How should bronchiolitis in infants be managed?

Management of Bronchiolitis in Infants

Bronchiolitis management is primarily supportive care—maintain hydration, provide supplemental oxygen only when SpO2 persistently falls below 90%, and avoid bronchodilators, corticosteroids, antibiotics, and routine diagnostic testing. 1, 2

Core Supportive Management

Oxygen Therapy

• Administer supplemental oxygen only if SpO2 persistently falls below 90% in previously healthy infants, with a target of maintaining SpO2 ≥90%. 3, 1
• Otherwise healthy infants with SpO2 ≥90% at sea level gain little benefit from supplemental oxygen, particularly without respiratory distress or feeding difficulties. 1, 2
• Discontinue oxygen when three criteria are met: SpO2 ≥90%, infant is feeding well, and minimal respiratory distress is present. 1, 2
• Avoid continuous pulse oximetry in stable infants, as it may lead to less careful clinical monitoring and unnecessarily prolong hospitalization due to transient desaturations that occur normally. 1

Hydration and Feeding Management

• When respiratory rate exceeds 60-70 breaths per minute, transition from oral feeding to IV or nasogastric fluids due to significantly increased aspiration risk. 3, 1, 2
• Infants with respiratory rates below 60 breaths per minute who feed well without respiratory compromise should continue oral feeding. 1, 2
• Use isotonic fluids exclusively for IV hydration, as infants with bronchiolitis frequently develop syndrome of inappropriate antidiuretic hormone (SIADH) secretion, placing them at risk for hyponatremia with hypotonic fluids. 1, 2
• The combination of increased respiratory rate, nasal flaring, intercostal retractions, and copious nasal secretions creates mechanical conditions that compromise safe swallowing. 3, 1

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—it has a preponderance of harm over benefit with no evidence of clinical improvement. 3, 1, 2

What NOT to Do: Avoiding Harmful Interventions

Pharmacologic Therapies to Avoid

• Do not use bronchodilators (albuterol) routinely—they lack evidence of benefit in bronchiolitis. 1, 2, 4
• Do not use corticosteroids routinely—meta-analyses show no significant benefit in length of stay or clinical scores. 1, 2, 4
• 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
• Use antibacterial medications only with specific indications of bacterial coinfection such as acute otitis media or documented bacterial pneumonia. 1, 2

Diagnostic Testing to Avoid

• 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, 4
• Approximately 25% of hospitalized infants have radiographic atelectasis or infiltrates, often misinterpreted as bacterial infection. 1

Risk Stratification and High-Risk Patients

High-Risk Categories Requiring Close Monitoring

• Infants younger than 12 weeks of age, particularly those younger than 6 weeks, are at higher risk for severe bronchiolitis and apnea. 1, 2
• Infants with a history of prematurity (born before 37 weeks gestation, especially before 32 weeks) have increased likelihood of severe disease. 1, 2
• Infants with hemodynamically significant congenital heart disease require close monitoring during oxygen weaning. 3, 1, 2
• Infants with chronic lung disease or bronchopulmonary dysplasia are at increased risk. 1, 2
• Infants with immunodeficiency require heightened surveillance. 1, 2

Severity Assessment

• Count respiratory rate over a full minute—tachypnea ≥70 breaths/minute indicates markedly increased severity risk and should prompt consideration of ICU transfer. 1, 2
• Assess work of breathing by looking for nasal flaring, grunting, and intercostal/subcostal retractions at each assessment. 1, 2
• The occurrence of apnea in infants younger than 6-12 weeks or in preterm infants is a criterion for hospital admission. 1

Critical Clinical 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. 1
• Do not treat based solely on pulse oximetry readings without clinical correlation, as transient desaturations can occur in healthy infants. 1, 2
• Do not overlook feeding difficulties, as aspiration risk increases significantly when respiratory rate exceeds 60-70 breaths/minute. 1
• Recognize that factors including fever, acidosis, and some hemoglobinopathies shift the oxyhemoglobin dissociation curve, so consider maintaining higher SpO2 in children with these risk factors. 3

Prevention Strategies

Prophylaxis for High-Risk Infants

• Palivizumab prophylaxis (15 mg/kg IM monthly for 5 doses starting November/December) is recommended for infants born ≤28 weeks gestation during their first RSV season within the first 12 months of life. 1, 2
• Palivizumab is recommended for infants born 29-32 weeks gestation up to 6 months of age. 1
• Palivizumab is recommended for infants with chronic lung disease requiring medical therapy within 6 months before RSV season. 1
• Palivizumab is recommended for children ≤24 months with hemodynamically significant congenital heart disease. 1

General Prevention Measures

• 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
• Limit visitor exposure during respiratory virus season to help prevent RSV transmission. 1, 2
• Hand hygiene and handwashing reduce transmission. 2

Expected Disease Course and Parent Education

• Symptoms of bronchiolitis, such as cough, congestion, and wheezing, are expected to last 2-3 weeks—this is normal and does not indicate treatment failure. 1, 2
• Continue breastfeeding if possible throughout the illness. 1