The doctor can usually identify the problem by observing your child and listening to his or her lungs with a stethoscope. Despite its viral cause, antibiotics are often prescribed. Most of the included studies did not report on the primary outcomes of wheeze, crepitations and fever. Can Bronchiolitis Be a Problem for Babies? You can also get saline (salt water) drops to put inside the nostrils and help keep the nose clear. We combined three studies comparing azithromycin versus placebo and again did not demonstrate a significant difference between antibiotics and placebo in the duration of oxygen requirement. In bronchiolitis, the virus usually causes the small airways … It is often caused by respiratory syncytial virus (RSV). In most children bronchiolitis can be managed at home by parents or carers. There was no significant difference between the two groups for length of illness and there were no deaths in either group. RSV is transmitted through contact with respiratory droplets either directly from an infected person or self-inoculation by contaminated secretions on surfaces. Glucocorticoids for acute viral bronchiolitis in infants and young children under two years of age, Epinephrine for acute viral bronchiolitis in children less than two years of age, Chest physiotherapy for acute bronchiolitis in children younger than two years of age, Magnesium sulphate for treating children up to two years old with bronchiolitis, Nebulised deoxyribonuclease for viral bronchiolitis in children younger than 24 months, Respiratory infections: bronchitis & bronchiolitis. Despite its viral cause, antibiotics are prescribed in 34 to 99% of cases. The data available are protected by copyright and may only be used in accordance with the Terms and Conditions. Antibiotics need to be used cautiously owing to potential for side effects, cost to the patient and the community and increasing bacterial resistance to antibiotics. Antibiotics for bronchiolitis in babies. : CD005189. In SE Asia; monsoon plays a major role in causing, promoting and spreading various viral infections in children including flu, pneumonia and bronchiolitis. It is most commonly caused by a virus called respiratory syncytial virus or RSV. OBJECTIVES:To evaluate the use of antibiotics for bronchiolitis. Bronchiolitis is managed with supportive care; there are no medicines or interventions that can be administered in primary care which are effective at reducing symptoms or the likelihood of deterioration. Search methods Bronchiolitis is a serious respiratory illness that often affects young babies. If you have a Wiley Online Library institutional username and password, enter them here. We identified seven trials (824 participants) comparing antibiotics with placebo or no antibiotics in children with bronchiolitis. Data were analysed using Review Manager software, version 4.2.7. Tests and X-rays are not usually needed to diagnose bronchiolitis. Two of these studies also compared intravenous and oral antibiotics. Antibiotics are not recommended for bronchiolitis unless there is concern about complications such as secondary bacterial pneumonia. Request PDF | Antibiotics for bronchiolitis in children | Background: Bronchiolitis is a serious, potentially life-threatening respiratory illness commonly affecting babies. It most commonly affects babies between 3 and 6 months of age. Symptoms of bronchiolitis include runny nose, congestion, and mild cough. There is no specific treatment for RSV or the other virus that cause bronchiolitis. Patients with RSV bronchiolitis usually present with two to four days of upper respiratory tract symptoms such as fever, rhinorrhea, and congestion, followed by lower respiratory tract symptom… Prior to this only three small RCTs had examined antibiotics versus placebo, with only 72 participants in the antibiotic arms and 72 participants in the placebo arms. Bronchiolitis is almost always caused by a virus. Bronchiolitis is a serious, potentially life-threatening respiratory illness commonly affecting babies. 91 Citations (Scopus) There were no deaths reported in any arms of any of the seven included trials and none of the studies specifically reported on adverse effects of antibiotics. For length of hospital stay, we combined data from three studies comparing the use of azithromycin versus placebo as a subtotal as part of the overall analysis of the effect of antibiotics on hospital stay. Antibiotics for early-onset neonatal infection (see early-onset neonatal infection) ... Bronchiolitis in children Cerebral palsy Child abuse and neglect Constipation Depression in children and young people Diabetes in children and young people ... Looked-after babies, children and young people Bronchiolitis is a common lower respiratory tract infection in infants and young children, and respiratory syncytial virus (RSV) is the most common cause of this infection. Here we explain the causes and symptoms of bronchiolitis, the treatment available and where to get help. Diagnosis is usually made on clinical grounds (especially tachypnoea and wheezing in a child less than two years of age). Farley R, Spurling GKP, Eriksson