Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis

Guidance for the Clinician in
Rendering Pediatric Care
CLINICAL PRACTICE GUIDELINE
Clinical Practice Guideline: The Diagnosis, Management,

and Prevention of Bronchiolitis
abstract Shawn L. Ralston, MD, FAAP, Allan S. Lieberthal, MD, FAAP,

H. Cody Meissner, MD, FAAP, Brian K. Alverson, MD, FAAP, Jill E.
Baley, MD, FAAP, Anne M. Gadomski, MD, MPH, FAAP,
This guideline is a revision of the clinical practice guideline, “Diagnosis
David W. Johnson, MD, FAAP, Michael J. Light, MD, FAAP,
and Management of Bronchiolitis,” published by the American Academy Nizar F. Maraqa, MD, FAAP, Eneida A. Mendonca, MD, PhD,
of Pediatrics in 2006. The guideline applies to children from 1 through FAAP, FACMI, Kieran J. Phelan, MD, MSc, Joseph J. Zorc, MD,
23 months of age. Other exclusions are noted. Each key action state- MSCE, FAAP, Danette Stanko-Lopp, MA, MPH, Mark A.
ment indicates level of evidence, benefit-harm relationship, and level Brown, MD, Ian Nathanson, MD, FAAP, Elizabeth
of recommendation. Key action statements are as follows: Pediatrics Rosenblum, MD, Stephen Sayles III, MD, FACEP, and Sinsi
Hernandez-Cancio, JD
2014;134:e1474–e1502
KEY WORDS
bronchiolitis, infants, children, respiratory syncytial virus,
evidence-based, guideline
DIAGNOSIS ABBREVIATIONS
AAP—American Academy of Pediatrics
1a. Clinicians should diagnose bronchiolitis and assess disease se- AOM—acute otitis media
verity on the basis of history and physical examination (Evidence CI—confidence interval
Quality: B; Recommendation Strength: Strong Recommendation). ED—emergency department
KAS—Key Action Statement
1b. Clinicians should assess risk factors for severe disease, such as LOS—length of stay
age less than 12 weeks, a history of prematurity, underlying car- MD—mean difference
diopulmonary disease, or immunodeficiency, when making decisions PCR—polymerase chain reaction
RSV—respiratory syncytial virus
about evaluation and management of children with bronchiolitis SBI—serious bacterial infection
(Evidence Quality: B; Recommendation Strength: Moderate Rec-
This document is copyrighted and is property of the American
ommendation). Academy of Pediatrics and its Board of Directors. All authors have
1c. When clinicians diagnose bronchiolitis on the basis of history and filed conflict of interest statements with the American Academy of
physical examination, radiographic or laboratory studies should Pediatrics. Any conflicts have been resolved through a process
approved by the Board of Directors. The American Academy of
not be obtained routinely (Evidence Quality: B; Recommendation Pediatrics has neither solicited nor accepted any commercial
Strength: Moderate Recommendation). involvement in the development of the content of this publication.
The recommendations in this report do not indicate an exclusive
TREATMENT course of treatment or serve as a standard of medical care. Variations,
taking into account individual circumstances, may be appropriate.
2. Clinicians should not administer albuterol (or salbutamol) to in-
All clinical practice guidelines from the American Academy of
fants and children with a diagnosis of bronchiolitis (Evidence Qual- Pediatrics automatically expire 5 years after publication unless
ity: B; Recommendation Strength: Strong Recommendation). reaffirmed, revised, or retired at or before that time.
3. Clinicians should not administer epinephrine to infants and children Dedicated to the memory of Dr Caroline Breese Hall.
with a diagnosis of bronchiolitis (Evidence Quality: B; Recommen-
dation Strength: Strong Recommendation). www.pediatrics.org/cgi/doi/10.1542/peds.2014-2742
4a. Nebulized hypertonic saline should not be administered to in-
doi:10.1542/peds.2014-2742
fants with a diagnosis of bronchiolitis in the emergency depart-
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
ment (Evidence Quality: B; Recommendation Strength: Moderate
Copyright © 2014 by the American Academy of Pediatrics
Recommendation).
4b. Clinicians may administer nebulized hypertonic saline to infants
and children hospitalized for bronchiolitis (Evidence Quality: B;
Recommendation Strength: Weak Recommendation [based on ran-
domized controlled trials with inconsistent findings]).
e1474 FROM THE AMERICAN ACADEMY OF PEDIATRICS

