What is the preferred nebulisation method for a 10-month-old paediatric child?

Preferred Nebulisation for a 10-Month-Old Child

A metered-dose inhaler (MDI) with spacer and face mask is the preferred first-line delivery system for a 10-month-old child, as it is equally effective to nebulisation while being cheaper, more convenient, and better tolerated. 1

Primary Delivery System Recommendation

• MDI with spacer and face mask should be used first unless the infant cannot tolerate the face mask or requires emergency treatment where nebulisation may be more practical 1
• The development of spacers with face masks has specifically reduced the indication for nebuliser use in infants and young children who previously could not use hand-held inhalers 1
• This approach is supported by both the British Thoracic Society and European Respiratory Society guidelines as Grade A and B evidence 1

When Nebulisation Is Indicated

If nebulisation is necessary (due to mask intolerance, severe acute illness, or emergency situations), the following approach should be used:

For Acute Wheezing/Asthma:

• Nebulised albuterol (salbutamol) 0.15 mg/kg (or 5 mg standard dose) is first-line treatment 2
• Administer every 20 minutes for up to 3 doses initially 2
• Use oxygen as the driving gas whenever possible, or alternatively use an electrical compressor or compressed air 1
• Face mask should be tight-fitting and the child should breathe with an open mouth 1

Nebuliser Interface Selection:

• Hood nebulisation may be superior to face mask in wheezy infants at this age, as it provides equal lung deposition (2.6% vs 2.4%) with better tolerance and less crying 3
• Hood systems allow medication administration during sleep and are preferred by parents 3
• If using a conventional face mask, ensure it is tight-fitting to maximize drug delivery 1

Technical Considerations:

• Mesh nebulisers deliver 2-4 times more drug than jet nebulisers when used with face masks or high-flow nasal cannula 4
• For jet nebulisers, use flow rates of 6-8 L/min with face mask 1
• Increasing flow rates with nasal cannula interfaces decreases aerosol delivery 4

Condition-Specific Guidance

For Bronchiolitis:

• Nebulised bronchodilators have not been consistently shown to be beneficial and should not be routinely used 1
• Nebulised ribavirin may be considered only in high-risk infants or those with severe disease 1

For Croup:

• Oral dexamethasone 0.6 mg/kg is first-line, NOT nebulised bronchodilators 5
• Nebulised budesonide 500 µg may reduce symptoms within 2 hours if oral route unavailable 5
• Nebulised epinephrine (0.5 ml/kg of 1:1000 solution) is reserved for severe croup to avoid intubation, but effect is short-lived (1-2 hours) 1, 5

Maintenance and Safety

• Nebulisers should be disassembled, washed in warm water with detergent daily, and carefully dried 1
• For antibiotics or corticosteroids, mouthpieces should be used when the child can tolerate them (typically >2 years), but face masks are acceptable for infants 1
• All nebuliser equipment should be single patient use 1

Common Pitfalls to Avoid

• Do not assume nebulisation is superior to MDI with spacer—this is a common misconception that leads to unnecessary expense and inconvenience 1
• Do not use loose-fitting face masks, as this dramatically reduces drug delivery 1
• Do not use nebulised bronchodilators for typical bronchiolitis, as evidence does not support benefit 1
• Do not confuse croup management (corticosteroids first) with asthma/wheeze management (bronchodilators first) 5, 2