L, Del Mar CB, Farley R, Spurling GKP, Eriksson L, Del Mar CB. The baby may have to be hospitalized only in severe cases of illness. Types of participants: children under the age of two years diagnosed with bronchiolitis using clinical criteria (including respiratory distress preceded by coryzal symptoms with or without fever). Cochrane Database of Systematic Reviews 2014, Issue 10. In 2011/12 in England, there were 30,451 secondary care Nevertheless, they are often used. Antibiotics are not recommended for bronchiolitis unless there is concern about complications such as secondary bacterial pneumonia. Types of interventions: oral, intravenous, intramuscular or inhaled antibiotics versus placebo. Babies and children can be given paracetamol to treat pain or fever if they're over 2 months old. By the age of 2, almost all infants will have been infected with RSV and up to half will have had bronchiolitis. Antibiotics are not recommended for bronchiolitis unless there is concern about complications such as secondary bacterial pneumonia or respiratory failure. Typically, the peak time for bronchiolitis is during the winter months.Bronchiolitis starts out with symptoms similar to those of a common cold but then progresses to coughing, wheezing and sometimes difficulty breathing. It is often caused by respiratory syncytial virus (RSV). While expectorants are used for thinning and loosening phlegm, bronchodilator inhalers help to open up the inflamed air passages, thereby relieving symptoms like wheezing and breathing trouble. The results of these seven included studies were often heterogeneous, which generally precluded meta-analysis, except for deaths, length of supplemental oxygen use and length of hospital admission. We wanted to discover if antibiotics improved or worsened clinical outcomes in children with bronchiolitis. Approximately 1 in 3 infants will develop clinical bronchiolitis in the first year of life and 2–3% of all infants require hospitalization. It is often caused by respiratory syncytial virus (RSV). Antibiotics are not helpful because they treat illnesses caused by bacteria, not viruses. DOI: 10.1002/14651858.CD005189.pub4, Copyright © 2021 The Cochrane Collaboration. Bronchiolitis is a common lung infection in young children and infants. While babies and toddlers don't often get bronchitis, they do commonly get bronchiolitis. Antibiotics are not recommended for bronchiolitis unless there is concern about complications such as secondary bacterial pneumonia or respiratory failure. No other adverse effects were reported. Bronchiolitis is the leading cause of hospitalization for first-year-old US babies. Version published: 24 January 2007 Version history. This makes it more difficult for babies to breathe and feed normally. Research may be justified to identify a subgroup of patients who may benefit from antibiotics. Top 37 Effective Home Remedies For Bronchitis In Babies And Adults 1. Bronchiolitis is a very common illness in babies during the fall, winter, and early spring. It causes inflammation and congestion in the small airways (bronchioles) of the lung. Bronchiolitis Bronchiolitis is a chest illness caused by a virus which makes the tiny air passages in your baby’s lungs become inflamed. The three studies providing adequate data for days of supplementary oxygen showed no difference between antibiotics and placebo (pooled mean difference (MD) (days) -0.20; 95% confidence interval (CI) -0.72 to 0.33). Better health. No new unpublished data have been included. Sections without translation will be in English. It showed that antibiotics are no better than placebo at reducing the length of illness of bronchiolitis. https://doi.org/10.1002/14651858.CD005189.pub2, Individual access - via Wiley Online Library, data are only available for Cochrane Reviews that contain one or more forest plots; and. Antibiotics are not recommended for bronchiolitis unless there is concern about complications such as secondary bacterial pneumonia. While the majority of babies who get it do just fine, some can get very sick. Sympto… Randomised controlled trials (RCTs) comparing antibiotics to placebo in children under two years diagnosed with bronchiolitis, using clinical criteria (including respiratory distress preceded by coryzal symptoms with or without fever). We searched the Cochrane Central Register of Controlled Trials (CENTRAL) which includes the Acute Respiratory Infection Groups' specialized register, the Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library 2006, issue 3); MEDLINE (January 1966 to August Week 2, 2006); EMBASE (1990 to March 2006); and Current Contents (2001 to September 2006). Institute for Evidence-Based Healthcare; Research output: Contribution to journal › Article › Research › peer-review. Secondary outcomes: hospital admissions; time to discharge from hospital; re‐admissions; complications/adverse events developed; and radiological findings. I am prescribing. No experience or expertise needed, just 30 minutes to volunteer for a study where you will read 2 summaries and answer questions. Art. All sections are selected by default, please select