What is the recommended treatment for a pediatric patient with bronchiolitis and no distressing symptoms?

Management of Bronchiolitis Without Distressing Symptoms

For infants with bronchiolitis and no distressing symptoms, observation alone is appropriate—no medications, no diagnostic tests, and no interventions beyond supportive care are indicated. 1

When Observation Alone is Sufficient

Infants with mild bronchiolitis who are feeding well and have minimal respiratory distress require only observation. 2 This approach is supported by the American Academy of Pediatrics, which emphasizes that otherwise healthy infants with SpO2 ≥90% at sea level while breathing room air gain little benefit from any intervention, particularly without respiratory distress or feeding difficulties. 1, 3

Specific Clinical Parameters to Monitor

Assess these key indicators to confirm the infant can be managed with observation alone:

• Feeding status: If the infant continues to feed normally without difficulty, oral feeding should continue without intervention. 1, 3
• Respiratory rate: When respiratory rate remains below 60-70 breaths per minute, feeding is typically not compromised and aspiration risk remains low. 1, 3
• Oxygen saturation: SpO2 ≥90% on room air indicates no need for supplemental oxygen. 1, 3
• Work of breathing: Absence of nasal flaring, grunting, or significant intercostal/subcostal retractions confirms mild disease. 1

What NOT to Do in Non-Distressing Bronchiolitis

Avoid these common pitfalls that lead to unnecessary interventions:

• Do not use bronchodilators (albuterol): They lack evidence of benefit in bronchiolitis and should not be used routinely. 1, 3
• Do not use corticosteroids: Meta-analyses show no significant benefit in length of stay or clinical scores. 1, 3
• Do not prescribe antibiotics: The risk of serious bacterial infection in infants with bronchiolitis is less than 1%, and fever alone does not justify antibiotics. 1, 4
• Do not order chest radiographs, viral testing, or laboratory studies: Bronchiolitis is a clinical diagnosis based on history and physical examination alone. 1, 3
• Do not use chest physiotherapy: It lacks evidence of benefit and has a preponderance of harm over benefit. 2

Supportive Measures That May Be Helpful

Gentle nasal suctioning may be used only as needed for symptomatic relief and temporary relief, but avoid deep suctioning as it is associated with longer hospital stays in infants 2-12 months of age. 1, 3

Parent Education and Expected Course

Counsel parents that symptoms of bronchiolitis—including cough, congestion, and wheezing—are expected to last 2-3 weeks, which is normal and does not indicate treatment failure. 1 This education is critical to prevent unnecessary return visits and inappropriate antibiotic prescribing.

When to Escalate Care

Monitor for these red flags that would require intervention:

• Respiratory rate exceeding 60-70 breaths per minute, which compromises feeding and increases aspiration risk significantly. 1, 3
• SpO2 persistently falling below 90%, which would indicate need for supplemental oxygen. 1, 3
• Development of feeding difficulties or signs of dehydration. 2, 1
• Increased work of breathing with nasal flaring, grunting, or significant retractions. 1

High-Risk Populations Requiring Closer Monitoring

Even without current distressing symptoms, infants under 12 weeks of age, those with a history of prematurity, hemodynamically significant congenital heart disease, chronic lung disease, or immunodeficiency require closer monitoring as they may deteriorate more rapidly. 1, 3, 4