Can nebulised budesonide be used in infants with bronchiolitis?

Nebulized Budesonide in Infants with Bronchiolitis

Nebulized budesonide should not be used routinely in infants with bronchiolitis as it has not been shown to provide short or long-term clinical benefits in the treatment of this condition. 1, 2

Evidence Against Routine Use

• Multiple studies have demonstrated no significant benefit of nebulized budesonide in the acute phase of bronchiolitis or in preventing post-bronchiolitic wheezing 2, 3
• The American Academy of Pediatrics (AAP) explicitly recommends against the routine use of corticosteroids in the management of bronchiolitis 1
• Randomized controlled trials have shown no difference in important clinical outcomes such as:
  • Duration of hospital stay 2, 3
  • Time to become symptom-free 2
  • Oxygen requirements 3
  • Respiratory readmission rates during follow-up 2

Clinical Trial Evidence

• A multicentre randomized double-blind placebo-controlled trial of 161 infants with RSV bronchiolitis found no short or long-term clinical benefits from nebulized budesonide (1 mg twice daily) compared to placebo 2
• Another randomized controlled trial of 40 infants with bronchiolitis (83% RSV positive) showed no significant differences between nebulized budesonide (1 mg every 12 hours for 5 days, then 500 μg every 12 hours for a total of 6 weeks) and placebo in:
  • Clinical scores at 48 hours
  • Mean oxygen requirements
  • Length of hospital stay
  • Prevalence of wheezing at 6-month follow-up 3
• A study of 73 hospitalized infants with bronchiolitis found no benefits from nebulized budesonide in either infants younger than 12 months or those between 12 and 24 months of age 4

Potential Exceptions

• One older study from 1996 suggested that nebulized budesonide might reduce subsequent wheezing episodes and hospital admissions after bronchiolitis, particularly in children with atopy 5
• However, more recent and larger studies have not confirmed these findings, and current guidelines do not support this practice 1, 2, 3

Recommended Management Approach for Bronchiolitis

• Bronchiolitis is primarily a clinical diagnosis that does not require diagnostic testing 1
• Management should focus on:
  • Assessing hydration and ability to take fluids orally 1
  • Providing supplemental oxygen if SpO2 falls persistently below 90% 1
  • Monitoring for signs of respiratory distress or failure 1
• For infants at high risk (premature infants, those with cardiopulmonary disease), consider:
  • Closer monitoring during the acute illness 1
  • Palivizumab prophylaxis according to guidelines 1

Common Pitfalls to Avoid

• Using nebulized corticosteroids based on their effectiveness in asthma - bronchiolitis has a different pathophysiology 1
• Continuing ineffective treatments - if a trial of any medication is attempted, objective measures should be used to document response 1
• Failing to implement appropriate infection control measures, which are crucial to prevent nosocomial spread of RSV 1

In conclusion, current evidence and guidelines strongly recommend against the routine use of nebulized budesonide in infants with bronchiolitis, as it does not improve clinical outcomes in either the short or long term.