What is the appropriate treatment for a young child under the age of 2 years diagnosed with bronchiolitis?

Treatment of Bronchiolitis in Young Children Under 2 Years

Bronchiolitis in children under 2 years requires supportive care only—do not use bronchodilators, corticosteroids, or antibiotics routinely, as these interventions lack evidence of benefit and may cause harm. 1, 2

Core Management: Supportive Care Algorithm

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, 2
• Discontinue oxygen when SpO2 is ≥90%, the infant is feeding well, and has minimal respiratory distress 1, 2

Hydration and Feeding Management

• Continue oral feeding if respiratory rate is less than 60 breaths per minute with minimal nasal flaring or retractions 1, 2
• Transition to IV or nasogastric fluids when respiratory rate exceeds 60-70 breaths per minute, as aspiration risk increases significantly at this threshold 1, 2
• Use isotonic fluids specifically if IV hydration is needed, because infants with bronchiolitis frequently develop syndrome of inappropriate antidiuretic hormone (SIADH) secretion and are at risk for hyponatremia with hypotonic fluids 1, 2

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, 2
• 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, 3
• Do not use corticosteroids routinely—meta-analyses show no significant benefit in length of stay or clinical scores 1, 2, 4
• 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, 2, 5
• 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, 3
• Approximately 25% of hospitalized infants have radiographic atelectasis or infiltrates, often misinterpreted as bacterial infection 1

Risk Stratification: Identifying High-Risk Infants

High-risk infants require closer monitoring and may have abnormal baseline oxygenation. These include: 1, 2

• Age less than 12 weeks 1, 2, 5
• History of prematurity 1, 2, 5
• Hemodynamically significant congenital heart disease 1, 2, 5
• Chronic lung disease or bronchopulmonary dysplasia 1, 2
• Immunodeficiency 1, 2, 5

Severity Assessment

• Count respiratory rate over a full minute—tachypnea ≥70 breaths/minute indicates increased severity risk 1, 2
• Assess work of breathing by looking for nasal flaring, grunting, and intercostal/subcostal retractions 1, 2

Critical Clinical Pitfalls to Avoid

• Do not treat based solely on pulse oximetry readings without clinical correlation, as transient desaturations can occur in healthy infants 1, 5
• Do not continue oral feeding based solely on oxygen saturation—an infant may have adequate SpO2 but still have tachypnea greater than 60-70 breaths/minute that makes feeding unsafe 1
• Avoid continuous pulse oximetry in stable infants, as it may lead to less careful clinical monitoring and is associated with longer hospital stays 1, 6

Expected Disease Course and Parent Education

• 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, 2
• 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

Prevention for High-Risk Infants

• 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