What is the treatment for bronchiolitis in pediatric (peds) patients?

Treatment of Pediatric Bronchiolitis

Bronchiolitis in children requires supportive care only—do not use bronchodilators, corticosteroids, or antibiotics routinely, as they provide no benefit. 1

Core Management: Supportive Care

The American Academy of Pediatrics emphasizes that bronchiolitis is a clinical diagnosis requiring no routine diagnostic testing, and treatment centers entirely on supportive measures 1, 2:

Oxygen Therapy

• Administer supplemental oxygen only if SpO2 persistently falls below 90% 1, 2
• Maintain SpO2 at or above 90% using standard oxygen delivery 1
• Discontinue oxygen when SpO2 ≥90%, infant feeds well, and has minimal respiratory distress 1
• Avoid continuous pulse oximetry in stable infants—it leads to less careful clinical monitoring and serial clinical assessments are more important 1

Hydration Management

• Assess hydration status and ability to take fluids orally 1
• Continue oral feeding if infant feeds well without respiratory compromise 1
• When respiratory rate exceeds 60-70 breaths/minute, feeding may be compromised and aspiration risk increases significantly 1, 3
• Use IV fluids only when infants cannot maintain adequate oral intake 1
• Use isotonic fluids if IV hydration is needed—infants with bronchiolitis may develop SIADH and are at risk for hyponatremia with hypotonic fluids 2

Airway Clearance

• Use gentle nasal suctioning only as needed for symptomatic relief 1, 2
• Avoid deep suctioning—it is associated with longer hospital stays in infants 2-12 months of age 1
• Do not use chest physiotherapy—it lacks evidence of benefit 1, 4

What NOT to Do: Avoid These Interventions

Pharmacologic Interventions to Avoid

The evidence is clear and consistent across multiple guidelines 1, 2, 5:

• Do not use bronchodilators routinely—they lack evidence of benefit 1, 2
• Do not use corticosteroids routinely—meta-analyses show no significant benefit in length of stay or clinical scores 1, 2
• Do not use antibiotics unless specific bacterial coinfection is documented (e.g., acute otitis media, documented bacterial pneumonia) 1, 2
• Fever alone does not justify antibiotics—the risk of serious bacterial infection in febrile infants with bronchiolitis is <1% 1, 3

Diagnostic Testing to Avoid

• Do not routinely order chest radiographs, viral testing, or laboratory studies—bronchiolitis is a clinical diagnosis 1, 2, 3
• Approximately 25% of hospitalized infants have radiographic atelectasis or infiltrates often misinterpreted as bacterial infection 1

Risk Stratification: Identify High-Risk Infants

High-risk infants require closer monitoring 1, 2, 3:

• Age <12 weeks 1, 3
• History of prematurity (≤35 weeks gestational age) 1, 6
• Hemodynamically significant congenital heart disease 1, 6
• Chronic lung disease/bronchopulmonary dysplasia 1, 6
• Immunodeficiency 1, 3

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

Prevention Strategies

Palivizumab Prophylaxis

For high-risk infants, the American Academy of Pediatrics recommends 2, 6:

• 15 mg/kg IM monthly for 5 doses starting November/December 2
• Indicated for infants with history of prematurity (≤35 weeks gestational age) who are ≤6 months at RSV season start 6
• Indicated for infants with bronchopulmonary dysplasia requiring medical treatment within previous 6 months who are ≤24 months at RSV season start 6
• Indicated for infants with hemodynamically significant congenital heart disease who are ≤24 months at RSV season start 6
• Children undergoing cardiopulmonary bypass should receive an additional dose as soon as possible after the procedure 6

Environmental Measures

• Promote breastfeeding—it reduces hospitalization risk by 72% 2
• Avoid tobacco smoke exposure—it significantly increases severity and hospitalization risk 1, 2
• Limit visitor exposure during respiratory virus season 1

Critical Clinical Pitfalls to Avoid

• Do not treat based solely on pulse oximetry readings without clinical correlation—transient desaturations can occur in healthy infants 1, 3
• Do not overlook feeding difficulties—aspiration risk increases significantly when respiratory rate exceeds 60-70 breaths/minute 1, 3
• Do not misinterpret radiographic findings as bacterial pneumonia—atelectasis and infiltrates are common in viral bronchiolitis 1
• Count respiratory rate over a full minute—tachypnea ≥70 breaths/minute indicates increased severity risk 2

Expected Clinical Course

• Symptoms (cough, congestion, wheezing) are expected to last 2-3 weeks—this is normal and does not indicate treatment failure 1
• Continue monthly palivizumab doses throughout RSV season even if infant develops RSV infection 6