hear something soon on whether that's reaffirmed. That doesn't mean that we go back to how we did it before. It just means that we haven't heard anything because these guidelines, they can be redacted, they can be revised even before that five years is up.


And this particular clinical practice guideline for bronchiolitis, it's not been reaffirmed but it also was not retired. It was not revised. There's nothing in the statement that we shouldn't use it anymore. 

There was one incorrect reference that was later they said there was a data point and they had referenced the wrong research for that particular statement. So that was just a minor correction. But the guidelines and recommendations themselves, we don't really have any evidence to show that those should change at this point, even though this particular guideline is technically expired. 

So this is going to be a little bit of shop talk now. And we do have a lot of pediatric providers, pediatricians, family practice doctors, nurse practitioners, physician assistants who listen to this program. And so I wanted to go a little bit more deeply into this clinical practice guidelines. 


And one reason for doing it is actually the last statement of the guideline because there's a long document where they really explained why they recommend what they recommend. But in the very beginning, it's just a list of bullet points of these are the recommendations. And the last recommendation is that clinicians and nurses should educate personal and family members on evidence-based diagnosis, treatment and prevention of bronchiolitis. 

So part of the guidelines is to educate all of you, whether you are a medical provider or even family members, of what it is that we should be doing and how we diagnose bronchiolitis and how we treat it, how we look for complications, and how we prevent it. And this is something that affects kids so much that it really is an important thing to consider especially this time of the year.


So what I wanted to do is just go through the recommendations as they're laid out. And then, anything that's kind of confusing explained. 

Now, one thing I love that the American Academy of Pediatrics does is with each of these recommendations, it lets you know the strength of the recommendation based on the quality of evidence that it's based on. So they're going to look at all of these different studies and say, "Okay, these are good studies," or "These are not so good studies." And then base the strength of that recommendation on the quality of what we know. 

So in terms of diagnosis, the first thing is that clinicians should diagnose bronchiolitis and assess disease severity on the basis of history and physical examination. So as we've said before, this is a clinical diagnosis. You don't have to test for the RSV virus. If it looks like bronchiolitis, smells like bronchiolitis, it is bronchiolitis, especially during bronchiolitis season. 

And the strength of the evidence is strong, so it's a strong recommendation that you're going to call it bronchiolitis and decide how severe it is based on how the kid looks and the history.


Clinicians should assess risk factors for severe disease such as age less than 12 weeks of age, history of prematurity, underlying cardiopulmonary disease or immunodeficiency when making decisions about evaluation and management of children with bronchiolitis. 

So it's not one size fits all. You have to take into account how old the kid is, were they premature? Do they have other chronic diseases including heart disease, lung disease and problems with the immune system as you decide what you're going to do. And that's a moderate recommendation based on the evidence. 

When clinicians diagnose bronchiolitis on the basis of history and physical examination, radiographic or X-ray or laboratory studies should not be obtained routinely. And, again, this is a moderate recommendation. 


You got to take into account all the data points. RSV testing might be useful for high-risk children because if they do have a cold and you find out that, yes, they have RSV and they're high risk, you're going to watch them more closely and be able to explain to the parents, "It's going to last longer, it's going to get more severe."

Usually around day four to six are sort of when things are going to get bad. And if you know at a high-risk kid, it's RSV, you can sort of prepare the parents for that. 

So there may be in role testing for RSV, not as a diagnosis of bronchiolitis, but to give the parents some idea of where this is going to go. But not routinely, only for maybe really high-risk kids. 

Chest X-ray, not routinely recommended but if you have a strong suspicion for pneumonia, there is a prolonged fever, there's return of fever, there's oxygen requirement that's not really consistent with the clinical picture. Those may be reasons then to go ahead and do an X-ray.


Again, moderate recommendation not to do lab studies or X-rays, but there may be some cases where you would do that. Okay, so moving on to treatment. Again, this is right from the guidelines. Clinicians should not administer albuterol to infants and children with a diagnosis of bronchiolitis. And that is a strong recommendation based on the quality of evidence. 

So if you're sure it's bronchiolitis and not asthma, especially these kids less than 12 months, then albuterol is not recommended. 

Also, clinicians should not administer epinephrine to infants and children with a diagnosis of bronchiolitis and that is also a strong recommendation. And again, we're talking about epinephrine to help them breathe, not if they are in cardiopulmonary failure and you're trying to resuscitate a child, then that's a different situation, and epinephrine would still be in play. But in terms of treating their bronchiolitis with epinephrine, that is not recommended. 


Nebulized hypertonic saline should not be administered to infants with the diagnosis of bronchiolitis in the emergency department. That's moderate recommendation. 

Clinicians may administer nebulized hypertonic saline to infants and children hospitalized for bronchiolitis. Although this is a weak recommendation based on the quality of evidence.

