What is the initial management for a 6-month-old infant with bronchiolitis, presenting with suprasternal indrawing and expiratory wheeze, and an oxygen saturation (SpO2) of 98% on room air?

Management of Bronchiolitis in a 6-Month-Old with Suprasternal Indrawing and Expiratory Wheeze

For a 6-month-old infant with bronchiolitis presenting with suprasternal indrawing and expiratory wheeze but maintaining good oxygen saturation (SpO2 98% on room air), supportive care with close monitoring is the most appropriate initial management approach. 1

Initial Assessment

This infant presents with:

• Suprasternal indrawing (sign of increased work of breathing)
• Expiratory wheeze
• Good oxygenation (SpO2 98% on room air)

Risk Assessment

• Age 6 months (less concerning than <12 weeks)
• No mention of prematurity or underlying conditions (lower risk)
• Good oxygenation despite respiratory distress signs

Management Recommendations

Respiratory Support

• No supplemental oxygen needed at this time as SpO2 is well above the 90% threshold 1, 2
• Continue monitoring oxygen saturation intermittently rather than continuously since the infant is maintaining good levels 1
• Position infant with head of bed slightly elevated to optimize breathing mechanics

Hydration and Nutrition

• Assess feeding ability and hydration status 1
• If respiratory rate exceeds 60-70 breaths/minute or if nasal secretions are copious, feeding may be compromised 1
• If able to feed safely, encourage normal feeding
• If feeding is difficult due to respiratory distress, consider smaller, more frequent feeds
• If unable to maintain adequate oral intake, IV fluids may be necessary 1

Airway Management

• Gentle nasal suctioning to clear secretions if present 2
• Elevate head of bed slightly

Medications to AVOID

1. Bronchodilators should not be used routinely 1, 2

   • No evidence of consistent benefit in bronchiolitis
   • May cause tachycardia and agitation without improving outcomes

2. Corticosteroids should not be administered 1, 2, 3

   • Studies show no benefit in typical viral bronchiolitis
   • A randomized controlled trial demonstrated no short-term or long-term benefits 3

3. Antibiotics should not be given unless specific evidence of bacterial co-infection 1, 2

4. Chest physiotherapy is not recommended 1

   • May cause stress to the infant without clinical benefit

Monitoring and Follow-up

• Monitor for:

  • Worsening respiratory distress (increased retractions, nasal flaring)
  • Decreased oxygen saturation below 90% 1
  • Inability to maintain adequate hydration
  • Lethargy or decreased responsiveness

• Consider escalation of care if:

  • SpO2 falls persistently below 90% (initiate oxygen) 1
  • Significant increase in work of breathing
  • Signs of respiratory failure
  • Inability to maintain hydration orally

Parent Education

• Explain the expected course of illness (typically 7-10 days with peak symptoms at 3-5 days)
• Advise on:
  • Maintaining adequate hydration
  • Monitoring for signs of respiratory distress
  • When to seek medical attention (worsening breathing, poor feeding, lethargy)
  • Avoiding exposure to tobacco smoke 1, 2

Common Pitfalls to Avoid

1. Overtreatment with medications: The American Academy of Pediatrics strongly recommends against routine use of bronchodilators, corticosteroids, and antibiotics in bronchiolitis 1, 2

2. Unnecessary diagnostic testing: Routine chest radiographs, viral testing, or laboratory evaluation are not recommended 4

3. Underestimating hydration needs: Infants with bronchiolitis may have increased insensible losses and decreased intake 1

4. Failure to recognize deterioration: While most cases are mild and self-limiting, some infants may develop progressive respiratory distress requiring escalation of care 5

This infant currently has mild-moderate bronchiolitis with good oxygenation, making supportive care with careful monitoring the most appropriate approach.