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In November 2019, the Haute Autorité de Santé (HAS) updated its recommendations for the treatment and management of acute bronchiolitis in infants under 12 months of age.
Until then in France, respiratory physiotherapy was placed at the center of care, even though it is not at all in most of our European and North American neighbors.
Criticized, the physiotherapy method consisted of unclog the baby’s bronchi in a series of maneuvers and manipulations sometimes impressive, and possibly distressing for the baby.
It turns out that after analyzing the results of the international scientific literature on the subject, the HAS experts (18 in the working group, including 4 physiotherapists) considered that it was not possible to observe a proven beneficial effect of respiratory physiotherapy in the management of bronchiolitis.
Until further notice, respiratory physiotherapy for bronchial de-congestion is therefore more recommended, both in city medicine and in hospitals.
Member of the panel of experts who drafted the new recommendations, Prof. Christèle Gras-Le Guen, head of the Pediatrics department of the Nantes University Hospital, sees no place for respiratory physiotherapy in the event of bronchiolitis, in young babies without associated pathology. . She believes that this approach “whose effectiveness has not been demonstrated for the child rather complicates the life of parents, is not pleasant for the baby, does not improve his state of health and is expensive for Social Security”, Hence its withdrawal from the official recommendations of the HAS.
“We do not say that physiotherapists do not have a major role, but simply that in the case of bronchiolitis, there is no service rendered to the child, and that it has become urgent to use their undisputed skills to take charge of pathologies where their intervention is much more important”, Specifies Pr Gras-Le Guen.
Note: Already excluded in the recommendations formulated in 2000, the old techniques, known as Anglo-Saxon, of bronchial de-congestion (vibration, clapping and postural drainage) are definitely banned and should no longer be used, re-specified the High Authority of Health. In its recommendations, the HAS further recalls that most drugs have no place in the management of acute bronchiolitis: “Bronchodilators, adrenaline, hypertonic saline or routine antibiotic therapy have no indication in this disease.“
What is bronchiolitis?
To understand why respiratory physiotherapy is no longer recommended by the HAS in the treatment of bronchiolitis, it is necessary to recall what bronchiolitis is. It is a viral disease for which there is no specific treatment. “Management is above all symptomatic”, Recalls Pr Christèle Gras Le Guen, pediatrician at Nantes University Hospital. It consists, for example, in prescribing paracetamol to improve the comfort of the infant.
Bronchiolitis affects the bronchioles (small bronchi) of infants and is characterized by an episode of difficulty breathing, the signs of which are coughing and rapid wheezing. Mostly benign, “its acute phase lasts an average of ten days, and the first two days require increased attention from the infant”Says the HAS.
Even so, bronchiolitis is a very contagious disease, affecting around 480 children each winter. The seasonal epidemic typically begins in mid-October, peaks in December, and ends in late winter. 000% of infants under 30 are affected each winter, and 2 to 2% of infants under one year are hospitalized for bronchiolitis each year, according to health authorities.
Also, both for the sake of action and to reassure parents, at first, the medical community – which may have felt helpless – turned to respiratory physiotherapy for bronchial clearance. This then took a prominent place in the care in France, “and this without there being solid scientific elements to affirm that this technique improves the state of health of the infant”, Underlines Pr Gras-Le Guen.
Rarely, it may even happen that respiratory physiotherapy is against-productive, for example in a baby who is already very tired and already has difficulty breathing, or when the child’s condition is already too precarious.
Professor Gras-le Guen assures us that the HAS experts do not however wish to convey the idea that physiotherapy is a dangerous practice: “The message is simply: beware, respiratory physiotherapy has not been shown to help children with bronchiolitis heal better or faster.“.
Bronchiolitis: which treatment and which management?
The main part of the management of bronchiolitis involves three actions:
- relieve the discomfort of the child, especially in case of fever, using paracetamol;
- unblock and declutter the nose of the baby usingeffective washing with physiological serum (a technical gesture that must be taught to parents). Because “the anatomy is such in the infant that nasal breathing predominates and the very young child cannot breathe only through the mouth”, Explains Professor Gras-Le Guen;
- split the baby’s feeding so that he gets enough food (for example with two 50 ml bottles spaced instead of one 100 ml), making sure that he takes about half of his usual rations.
“In all cases, if the child is embarrassed to breathe and / or has a fever, it is advisable to consult his or her attending physician or another on-call physician. in a nursing home for example”, Indicates the head of department in pediatrics. Prof. Gras-Le Guen adds that bronchiolitis lasts 8 to 10 days, during which the child will be “uncomfortable“,”bad sleep“And”eat less“. In short, it’s a bad time to spend, you have to help and watch him above all to make sure it doesn’t run out.
If despite these first actions, the child’s condition does not improve or even worsen, it is imperative to consult again. “If babies under three months old need to be seen in an early consultation, babies under six weeks old with symptoms suggestive of bronchiolitis may be taken directly to the emergency room, because the vast majority will be kept in hospital”, Further specifies Professor Gras-Le Guen.
The importance of sleeping and breastfeeding assistance
Little known, other non-drug approaches are very important in the management of bronchiolitis. “During an ongoing infection in an infant, special care should be taken in their sleeping positions.”, Indicates Pr Gras-Le Guen. That is to say : no bed bumper, no soft toys in the bed, a bed on the back and not too covered, no inclined plane (on which the child risks slipping). In addition, because a toddler with bronchiolitis does not breastfeed well, his mother may find herself helpless when breastfeeding. She then needs help and advice to overcome this milestone and not give up: expressing her milk, giving the baby milk in a different way, etc.
When is respiratory physiotherapy recommended for an infant?
If it is not recommended for the management of bronchiolitis without other associated pathology, respiratory physiotherapy “can be discussed in children in the event of comorbidities (eg: chronic respiratory pathology, neuromuscular pathology)”, Estimates the HAS in its recommendations of November 2019.
“There are other chronic respiratory pathologies (such as cystic fibrosis for example), neurological or even trauma where respiratory physiotherapy is an integral part of the care”, Underlines Pr Gras-Le Guen. “The physiotherapist has a major role in the care of an infant suffering from a chronic disease“.
Physiotherapy, a role and a place to rethink in the management of bronchiolitis
Until then very involved and very busy in the management of bronchiolitis, physiotherapists risk suffering from these new recommendations, losing a significant part of their activity. In the months and years to come, the physiotherapy network will therefore have to reflect on and rethink its place in the management and monitoring of bronchiolitis epidemics.
Apart from the bronchial decluttering manipulations, the physiotherapist can act by evaluating the state of health of the baby, and by unclogging the baby’s upper airways (in other words the nose) with physiological serum. As we have seen, in infants, nasal breathing is predominant, also teaching young parents how to wash the nose is essential to cope with an episode of bronchiolitis.
Sources and additional information:
- Management of the first episode of acute bronchiolitis in infants less than 12 months of age, HAS recommendations, November 2019
- Tool sheet for parents: 1st episode of acute bronchiolitis, HAS, November 2019