Clinicians should not administer systemic corticosteroid to infants with the diagnosis of bronchiolitis in any setting. And this is a strong recommendation. So this is a continued recommendation even from 25 years ago -- no steroids for bronchiolitis.

Clinicians may choose not to administer supplemental oxygen if the oxygen saturation exceeds 90% in infants and children with a diagnosis of a bronchiolitis. This is a weak recommendation that's based on low level evidence and reasoning from other principals. 


So, again, your child's doctor may sort of differ on this. At what point do you put kids with bronchiolitis on supplemental oxygen? If you're putting them on oxygen, they're also most likely getting admitted to the hospital. And so, what level of oxygen saturation, where's your arbitrary cutoff going to be when we check an oxygen saturation? 

It sort of shifted. It used to be, if it's below 95%, now we're saying, you may be able to say if it's less than 90%, if it's been between 90 and 94, it's still going to be sort of a judgment call.  Clinicians may choose not to use continuous pulse light symmetry for infants and children with the diagnosis of bronchiolitis, but this is a weak recommendation.

Clinicians should not use chest physiotherapy for infants and children with the diagnosis of bronchiolitis. So there's no reason to sort of beat and pound on their chest to help them get better. That's a moderate recommendation. 


And clinician should not administer anti-bacterial medications or antibiotics to infants and children with the diagnosis of bronchiolitis. Unless there is a known bacterial infection along with the bronchiolitis or there is a strong suspicion of one, such as pneumonia, ear infections, sinus infections. Although those are pretty unlikely in little babies, but possible. 

And that strength of recommendation is strong based on the quality of evidence. Antibiotics only if there's a bacterial infection that you strongly suspect or you know for sure.

And then, clinicians should administer either nasogastric or intravenous fluids for infants with the diagnosis of bronchiolitis who cannot maintain hydration orally. That's a strong recommendation. 

So again, kids who were working so hard to breath that they're not able to eat, they're not able to keep themselves hydrated, this would be a reason to admit them to the hospital with IV fluids. 


Now what about complications of bronchiolitis? The things that we're going to worry  about the most are going to be low blood oxygen because of difficulty breathing. Rapid breathing that leads to fatigue, and as I mentioned, apnea. So, now, you're breathing fast and you tire out and now you're not breathing as well. 

Respiratory failure, of course, pneumonia and ear infections and poor feeding and dehydration. All the things we kind of covered as we'd gone along here will be complications of bronchiolitis. 

And then, possible reasons for hospitalization. Again, if they need oxygen, if their oxygen saturation is persistently less than 90%, or between 90 and 94% if you're a bit more conservative, if they have rapid breathing that's persistently over 70 times a minutes, we worry about fatigue and respiratory failure being at a higher risk. 

Young babies who are less than a couple months of age who have bronchiolitis, we worry more about them and would be quicker to admit them to the hospital. 


And persistent increase work of breathing. So kids who are really struggling to breath, even if it's not quite 70 breaths per minute and they're 96% oxygen saturation. But they're working hard, they're retracting, their nasal flaring, they're grunting. Even after you've cleared out the nasal congestion, it's likely that they're not going to eat very well. And again, poor feeding, vomiting, dehydration, all of these would be reasons to admit these kids to the hospital. 

But as I mentioned, bronchiolitis and respiratory syncytial virus, or RSV, has kind of a bad reputation because most babies with severe respiratory illness that requires hospitalization this time of the year end up having RSV. 

And so you think, wow, this is a terrible disease because most of these kids who look bad and are bad end up in the hospital, that's what they have. But we have to keep in mind, most babies and kids with RSV and bronchiolitis do not end up in the hospital. 

There's some very serious cases and there are some babies unfortunately who dies from RSV bronchiolitis but most do well. And in many cases, the symptoms are similar to sort of a lingering hold. 


So we have to watch these kids. We have to teach parents what to watch for, which is why I'm going into all of these detail. When you have a baby who has a lot of nasal congestion, you take it hour by hour, sometimes, minute by minute, and just watch for them to get worse and have really low threshold for going in and being seen if things are getting bad. 

All right, what about prevention? So there is sort of passive short-lived protection for really high risk kids during RSV season. The trade name is Synagis. And this is a monthly injection that basically provides antibodies against RSV. It's really expensive and so we want to use it only in the kids who are most at risk. 


And so, as we consider the American Academy of Pediatric Guidelines with regard to prevention, we're going to talk about this. Clinicians should not administer Synagis to otherwise healthy infants with a gestational age of 29 weeks or greater. They should administer Synagis during the first year of life to infants with hemodynamically significant heart disease or chronic lung disease, prematurity defined as preterm infants who are less than 32 weeks gestation, who require 21% oxygen supplementation, greater than 21% oxygen. So the more than room air, they need some extra oxygen for at least the first 28 days of life. And that's a moderate recommendation. 

