The main treatment for bronchiolitis in young children should be support and observation, according to new clinical practice guidelines for diagnosing, managing, and preventing bronchiolitis.
The guidelines apply to children aged 1-23 months and emphasize clinical diagnosis and no medications except nebulized hypertonic saline for infants hospitalized with bronchiolitis, wrote Dr. Shawn L. Ralston, Dr. Allan S. Lieberthal, and their associates (Pediatrics 2014 October 27 [doi:10.1542/peds.2014-2742]). These guidelines update and replace the ones issued by the American Academy of Pediatrics in 2006 (Pediatrics 2006 118:1774-93). The findings are based on a review of the evidence in the Cochrane Library, Medline, and the Cumulative Index of Nursing and Allied Health Literature (CINAHL) from 2004 through May 2014.
Dr. Shawn Ralston
The most notable change to these updated guidelines, according to Dr. Lieberthal, is the preventive recommendation for palivizumab, which is now not indicated for children born at 29 weeks’ gestation or older unless they have hemodynamically significant heart disease or chronic lung disease of prematurity (those born at less than 32 weeks’ gestation who needed at least 21% oxygen for their first month). Infants who qualify for prophylactic palivizumab should receive five monthly doses during respiratory syncytial virus season.
Dr. Lieberthal noted in an interview that several other recommendations state that certain treatments should not be used at all rather than simply not being routinely used. These include albuterol, epinephrine, corticosteroids, chest physiotherapy, and antibiotics.
“Bronchiolitis is a self-limited viral illness,” he said. Because it is diagnosed by signs and symptoms, no lab tests, oximetry, imaging, or other tests are needed, and treatment involves only support and observation. “None of the treatments that have been tested have been shown to affect the outcome of the illness,” said Dr. Lieberthal, who practices general pediatrics and clinical pediatric pulmonology at Kaiser-Permanente in Panorama City, Calif.
Dr. Ralston noted in an interview that a new recommendation exists for using hypertonic saline to children who are hospitalized for bronchiolitis (although not in the emergency department), but the evidence for it is weak and its therapeutic value limited.
“This medication appears to have a slow onset and to provide a favorable response only in settings where patients are hospitalized for longer than is typical in most U.S. hospitals, as most of the studies were performed outside the U.S.,” said Dr. Ralston, a pediatrician at Dartmouth-Hitchcock Medical Center, Lebanon, N.H.
The guidelines also note that clinicians “may choose not to administer supplemental oxygen if the oxyhemoglobin saturation exceeds 90%” in children, although the evidence for this recommendation is also weak. Children should receive nasogastric or intravenous fluids if they cannot maintain oral hydration.
Parents should be advised that children who avoid secondhand tobacco smoke and are exclusively breastfed for at least 6 months have a reduced risk of bronchiolitis. Further, anyone caring for a child with bronchiolitis should disinfect their hands using an alcohol-based rub or soap and water after direct contact with the child and the child’s immediate environment.
Dr. Ralston said that important points stressed in both this recommendation and in the previous one include clinical diagnosis and avoiding exposure to tobacco smoke to reduce children’s risk of bronchiolitis.
“This guideline is mostly about what you shouldn’t do for the disease since because of the high volume of disease bronchiolitis represents a major area of unnecessary medical intervention in children,” she said. “We know that the vast majority of children will suffer only side effects from the medications or testing typically used in bronchiolitis care.”
Funding was provided by the American Academy of Pediatrics with travel support from the American Academy of Family Physicians, the American College of Chest Physicians, the American Thoracic Society, and the American College of Emergency Physicians for their representatives.