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FROM THE AMERICAN ACADEMY OF PEDIATRICS
5. Clinicians should not administer 29 weeks, 0 days or greater 12b. Clinicians should counsel care-
systemic corticosteroids to infants (Evidence Quality: B; Recom- givers about exposing the in-
with a diagnosis of bronchiolitis in mendation Strength: Strong fant or child to environmental
any setting (Evidence Quality: A; Rec- Recommendation). tobacco smoke and smoking
ommendation Strength: Strong Rec- 10b. Clinicians should administer cessation when assessing a
ommendation). palivizumab during the first child for bronchiolitis (Evidence
6a. Clinicians may choose not to ad- year of life to infants with he- Quality: B; Recommendation
minister supplemental oxygen if modynamically significant heart Strength: Strong).
the oxyhemoglobin saturation ex- disease or chronic lung disease 13. Clinicians should encourage ex-
ceeds 90% in infants and children of prematurity defined as pre- clusive breastfeeding for at least
with a diagnosis of bronchiolitis term infants <32 weeks 0 days’ 6 months to decrease the mor-
(Evidence Quality: D; Recommen- gestation who require >21% bidity of respiratory infections.
dation Strength: Weak Recommen- oxygen for at least the first (Evidence Quality: B; Recommen-
dation [based on low level evidence 28 days of life (Evidence Quality: dation Strength: Moderate Rec-
and reasoning from first princi- B; Recommendation Strength: ommendation).
ples]). Moderate Recommendation). 14. Clinicians and nurses should ed-
6b. Clinicians may choose not to use 10c. Clinicians should administer ucate personnel and family mem-
continuous pulse oximetry for in- a maximum 5 monthly doses bers on evidence-based diagnosis,
fants and children with a diagnosis (15 mg/kg/dose) of palivizumab treatment, and prevention in bron-
of bronchiolitis (Evidence Quality: during the respiratory syncytial chiolitis. (Evidence Quality: C; obser-
D; Recommendation Strength: Weak virus season to infants who vational studies; Recommendation
Recommendation [based on low- qualify for palivizumab in the Strength: Moderate Recommenda-
level evidence and reasoning from first year of life (Evidence Quality: tion).
first principles]). B; Recommendation Strength:
7. Clinicians should not use chest Moderate Recommendation). INTRODUCTION
physiotherapy for infants and chil- 11a. All people should disinfect hands
dren with a diagnosis of bron- before and after direct contact In October 2006, the American Acad-
chiolitis (Evidence Quality: B; with patients, after contact with emy of Pediatrics (AAP) published the
Recommendation Strength: Mod- inanimate objects in the direct clinical practice guideline “Diagnosis
erate Recommendation). vicinity of the patient, and after and Management of Bronchiolitis.”1
8. Clinicians should not administer removing gloves (Evidence Qual- The guideline offered recommendations
antibacterial medications to in- ity: B; Recommendation Strength: ranked according to level of evidence
fants and children with a diagno- Strong Recommendation). and the benefit-harm relationship. Since
sis of bronchiolitis unless there 11b. All people should use alcohol- completion of the original evidence re-
is a concomitant bacterial infec- based rubs for hand decontam- view in July 2004, a significant body of
tion, or a strong suspicion of one ination when caring for children literature on bronchiolitis has been
(Evidence Quality: B; Recommen- with bronchiolitis. When alcohol- published. This update of the 2006 AAP
dation Strength: Strong Recom- based rubs are not available, bronchiolitis guideline evaluates pub-
mendation). individuals should wash their lished evidence, including that used in
9. Clinicians should administer naso- hands with soap and water the 2006 guideline as well as evidence
gastric or intravenous fluids for (Evidence Quality: B; Recom- published since 2004. Key action state-
infants with a diagnosis of bron- mendation Strength: Strong ments (KASs) based on that evidence
chiolitis who cannot maintain hy- Recommendation). are provided.
dration orally (Evidence Quality: X; 12a. Clinicians should inquire about The goal of this guideline is to provide
Recommendation Strength: Strong the exposure of the infant or an evidence-based approach to the di-
Recommendation). child to tobacco smoke when agnosis, management, and prevention
assessing infants and chil- of bronchiolitis in children from 1 month
PREVENTION dren for bronchiolitis (Evidence through 23 months of age. The guideline
10a. Clinicians should not administer Quality: C; Recommendation is intended for pediatricians, family
palivizumab to otherwise healthy Strength: Moderate Recom- physicians, emergency medicine spe-
infants with a gestational age of mendation). cialists, hospitalists, nurse practitioners,
PEDIATRICS Volume 134, Number 5, November 2014 e1475