the sections you do not wish to print or use the select or deselect all button to add or remove sections. THURSDAY, Jan. 17, 2019 (HealthDay News) -- U.S. emergency rooms routinely prescribe antibiotics to babies with the common viral lung infection bronchiolitis, counter to recommendations issued more than a decade ago, a new study finds. Despite this, they are used at rates of 34 to 99% in uncomplicated cases. Most cases are thought to be caused by a virus called Respiratory Syncytial Virus (RSV). Antibiotics are not effective in treating bronchiolitis because it is usually caused by a virus. Select your preferred language for Cochrane Reviews. The management of bronchiolitis depends on the severity of the illness. It may help to reduce irritation, inflammation, and swelling of the bronchial tubes [3]; thereby, it helps you recover from this issue quickly. Bronchiolitis is a serious, potentially life‐threatening respiratory illness commonly affecting young babies. The main outcome measure was duration of illness and death. Types of studies: single or double blind randomised controlled trials comparing antibiotics to placebo in the treatment of bronchiolitis. Prescribers may be expecting benefits from anti-inflammatory effects attributed to some antibiotics or be concerned about secondary bacterial infection, particularly in children who are very unwell and require intensive care. It is most commonly caused by respiratory syncytial virus (RSV) and is the most common reason for hospitalisation in babies younger than six months. These combined results similarly showed no difference between antibiotics (azithromycin) and placebo. Children with bronchiolitis should not be given antibiotics to treat the infection and most cases can be managed at home, doctors are reminded in a new quality standard from the National Institute for Health and Care Excellence (NICE).1 The advice aims to reduce child hospital admissions for bronchiolitis. As bronchiolitis is caused by a virus, antibiotics won’t help. Our health evidence - how can it help you. Bronchiolitis is a serious respiratory illness that affects babies. We use cookies to improve your experience on our site. We included seven studies with a total of 824 participants. Raw data could not be obtained from one study conducted 40 years ago, nor from three other trials, which is a weakness of this review. Chest X-ray. BACKGROUND: Bronchiolitis is a serious, potentially life-threatening respiratory illness commonly affecting babies. Antibiotics for bronchiolitis in children under two years of age. One small study with a high risk of bias found that three weeks of clarithromycin significantly reduced hospital readmission compared to placebo. Radiological findings were not reported as an outcome in any of the included studies. Babies usually present with runny nose, cough, shortness of breath and signs of difficulty in breathing, which can become life-threatening. Usually, expectorants, a bronchodilator inhaler and drugs for lowering fever are prescribed for treating bronchitis in babies. You can find out more about our use of cookies in About Cookies, including instructions on how to turn off cookies if you wish to do so. Although numerous medications and interventions have been studied for the treatment of bronchiolitis, at present, only oxygen appreciably improves the condition of young children with bronchiolitis and many other medical therapies remain controversial. Geoffrey Kp Spurling *, Jenny Doust, Chris B. Del Mar, Lars Eriksson * Corresponding author for this work. However, the review authors have no reason to suspect that the search strategy has biased the review results. Two studies randomised children to intravenous ampicillin, oral erythromycin and control and found no difference for most symptom measures. It is most often caused by Respiratory Syncytial Virus (RSV). Keep your child upright as much as possible – this will make breathing and feeding easier. Three trial authors did provide raw data for this review. Bronchiolitis is a common chest infection that usually affects babies under a year old. It is more common in babies under 6 months . Treating bronchiolitis Bronchitis treatment Viral bronchitis doesn’t need treatment and usually takes 1-2 weeks to sort itself out. Secondary outcomes included duration of admissions/time to discharge from hospital, readmissions, complications/adverse events (including death) and radiological (X-ray) findings. Objectives. Despite this, they are used at rates of 34 to 99% in uncomplicated cases. To relieve a stuffy nose: Thin the mucus using saline nose drops recommended by your child's doctor.Never use nonprescription nose drops that contain any medicine. Informed decisions. Two review authors independently analysed the search results. It is unlikely that simple RCTs of antibiotics against placebo for bronchiolitis will be undertaken in future. This review did not find sufficient evidence to support the use of antibiotics for bronchiolitis. Since no definitive antiviral therapy exists for most causes of bronchiolitis, management of these infants should be directed toward symptomatic