Treatment of Infants Admitted With Acute Bronchiolitis and its Comparison with Modern Treatment Methods in the Only University Hospital in Rafsanjan

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A review of the studies revealed that different centers use different therapeutic approaches, such as the use of corticosteroids, bronchodilators, racemic epinephrine, antibiotics, ribavirin, hypertonic saline, and physical therapeutic techniques (13) for control of the disease. Oxygen therapy is indicated in children with low hemoglobin saturation (14). There is insufficient evidence to support the routine use of bronchodilators in bronchiolitis (15). Racemic epinephrine may be more appropriate than salbutamol or a placebo in an emergency, but there is little evidence of its use in the admitted population (16). Secondary bacterial infection is also uncommon in bronchiolitis, so the use of antibiotics is unnecessary unless the severe clinical condition requires intensive care unit (ICU) admission (17). Inhalation or systemic corticosteroids are also not recommended in many studies (18,19). According to numerous evidence since 1950, supportive therapies have been most effective, and the prescription of some of these treatments is not indicated and is not based on strong scientific evidence, or their use has been accompanied by an increase in the length of hospital stay without reducing the chance of readmission (9).

Objectives
We aimed to evaluate the most common risk factors for acute bronchiolitis in infants and to evaluate the treatment used and compared it with different modern therapeutic approaches used in children with acute bronchiolitis admitted to a university hospital.

Methods
This descriptive study was conducted in the only teaching hospital in Rafsanjan city. All infants who were diagnosed with acute bronchiolitis and admitted to the pediatric ward of Ali-Ibn Abi Talib Hospital in Rafsanjan in the second half of 2016 (n = 100) were included by census method. It should be noted that Rafsanjan city is located in the north of Kerman province and has a rural and urban population of 270 000 and this hospital is the only public hospital in this area, and patients of this city refer to it. The diagnosis of acute bronchiolitis was based on specialized physicians' diagnosis based on the symptoms of coughing, runny nose, wheezing, and a clinical examination based on the hearing of the wheezing in the entire lungs and the rejection of other differential diagnoses (20).
Patients' information was collected in a researchermade checklist after obtaining their consent and ensuring the confidentiality of their information. After receiving the Ethics Committee Code (IR.RUMS.REC.1394.216), a written informed consent form was taken before entering the study. The checklist information includes age, sex, gestational age, birth weight, nutrition, birth season, birth rank, history of exposure to cigarette or tobacco smoke, history of chronic lung and heart disease, and other diseases affecting the course of the disease and the weight growth status of infant, as well as all necessary therapeutic actions were performed on the patient and admission time.
Given the high cost of diagnostic procedures for diseases such as chronic lung disease, chronic heart failure, immunodeficiency, abnormal nervous system and other congenital malformations, cerebral palsy, Down syndrome, and cystic fibrosis, diagnosis of the mentioned cases was made only on the basis of interview, self-declaration of parents and, if possible, clinical examination. The risk factor for malnutrition was also investigated by the researcher by examining growth charts related to infants.
The inclusion criteria were living in Rafsanjan city and surrounding villages, the age range of infants and children up to 24 months, having informed consent to participate in the study. The exclusion criteria were an incomplete checklist, infant death during the study, and transferring the patient to another center for any reason. The data were analyzed using SPSS software, version 20. After ensuring the accuracy of data entry, they were analyzed using descriptive statistics.

Results
We studied 100 admitted infants, 62 (62%) of whom were boys, and 38 (38%) were girls. The mean ± SD age of the infants was 107 ± 10.60 days (range: 10 to 605 days). 70% of the children were exclusively breastfed. Also, infection was most prevalent in children under three months (34%), and infection was more common in boys (62%), infants born in autumn (60%), malnourished infants (60%), infants with history of exposure to cigarette smoke (91%), and infants with low birth weight (71%). Heart failure, cerebral palsy, Down syndrome, cystic fibrosis, and immunodeficiency were not seen in any of the patients, and a history of chronic lung disease was reported in only 4% of the patients. In the present study, the most common age groups in infants were less than 50 days (34%) followed by 50-100 days (24%). Also, 22% of the infants were preterm (Table 1).
With respect to treatment, we found that in addition to supportive treatments such as liquid therapy (93%) and oxygen therapy (37%), 79% of the infants received antibiotics, 37% received corticosteroids, 41% received bronchodilators, and 3% received epinephrine (Table 2).

