What is the treatment approach for an infant over 6 months old with Respiratory Syncytial Virus (RSV) bronchiolitis?

Treatment Algorithm for RSV Bronchiolitis

The treatment of RSV bronchiolitis is purely supportive care—maintain hydration, provide oxygen only if SpO2 persistently falls below 90%, and avoid bronchodilators, corticosteroids, and antibiotics, as these interventions lack evidence of benefit. 1, 2

Step 1: Initial Assessment and Risk Stratification

Diagnose clinically without routine testing. Bronchiolitis is a clinical diagnosis based on history and physical examination alone—do not order routine chest radiographs, viral testing, or laboratory studies. 1, 2

Identify high-risk infants who require closer monitoring:

• Age <12 weeks 1
• History of prematurity (especially ≤35 weeks gestation) 1, 3
• Chronic lung disease/bronchopulmonary dysplasia 1, 3
• Hemodynamically significant congenital heart disease 1, 3
• Immunodeficiency 1, 3

Assess respiratory status systematically:

• Count respiratory rate over a full minute (tachypnea ≥70 breaths/minute indicates increased severity risk) 1, 2
• Evaluate work of breathing: look for nasal flaring, grunting, intercostal/subcostal retractions 1
• Measure oxygen saturation, but verify accuracy by repositioning the probe before making treatment decisions 2

Step 2: Oxygen Therapy Decision

Administer supplemental oxygen ONLY if SpO2 persistently falls below 90%. 1, 2

Before initiating oxygen:

• Verify the pulse oximetry reading accuracy by repositioning the probe and repeating the measurement 2
• Maintain SpO2 at ≥90% as the target 1, 2

Do not treat based solely on pulse oximetry readings without clinical correlation—transient desaturations can occur in healthy infants and continuous pulse oximetry may lead to less careful clinical monitoring. 1, 3

Oxygen may be discontinued when SpO2 is ≥90%, the infant is feeding well, and has minimal respiratory distress. 1 High-risk infants require close monitoring during oxygen weaning. 1

Step 3: Hydration and Nutrition Management

Assess respiratory rate to guide feeding decisions:

• If respiratory rate <60 breaths/minute with minimal nasal flaring or retractions and feeding remains unaffected: Continue oral feeding 1, 2

• If respiratory rate ≥60-70 breaths/minute with significant nasal flaring, intercostal/sternal retractions, or prolonged expiratory wheezing: Transition to IV or nasogastric fluids due to significantly increased aspiration risk 1, 2

Critical fluid management consideration: 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

Common pitfall 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

Step 4: Airway Clearance

Use gentle nasal suctioning only as needed for symptomatic relief. 1, 2

Avoid deep suctioning—it is associated with longer hospital stays in infants 2-12 months of age. 1

Do not use chest physiotherapy—it lacks evidence of benefit. 1, 3

Step 5: What NOT to Do—Ineffective Therapies

Bronchodilators: Do not use routinely—they lack evidence of benefit. 1, 2 A carefully monitored trial may be considered, but should only be continued if there is documented positive clinical response. 1

Corticosteroids: Do not use routinely—meta-analyses have shown no significant benefit in length of stay or clinical scores. 1, 3

Antibiotics: Use only with specific indications of bacterial coinfection (acute otitis media or documented bacterial pneumonia). The risk of serious bacterial infection in febrile infants with bronchiolitis is <1%. 1, 2

Ribavirin: Do not use routinely—it should not be used in children with bronchiolitis except in highly selected situations such as severely immunocompromised patients or hematopoietic stem cell transplant recipients with documented severe RSV infection. 3, 4

Step 6: Prevention Strategies

Hand hygiene is the single most important measure to prevent RSV transmission. Use alcohol-based hand rubs before and after direct contact with the infant. 2, 3

Environmental modifications:

• Avoid tobacco smoke exposure completely—it significantly increases RSV infection risk and hospitalization rates 2, 3
• Keep infants away from crowds and situations where exposure to infected individuals cannot be controlled 5, 2
• Restrict participation in group child care during RSV season for high-risk infants 5

Continue breastfeeding—breastfed infants have shorter hospital stays, less severe illness, and a 72% reduction in hospitalization risk for respiratory diseases. 1, 2

Step 7: Palivizumab Prophylaxis (Prevention, Not Treatment)

Palivizumab has NO therapeutic benefit for treating established RSV infection—it is only approved for prevention in high-risk infants and should never be used as treatment. 3

Prophylaxis indications:

• Infants born ≤28 weeks gestation: prophylaxis during their first RSV season, whenever that occurs during the first 12 months of life 5, 2
• Infants born 29-32 weeks gestation: prophylaxis up to 6 months of age 5
• Infants with chronic lung disease requiring medical therapy within 6 months before RSV season 5
• Children ≤24 months with hemodynamically significant congenital heart disease 5

Dosing: 15 mg/kg intramuscularly monthly for 5 doses throughout RSV season (typically November through March). 5, 2

Clinical Pitfalls to Avoid

• Do not overlook feeding difficulties—aspiration risk increases significantly when respiratory rate exceeds 60-70 breaths/minute 1
• Do not use continuous pulse oximetry in stable infants—serial clinical assessments are more important than continuous monitoring 1, 3
• Do not order chest radiographs routinely—approximately 25% of hospitalized infants have radiographic atelectasis or infiltrates often misinterpreted as bacterial infection 1
• Fever alone does not justify antibiotics—the risk of serious bacterial infection is <1% 1