And then, when you are going to give Synagis, clinicians should administer a maximum of five monthly doses during the respiratory syncytial virus season to infants who qualify for it in the first year of life. 


So you don't have to memorize these things. They're in the guideline. That's a moderate recommendation, so as we think about who is going to get Synagis monthly injection during RSV season to protect their babies. 

The bottom-line is that the kids who are less than 28 weeks... Or, I'm sorry, less than 29 weeks, so 28 weeks or less preemies, those kids are going to definitely qualify.

And if you're 29 weeks or older, but still less than 32 weeks, and you have evidence of lung disease or heart disease, then you may qualify. 

So from a parent standpoint, you don't need to memorize any of these. Just if you have a premature baby or a baby who have  a long NICU stay in the newborn ICU or they have heart disease or chronic illness, you want to ask your doctor, "When it's RSV season, do I need this monthly shots?" And then, they can look up the current guidelines for you.


Okay, all people in terms of prevention, let's move away from the Synagis now. All people should disinfect hands before and after direct contact with patients, after contact within inanimate objects in the direct vicinity of the patient and after removing gloves. And that is a strong recommendation. So lots of hand washing by family members and medical providers. 

All people should use alcohol-based rubs for hand decontamination when caring for children with bronchiolitis. When alcohol-based rubs are not available, individuals should wash their hands with soap and water. Again, 20 seconds, sing that ABC song. And that is a strong recommendation.

Clinicians should inquire about the exposure of the infant or child to tobacco smoke when assessing infants and children for bronchiolitis. Irritation from smoke is going to make things worse and that's a moderate recommendation. 

Clinicians should counsel caregivers about exposing the infant or child to environment tobacco smoke and smoking cessation when assessing the child for bronchiolitis. And that is a strong recommendation. 


So really counseling our families that cigarette smoke can make this worse. And please stop smoking, that's going to be important to do.

Clinician should encourage exclusive breastfeeding for six months to decrease the morbidity of respiratory infections, so kids are healthier when they breastfeed for at least six months. And that is a moderate recommendation.

And then, I'm going to end with the first one. Clinicians and nurses should educate personnel, so folks you work with and family members on evidence-based diagnosis treatment and prevention of bronchiolitis. That's a moderate recommendation based on evidence, but it sure makes sense to me and that's why we are doing this right now. 

Again, I'm going to put a link to the Clinical Practice Guidelines: The Diagnosis, Management and Prevention of Bronchiolitis. It goes into way more detail from the American Academy of Pediatrics and I will put that in the show notes for this episode 447 over at


Another bottom-line thing that I think is going to be important is as we approach the holidays here, you're going to be going to parties, you're going to be going to family events, don't take your young or high-risk babies to those events, especially if there's going to be older kids or adults with colds.

It may just be a mild cold but it could be respiratory syncytial virus that's causing that cold or other viruses that in young babies can cause bronchiolitis. And so, you are exposing your child to bronchiolitis even if the adult has or the older kid only has a little bit of a cold. 

So if you have a high-risk baby, this may be the year to sort of take off from the holiday get-togethers. But you know, you could still get together by FaceTime or other ways online, remotely connect in to the party if you have a little one who's high risk.

And then, if you have a cold, even a mild one, avoid contact with babies. Wash your hands frequently, definitely before holding a baby. Although, if you have a cold please, just don't hold the baby. 
And don't touch or kiss other people's babies. What's with that? Don't do that. If you don't really know the parents and the family well, not a time to touch and kiss babies anytime of the year, in my opinion.


Also, I did write a blog post like I did on croup. It's called RSV and Bronchiolitis: What do I Need to Know. And I'll put a link to that in the show notes for this episode, 447, over at 



Dr. Mike Patrick: We are back with just enough time to  say thanks once again to all of you for taking time out  of your day and making PediaCast a part of it. Really do appreciate it.

If you've gotten this far in the program, you get an A+ because we definitely took a deep dive into croup and bronchiolitis. But consider yourself very well informed regarding this very common respiratory viral, respiratory infections. So I do want to thank all of you for supporting this program and for listening. 

Don't forget, you may find there is an easier way for you to stay up to date with all of our programs. We are in the Apple podcast app, which makes it really easy to subscribe and listen. We're in iTunes, Google Play, iHeart Radio, Spotify, SoundCloud and most mobile apps for iOS and Android.

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And there are things that we say now that in five years, we may be saying something different. And so we will evolve as our knowledge and evidence evolves. You can always count on that in this program. So let them know that's kind where we're coming from. 

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Thanks again for stopping by. Once again, I wish all of you the happiest of holidays, the merriest of Christmases, and a wonderful upcoming new year. I will see you on the other side of the 2020 dateline.

Until then, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long, everybody.


Announcer 1: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.

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