What are the current guidelines for managing bronchiolitis in infants?

Management of Bronchiolitis in Infants: 2025 Guidelines

The cornerstone of bronchiolitis management is supportive care alone—oxygen when SpO2 persistently falls below 90%, hydration support when oral intake is inadequate, and gentle nasal suctioning—while avoiding all routine pharmacologic interventions including bronchodilators, corticosteroids, and antibiotics. 1

Diagnosis

• Bronchiolitis is a clinical diagnosis based on history and physical examination alone. 1, 2
• Do NOT routinely order chest radiographs, viral testing, or laboratory studies. 1, 2
• The diagnosis applies to infants presenting with upper respiratory symptoms (fever, rhinorrhea, congestion) followed by lower respiratory tract symptoms (cough, wheezing, increased respiratory effort). 3

Oxygen Therapy

• Administer supplemental oxygen ONLY if SpO2 persistently falls below 90% in previously healthy infants. 4, 1
• Maintain SpO2 at or above 90% using standard oxygen delivery. 1
• Discontinue oxygen when SpO2 is ≥90%, the infant is feeding well, and has minimal respiratory distress. 4
• Otherwise healthy infants with SpO2 ≥90% at sea level while breathing room air gain little benefit from supplemental oxygen. 1
• Avoid continuous pulse oximetry in stable infants, as it may lead to less careful clinical monitoring and serial clinical assessments are more important. 1

Hydration Management

• Assess hydration status and ability to take fluids orally. 4, 1
• Continue oral feeding if the infant feeds well without respiratory compromise. 1
• When respiratory rate exceeds 60-70 breaths per minute, feeding may be compromised and aspiration risk increases significantly. 4, 1
• Administer IV fluids only when oral intake is inadequate. 1
• Use isotonic fluids if IV hydration is needed, as infants with bronchiolitis may develop syndrome of inappropriate antidiuretic hormone (SIADH) secretion and are at risk for hyponatremia with hypotonic fluids. 1

Airway Clearance

• Use gentle nasal suctioning only as needed for symptomatic relief. 1, 5
• Avoid deep suctioning, as it is associated with longer hospital stays in infants 2-12 months of age. 1
• Do NOT use chest physiotherapy routinely, as it has a preponderance of harm over benefit. 4

What NOT to Do: Avoiding Unnecessary Interventions

Bronchodilators

• Do NOT use bronchodilators routinely for infants with bronchiolitis, as they lack evidence of benefit. 1, 5, 2

Corticosteroids

• Do NOT use corticosteroids routinely for infants with bronchiolitis, as they lack evidence of benefit. 1, 5, 2

Antibiotics

• Do NOT use antibacterial medications routinely. 1, 5, 2
• The risk of serious bacterial infection in infants with bronchiolitis is less than 1%. 1, 2
• Fever alone does NOT justify antibiotics. 1, 2
• Use antibiotics ONLY with specific indications of bacterial coinfection, such as documented acute otitis media or bacterial pneumonia. 4, 1

Risk Stratification: High-Risk Infants Requiring Closer Monitoring

High-risk infants include those with: 1, 5, 2

• Age less than 12 weeks
• History of prematurity (≤35 weeks gestational age)
• Hemodynamically significant congenital heart disease
• Chronic lung disease of prematurity (bronchopulmonary dysplasia)
• Immunodeficiency

These infants require close monitoring during oxygen weaning and may have abnormal baseline oxygenation. 4, 1

Prevention: Palivizumab Prophylaxis

Administer palivizumab (15 mg/kg IM monthly) during RSV season to high-risk infants, including: 6

• Infants with history of premature birth (≤35 weeks gestational age) who are ≤6 months of age at the beginning of RSV season
• Infants with bronchopulmonary dysplasia requiring medical treatment within the previous 6 months who are ≤24 months of age
• Infants with hemodynamically significant congenital heart disease who are ≤24 months of age

Children undergoing cardiopulmonary bypass should receive an additional dose of palivizumab as soon as possible after the procedure, even if sooner than a month from the previous dose. 6

Additional Prevention Strategies

• Continue breastfeeding if possible, as breastfed infants have a 72% reduction in hospitalization risk for respiratory diseases. 1
• Avoid tobacco smoke exposure, as it significantly increases severity and hospitalization risk. 1
• Limit visitor exposure during respiratory virus season to prevent RSV transmission. 1

Common Clinical Pitfalls to Avoid

• Do NOT treat based solely on pulse oximetry readings without clinical correlation, as transient desaturations to SpO2 <89% can occur in healthy infants. 4, 1, 2
• Do NOT overlook feeding difficulties—count respiratory rate over a full minute and assess for nasal flaring, grunting, and retractions. 1, 2
• Do NOT assume fever indicates bacterial infection requiring antibiotics. 1, 2
• Recognize that symptoms (cough, congestion, wheezing) typically last 2-3 weeks, which is normal and does not indicate treatment failure. 1