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Letters to the Editor


Ricart, Silvia MD; Garcia-Garcia, Juan José MD, PhD; Marcos, Maria Angeles MD, PhD

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The Pediatric Infectious Disease Journal: July 2015 - Volume 34 - Issue 7 - p 800-801
doi: 10.1097/INF.0000000000000731
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The term bronchiolitis refers to a pathologic description: inflammation of the bronchioles. Because these findings are rarely observed directly but inferred in an infant with respiratory distress and signs of viral infection, definitions of bronchiolitis differ between guidelines and studies.1 We agree that what we infer as bronchiolitis in an infant less than 6 months of age is not the same disease as virus-induced wheezing in 12-to-24-month-old. Recent American Academy of Pediatrics guidelines2 no longer recommend systematic use of salbutamol to infants with a diagnosis of bronchiolitis (evidence quality B; strong recommendation). However, clinical experience indicates that inhaled sympathomimetics are an effective treatment in infants older than 12 months. Moreover, apnea is an uncommon manifestation of bronchiolitis (3.9–6.7% in our study,3 which affects almost exclusively young infants: 72.5% of the infants with apnea in our cohort had a postconceptional age <44 weeks). This also suggests that age plays an important role in the spectrum of symptoms after an acute respiratory viral infection in young children. It is difficult to establish a definite cutoff age because there is a clinical overlap in many of the infants, with some crackles and wheezing but partial response to sympathomimetics. However, to classify cases according to the etiology as suggested by Korppi et al4 is not a practical approach because there is a high rate of viral coinfections, and multiple rapid viral testing is not available in many settings. Although the best way to study the role of each respiratory virus in the development of apnea would be a multivariate analysis, because of the several potential risk factors, confounders (including the 15 respiratory viruses, age, underlying illnesses, prematurity, tobacco use in households, in utero smoke exposure, coinfections, maternal lactation, air pollution, days of illness) and the low rate of apnea, this analysis was not feasible in our study. Large, multicenter studies addressed to determine the clinical, environmental and viral factors involved in apneas would be needed to determine the exact role of RSV in development of apnea. What our study adds is that not only RSV is responsible for apnea in a bronchiolitis context because we have identified other respiratory viruses that are also involved. Other studies did not find an association between specific respiratory virus and the risk of apnea,5 but demonstrated corrected age <8 weeks as an independent risk factor for apnea. Age plays a critical role in the spectrum of manifestations of viral respiratory infections. Certainly, age limits in bronchiolitis are needed.

Silvia Ricart, MD

Juan José Garcia-Garcia, MD, PhD

Department of Pediatrics, Hospital Sant Joan de Déu

Universitat de Barcelona

Barcelona, Spain

Maria Angeles Marcos, MD, PhD

Department of Microbiology

Barcelona Centre for International Health Research (CRESIB, Hospital Clinic – Universitat de Barcelona)

Barcelona, Spain


1. Zorc JJ, Hall CB.. Bronchiolitis: recent evidence on diagnosis and management. Pediatrics. 2010;125:342–349
2. Ralston SL, Lieberthal AS, Meissner HC, et al.American Academy of Pediatrics. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014;134:e1474–e1502
3. Ricart S, Rovira N, Garcia-Garcia JJ, et al. Frequency of apnea and respiratory viruses in infants with bronchiolitis. Pediatr Infect Dis J. 2014;33:988–990
4. Korppi M.. Bronchiolitis: the disease of <6-month-old, <12-month-old or <24-month-old infants? Pediatr Infect Dis J. 2015;34:799–800
    5. Schroeder AR, Mansbach JM, Stevenson M, et al. Apnea in children hospitalized with bronchiolitis. Pediatrics. 2013;132:e1194–e1201
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