and physician assistants who care for pneumovirus, influenza, adenovirus, average RSV hospitalization rate was
these children. The guideline does not coronavirus, human, and parainflu- 5.2 per 1000 children younger than 24
apply to children with immunodeficien- enza viruses. In a study of inpatients months of age during the 5-year pe-
cies, including those with HIV infection and outpatients with bronchiolitis,9 riod between 2000 and 2005.11 The
or recipients of solid organ or hema- 76% of patients had RSV, 39% had highest age-specific rate of RSV hos-
topoietic stem cell transplants. Children human rhinovirus, 10% had influenza, pitalization occurred among infants
with underlying respiratory illnesses, 2% had coronavirus, 3% had human between 30 days and 60 days of age
such as recurrent wheezing, chronic metapneumovirus, and 1% had para- (25.9 per 1000 children). For preterm
neonatal lung disease (also known as influenza viruses (some patients had infants (<37 weeks’ gestation), the
bronchopulmonary dysplasia), neuro- coinfections, so the total is greater than RSV hospitalization rate was 4.6 per
muscular disease, or cystic fibrosis and 100%). 1000 children, a number similar to
those with hemodynamically significant Bronchiolitis is the most common cause the RSV hospitalization rate for term
congenital heart disease are excluded of hospitalization among infants during infants of 5.2 per 1000. Infants born
from the sections on management un- the first 12 months of life. Approximately at <30 weeks’ gestation had the
less otherwise noted but are included in 100 000 bronchiolitis admissions occur highest hospitalization rate at 18.7
the discussion of prevention. This guide- annually in the United States at an children per 1000, although the small
line will not address long-term sequelae estimated cost of $1.73 billion.10 One number of infants born before 30
of bronchiolitis, such as recurrent prospective, population-based study weeks’ gestation make this number
wheezing or risk of asthma, which is sponsored by the Centers for Disease unreliable. Other studies indicate the
a field with a large and distinct lit- Control and Prevention reported the RSV hospitalization rate in extremely
erature.
Bronchiolitis is a disorder commonly
caused by viral lower respiratory tract
infection in infants. Bronchiolitis is
characterized by acute inflammation,
edema, and necrosis of epithelial cells
lining small airways, and increased
mucus production. Signs and symp-
toms typically begin with rhinitis and
cough, which may progress to tachy-
pnea, wheezing, rales, use of accessory
muscles, and/or nasal flaring.2
Many viruses that infect the respiratory
system cause a similar constellation of
signs and symptoms. The most com-
mon etiology of bronchiolitis is re-
spiratory syncytial virus (RSV), with the
highest incidence of infection occurring
between December and March in North
America; however, regional variations
occur3 (Fig 1).4 Ninety percent of chil-
dren are infected with RSV in the first
2 years of life,5 and up to 40% will
experience lower respiratory tract in-
fection during the initial infection.6,7
Infection with RSV does not grant per-
manent or long-term immunity, with
reinfections common throughout life.8
FIGURE 1
Other viruses that cause bronchiolitis RSV season by US regions. Centers for Disease Control and Prevention. RSV activity—United States,
include human rhinovirus, human meta- July 2011–Jan 2013. MMWR Morb Mortal Wkly Rep. 2013;62(8):141–144.

preterm infants is similar to that of view encompasses the period from of Family Physicians, and American
term infants.12,13 2004 through May 2014. College of Emergency Physicians; other
The evidence-based approach to guide- outside organizations; and other in-
METHODS line development requires that the evi- dividuals identified by the subcom-
dence in support of a policy be identified, mittee as experts in the field. The
In June 2013, the AAP convened a new resulting comments were reviewed
appraised, and summarized and that an
subcommittee to review and revise the by the subcommittee and, when ap-
explicit link between evidence and rec-
2006 bronchiolitis guideline. The sub- propriate, incorporated into the guide-
ommendations be defined. Evidence-
committee included primary care physi- line.
based recommendations reflect the
cians, including general pediatricians,
quality of evidence and the balance of This clinical practice guideline is not
a family physician, and pediatric sub-
benefit and harm that is anticipated intended as a sole source of guidance
specialists, including hospitalists, pul-
when the recommendation is followed. in the management of children with
monologists, emergency physicians, a
The AAP policy statement “Classify- bronchiolitis. Rather, it is intended to
neonatologist, and pediatric infectious
ing Recommendations for Clinical assist clinicians in decision-making.
disease physicians. The subcommit-
Practice”14 was followed in designat- It is not intended to replace clinical
tee also included an epidemiologist
ing levels of recommendation (Fig 2; judgment or establish a protocol for
trained in systematic reviews, a guide-
Table 1). the care of all children with bronchi-
line methodologist/informatician, and a
A draft version of this clinical practice olitis. These recommendations may not
parent representative. All panel mem-
guideline underwent extensive peer provide the only appropriate approach
bers reviewed the AAP Policy on Conflict
review by committees, councils, and to the management of children with
of Interest and Voluntary Disclosure and
sections within AAP; the American bronchiolitis.
were given an opportunity to declare any
potential conflicts. Any conflicts can be Thoracic Society, American College of All AAP guidelines are reviewed every
found in the author listing at the end of Chest Physicians, American Academy 5 years.
this guideline. All funding was provided
by the AAP, with travel assistance from
the American Academy of Family Phy-
sicians, the American College of Chest
Physicians, the American Thoracic
Society, and the American College
of Emergency Physicians for their
liaisons.
The evidence search and review included
electronic database searches in The
Cochrane Library, Medline via Ovid,
and CINAHL via EBSCO. The search
strategy is shown in the Appendix. Re-
lated article searches were conducted
in PubMed. The bibliographies of arti-
cles identified by database searches
were also reviewed by 1 of 4 members
of the committee, and references iden-
tified in this manner were added to
the review. Articles included in the
2003 evidence report on bronchiolitis
in preparation of the AAP 2006 guide-
line2 also were reviewed. In addition,
the committee reviewed articles pub-
lished after completion of the sys- FIGURE 2
Integrating evidence quality appraisal with an assessment of the anticipated balance between benefits
tematic review for these updated and harms leads to designation of a policy as a strong recommendation, moderate recommendation,
guidelines. The current literature re- or weak recommendation.

