It almost always starts like a cold. The nose blocks up, a cough appears, the baby feeds worse and sleeps worse. For many babies, that is as far as it goes. But in some, two or three days later, the breathing changes: it becomes faster, harder, more tiring.
This is bronchiolitis: a viral infection of the smallest airways, the bronchioles, which affects children under two years old, mostly in the first year of life, peaking between 3 and 6 months. Respiratory syncytial virus (RSV) is the most common cause. In most cases, the illness is mild and needs no specific treatment or hospital stay. But it does require parents to recognise the moment when a baby needs more than rest and cuddles.
Symptoms are often at their worst between the third and fifth day of illness. Babies under three months, premature babies and those with certain pre-existing conditions are at higher risk of developing severe forms.
We have already explained on this blog what bronchiolitis is, its causes and its symptoms. Here, we answer three questions that parents ask us: when should I worry, what can I do at home, and how can respiratory physiotherapy help.
When not to wait
The guidance from NICE (the UK’s National Institute for Health and Care Excellence) recommends immediate referral for emergency hospital care if any of these signs is present:
- pauses in breathing (apnoea), observed or reported;
- intense breathing effort: grunting with each breath out, ribs and chest “sinking in” with each breath, or very fast breathing (more than 70 breaths per minute);
- a bluish colour around the lips or tongue;
- a baby who looks very unwell.
In these situations, call 112.
Even without these emergency signs, it is important to seek medical assessment if the baby is breathing faster than usual, especially above 60 breaths per minute, is feeding much less (about half to three quarters of the usual amount) or shows signs of dehydration, such as noticeably fewer wet nappies.
To count breaths, watch the baby’s chest for a full minute while they are calm. If in doubt, SNS 24, Portugal’s national health line (808 24 24 24), can guide you.
What you can do at home
Treatment of bronchiolitis is mainly supportive: keeping the baby hydrated, comfortable and with a clear nose. Saline can help ease a blocked nose, particularly before feeds, when needed.
If the baby tires while breastfeeding or eating, smaller and more frequent feeds are usually better tolerated.
During sleep, the baby should continue to sleep on their back, on a firm, flat surface, without pillows or a raised mattress.
Bronchodilators and corticosteroids are not routinely recommended in bronchiolitis. Do not give medication without medical advice.
How respiratory physiotherapy can help
When a baby is breathing with effort, it is natural for parents to look for ways to help them breathe better. Respiratory physiotherapy can have a role in specific clinical situations, but it is not routinely recommended in bronchiolitis.
NICE does not recommend chest physiotherapy for babies with bronchiolitis who have no other relevant clinical conditions, such as spinal muscular atrophy or severe tracheomalacia, and accepts a physiotherapy assessment when those conditions make it harder to clear secretions.
The decision to intervene always depends on the baby’s assessment, the severity of the symptoms and the presence of other clinical conditions. When there is a clinical indication, we may use techniques adapted to the baby’s age and condition, aiming to improve their breathing comfort.
In practice, we start by assessing the baby, their breathing and their comfort. We try to understand their needs and decide on the most appropriate approach, always with the parents present and in a calm environment.
Parents also have a key role. We teach nasal hygiene strategies, help you recognise changes in breathing and explain which signs need medical assessment.
It is often this guidance that gives confidence back to those at home, at three in the morning, with a baby who is breathing with difficulty.
Research has helped us understand better the role of respiratory physiotherapy in bronchiolitis. A 2023 Cochrane review and studies such as FIBARRIX identified possible benefits of slow expiratory techniques in babies with moderate bronchiolitis, mainly in hospital settings. However, the evidence is still limited and clinical guidelines do not recommend respiratory physiotherapy as routine. The decision to intervene should therefore always be individualised.
The role of Physiotherapy at Physioclem
At Physioclem, Respiratory Physiotherapy supports people of all ages, including babies and children, through an individualised approach, specific techniques when indicated and teaching strategies to families.
But bronchiolitis demands more than technique: it demands judgement.
Before intervening, we assess the baby, the clinical context and, whenever necessary, coordinate with the baby’s paediatrician.
The question that guides us is not “what can we do?”, but “what helps this baby, right now?”.
Sometimes the answer is a specific intervention. Sometimes it is teaching the parents and supporting them. Sometimes it is referring the baby for urgent medical assessment.
When a baby breathes with effort, the most important thing is not to do more. It is to understand better.
Sources
Roqué-Figuls, M., Giné-Garriga, M., Granados Rugeles, C., Perrotta, C., & Vilaró, J. (2023). Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old. Cochrane database of systematic reviews, (4), CD004873.
Conesa-Segura, E., Reyes-Dominguez, S. B., Ríos-Díaz, J., Ruiz-Pacheco, M. A., Palazón-Carpe, C., & Sánchez-Solís, M. (2019). Prolonged slow expiration technique improves recovery from acute bronchiolitis in infants: FIBARRIX randomized controlled trial. Clinical rehabilitation, 33(3), 504.
National Institute for Health and Care Excellence. (2021). Bronchiolitis in children: diagnosis and management (NG9). NICE. https://www.nice.org.uk/guidance/ng9
