What is the treatment for pediatric bronchiolitis?

Treatment of Pediatric Bronchiolitis

The treatment of pediatric bronchiolitis is supportive care only—do not use bronchodilators, corticosteroids, or antibiotics routinely, as they provide no benefit and may cause harm. 1, 2

Core Management: What TO Do

Oxygen Therapy

• Administer supplemental oxygen only if SpO2 persistently falls below 90%, and maintain SpO2 at or above 90% using standard oxygen delivery methods 1, 2
• Otherwise healthy infants with SpO2 ≥90% at sea level while breathing room air gain little benefit from supplemental oxygen, particularly without respiratory distress or feeding difficulties 1
• Discontinue oxygen when SpO2 is ≥90%, the infant is feeding well, and has minimal respiratory distress 1

Hydration Management

• Assess hydration status and ability to take fluids orally—infants who feed well without respiratory compromise should continue oral feeding 1
• When respiratory rate exceeds 60-70 breaths per minute, feeding may be compromised and aspiration risk increases significantly—consider IV or nasogastric tube hydration at this threshold 1, 3
• 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 2
• Enteral hydration via nasogastric tube (bolus or continuous) is safe in infants receiving high-flow oxygen therapy, with no documented cases of pulmonary aspiration in a large trial 4

Airway Clearance

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

What NOT To Do: Avoiding Harmful Interventions

Pharmacologic Interventions to Avoid

• Do not use bronchodilators (albuterol) routinely—they lack evidence of benefit in bronchiolitis 1, 2, 5
• The FDA label for albuterol notes safety and effectiveness have not been established in children below 2 years of age 6
• Do not use corticosteroids routinely—meta-analyses show no significant benefit in length of stay or clinical scores 1, 2
• Do not use antibiotics routinely—the risk of serious bacterial infection in infants with bronchiolitis is less than 1%, and fever alone does not justify antibiotics 1, 3, 2
• Use antibacterial medications only with specific indications of bacterial coinfection such as acute otitis media or documented bacterial pneumonia 1, 2

Diagnostic Testing to Avoid

• Bronchiolitis is a clinical diagnosis based on history and physical examination alone—do not routinely order chest radiographs, viral testing, or laboratory studies 1, 2
• Approximately 25% of hospitalized infants have radiographic atelectasis or infiltrates, often misinterpreted as bacterial infection 1

Monitoring Pitfalls

• Avoid continuous pulse oximetry in stable infants, as it may lead to less careful clinical monitoring and is associated with longer hospital stays 1, 7
• Serial clinical assessments are more important than continuous monitoring in stable infants 1
• Do not treat based solely on pulse oximetry readings without clinical correlation, as transient desaturations can occur in healthy infants 1, 3

Risk Stratification and High-Risk Patients

High-Risk Categories Requiring Closer Monitoring

• Age less than 12 weeks 1, 3, 2
• History of prematurity 1, 2, 8
• Hemodynamically significant congenital heart disease 1, 2, 8
• Chronic lung disease or bronchopulmonary dysplasia 1, 2, 8
• Immunodeficiency 1, 2, 8

Clinical Assessment Parameters

• Count respiratory rate over a full minute—tachypnea ≥70 breaths/minute indicates increased severity risk 2
• Assess work of breathing by looking for nasal flaring, grunting, and intercostal/subcostal retractions 2
• High-risk infants may have abnormal baseline oxygenation and require close monitoring during oxygen weaning 1

Prevention Strategies

Pharmacologic Prophylaxis

• Palivizumab prophylaxis is recommended for high-risk infants, with 5 monthly doses (15 mg/kg IM) starting November/December, to reduce the risk of hospitalization due to RSV infection 2

Non-Pharmacologic Prevention

• Promote breastfeeding—breastfed infants have shorter hospital stays, less severe illness, and a 72% reduction in hospitalization risk for respiratory diseases 1, 2
• Avoid tobacco smoke exposure, as it significantly increases severity and hospitalization risk 1, 2
• Limit visitor exposure during respiratory virus season to help prevent RSV transmission 1
• Hand hygiene and handwashing reduce transmission 9

Expected Disease Course

• Symptoms of bronchiolitis, such as cough, congestion, and wheezing, are expected to last 2-3 weeks, which is normal and does not indicate treatment failure 1
• Bronchiolitis remains a self-limited disease whose mainstay of therapy is supportive care 7, 10