TABLE 1 Guideline Definitions for Evidence-Based Statements
Statement Definition Implication
Strong recommendation A particular action is favored because anticipated benefits Clinicians should follow a strong recommendation unless
clearly exceed harms (or vice versa), and quality of evidence a clear and compelling rationale for an alternative approach
is excellent or unobtainable. is present.
Moderate recommendation A particular action is favored because anticipated benefits Clinicians would be prudent to follow a moderate
clearly exceed harms (or vice versa), and the quality of recommendation but should remain alert to new
evidence is good but not excellent (or is unobtainable). information and sensitive to patient preferences.
Weak recommendation (based on A particular action is favored because anticipated benefits Clinicians would be prudent to follow a weak recommendation
low-quality evidence clearly exceed harms (or vice versa), but the quality of but should remain alert to new information and very
evidence is weak. sensitive to patient preferences.
Weak recommendation (based on Weak recommendation is provided when the aggregate Clinicians should consider the options in their decision making,
balance of benefits and harms) database shows evidence of both benefit and harm that but patient preference may have a substantial role.
appear similar in magnitude for any available courses of
action
DIAGNOSIS uation and management of children Action Statement Profile KAS 1b

Key Action Statement 1a with bronchiolitis (Evidence Quality: Aggregate B
B; Recommendation Strength: Mod- evidence
Clinicians should diagnose bronchi- erate Recommendation). quality
olitis and assess disease severity Benefits Decreased radiation
exposure, noninvasive
on the basis of history and physical Action Statement Profile KAS 1b (less procedure-associated
examination (Evidence Quality: B; discomfort), decreased
Aggregate B
Recommendation Strength: Strong evidence
antibiotic use, cost savings,
Recommendation). time saving
quality
Risk, harm, cost Misdiagnosis, missed
Benefits Improved ability to predict
diagnosis of comorbid
Action Statement Profile KAS 1a course of illness,
condition
appropriate disposition
Benefit-harm Benefits outweigh harms
Aggregate evidence B Risk, harm, cost Possible unnecessary
assessment
quality hospitalization parental
Value judgments None
Benefits Inexpensive, anxiety
Intentional None
noninvasive, accurate Benefit-harm Benefits outweigh harms
vagueness
Risk, harm, cost Missing other assessment
Role of patient None
diagnoses Value judgments None
preferences
Benefit-harm Benefits outweigh Intentional “Assess” is not defined
Exclusions Infants and children with
assessment harms vagueness
unexpected worsening
Value judgments None Role of patient None
disease
Intentional vagueness None preferences
Strength Moderate recommendation
Role of patient None Exclusions None
Differences of None
preferences Strength Moderate recommendation
opinion
Exclusions None Differences of None
Strength Strong recommendation opinion
Differences of opinion None
The main goals in the history and

physical examination of infants pre-
Key Action Statement 1c senting with wheeze or other lower
Key Action Statement 1b When clinicians diagnose bronchi- respiratory tract symptoms, particularly
Clinicians should assess risk fac- olitis on the basis of history and in the winter season, is to differentiate
tors for severe disease, such as physical examination, radiographic infants with probable viral bronchiolitis
age <12 weeks, a history of pre- or laboratory studies should not be from those with other disorders. In ad-
maturity, underlying cardiopulmo- obtained routinely (Evidence Qual- dition, an estimate of disease severity
nary disease, or immunodeficiency, ity: B; Recommendation Strength: (increased respiratory rate, retractions,
when making decisions about eval- Moderate Recommendation). decreased oxygen saturation) should

