In the Journals

AAP updates guidelines for diagnosis, management of bronchiolitis

The AAP recently revised the clinical practice guidelines for the diagnosis and management of bronchiolitis among children aged younger than 2 years, last updated in 2006.

Shawn L. Ralston, MD, FAAP, chair of the AAP’s Subcommittee on Bronchiolitis, and colleagues reviewed and revised the 2006 bronchiolitis guidelines in June of 2013 and conducted a literature review of articles published from 2004 through May 2014. The subcommittee also reviewed articles included in the previous guideline.

Shawn Ralston

Shawn L. Ralston

Regarding diagnosis of bronchiolitis, the AAP recommends physicians do the following:

  • Diagnose bronchiolitis and assess disease severity based on patient’s history and physical examination;
  • Assess risk factors for severe disease, including age less than 12 weeks, premature birth, underlying cardiopulmonary disease or immunodeficiency, when evaluating and managing children with bronchiolitis;
  • Avoid routine radiographic or laboratory studies when diagnosing bronchiolitis based on history and physical examination.

Regarding treatment, the AAP recommends the following:

  • Albuterol, salbutamol and epinephrine should not be administered to infants and children diagnosed with bronchiolitis;
  • Nebulized hypertonic saline should not be administered to infants diagnosed with bronchiolitis in the ED, though the treatment may be administered to infants and children hospitalized with bronchiolitis;
  • Physicians should not administer systemic corticosteroids to infants diagnosed in any setting;
  • If oxyhemoglobin saturation exceeds 90%, physicians may choose not to administer supplemental oxygen to infants or children with bronchiolitis;
  • Continuous pulse oximetry is optional for infants and children diagnosed with bronchiolitis;
  • Chest physiotherapy should not be used among infants and children diagnosed with bronchiolitis;
  • Antibacterial medications should not be administered to infants and children with bronchiolitis, unless there is a concomitant bacterial infection or a strong suspicion of one;
  • Infants who cannot maintain hydration orally should receive nasogastric or IV fluids.

Regarding prevention of bronchiolitis, the AAP recommends:

  • Palivizumab should not be administered to otherwise healthy infants with a gestational age of 29 weeks or more;
  • Palivizumab should be administered during the first year of life to infants with hemodynamically significant heart disease or chronic lung disease, who were premature with a gestational age less than 32 weeks and who require more than 21% oxygen for the first 28 days of life;
  • Children who qualify for palivizumab during the first year of life should receive a maximum of five monthly doses at 15 mg/kg/dose during the respiratory virus syncytial season;
  • Practice good hand hygiene; disinfect hands before and after direct contact with patients, after contact with objects near patients and after removing gloves;
  • When caring for children with bronchiolitis, use alcohol-based rubs for hand decontamination. If rubs are not available, use soap and water;
  • Obtain a patient history of exposure to tobacco smoke when assessing for bronchiolitis and counsel caregivers about infant and child exposure to tobacco smoke and smoking cessation;
  • Exclusive breastfeeding for at least 6 months should be encouraged to decrease morbidity of respiratory infections;
  • Personnel and caregivers should be educated on evidence-based diagnosis, treatment and prevention of bronchiolitis.

“This clinical guideline is not intended as a sole source of guidance in the management of children with bronchiolitis. Rather, it is intended to assist clinicians in decision-making. It is not intended to replace clinical judgment or establish a protocol for the care of all children with bronchiolitis,” the researchers wrote.

Disclosure: The researchers report no relevant financial disclosures.

The AAP recently revised the clinical practice guidelines for the diagnosis and management of bronchiolitis among children aged younger than 2 years, last updated in 2006.

Shawn L. Ralston, MD, FAAP, chair of the AAP’s Subcommittee on Bronchiolitis, and colleagues reviewed and revised the 2006 bronchiolitis guidelines in June of 2013 and conducted a literature review of articles published from 2004 through May 2014. The subcommittee also reviewed articles included in the previous guideline.

Shawn Ralston

Shawn L. Ralston

Regarding diagnosis of bronchiolitis, the AAP recommends physicians do the following:

  • Diagnose bronchiolitis and assess disease severity based on patient’s history and physical examination;
  • Assess risk factors for severe disease, including age less than 12 weeks, premature birth, underlying cardiopulmonary disease or immunodeficiency, when evaluating and managing children with bronchiolitis;
  • Avoid routine radiographic or laboratory studies when diagnosing bronchiolitis based on history and physical examination.

Regarding treatment, the AAP recommends the following:

  • Albuterol, salbutamol and epinephrine should not be administered to infants and children diagnosed with bronchiolitis;
  • Nebulized hypertonic saline should not be administered to infants diagnosed with bronchiolitis in the ED, though the treatment may be administered to infants and children hospitalized with bronchiolitis;
  • Physicians should not administer systemic corticosteroids to infants diagnosed in any setting;
  • If oxyhemoglobin saturation exceeds 90%, physicians may choose not to administer supplemental oxygen to infants or children with bronchiolitis;
  • Continuous pulse oximetry is optional for infants and children diagnosed with bronchiolitis;
  • Chest physiotherapy should not be used among infants and children diagnosed with bronchiolitis;
  • Antibacterial medications should not be administered to infants and children with bronchiolitis, unless there is a concomitant bacterial infection or a strong suspicion of one;
  • Infants who cannot maintain hydration orally should receive nasogastric or IV fluids.

Regarding prevention of bronchiolitis, the AAP recommends:

  • Palivizumab should not be administered to otherwise healthy infants with a gestational age of 29 weeks or more;
  • Palivizumab should be administered during the first year of life to infants with hemodynamically significant heart disease or chronic lung disease, who were premature with a gestational age less than 32 weeks and who require more than 21% oxygen for the first 28 days of life;
  • Children who qualify for palivizumab during the first year of life should receive a maximum of five monthly doses at 15 mg/kg/dose during the respiratory virus syncytial season;
  • Practice good hand hygiene; disinfect hands before and after direct contact with patients, after contact with objects near patients and after removing gloves;
  • When caring for children with bronchiolitis, use alcohol-based rubs for hand decontamination. If rubs are not available, use soap and water;
  • Obtain a patient history of exposure to tobacco smoke when assessing for bronchiolitis and counsel caregivers about infant and child exposure to tobacco smoke and smoking cessation;
  • Exclusive breastfeeding for at least 6 months should be encouraged to decrease morbidity of respiratory infections;
  • Personnel and caregivers should be educated on evidence-based diagnosis, treatment and prevention of bronchiolitis.

“This clinical guideline is not intended as a sole source of guidance in the management of children with bronchiolitis. Rather, it is intended to assist clinicians in decision-making. It is not intended to replace clinical judgment or establish a protocol for the care of all children with bronchiolitis,” the researchers wrote.

Disclosure: The researchers report no relevant financial disclosures.