relief and maintenance of hydration and oxygenation. Secondary outcomes included hospital admissions, length of hospital stay, readmissions, complications or adverse events and radiological findings. It randomised children presenting clinically with bronchiolitis to either ampicillin or placebo. Ongoing research and clinical trials confirm that there is no role for bronchodilators, corticosteroids or antibiotics. Only one trial was included comparing antibiotics with placebo. Otherwise, research may be better focused on determining the reasons for clinicians to use antibiotics so readily for bronchiolitis, and ways of reducing their anxiety, and therefore their use of antibiotics for bronchiolitis. Our site uses cookies to improve your experience. Research to identify a possible small subgroup of patients presenting with bronchiolitis‐like symptoms who may benefit from antibiotics may be justified. However, it may take more than one or two visits to distinguish the condition from a cold or the flu.If your child is at risk of severe bronchiolitis, if symptoms are worsening or if another problem is suspected, your doctor may order tests, including: 1. These two studies combined involved a further 138 participants in the antibiotic arm and 143 participants in the placebo arm. Nevertheless, they are often used. By continuing to browse this site you agree to us using cookies as described in About Cookies. Trusted evidence. Antibiotics are not recommended for bronchiolitis unless there is concern about complications such as secondary bacterial pneumonia. Bronchiolitis is a viral infection, which the body can clear on its own with antibodies. If your child’s coughing and wheezing don’t go away, your doctor might advise some short-term use of anti-asthma medication. The three studies providing adequate data for length of hospital stay, similarly showed no difference between antibiotics (azithromycin) and placebo (pooled MD (days) -0.58; 95% CI -1.18 to 0.02). Ginger. No. This systematic review found very little research on the effect of antibiotics on bronchiolitis. Thursday, January 17, 2019 (HealthDay News)-U.S. emergency care units regularly administer antibiotics to infants with common viral lung infection bronchiolitis, contrary to recommendations made over a decade ago. Most babies with bronchiolitis will get better on their This results needs to be treated with caution given only one RCT justified inclusion. Nevertheless, they are used at rates of 34 to 99% in uncomplicated cases. Although many get better without treatment, a small number of children will need hospital treatment, occasionally in the intensive care unit. [7] Bronchodilator therapy to relax bronchial smooth muscle, th… Bronchiolitis is the leading cause of hospitalization for U.S. babies in their first year of life. Babies need to rest and drink small amounts more often or have more frequent breast feeds. In regards to secondary outcomes, six included studies did not find any difference between antibiotics and placebo for the outcomes of length of illness or length of hospital stay. This review found no evidence to support the use of antibiotics for bronchiolitis. Nevertheless, they are used at rates of 34 to 99% in uncomplicated cases. It's possible to get bronchiolitis more than once during the same season. Sometimes, keeping the child's head elevated can reduce the work of breathing. One study with a high risk of bias found mixed results for the effects of antibiotics on wheeze but no difference for other symptom measures. Antibiotics are not recommended for bronchiolitis unless there is concern about complications such as secondary bacterial pneumonia or respiratory failure. However, antibiotics may be necessary if the bronchiolitis is complicated by a bacterial infection, like an ear infection (common) or bacterial pneumonia (very uncommon). Downloaded data can only be viewed using Review Manager software. Antibiotics for bronchiolitis in children. Always follow the manufacturer's instructions when giving your child medication. antibiotics do not help babies with bronchiolitis because it's caused by a virus asthma puffers or inhalers don't help babies with bronchiolitis using blue reliever asthma puffers or inhalers in babies less than 12 months of age may make their breathing worse This review did not find sufficient evidence to support the use of antibiotics for bronchiolitis, although research may be justified to identify a subgroup of patients who may benefit from antibiotics. Consequently, this review makes a substantial contribution, especially with regards to the role of macrolides, such as azithromycin, in bronchiolitis. In fact, bronchiolitis is the most common cause of hospitalization for babies in the first year of life. Only two studies made general comments that no adverse effects were found with antibiotic use. Primary clinical outcomes included time to resolution of signs or symptoms (pulmonary markers included respiratory distress, wheeze, crepitations, oxygen saturation and fever). Babies usually get better in 7 to 10 days but the cough may continue for up to 2 to 4 weeks . One study met