be made. Most clinicians recognize rate in otherwise healthy children suggesting that it reliably detects hyp-
bronchiolitis as a constellation of clin- changes considerably over the first oxemia not suspected on physical
ical signs and symptoms occurring in year of life.22–25 In hospitalized children, examination36,40; however, few studies
children younger than 2 years, includ- the 50th percentile for respiratory rate have assessed the effectiveness of
ing a viral upper respiratory tract decreased from 41 at 0 to 3 months of pulse oximetry to predict clinical out-
prodrome followed by increased re- age to 31 at 12 to 18 months of age.26 comes. Among inpatients, perceived
spiratory effort and wheezing. Clinical Counting respiratory rate over the need for supplemental oxygen on the
signs and symptoms of bronchiolitis course of 1 minute is more accurate basis of pulse oximetry has been as-
consist of rhinorrhea, cough, tachypnea, than shorter observations.27 The pres- sociated with prolonged hospitaliza-
wheezing, rales, and increased respi- ence of a normal respiratory rate tion, ICU admission, and mechanical
ratory effort manifested as grunting, suggests that risk of significant viral ventilation.16,34,41 Among outpatients,
nasal flaring, and intercostal and/or or bacterial lower respiratory tract available evidence differs on whether
subcostal retractions. infection or pneumonia in an infant is mild reductions in pulse oximetry (<95%
The course of bronchiolitis is variable low (negative likelihood ratio approxi- on room air) predict progression of
and dynamic, ranging from transient mately 0.5),27–29 but the presence of disease or need for a return obser-
events, such as apnea, to progressive tachypnea does not distinguish be- vational visit.38
respiratory distress from lower airway tween viral and bacterial disease.30,31 Apnea has been reported to occur with
obstruction. Important issues to assess The evidence relating the presence of a wide range of prevalence estimates
in the history include the effects of re- specific findings in the assessment of and viral etiologies.42,43 Retrospective,
spiratory symptoms on mental status, bronchiolitis to clinical outcomes is hospital-based studies have included
feeding, and hydration. The clinician limited. Most studies addressing this a high proportion of infants with risk
should assess the ability of the family issue have enrolled children when factors, such as prematurity or neuro-
to care for the child and to return for presenting to hospital settings, in- muscular disease, that may have biased
further evaluation if needed. History cluding a large, prospective, multicen- the prevalence estimates. One large
of underlying conditions, such as pre- ter study that assessed a variety of study found no apnea events for infants
maturity, cardiac disease, chronic outcomes from the emergency de- assessed as low risk by using several
pulmonary disease, immunodeficiency, partment (ED) and varied inpatient risk factors: age >1 month for full-term
or episodes of previous wheezing, should settings.18,32,33 Severe adverse events, infants or 48 weeks’ postconceptional
be identified. Underlying conditions that such as ICU admission and need for age for preterm infants, and absence
may be associated with an increased mechanical ventilation, are uncommon of any previous apneic event at pre-
risk of progression to severe disease among children with bronchiolitis and sentation to the hospital.44 Another
or mortality include hemodynamically limit the power of these studies large multicenter study found no asso-
significant congenital heart disease, to detect clinically important risk fac- ciation between the specific viral agent
chronic lung disease (bronchopulmonary tors associated with disease pro- and risk of apnea in bronchiolitis.42
dysplasia), congenital anomalies,15–17 gression.16,34,35 Tachypnea, defined as The literature on viral testing for bron-
in utero smoke exposure,18 and the a respiratory rate ≥70 per minute, has chiolitis has expanded in recent years
presence of an immunocompromising been associated with increased risk of with the availability of sensitive poly-
state.19,20 In addition, genetic abnormal- severe disease in some studies35–37 but merase chain reaction (PCR) assays.
ities have been associated with more not others.38 Many scoring systems Large studies of infants hospitalized for
severe presentation with bronchiolitis.21 have been developed in an attempt to bronchiolitis have consistently found
Assessment of a child with bronchiolitis, objectively quantify respiratory dis- that 60% to 75% have positive test results
including the physical examination, can tress, although none has achieved for RSV, and have noted coinfections
be complicated by variability in the dis- widespread acceptance and few have in up to one-third of infants.32,33,45
ease state and may require serial demonstrated any predictive validity, In the event an infant receiving
observations over time to fully assess the likely because of the substantial tem- monthly prophylaxis is hospitalized
child’s status. Upper airway obstruction poral variability in physical findings in with bronchiolitis, testing should be
contributes to work of breathing. Suc- infants with bronchiolitis.39 performed to determine if RSV is the
tioning and positioning may decrease Pulse oximetry has been rapidly adopted etiologic agent. If a breakthrough RSV
the work of breathing and improve the into clinical assessment of children infection is determined to be present
quality of the examination. Respiratory with bronchiolitis on the basis of data based on antigen detection or other

assay, monthly palivizumab prophylaxis and children with a diagnosis of A recently updated Cochrane system-
should be discontinued because of the bronchiolitis (Evidence Quality: B; atic review assessing the impact of
very low likelihood of a second RSV Recommendation Strength: Strong bronchodilators on oxygen saturation,
infection in the same year. Apart from Recommendation). the primary outcome measure, reported
this setting, routine virologic testing is 30 randomized controlled trials in-
not recommended. Action Statement Profile KAS 2 volving 1992 infants in 12 countries.56
Infants with non-RSV bronchiolitis, in Aggregate B Some studies included in this review
evidence evaluated agents other than albuterol/
particular human rhinovirus, appear to quality
have a shorter courses and may rep- Benefits Avoid adverse effects, avoid
salbutamol (eg, ipratropium and meta-
resent a different phenotype associated ongoing use of ineffective proterenol) but did not include epi-
medication, lower costs nephrine. Small sample sizes, lack of
with repeated wheezing.32 PCR assay
Risk, harm, cost Missing transient benefit of
results should be interpreted cautiously, drug
standardized methods for outcome
given that the assay may detect pro- Benefit-harm Benefits outweigh harms evaluation (eg, timing of assessments),
assessment and lack of standardized intervention
longed viral shedding from an unrelated
Value judgments Overall ineffectiveness
previous illness, particularly with rhi- outweighs possible
(various bronchodilators, drug dosages,
novirus. In contrast, RSV detected by transient benefit routes of administration, and nebuliza-
PCR assay almost always is associated Intentional None tion delivery systems) limit the in-
vagueness
with disease. At the individual patient terpretation of these studies. Because
Role of patient None
level, the value of identifying a spe- preferences of variable study designs as well as the
cific viral etiology causing bronchi- Exclusions None inclusion of infants who had a history of
Strength Strong recommendation
olitis has not been demonstrated.33 previous wheezing in some studies,
Differences of None
Current evidence does not support opinion there was considerable heterogeneity
routine chest radiography in children
Notes This guideline no longer in the studies. Sensitivity analysis (ie,
recommends a trial of including only studies at low risk of
with bronchiolitis. Although many albuterol, as was considered
infants with bronchiolitis have abnor- in the 2006 AAP bronchiolitis bias) significantly reduced heterogene-
malities on chest radiography, data guideline ity measures for oximetry while having
are insufficient to demonstrate that little effect on the overall effect size of
chest radiography correlates well with oximetry (mean difference [MD] –0.38,
disease severity. Atelectasis on chest 95% confidence interval [CI] –0.75 to
Although several studies and reviews
radiography was associated with in- 0.00). Those studies showing benefit57–59
have evaluated the use of bronchodi-
creased risk of severe disease in 1 are methodologically weaker than other
lator medications for viral bronchiolitis,
outpatient study.16 Further studies, in- studies and include older children with
most randomized controlled trials have
cluding 1 randomized trial, suggest recurrent wheezing. Results of the
failed to demonstrate a consistent ben-
Cochrane review indicated no benefit in
children with suspected lower respi- efit from α- or β-adrenergic agents.
ratory tract infection who had radiog- the clinical course of infants with
Several meta-analyses and systematic
raphy performed were more likely to bronchiolitis who received bronchodi-
reviews48–53 have shown that broncho-
receive antibiotics without any differ- dilators may improve clinical symptom lators. The potential adverse effects
ence in outcomes.46,47 Initial radiography scores, but they do not affect disease (tachycardia and tremors) and cost of
should be reserved for cases in which resolution, need for hospitalization, or these agents outweigh any potential
respiratory effort is severe enough to length of stay (LOS). Because clinical benefits.
warrant ICU admission or where signs scores may vary from one observer to In the previous iteration of this guideline,
of an airway complication (such as the next39,54 and do not correlate with a trial of β-agonists was included as
pneumothorax) are present. more objective measures, such as pul- an option. However, given the greater
monary function tests,55 clinical scores strength of the evidence demonstrat-
TREATMENT are not validated measures of the effi- ing no benefit, and that there is no
ALBUTEROL cacy of bronchodilators. Although tran- well-established way to determine an
sient improvements in clinical score “objective method of response” to
Key Action Statement 2 have been observed, most infants bronchodilators in bronchiolitis, this
Clinicians should not administer treated with bronchodilators will not option has been removed. Although it
albuterol (or salbutamol) to infants benefit from their use. is true that a small subset of children

