What is the appropriate management for an infant (<24 months) with bronchiolitis and no fever?

Treatment of Bronchiolitis in a Child Without Fever

Supportive care is the only evidence-based treatment for bronchiolitis regardless of fever status, with oxygen supplementation reserved exclusively for infants with SpO2 persistently below 90%. 1, 2

Core Management Approach

The American Academy of Pediatrics emphasizes that bronchiolitis management consists entirely of supportive measures, with no role for routine pharmacologic interventions. 1, 2 The absence of fever does not change this approach—fever is neither a treatment indication nor a contraindication for any intervention. 1

Oxygen Therapy

• Administer supplemental oxygen only if SpO2 persistently falls below 90%, maintaining saturation at or above this threshold 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, 3
• Discontinue oxygen when three criteria are met: SpO2 ≥90%, the infant feeds well, and minimal respiratory distress is present. 1, 2, 3
• Avoid continuous pulse oximetry in stable infants, as serial clinical assessments are more important and continuous monitoring may lead to less careful clinical evaluation. 2, 3

Hydration and Feeding Management

• Continue oral feeding if respiratory rate remains below 60 breaths per minute with minimal nasal flaring or retractions. 1, 2
• Transition to IV or nasogastric fluids when respiratory rate reaches 60-70 breaths per minute, as aspiration risk increases significantly at this threshold. 1, 2
• Use isotonic fluids specifically for IV hydration, as infants with bronchiolitis frequently develop syndrome of inappropriate antidiuretic hormone (SIADH) secretion and are at risk for hyponatremia with hypotonic fluids. 1, 2

Airway Clearance

• Use gentle nasal suctioning only as needed for symptomatic relief and temporary relief. 1, 2, 3
• Avoid deep suctioning, as it is associated with longer hospital stays in infants 2-12 months of age. 1, 2, 3
• Do not use chest physiotherapy, as it lacks evidence of benefit. 1, 2, 3

What NOT to Do: Avoiding Harmful Interventions

The absence of fever does not justify any of the following interventions:

• Do not use bronchodilators (albuterol) routinely—they lack evidence of benefit in bronchiolitis. 1, 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
• Do not routinely order chest radiographs, viral testing, or laboratory studies—bronchiolitis is a clinical diagnosis based on history and physical examination alone. 1, 2

Risk Stratification and Monitoring

Assess severity by counting respiratory rate over a full minute, with tachypnea ≥70 breaths/minute indicating increased severity risk. 1, 2 Evaluate work of breathing by looking for nasal flaring, grunting, and intercostal/subcostal retractions. 1, 2

High-risk infants requiring closer monitoring include:

• Those less than 12 weeks old 1, 2, 3
• History of prematurity 1, 2
• Hemodynamically significant congenital heart disease 1, 2, 3
• Chronic lung disease or bronchopulmonary dysplasia 1, 2
• Immunodeficiency 1, 2

Critical Pitfalls 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. 2
• Do not treat based solely on pulse oximetry readings without clinical correlation, as transient desaturations can occur in healthy infants. 2, 3
• The absence of fever does not indicate less severe disease or change management—fever is present in less than half of bronchiolitis cases and has no prognostic significance. 1

Expected Disease Course and Parent Education

• 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. 1
• Promote breastfeeding—breastfed infants have shorter hospital stays, less severe illness, and a 72% reduction in hospitalization risk for respiratory diseases. 1, 2
• Avoid tobacco smoke exposure, as it significantly increases severity and hospitalization risk. 1, 2
• Hand hygiene and limiting visitor exposure during respiratory virus season reduce transmission. 1, 2