Should a 7-month-old with an upper respiratory tract infection be discharged with albuterol (bronchodilator) and steroids (corticosteroids)?

Should a 7-Month-Old with Upper Respiratory Tract Infection Be Discharged with Albuterol and Steroids?

No, a 7-month-old with an upper respiratory tract infection should NOT be discharged with albuterol or steroids, as these medications provide no clinical benefit for bronchiolitis or simple upper respiratory infections in infants and may cause harm. 1, 2, 3

Albuterol (Bronchodilators) - Strong Recommendation Against Use

The American Academy of Pediatrics provides a strong recommendation against administering albuterol to infants with bronchiolitis, based on robust evidence demonstrating no benefit: 1

• Systematic reviews of 30 randomized controlled trials involving 1,992 infants showed no improvement in oxygen saturation, disease resolution, need for hospitalization, or length of stay 1
• While bronchodilators may produce transient improvements in clinical scores, these do not correlate with objective measures like pulmonary function tests and most infants will not benefit 1
• Potential harms outweigh any theoretical benefits: tachycardia and tremors are clinically significant adverse effects 1
• The previous guideline option for a "trial of β-agonists" was removed because evidence demonstrated no benefit and there is no validated method to identify responders 1

Key Pitfall to Avoid

Do not attempt a therapeutic trial of albuterol based on the assumption that "some infants might respond" - attempts to define a subgroup of responders have been unsuccessful, and the variability of clinical assessments limits the ability to observe clinically relevant responses 1

Corticosteroids - Clear Evidence Against Use

Steroids are not recommended for upper respiratory tract infections or bronchiolitis in infants: 2, 3

• Systematic reviews and meta-analyses involving nearly 1,200 children have not shown sufficient evidence to support steroid use in bronchiolitis 2
• The AAP recommends against routine steroid treatment for upper respiratory tract infections, as randomized controlled trials have not shown differences in important clinical outcomes 3
• One study specifically demonstrated that corticosteroids do not change the rate of clinical improvement in acute bronchiolitis, nor do they affect lung function 2-4 weeks later 4

Important Distinction

The research showing benefit from steroids in children with upper respiratory infections applies only to children with established asthma who are experiencing exacerbations triggered by viral infections 5, 6 - this does not apply to a 7-month-old with a simple upper respiratory infection who has no history of recurrent wheezing or asthma.

What TO Do Instead - Supportive Care Approach

Focus on assessment and supportive measures: 2, 3

• Assess hydration status and ability to take fluids orally (strong recommendation) 2
• Provide supplemental oxygen only if SpO2 falls persistently below 90% in previously healthy infants 2
• Discontinue oxygen when SpO2 is at or above 90% and the infant is feeding well with minimal respiratory distress 2
• Monitor for signs of severe disease: age less than 12 weeks, history of prematurity, underlying cardiopulmonary disease, or immunodeficiency are risk factors requiring closer observation 2

Discharge Instructions Should Include

• Hand hygiene education as the most important step in preventing spread of respiratory syncytial virus 2
• Avoidance of passive smoke exposure (strong recommendation) 2
• Return precautions for worsening respiratory distress, poor feeding, or persistent hypoxemia 2