with bronchiolitis may have reversible EPINEPHRINE analysis by Hartling et al64 systemati-
airway obstruction resulting from Key Action Statement 3 cally evaluated the evidence on this
smooth muscle constriction, attempts topic and found no evidence for utility
Clinicians should not administer in the inpatient setting. Two large,
to define a subgroup of responders
epinephrine to infants and children multicenter randomized trials com-
have not been successful to date. If
with a diagnosis of bronchiolitis paring nebulized epinephrine to pla-
a clinical trial of bronchodilators is (Evidence Quality: B; Recommenda-
undertaken, clinicians should note that the cebo65 or albuterol66 in the hospital
tion Strength: Strong Recommen- setting found no improvement in LOS
variability of the disease process, the host’s dation). or other inpatient outcomes. A recent,
airway, and the clinical assessments, par-
large multicenter trial found a similar
ticularly scoring, would limit the clinician’s Action Statement Profile KAS 3 lack of efficacy compared with pla-
ability to observe a clinically relevant re- Aggregate B cebo and further demonstrated lon-
sponse to bronchodilators. evidence
ger LOS when epinephrine was used
quality
Chavasse et al60 reviewed the available Benefits Avoiding adverse effects, lower on a fixed schedule compared with an
literature on use of β-agonists for chil- costs, avoiding ongoing use as-needed schedule.67 This evidence
dren younger than 2 years with re- of ineffective medication suggests epinephrine should not be
Risk, harm, cost Missing transient benefit of
current wheezing. At the time of that drug used in children hospitalized for bron-
review, there were 3 studies in the Benefit-harm Benefits outweigh harms chiolitis, except potentially as a rescue
assessment agent in severe disease, although for-
outpatient setting, 2 in the ED, and 3 Value judgments The overall ineffectiveness
in the pulmonary function laboratory outweighs possible transient
mal study is needed before a recom-
setting. This review concluded there benefit mendation for the use of epinephrine
Intentional None in this setting.
were no clear benefits from the use vagueness
of β-agonists in this population. The Role of patient None The role of epinephrine in the out-
authors noted some conflicting evi- preferences patient setting remains controver-
Exclusions Rescue treatment of rapidly
dence, but further study was recom- sial. A major addition to the evidence
deteriorating patients
mended only if the population could be Strength Strong recommendation base came from the Canadian Bron-
clearly defined and meaningful out-
Differences of None chiolitis Epinephrine Steroid Trial.68
opinion
This multicenter randomized trial
come measures could be identified.
enrolled 800 patients with bron-
The population of children with bronchiolitis from 8 EDs and compared
chiolitis studied in most trials of
hospitalization rates over a 7-day
bronchodilators limits the ability to Epinephrine is an adrenergic agent
period. This study had 4 arms: neb-
make recommendations for all clinical with both β- and α-receptor agonist
ulized epinephrine plus oral dexa-
scenarios. Children with severe disease activity that has been used to treat
methasone, nebulized epinephrine
or with respiratory failure were gen- upper and lower respiratory tract ill-
plus oral placebo, nebulized placebo
erally excluded from these trials, and nesses both as a systemic agent and
plus oral dexamethasone, and neb-
this evidence cannot be generalized to directly into the respiratory tract,
ulized placebo plus oral placebo. The
where it is typically administered as
these situations. Studies using pulmo- group of patients who received epi-
a nebulized solution. Nebulized epi-
nary function tests show no effect of nephrine concomitantly with corti-
nephrine has been administered in
albuterol among infants hospitalized costeroids had a lower likelihood
the racemic form and as the purified
with bronchiolitis.56,61 One study in L-enantiomer, which is commercially of hospitalization by day 7 than the
a critical care setting showed a small available in the United States for in- double placebo group, although this
decrease in inspiratory resistance af- travenous use. Studies in other dis- effect was no longer statistically sig-
ter albuterol in one group and leval- eases, such as croup, have found no nificant after adjusting for multiple
buterol in another group, but therapy difference in efficacy on the basis of comparisons.
was accompanied by clinically signifi- preparation,63 although the compari- The systematic review by Hartling
cant tachycardia.62 This small clinical son has not been specifically studied et al64 concluded that epinephrine
change occurring with significant ad- for bronchiolitis. Most studies have reduced hospitalizations compared
verse effects does not justify recom- compared L-epinephrine to placebo or with placebo on the day of the ED visit
mending albuterol for routine care. albuterol. A recent Cochrane meta- but not overall. Given that epinephrine

