Home            Past Issues            About IP            About IAP           Author Information            Subscription            Advertisement              Search  


Indian Pediatr 2014;51: 2364-235

Authors’ Reply

Rakesh Lodha and SK Kabra

Email: skkabra@hotmail.com 

We thank Dr. Sharma for her interest in our article [1]. We provided an evidence-based update on management of bronchiolitis. Unfortunately, there are gray areas where there is inadequate evidence to guide the management.

We do appreciate that there may be difficulty in clinically differentiating between bronchiolitis or viral bronchopneumonia or wheezing due to asthma. There may be certain indicators for asthma like multiple previous similar episodes or family history of atopy/asthma.

The definition mentioned in the AAP guidelines is of little clinical relevance as it describes the pathophysiologic process in bronchiolitis [2]. It is further complicated by other phenotypes of wheezing, including transient wheezing during infancy, episodic and multi-trigger wheezing [3]. We mentioned that some authors have used the definition ‘the first episode of wheezing in a child younger than 12 to 24 months who has physical findings of a viral respiratory infection and has no other explanation for the wheezing, such as pneumonia or atopy’; it is important to note the later part of the definition highlighting that there is no other explanation for the wheezing. A child with repeated episodes of wheezing may have bronchiolitis but other conditions like wheeze-associated lower respiratory infection, multi-trigger wheeze/ asthma are more likely.

As mentioned by the author, there is little evidence to support use of steroids or bronchodilators. Some of the children clinically diagnosed as bronchiolitis may have asthma which responds to bronchodilators; this is the rationale for a trial of bronchodilators. It will not be advisable to use therapies that have not demonstrated any benefits in clinical trials.

There are various clinical scores which include measures of respiratory rate, respiratory effort, severity of wheezing, and oxygenation. The most widely used score is Respiratory Distress Assessment Instrument [4]. However, none of the clinical evaluation scores have been found to be predictive of outcomes, or validated for use to titrate therapy [2].


1. Verma N, Lodha R, Kabra SK. Recent advances in management of bronchiolitis. Indian Pediatr. 2013;50:939-49.

2. American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics. 2006;118:1774-93.

3. Brand PL, Baraldi E, Bisgaard H, Boner AL, Castro-Rodriguez JA, Custovic A, et al. Definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach. Eur Respir J. 2008;32:1096-110.

4. Lowell DI, Lister G, Von Koss H, McCarthy P. Wheezing in infants: the response to epinephrine. Pediatrics. 1987;79:939-45.


Copyright 1999-2014 Indian Pediatrics