Dexamethasone for Bronchiolitis in Neonates
Do not use dexamethasone or any corticosteroids for bronchiolitis in neonates—the evidence consistently shows no benefit for clinical outcomes and the American Academy of Pediatrics explicitly recommends against their routine use. 1
Why Corticosteroids Don't Work in Bronchiolitis
The evidence against corticosteroid use is robust and unequivocal:
A Cochrane meta-analysis of 17 trials with 2,596 infants found that corticosteroids do not reduce hospital admissions (pooled risk ratio 0.92; 95% CI 0.78-1.08) and do not reduce length of hospital stay (mean difference -0.18 days; 95% CI -0.39 to 0.04). 1
Multiple large randomized controlled trials specifically testing dexamethasone showed no benefit. A multicenter trial of 600 infants found that 1 mg/kg oral dexamethasone resulted in a 39.7% admission rate versus 41.0% for placebo (absolute difference -1.3%; 95% CI -9.2 to 6.5)—essentially identical outcomes. 2
Even in outpatient settings, dexamethasone failed to improve outcomes. A trial in Paraguay found no differences in respiratory distress scores, hospitalization rates (21% vs 25%, p=0.9), or oxygen saturation between dexamethasone and placebo groups. 3
The American Academy of Pediatrics gives this a strong recommendation with aggregate evidence quality of A, meaning the benefits clearly do not outweigh harms. 1
The Controversial Exception That Still Doesn't Apply
One trial (the Canadian Bronchiolitis Epinephrine Steroid Trial) showed a potential benefit when combining nebulized epinephrine with oral dexamethasone, but this finding became statistically insignificant after adjusting for multiple comparisons (P=0.07). 1
Importantly, this combination therapy remains unproven and is not recommended for routine use, as other trials using fixed simultaneous bronchodilator-corticosteroid regimens have not consistently shown benefit. 1
What TO Do Instead: Evidence-Based Supportive Care
Focus exclusively on supportive measures that actually improve outcomes:
Assess hydration status and ability to take fluids orally. If respiratory rate exceeds 60-70 breaths/minute, transition to IV fluids using isotonic solutions (infants with bronchiolitis develop SIADH and are at risk for hyponatremia with hypotonic fluids). 4, 5
Provide supplemental oxygen only if SpO2 persistently falls below 90%, and maintain SpO2 at or above 90%. 1, 4
Use gentle nasal suctioning only as needed for symptomatic relief—avoid deep suctioning as it prolongs hospital stays. 4
Continue breastfeeding if possible, which reduces hospitalization risk by 72%. 4, 5
Special Considerations for Neonates
Neonates (age <12 weeks) are in the highest-risk category for severe bronchiolitis and require closer monitoring:
Assess for risk factors including prematurity, underlying cardiopulmonary disease, or immunodeficiency. 1, 4
Monitor respiratory rate, work of breathing (nasal flaring, grunting, retractions), and feeding ability. 4, 5
These high-risk infants require close monitoring during oxygen weaning. 1
Critical Pitfalls to Avoid
Do not prescribe corticosteroids "just in case" or because the infant appears ill—bronchiolitis is a self-limited viral illness where corticosteroids provide no benefit and expose the infant to unnecessary medication. 1, 5
Do not use antibiotics unless there is specific evidence of bacterial coinfection (such as acute otitis media or documented bacterial pneumonia)—the risk of serious bacterial infection in bronchiolitis is <1%. 1, 4
Do not order routine chest radiographs or viral testing—bronchiolitis is a clinical diagnosis based on history and physical examination alone. 1, 4
Despite up to 60% of hospitalized infants receiving corticosteroids in practice, this represents overtreatment not supported by evidence. 5