has a transient effect and home ad- Recommendation [based on ran- for the analysis of LOS with an aggregate
ministration is not routine practice, domized controlled trials with 1-day decrease reported, a result largely
discharging an infant after observing inconsistent findings]). driven by the inclusion of 3 studies with
a response in a monitored setting relatively long mean length of stay of 5 to
raises concerns for subsequent pro- Action Statement Profile KAS 4b 6 days. The analysis of effect on clinical
gression of illness. Studies have not Aggregate B scores included 7 studies involving 640
found a difference in revisit rates, evidence patients in both inpatient and outpatient
quality
although the numbers of revisits are settings and demonstrated incremental
Benefits May shorten hospital stay if LOS
small and may not be adequately is >72 h positive effect with each day posttreat-
powered for this outcome. In summary, Risk, harm, cost Adverse effects such as ment from day 1 to day 3 (–0.88 MD on
the current state of evidence does not wheezing and excess day 1, –1.32 MD on day 2, and –1.51 MD
secretions; cost
support a routine role for epineph- Benefit-harm Benefits outweigh harms for on day 3). Finally, Zhang et al73 found no
rine for bronchiolitis in outpatients, assessment longer hospital stays effect on hospitalization rates in the
although further data may help to Value judgments Anticipating an individual pooled analysis of 1 outpatient and 3 ED
child’s LOS is difficult. Most
better define this question. US hospitals report an
studies including 380 total patients.
average LOS of <72 h for Several randomized trials published after
patients with bronchiolitis.
HYPERTONIC SALINE the Cochrane review period further in-
This weak recommendation
applies only if the average formed the current guideline recommen-
Key Action Statement 4a length of stay is >72 h dation. Four trials evaluated admission
Nebulized hypertonic saline should Intentional This weak recommendation is
rates from the ED, 3 using 3% saline and 1
vagueness based on an average LOS and
not be administered to infants with does not address the using 7% saline.74–76 A single trial76 dem-
a diagnosis of bronchiolitis in the individual patient. onstrated a difference in admission rates
emergency department (Evidence Role of patient None
from the ED favoring hypertonic saline,
preferences
Quality: B; Recommendation Strength: Exclusions None although the other 4 studies were con-
Moderate Recommendation). Strength Weak cordant with the studies included in the
Differences of None Cochrane review. However, contrary to the
Action Statement Profile KAS 4a opinion
studies included in the Cochrane review,
Aggregate B none of the more recent trials reported
evidence improvement in LOS and, when added to
quality Nebulized hypertonic saline is an in-
Benefits Avoiding adverse effects, such creasingly studied therapy for acute the older studies for an updated meta-
as wheezing and excess viral bronchiolitis. Physiologic evidence analysis, they significantly attenuate the
secretions, cost summary estimate of the effect on LOS.76,77
Risk, harm, cost None suggests that hypertonic saline in-
Benefit-harm Benefits outweigh harms creases mucociliary clearance in both Most of the trials included in the Cochrane
assessment normal and diseased lungs.69–71 Because review occurred in settings with typical
Value judgments None LOS of more than 3 days in their usual
Intentional None
the pathology in bronchiolitis involves
vagueness airway inflammation and resultant care arms. Hence, the significant decrease
Role of patient None mucus plugging, improved mucocili- in LOS noted by Zhang et al73 may not be
preferences generalizable to the United States where
ary clearance should be beneficial, al-
Exclusions None
Strength Moderate recommendation though there is only indirect evidence the average LOS is 2.4 days.10 One other
Differences of None to support such an assertion. A more ongoing clinical trial performed in the
opinion specific theoretical mechanism of ac- United States, unpublished except in ab-
tion has been proposed on the basis of stract form, further supports the obser-
the concept of rehydration of the air- vation that hypertonic saline does not
way surface liquid, although again, decrease LOS in settings where expected
Key Action Statement 4b evidence remains indirect.72 stays are less than 3 days.78
Clinicians may administer nebulized A 2013 Cochrane review73 included 11 The preponderance of the evidence sug-
hypertonic saline to infants and trials involving 1090 infants with mild to gests that 3% saline is safe and effective at
children hospitalized for bron- moderate disease in both inpatient and improving symptoms of mild to moderate
chiolitis (Evidence Quality: B; Rec- emergency settings. There were 6 studies bronchiolitis after 24 hours of use and
ommendation Strength: Weak involving 500 inpatients providing data reducing hospital LOS in settings in which