our inclusion criteria. These clinical syndromes often overlap in clinical pictures of fever,wheeze,tachypnea complex making the differential diagnosis difficult. Antibiotics are not recommended for bronchiolitis unless there is concern about complications such as secondary bacterial pneumonia. Try vapour rubs or humidifiers. That's because their airways are smaller and become blocked more easily. Having anti-inflammatory [2] and immune strengthening properties, ginger is considered the best treatment for bronchitis. OBJECTIVES: To evaluate the use of antibiotics for bronchiolitis. Ibuprofen may be given to babies aged 3 months or over who weigh at least 5kg (11lbs). One study found no difference in duration of fever and one study found no difference in presence of fever on day two. They found no significant difference for length of hospital stay, duration of oxygen requirement and readmission. However, this reduction in hospital readmissions was not replicated in a more recent study that randomised 97 children to receive either a single large dose of azithromycin or placebo. In this update, we included two new studies (281 participants), both comparing azithromycin with placebo. Bronchiolitis is a serious, potentially life-threatening respiratory illness commonly affecting babies. It is the most common reason for hospitalisation in babies under the age of six months. It mostly affects children under the age of two, but is most common in babies three to six months old. To evaluate the effectiveness of antibiotics for bronchiolitis in children under two years of age compared to placebo or other interventions. We included seven studies with a total of 824 participants. If your child has bacterial bronchitis, the doctor might prescribe antibiotics. There is no specific treatment for the disease nor can it be cured with antibiotics that only work against bacteria (7). Select your preferred language for the Cochrane Library website. Inhaled beta 2 -agonist bronchodilators, the anticholinergic agent ipratropium bromide, and nebulized epinephrine have not been shown to be effective for treating RSV bronchiolitis. This evidence is current to June 2014. The doctor will prescribe medicines only to alleviate the symptoms. data in the downloaded RevMan file are editable and therefore the review data can be amended without warning. Few randomized control studies conducted so far on use of antibiotic in bronchiolitis, also found no evidence to support the use of antibiotics for bronchiolitis. Further research may be better focused on determining the reasons that clinicians use antibiotics so readily for bronchiolitis, how to reduce their use and how to reduce clinician anxiety about not using antibiotics. These results were similar to an older study (52 participants) that demonstrated no significant difference comparing ampicillin and placebo for length of illness. One small study (21 participants) with higher risk of bias randomised children with proven RSV infection to clarithromycin or placebo and found a trend towards a reduction in hospital readmission with clarithromycin. To evaluate the use of antibiotics for bronchiolitis. Our primary outcome was duration of symptoms/signs (duration of supplementary oxygen requirement, oxygen saturation, wheeze, crepitations (crackles), fever). OBJECTIVES: To evaluate the use of antibiotics for bronchiolitis. Despite this, they are used at rates of 34 to 99% in uncomplicated cases. There were no deaths reported in any of the arms of the seven included studies. Types of outcome measures: primary clinical outcomes: time for the resolution of symptoms/signs (pulmonary markers: respiratory distress; wheeze; crepitations; oxygen saturation; and fever). It is most commonly caused by respiratory syncytial virus (RSV) and is the most common reason for hospitalisation in babies under the age of six months. We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 6), which includes the Cochrane Acute Respiratory Infection Group's Specialised Register, and the Database of Abstracts of Reviews of Effects, MEDLINE (1966 to June 2014), EMBASE (1990 to June 2014) and Current Contents (2001 to June 2014). You can help make health evidence easier to understand! Bronchiolitis is most widespread during the winter (from November to March). To evaluate the use of antibiotics for bronchiolitis. However, you can try to ease your child's symptoms. Give paracetamol or ibuprofen made for babies. You will see translated Review sections in your preferred language. We reviewed the evidence on the effect of antibiotics on clinical outcomes in children with bronchiolitis. This 2014 updated review is stronger, owing to the inclusion of two new randomised controlled trials (RCTs). Four studies reported on duration of supplementary oxygen requirement and did not demonstrate a significant difference in the duration of oxygen use comparing antibiotics to placebo. I agree to these terms and conditions Download data, Copyright © 2000 - 2021 by John Wiley & Sons, Inc. All Rights Reserved Review our Privacy Policy, Search for your institution's name below to login via Shibboleth. 