New AAP guidelines for bronchiolitis in infants

The American Academy of Pediatrics (AAP) Subcommittee on Bronchiolitis has published a new clinical practice guideline on diagnosing and managing bronchiolitis in infants aged 1 to 23 months. The new guidelines update the 2006 version and are based on a review of the evidence published since the original evidence review in 2004.

Diagnostic guidelines for bronchiolitis recommend that physicians base diagnosis on history and physical examination and avoid routinely ordering radiographic or laboratory studies. Doctors also need to consider risk factors for severe disease-including age younger than 12 weeks, prematurity, underlying cardiopulmonary disease, and immunodeficiency-when making evaluation and management decisions.

Regarding treatment, the AAP recommends against administering albuterol (or salbutamol), epinephrine, or systemic corticosteroids to infants and children with bronchiolitis. Clinicians should give antibiotics only when the patient has, or is strongly suspected to have, a concurrent bacterial infection. Nebulized hypertonic saline shouldn’t be administered in the emergency department, but it may be given to hospitalized infants and children. Children who can’t sustain oral hydration should receive nasogastric or intravenous fluids. Physicians shouldn’t use chest physiotherapy on infants and children with bronchiolitis.

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For preventing bronchiolitis, the guidelines recommend against giving palivizumab to otherwise healthy infants of gestational age 29 weeks or older, but endorse giving the drug during the first year of life to infants with hemodynamically significant heart disease or chronic lung disease associated with prematurity (preterm infants aged younger than 32 days who require more than 21% oxygen for at least the first 28 days of life). Infants who qualify for palivizumab in their first year should receive a maximum of 5 monthly doses (15 mg/kg/dose) during respiratory syncytial virus season.

All caregivers of infants with bronchiolitis should disinfect their hands with alcohol-based rubs (preferably) or soap and water before and after direct contact with the patient or inanimate objects in the immediate vicinity and after removing gloves.

When assessing for bronchiolitis, clinicians should ask about exposure to tobacco smoke and counsel caregivers about preventing exposure and undertaking smoking cessation. They should also encourage exclusive breastfeeding for at least 6 months to minimize the effects of respiratory infection and educate families about diagnosis, treatment, and prevention of bronchiolitis. 

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