Management of Viral Bronchiolitis in a 3-Month-Old
For a 3-month-old with viral bronchiolitis, provide supportive care only: supplemental oxygen if SpO2 falls persistently below 90%, hydration support when respiratory rate exceeds 60-70 breaths/minute, and gentle nasal suctioning as needed—avoid bronchodilators, corticosteroids, antibiotics, chest radiographs, and routine viral testing. 1, 2
Immediate Assessment Priorities
At 3 months of age, this infant falls into a high-risk category requiring close monitoring. 1, 2 Count the respiratory rate over a full minute—tachypnea ≥70 breaths/minute indicates increased severity risk. 1 Assess work of breathing by looking for nasal flaring, grunting, and intercostal/subcostal retractions. 1, 2
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 that are often misinterpreted as bacterial infection, leading to unnecessary antibiotic use. 2
Oxygen Management
Administer supplemental oxygen only if SpO2 persistently falls below 90%, and maintain SpO2 at or above 90% using standard oxygen delivery methods. 1, 2, 3 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, 3 However, given this infant's young age (<12 weeks), close monitoring during oxygen weaning is essential. 2, 3
Critical pitfall to avoid: Do not treat based solely on pulse oximetry readings without clinical correlation—transient desaturations can occur in healthy infants. 2 Avoid continuous pulse oximetry in stable infants, as it may lead to less careful clinical monitoring and serial clinical assessments are more important. 2
Hydration and Feeding Management
Assess hydration status and ability to take fluids orally. 1, 2, 3 Infants who feed well without respiratory compromise should continue oral feeding. 1, 2
When respiratory rate exceeds 60-70 breaths per minute, feeding may be compromised and aspiration risk increases significantly—transition to IV or nasogastric tube hydration at this threshold. 1, 2 The combination of increased respiratory rate, nasal flaring, intercostal retractions, and copious nasal secretions creates mechanical conditions that compromise safe swallowing. 2
Use isotonic fluids if IV hydration is needed, as infants with bronchiolitis may develop syndrome of inappropriate antidiuretic hormone (SIADH) secretion and are at risk for hyponatremia with hypotonic fluids. 1, 2, 3
Common pitfall: 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. 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 or Ineffective Interventions
Do not use bronchodilators (albuterol) routinely—they lack evidence of benefit in bronchiolitis. 1, 2, 3 While a carefully monitored trial may be considered in select cases, it should only be continued if there is a documented positive clinical response. 2, 3
Do not use corticosteroids routinely—meta-analyses show no significant benefit in length of stay or clinical scores. 1, 2, 3
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, 3 Use antibacterial medications only with specific indications of bacterial coinfection such as acute otitis media or documented bacterial pneumonia. 1, 2, 3
Parent Education and Expected Course
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. 4, 1, 2 Parents often seek care in multiple settings during this time period, so clear education about the expected disease course is essential. 4
Educate parents about prevention of transmission: hand hygiene, avoiding tobacco smoke exposure (which significantly increases severity and hospitalization risk), and limiting visitor exposure during respiratory virus season. 4, 1, 2, 3
Promote breastfeeding if possible—breastfed infants have shorter hospital stays, less severe illness, and a 72% reduction in hospitalization risk for respiratory diseases. 4, 1, 2
High-Risk Considerations for This 3-Month-Old
At less than 12 weeks of age, this infant is in a high-risk category requiring closer monitoring. 1, 2, 3 Additional high-risk factors to assess include history of prematurity, hemodynamically significant congenital heart disease, chronic lung disease or bronchopulmonary dysplasia, and immunodeficiency. 1, 2, 3