Management of Acute Bronchiolitis in Infants and Children Under Two Years
Supportive Care is the Cornerstone—Avoid Routine Pharmacologic Interventions
The American Academy of Pediatrics recommends that supportive care alone is the cornerstone of bronchiolitis management, and routine pharmacologic interventions including bronchodilators, corticosteroids, and antibiotics should be avoided. 1, 2
Diagnosis
Bronchiolitis is a clinical diagnosis based on history and physical examination alone—routine chest radiographs, viral testing, or laboratory studies should not be ordered. 1, 2
Key diagnostic features include:
The pathophysiology involves viral infection (most commonly RSV) causing acute inflammation, edema, and necrosis of epithelial cells lining small airways, combined with increased mucus production and bronchospasm. 1
Oxygen Therapy
Administer supplemental oxygen ONLY if SpO2 persistently falls below 90%, and maintain SpO2 at ≥90%. 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. 2
Avoid continuous pulse oximetry in stable infants—it may lead to less careful clinical monitoring, and serial clinical assessments are more important than continuous monitoring. 2
Do not treat based solely on pulse oximetry readings without clinical correlation, as transient desaturations can occur in healthy infants. 2
Hydration Management
Continue oral feeding if the infant feeds well without respiratory compromise. 1, 2
Transition to IV or nasogastric fluids when respiratory rate exceeds 60-70 breaths per minute, as feeding may be compromised and aspiration risk increases significantly. 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. 2
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
Gentle nasal suctioning may provide temporary relief, but use 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. 2
Chest physiotherapy is not recommended due to lack of evidence of benefit. 1, 2
Bronchodilators—Do NOT Use Routinely
Bronchodilators should not be used routinely for infants with bronchiolitis, as they lack evidence of benefit. 2
A carefully monitored trial may be considered, but should only be continued if there is a documented positive clinical response. 2
Systemic Corticosteroids—Do NOT Use Routinely
- Corticosteroids should not be used routinely for infants with bronchiolitis, as meta-analyses have shown no significant benefit in length of stay or clinical scores. 2
Antibiotics—Reserve for Specific Bacterial Coinfection
Antibacterial medications should only be used with specific indications of bacterial coinfection, such as acute otitis media or documented bacterial pneumonia. 2
The risk of serious bacterial infection in infants with bronchiolitis is very low (<1%). 2
Fever alone does not justify antibiotics—the risk of serious bacterial infection in febrile infants with bronchiolitis is <1%. 2
Admission Criteria and Risk Stratification
High-Risk Infants Requiring Closer Monitoring:
- Age <12 weeks 1, 2
- History of prematurity 2
- Hemodynamically significant congenital heart disease 2
- Chronic lung disease 2
- Immunodeficiency 2
Admission Criteria:
- Respiratory rate ≥70 breaths/minute indicating increased severity risk 2
- Work of breathing with nasal flaring, grunting, intercostal/subcostal retractions 2
- SpO2 persistently <90% 1, 2
- Inability to maintain adequate oral intake 1, 2
Discharge Readiness Criteria:
- SpO2 ≥90% on room air 1
- Feeding well without respiratory compromise 1
- Minimal respiratory distress 1
- Reliable follow-up arranged 1
- Parents educated on warning signs 1
Ribavirin for High-Risk Infants
Ribavirin should not be used routinely, but may be considered in highly selected situations such as documented RSV bronchiolitis with severe disease or high-risk patients (e.g., immunosuppression, severe cardiopulmonary disease). 2, 3
The FDA indicates ribavirin is approved for hospitalized infants and young children with severe lower respiratory tract infections due to RSV, but treatment should be based on severity of infection. 3
Use is limited due to adverse side effects and risks to healthcare providers. 4
Use of aerosolized ribavirin in patients requiring mechanical ventilator assistance should be undertaken only by physicians and support staff familiar with this mode of administration. 3
Palivizumab Prophylaxis (NOT Treatment)
Indications for Prophylaxis:
Infants born ≤28 weeks gestation during their first RSV season, whenever that occurs during the first 12 months of life 2, 5
Infants born 29-32 weeks gestation up to 6 months of age 2
Infants with chronic lung disease requiring medical therapy within 6 months before RSV season 2
Children ≤24 months with hemodynamically significant congenital heart disease 2
Important Caveat:
- Palivizumab is for prophylaxis only—NOT for treatment of acute bronchiolitis. A 2019 randomized trial showed that intravenous palivizumab did not help or harm young infants with acute RSV-positive bronchiolitis. 6
Prevention Strategies
Exclusive breastfeeding can reduce hospitalization risk by 72%. 1, 2
Avoid tobacco smoke exposure—it significantly increases severity and hospitalization risk. 1, 2
Limit visitor exposure during respiratory virus season. 1, 2
Keep high-risk infants away from crowds and restrict participation in group child care during RSV season. 2