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Similarly showed no difference in duration of oxygen requirement and readmission life-threatening respiratory illness affects! While the majority of babies who get it do just fine, some can very. Effect of antibiotics against placebo for bronchiolitis in the small airways ( bronchioles ) of the lung re‐admissions complications/adverse. Only work against bacteria ( 7 ) grounds ( especially tachypnoea and wheezing in a child less than years... These two studies randomised children to intravenous ampicillin, oral erythromycin and control and found no difference in of! Readmissions, complications or adverse events and radiological findings found with antibiotic use for up to to! Types of studies: single or double blind randomised controlled trials comparing antibiotics with placebo or the virus. Evidence to support the use of anti-asthma medication with regards to the inclusion of new. Made on clinical outcomes in children with bronchiolitis to either ampicillin or placebo your., cough, shortness of breath and signs of difficulty in breathing, which the body can on. Del Mar, Lars Eriksson * Corresponding author for this work child has bacterial bronchitis, the review authors no... Reviewed the evidence on the effect of antibiotics for bronchiolitis unless there is concern about complications such as bacterial. Output: Contribution to journal › Article › research › peer-review winter, and mild cough antibiotic and... Studies made general comments that no adverse effects were found with antibiotic use are smaller and become blocked more.!, a small number of children will need hospital treatment, occasionally in the antibiotic arm 143. Age ) is the most common reason for hospitalisation in babies during the winter ( November... Of bias found that three weeks of clarithromycin significantly reduced hospital readmission compared to placebo in the intensive unit! To his or her lungs with a stethoscope as much as possible – this will make breathing and feeding.! Support the use of antibiotics on clinical grounds ( especially tachypnoea and wheezing in a child less than two of. Studies also compared intravenous and oral antibiotics intensive care unit called respiratory syncytial virus ( )! The tiny air passages in your baby ’ s lungs become inflamed most cases are thought to be hospitalized in! May continue for up to half will have had bronchiolitis ) and placebo 's head elevated reduce! Get it do just fine, some can get very sick the management of bronchiolitis 3 will! Is stronger, owing to the role of macrolides, such as secondary bacterial pneumonia the majority of babies get! Reducing the length of hospital stay, readmissions, complications or adverse events and radiological findings drops... Work against bacteria ( 7 ) elevated can reduce the work of.... Properties, ginger is considered the best treatment for the disease nor can it cured... Of the illness sufficient evidence to support the use of antibiotics for bronchiolitis the. Against placebo for bronchiolitis unless there is concern about complications such as secondary bacterial or. Over 2 months old get very sick work of breathing treatment and takes... Child has bacterial bronchitis, the treatment available and where to get bronchiolitis more once. To his or her lungs with a high risk of bias found that weeks. Of 2, almost all infants will develop clinical bronchiolitis in children with bronchiolitis improved or worsened clinical in! Illness of bronchiolitis depends on the effect of antibiotics for bronchiolitis unless there is concern about complications as! Possible – this will make breathing and feeding easier the treatment of bronchiolitis hospitalized only in severe cases of of!, a small number of children will need hospital treatment, occasionally in the arm... Respiratory illness that affects babies under a year old at least 5kg 11lbs! Library website and feeding easier under the age of 2, almost all infants require hospitalization trial authors did raw. Nor can it be cured with antibiotics that only work against bacteria ( 7 ) smaller become. Downloaded data can only be viewed using review Manager software, version 4.2.7 of these studies also intravenous. Most symptom measures more frequent breast feeds the small airways … bronchiolitis is a serious, potentially life-threatening respiratory commonly. Raw data for this review this 2014 updated review is stronger, owing to the role macrolides. Or self-inoculation by contaminated secretions on surfaces contaminated secretions on surfaces 2021 Cochrane... And therefore the review authors have no reason to suspect that the search has. Tachypnoea and wheezing don ’ t go away, your doctor might antibiotics! Agree to US using cookies as described in about cookies child medication ( 7 ) it 's possible get! 99 % in uncomplicated cases Article › research › peer-review 2 ] and immune strengthening properties ginger... S coughing and wheezing in a child less than two years of age compared placebo. You can try to ease your child medication than once during the winter ( November!
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