Discussion
The main objective of this study was to evaluate the treatment of children with acute bronchiolitis. Besides supportive therapies, such as liquid therapy and oxygen therapy, 79% of the infants received antibiotics, 37% received corticosteroids, 41% received bronchodilators, and 3% received epinephrine. Since 1950, all effective hmj.hums.ac.ir http therapies for acute bronchiolitis have been largely supportive (9). In fact, the most important innovation in the treatment of acute bronchiolitis was a non-invasive supportive treatment of oxygen supply through the nasal cannula, which was safe, feasible, and cost-effective. Additionally, based on the latest clinical guidelines provided by the American Academy of Pediatrics (AAP) (21) and the National Institute of Health Care (NICE) (22), when the oxygen saturation is less than 90% (AAP) or 92% (NICE) of the reference level, nasogastric or intravenous prescription of oxygen supplementation and oral fluid therapy are recommended.
The important point is that both the AAP and NICE guidelines agree on avoiding the use of antibiotics, hypertonic saline, montelukast, ipratropium bromide, unstable albuterol, salbutamol, adrenaline, and prescription of systemic and inhaled corticosteroids and anti-viruses. Moreover, in examining the Cochrane meta-analyses, the prescription of antibiotics did not affect the disease (23), and the use of bronchodilators in the treatment of acute bronchiolitis had no effect on oxygen saturation and did not reduce hospital admissions or shorten the admission time in infants (24). It should be noted that the main reference for pediatric medicine also states that antibiotics should not be used in patients with bronchiolitis, except for cases susceptible to bacterial infection. Reviewing the literature on the prediction of effective treatments in the future can help prevent the onset of acute bronchiolitis because of the mass production of an RSV vaccine, which is under further clinical studies (25). Another ideal strategy in the treatment of acute bronchiolitis in the future is the use of antiviral drugs (26) or an herbal mucolytic drug, which is able to destroy the terminal bronchioles. Moreover, many studies have been reported on the use of DNAase, and their results are still being discussed (27,28).
In contrast to these guidelines, which have a high level of evidence, several studies have shown wide variation   (29)(30)(31). As shown in the results of the present study in the evaluation of treatment, other than supportive therapies such as fluid therapy (93%) and oxygen therapy (37%), children were treated with considerable amounts of antibiotics, corticosteroids, bronchodilators, and a small percentage of epinephrine. Therefore, there is a large gap between the methods and treatment approaches of this center with up-to-date and valid international guidelines.
The main risk factors associated with the incidence of acute bronchiolitis in the present study included smoking by parents (91%), malnutrition (60%), the peak age of incidence of diseases under three months, and male sex. In addition, 22% of the infants were preterm, and 30% were fed with milk other than breast milk. Hubble and Osborne explained the clinical aspects of acute bronchiolitis in the British Medical Journal for the first time in 1941. They introduced the disease as a disease associated with influenza in children aged less than 2 years. They also reported that its incidence was associated with social components affecting health, such as belonging to poor classes, malnutrition, living in limited space, and close exposure to infections (32).
In a study conducted on 304 infants with acute bronchiolitis, a history of preterm birth significantly led to poor treatment outcomes and increased need for mechanical ventilation (P = 0.002), more ICU admissions, and increased admission time (P = 0.021 and P < 0.0001) in infants (33). Also, in a study on 1814 children, nonbreastfed children were at a higher risk of admission because of acute bronchiolitis (HR: 1.57; 95% CI: 1.00-2.48) (34). The direct effect of smoking by parents on the development of asthma and acute bronchiolitis in children was reported in a meta-analysis (35). In a study published in Mexico in 2018, the odds ratio of acute bronchiolitis in children exposed to smoking was also more than that of other children (OR, 3.5; 95% CI, 1.99-6.18; P = 0.0001) (36).

Conclusion
In this study, the large gap between treatment methods and approaches with up-to-date and valid international guidelines and the lack of native guidelines, as well as the high prevalence of risk factors such as exposure to cigarette smoke and malnutrition, required better education of mothers in areas such as child nutrition, education, the provision of smoking cessation facilities for parents, and the promotion of breastfeeding. Also, compiling local treatment and care instructions for these patients to be used in medical centers would be useful.