What is the treatment for bronchiolitis in a one-year-old?

Treatment of Bronchiolitis in a One-Year-Old

Bronchiolitis in a one-year-old is treated primarily with supportive care only—bronchodilators, corticosteroids, antibiotics, and chest physiotherapy should NOT be used routinely. 1, 2

Core Management Principles

The treatment approach is fundamentally supportive, as bronchiolitis is a self-limited viral illness where most pharmacologic interventions have failed to demonstrate clinical benefit. 1

What TO Do: Supportive Care

Hydration and Nutrition:

• Assess the child's hydration status and ability to take fluids orally as a priority. 1, 2
• Provide intravenous or nasogastric hydration if the child cannot maintain adequate oral intake. 2

Oxygen Therapy:

• Administer supplemental oxygen only if SpO₂ falls persistently below 90%. 1, 2
• Maintain SpO₂ at or above 90% with adequate supplemental oxygen. 1, 2
• Discontinue oxygen when SpO₂ remains ≥90%, the infant feeds well, and has minimal respiratory distress. 1, 2
• Continuous SpO₂ monitoring is not routinely needed as clinical course improves. 1, 2

Airway Management:

• Nasal suctioning and positioning may decrease work of breathing and should be utilized. 1

What NOT To Do: Avoid Non-Evidence-Based Interventions

Bronchodilators:

• Do not use bronchodilators (albuterol, nebulized epinephrine) routinely. 1, 2
• A carefully monitored trial of α-adrenergic or β-adrenergic medication is an option, but should only be continued if there is documented positive clinical response using objective evaluation. 1
• Despite some support for epinephrine in the literature, routine use is not recommended. 3

Corticosteroids:

• Do not use corticosteroid medications routinely. 1, 2
• Multiple studies and meta-analyses have failed to show significant benefit. 4, 3

Antibiotics:

• Use antibacterial medications only when there are specific indications of coexisting bacterial infection. 1, 2
• When bacterial infection is present, treat it as you would in the absence of bronchiolitis. 1

Other Non-Recommended Therapies:

• Do not use chest physiotherapy routinely. 1, 2
• Ribavirin should not be used routinely. 1
• Hypertonic saline is not recommended for routine use. 5

Diagnostic Approach

Clinical Diagnosis:

• Diagnose bronchiolitis based on history and physical examination alone. 1, 2
• Do not routinely order chest radiographs, viral testing, or laboratory studies in typical presentations. 1, 2, 5

Key Clinical Features to Assess:

• Viral upper respiratory prodrome followed by increased respiratory effort and wheezing. 1
• Rhinorrhea, cough, tachypnea, wheezing, rales, retractions (intercostal/subcostal), nasal flaring, and grunting. 1
• Effects on mental status, feeding, and hydration. 1
• Respiratory rate (count over full minute for accuracy). 1

Risk Stratification

Assess for Risk Factors for Severe Disease:

• Age less than 12 weeks. 1, 2
• History of prematurity. 1, 2
• Underlying cardiopulmonary disease (bronchopulmonary dysplasia, congenital heart disease). 1, 2
• Immunodeficiency. 1, 2

Special Monitoring for High-Risk Infants:

• Infants with hemodynamically significant heart or lung disease and premature infants require close monitoring during oxygen weaning. 1, 2

Prevention Considerations

For Future RSV Seasons:

• Consider palivizumab prophylaxis for high-risk infants (prematurity <35 weeks' gestation or congenital heart disease). 1, 2
• Administer in 5 monthly doses at 15 mg/kg intramuscularly, typically starting November or December. 1, 2

General Prevention:

• Educate families on hand hygiene (alcohol-based rubs preferred) to prevent RSV spread. 1, 2
• Counsel against tobacco smoke exposure. 1, 2
• Encourage breastfeeding to decrease risk of lower respiratory tract disease. 1, 2

Common Pitfalls to Avoid

The most critical pitfall is the continued widespread use of bronchodilators and corticosteroids despite clear evidence against their routine use. 5, 4 Physicians continue to favor these therapies despite multiple studies showing no benefit, likely due to clinical inertia and patient/family pressure. 3, 6

De-implementation of non-evidence-based interventions should be a major goal, with educational interventions for both clinicians and parents to promote high-value care. 4

Standardized clinical pathways spanning emergency department to inpatient care can optimize resource utilization while improving outcomes and reducing hospital length of stay and costs. 5