Management of Bronchiolitis in Infants and Young Children
Diagnosis
Bronchiolitis is a clinical diagnosis based solely on history and physical examination—do not order routine chest radiographs, viral testing, or laboratory studies. 1, 2
The diagnosis requires:
- Age 1-24 months with first episode of wheezing 2
- Upper respiratory prodrome (2-4 days of rhinorrhea, congestion, low-grade fever) followed by lower respiratory symptoms 2, 3
- Lower respiratory findings: tachypnea, increased work of breathing (nasal flaring, grunting, intercostal/subcostal retractions), wheezing, and/or crackles 4, 2
When to Consider Chest Radiography
Order chest X-ray only if:
- Considering intubation 2
- Unexpected clinical deterioration 2
- Suspicion of bacterial pneumonia (high fever >38°C, focal findings, tachycardia >100 bpm in context) 5
- Underlying cardiac or pulmonary disorder 2
Risk Stratification
Immediately identify high-risk infants who require closer monitoring and may progress to severe disease: 1, 2
- Age <12 weeks (especially <6 weeks) 4, 1
- Prematurity (<37 weeks gestation, especially <32 weeks) 4, 1
- Chronic lung disease of prematurity 1, 6
- Hemodynamically significant congenital heart disease 4, 1
- Immunodeficiency 1, 2
- Neuromuscular disease 2, 6
Supportive Care Management
Oxygen Therapy
Administer supplemental oxygen ONLY if SpO₂ persistently falls below 90%, and maintain SpO₂ ≥90%. 1, 3
- Otherwise healthy infants with SpO₂ ≥90% at sea level gain no benefit from supplemental oxygen 1
- Discontinue oxygen when: SpO₂ ≥90%, infant feeds well, and minimal respiratory distress present 1
- Avoid continuous pulse oximetry in stable infants—it leads to less careful clinical monitoring and prolongs hospital stays due to transient desaturations 1
- Use serial clinical assessments (respiratory rate, work of breathing, feeding ability) rather than continuous monitoring 1
Hydration and Feeding Management
Use this algorithm for feeding decisions based on respiratory rate: 1
If respiratory rate <60 breaths/minute:
- Continue oral feeding with minimal nasal flaring/retractions 1
- Continue breastfeeding if possible (reduces hospitalization risk by 72%) 1
If respiratory rate ≥60-70 breaths/minute:
- Stop oral feeding immediately—aspiration risk increases significantly 1
- Transition to IV or nasogastric fluids 1, 3
- Use isotonic fluids specifically because infants with bronchiolitis frequently develop SIADH and are at risk for hyponatremia with hypotonic fluids 1, 2
Airway Clearance
- Gentle nasal suctioning only as needed for symptomatic relief 1, 6
- Avoid deep suctioning—associated with longer hospital stays in infants 2-12 months 1
- Do not use chest physiotherapy—no evidence of benefit 1, 6
What NOT to Do
Pharmacologic Interventions to Avoid
Do not routinely use the following—they lack evidence of benefit: 1, 3
- Bronchodilators (albuterol, salbutamol): No reduction in hospital admissions or length of stay 1, 7
- Corticosteroids (systemic or inhaled): Meta-analyses show no significant benefit 1, 6
- Antibiotics: Use only with specific bacterial coinfection (acute otitis media, documented bacterial pneumonia)—risk of serious bacterial infection is <1% even with fever 1, 5
- Nebulized hypertonic saline: Not recommended 1, 6
- Ribavirin: Do not use routinely 1
Common Clinical Pitfalls
- Do not treat based solely on pulse oximetry readings without clinical correlation—transient desaturations occur in healthy infants 1
- Do not continue oral feeding based only on adequate SpO₂—an infant may have SpO₂ ≥90% but tachypnea >60-70 breaths/minute making feeding unsafe 1
- Do not misinterpret radiographic infiltrates as bacterial pneumonia—approximately 25% of hospitalized infants have atelectasis often mistaken for bacterial infection 1
- Fever alone does not justify antibiotics—serious bacterial infection rate is <1% in febrile infants with bronchiolitis 1
Criteria for Hospitalization
Admit if any of the following are present: 1, 6
- Persistent SpO₂ <90-92% 6
- Moderate-to-severe respiratory distress 6
- Respiratory rate ≥60-70 breaths/minute with inability to maintain oral intake 1
- Dehydration 6
- Apnea (especially in infants <6-12 weeks or premature infants) 4, 2
- High-risk factors requiring closer monitoring 1
Criteria for ICU Transfer
Escalate to intensive care if: 1
- Worsening respiratory effort despite supplemental oxygen 1
- Fatigue or exhaustion 1
- Decreased level of consciousness 1
- Persistent hypoxemia despite supplemental oxygen 1
- Respiratory rate ≥70 breaths/minute (correlates with increased risk of severe disease) 4, 1
Prevention Strategies
Environmental Measures
- Hand hygiene and limiting visitor exposure during RSV season 1, 3
- Avoid tobacco smoke exposure—significantly increases severity and hospitalization risk 1
- Keep infants away from crowds and group childcare during RSV season 1
Palivizumab Prophylaxis
Administer monthly during RSV season to: 1, 3
- Infants born ≤28 weeks gestation during first RSV season in first 12 months of life 1
- Infants born 29-32 weeks gestation up to 6 months of age 1
- Infants with chronic lung disease requiring medical therapy within 6 months before RSV season 1
- Children ≤24 months with hemodynamically significant congenital heart disease 1
Expected Clinical Course
Educate parents that symptoms are expected to last 2-3 weeks—this is normal and does not indicate treatment failure: 1, 2