AAP updates bronchiolitis guideline

A revised guideline on bronchiolitis in children aged 1 to 23 months from the American Academy of Pediatrics (AAP) recommends dispensing with routine chest radiographs and respiratory syncytial virus (RSV) swabs for diagnosis and foregoing albuterol, epinephrine, systemic corticosteroids, chest physiotherapy, and antibiotics during treatment.

The clinical practice guideline, a revision of the 2006 guideline “Diagnosis and Management of Bronchiolitis,” strongly recommends basing diagnosis and assessment of disease severity on history and physical examination and advises against routinely ordering radiographic studies (chest X-rays) and laboratory tests (virologic testing, as for RSV). Evaluation should include assessment of risk factors for severe disease, such as age younger than 12 weeks, history of prematurity, underlying cardiopulmonary disease, and immunodeficiency.

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Routine RSV testing isn’t recommended even though RSV is the most frequent cause of bronchiolitis because other viruses also can trigger the condition and the value of pinpointing a specific viral cause hasn’t been demonstrated, the guideline notes. Testing for RSV is appropriate, however, when an infant receiving monthly prophylaxis with palivizumab is admitted to the hospital with bronchiolitis. If breakthrough RSV infection is detected, prophylaxis should be discontinued because a second infection within the year is unlikely.

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With regard to treatment, the guideline strongly recommends against giving albuterol or salbutamol, epinephrine, or systemic corticosteroids to children diagnosed with bronchiolitis. It also advises against giving antibiotics unless bacterial infection is present or strongly suspected.

The recommendation against albuterol or salbutamol is based on a lack of evidence in the literature for clinical benefit from bronchodilators in bronchiolitis. Studies also don’t support a benefit from corticosteroids. Although epinephrine has temporarily improved symptoms in the emergency department (ED), it hasn’t been shown to decrease admissions for bronchiolitis.

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Chest physiotherapy is discouraged based on lack of clear clinical benefit as is administering nebulized hypertonic saline in the ED because of lack of clear evidence that it reduces hospitalization rates. Nebulized hypertonic saline may be given to hospitalized infants and children, however. Use of supplemental oxygen or continuous pulse oximetry are left up to the clinician’s judgment.

The AAP strongly recommends giving nasogastric or intravenous fluids to infants who can’t maintain hydration orally.

Regarding prevention, the guideline strongly recommends against giving palivizumab to otherwise healthy infants with a gestational age of 29 or more weeks. Palivizumab should be administered during the first year of life to infants with hemodynamically significant heart disease or chronic lung disease of prematurity (infants less than 32 weeks’ gestation who require more than 21% oxygen for at least the first 28 days of life). These infants should receive a maximum of 5 monthly doses of 15 mg/kg/dose during the RSV season.