What is the treatment for Respiratory Syncytial Virus (RSV) bronchiolitis in infants?

Treatment of RSV Bronchiolitis in Infants

The treatment of RSV bronchiolitis in infants is primarily supportive care focusing on hydration, nasal suctioning, and monitoring for complications, with no prescription medications indicated unless specific complications arise. 1

Diagnosis and Assessment

• RSV bronchiolitis remains a clinical diagnosis based on history and physical examination
• Routine viral testing is not recommended 2, 1
• Key clinical findings include:
  • Initial upper respiratory symptoms (rhinorrhea, congestion)
  • Progression to lower respiratory symptoms (cough, wheezing, increased work of breathing)
  • Poor feeding as a critical indicator of respiratory distress 1

Treatment Algorithm

First-Line Management (All Infants)

1. Supportive Care

   • Maintain adequate hydration (oral, nasogastric, or IV as needed) 2, 1
   • Nasal suctioning to clear secretions 1
   • Positioning with slightly elevated head 1
   • Cool-mist humidifier in the room 1

2. Oxygen Supplementation

   • Provide supplemental oxygen if SpO₂ is below 90% 2, 1
   • Continuous pulse oximetry is not required in all cases and may lead to unnecessarily prolonged hospitalization 1

What NOT to Use (Strong Evidence Against)

• Bronchodilators (albuterol/salbutamol) are not recommended 2, 1
• Corticosteroids are not effective 1, 3
• Antibiotics should not be used unless there is specific evidence of bacterial co-infection 2, 3
• Epinephrine is not recommended 3
• Chest physiotherapy is not beneficial 3

Special Considerations for High-Risk Infants

High-risk infants (premature, chronic lung disease, congenital heart disease, immunodeficiency) require:

• Closer monitoring for disease progression 1
• Lower threshold for hospitalization 2

Hospitalization Criteria

Consider hospital admission if:

• Oxygen saturation ≤92% on room air
• Significant respiratory distress
• Inability to maintain adequate hydration
• Apnea episodes
• Lethargy or altered mental status 1

Antiviral Therapy

• Ribavirin is the only FDA-approved antiviral for RSV but is not recommended for routine use due to:
  • Limited clinical benefit
  • Potential health hazards to healthcare workers
  • Difficult administration
  • High cost 2
  • May be considered only for severe cases with underlying conditions associated with increased mortality 1

Prevention Strategies

1. Standard Precautions

   • Hand hygiene
   • Limiting exposure to sick contacts
   • Avoiding crowded places during RSV season 1

2. Immunoprophylaxis

   • Palivizumab (monoclonal antibody) is indicated for prevention in high-risk infants:
     • Premature infants ≤35 weeks gestational age who are ≤6 months at the start of RSV season
     • Children ≤24 months with bronchopulmonary dysplasia requiring treatment in the previous 6 months
     • Children ≤24 months with hemodynamically significant congenital heart disease 4
   • Administered monthly at 15 mg/kg IM during RSV season 4
   • Reduces RSV-related hospitalization by 45-55% in high-risk groups 1
   • Not indicated for treatment of active RSV infection 4

Common Pitfalls to Avoid

1. Unnecessary diagnostic testing (chest X-rays, viral testing) that doesn't change management 2
2. Prescribing ineffective medications (bronchodilators, steroids, antibiotics) 1, 3
3. Overreliance on continuous pulse oximetry leading to prolonged hospitalization 1
4. Failing to identify high-risk infants who may benefit from closer monitoring or prophylaxis 2
5. Using palivizumab for treatment rather than prevention 4

By focusing on supportive care and appropriate oxygen supplementation while avoiding unnecessary medications and interventions, clinicians can provide optimal evidence-based care for infants with RSV bronchiolitis.