What are the aspiration precautions for an infant with bronchiolitis?

Aspiration Precautions in Infants with Bronchiolitis

Infants with bronchiolitis who have a respiratory rate exceeding 60-70 breaths per minute should be transitioned from oral feeding to intravenous fluids due to significantly increased aspiration risk. 1, 2

Understanding the Aspiration Risk

Bronchiolitis creates a dangerous combination of factors that predispose infants to aspiration:

• Previously healthy infants can aspirate during acute RSV bronchiolitis, as demonstrated by barium swallow studies showing aspiration in 25% of infants during the acute phase, with complete resolution 2-4 weeks after recovery 3
• Aspiration may contribute to rapid clinical deterioration in infants requiring mechanical ventilation, with lipid-laden macrophage indices >100 (highly suggestive of aspiration) found in 83% of previously healthy infants who deteriorated rapidly 4
• The combination of increased respiratory rate, nasal flaring, intercostal retractions, and copious nasal secretions creates mechanical conditions that compromise safe swallowing 1

Clinical Algorithm for Feeding Management

Assess Respiratory Rate and Work of Breathing First 1, 2

Continue oral feeding if:

• Respiratory rate <60 breaths per minute 1, 2
• Minimal nasal flaring or retractions 1
• Feeding remains unaffected 1

Transition to IV or nasogastric fluids if: 1, 2, 5

• Respiratory rate ≥60-70 breaths per minute
• Significant nasal flaring, intercostal/sternal retractions present
• Prolonged expiratory wheezing
• Any difficulty with safe feeding observed

Critical Fluid Management Considerations

When providing IV fluids, use isotonic fluids specifically because infants with bronchiolitis frequently develop syndrome of inappropriate antidiuretic hormone (SIADH) secretion, placing them at risk for hyponatremia with hypotonic fluids 1, 2

Airway Management to Reduce Aspiration Risk

Gentle nasal suctioning should be performed as needed to clear secretions that contribute to upper airway obstruction and feeding difficulties 2, 6

Avoid deep suctioning, as it is associated with longer hospital stays in infants 2-12 months of age and provides no additional benefit 2, 6

Common Pitfalls to Avoid

• Do not continue oral feeding based solely on oxygen saturation - an infant may have adequate SpO2 but still have tachypnea >60-70 breaths/minute that makes feeding unsafe 1, 2
• Do not overlook the aspiration risk in previously healthy infants - the misconception that only high-risk infants aspirate is contradicted by evidence showing even healthy infants are vulnerable during acute bronchiolitis 3, 4
• Do not use hypotonic IV fluids when transitioning from oral feeds, as SIADH is common in bronchiolitis 2

Monitoring for Aspiration Complications

Watch for signs of rapid deterioration that may indicate aspiration has occurred 4:

• Sudden worsening of respiratory status
• Increased oxygen requirements
• New infiltrates on chest imaging (though routine radiographs are not recommended) 2, 5