the duration of stay typically exceeds 3 respiratory diseases, such as asthma why simultaneous administration of
days. It has not been shown to be effective and croup,82–84 the evidence on corti- these drugs could be synergistic.89–92
at reducing hospitalization in emergency costeroid use in bronchiolitis is nega- However, other bronchiolitis trials of
settings or in areas where the length tive. The most recent Cochrane corticosteroids administered by us-
of usage is brief. It has not been systematic review shows that cortico- ing fixed simultaneous bronchodila-
studied in intensive care settings, steroids do not significantly reduce tor regimens have not consistently
and most trials have included only outpatient admissions when compared shown benefit93–97; hence, a recommen-
patients with mild to moderate dis- with placebo (pooled risk ratio, 0.92; dation regarding the benefit of com-
ease. Most studies have used a 3% 95% CI, 0.78 to 1.08; and risk ratio, 0.86; bined dexamethasone and epinephrine
saline concentration, and most have 95% CI, 0.7 to 1.06, respectively) and therapy is premature.
combined it with bronchodilators do not reduce LOS for inpatients (MD The systematic review of cortico-
with each dose; however, there is –0.18 days; 95% CI –0.39 to 0.04).85 No steroids in children with bronchiolitis
retrospective evidence that the rate other comparisons showed relevant cited previously did not find any dif-
of adverse events is similar without differences for either primary or sec- ferences in short-term adverse events
bronchodilators,79 as well as pro- ondary outcomes. This review con- as compared with placebo.86 However,
spective evidence extrapolated from tained 17 trials with 2596 participants corticosteroid therapy may prolong
2 trials without bronchodilators.79,80 and included 2 large ED-based ran- viral shedding in patients with bron-
A single study was performed in the domized trials, neither of which showed chiolitis.17
ambulatory outpatient setting81; how- reductions in hospital admissions with In summary, a comprehensive sys-
ever, future studies in the United States treatment with corticosteroids as com- tematic review and large multicenter
should focus on sustained usage on pared with placebo.69,86 randomized trials provide clear evi-
the basis of pattern of effects dis-
One of these large trials, the Canadian dence that corticosteroids alone do
cerned in the available literature.
Bronchiolitis Epinephrine Steroid Trial, not provide significant benefit to
however, did show a reduction in hos- children with bronchiolitis. Evidence
CORTICOSTEROIDS pitalizations 7 days after treatment with for potential benefit of combined
Key Action Statement 5 combined nebulized epinephrine and corticosteroid and agents with both
Clinicians should not administer oral dexamethasone as compared with α- and β-agonist activity is at best
systemic corticosteroids to infants placebo.69 Although an unadjusted ana- tentative, and additional large trials
with a diagnosis of bronchiolitis in lysis showed a relative risk for hospi- are needed to clarify whether this
any setting (Evidence Quality: A; talization of 0.65 (95% CI 0.45 to 0.95; therapy is effective.
Recommendation Strength: Strong P = .02) for combination therapy as Further, although there is no evidence
Recommendation). compared with placebo, adjustment of short-term adverse effects from
for multiple comparison rendered the corticosteroid therapy, other than
Action Statement Profile KAS 5 result insignificant (P = .07). These prolonged viral shedding, in infants
Aggregate A results have generated considerable and children with bronchiolitis, there
evidence quality controversy.87 Although there is no is inadequate evidence to be certain
Benefits No clinical benefit, avoiding standard recognized rationale for why of safety.
adverse effects
Risk, harm, cost None
combination epinephrine and dexa-
Benefit-harm Benefits outweigh harms methasone would be synergistic in
assessment
OXYGEN
infants with bronchiolitis, evidence in
Value judgments None Key Action Statement 6a
Intentional None
adults and children older than 6
vagueness years with asthma shows that adding Clinicians may choose not to ad-
Role of patient None inhaled long-acting β agonists to minister supplemental oxygen if the
preferences
Exclusions None
moderate/high doses of inhaled cor- oxyhemoglobin saturation exceeds
Strength Strong recommendation ticosteroids allows reduction of the 90% in infants and children with a
Differences of None corticosteroid dose by, on average, diagnosis of bronchiolitis (Evidence
opinion
60%.88 Basic science studies focused Quality: D; Recommendation Strength:
on understanding the interaction be- Weak Recommendation [based on
Although there is good evidence of tween β agonists and corticosteroids low-level evidence and reasoning
benefit from corticosteroids in other have shown potential mechanisms for from first principles]).

Action Statement Profile KAS 6a associated closely with a perceived do not have impaired intellectual abil-
Benefits Decreased hospitalizations, need for hospitalization in infants with ities or behavioral disturbance.106–108
decreased LOS bronchiolitis.98,99 Additionally, oxygen Supplemental oxygen provided for in-
Risk, harm, cost Hypoxemia, physiologic stress,
saturation has been implicated as fants not requiring additional re-
prolonged LOS, increased
hospitalizations, increased a primary determinant of LOS in spiratory support is best initiated with
LOS, cost bronchiolitis.40,100,101 nasal prongs, although exact mea-
Benefit-harm Benefits outweigh harms
assessment Physiologic data based on the oxyhe- surement of fraction of inspired oxy-
Value judgments Oxyhemoglobin saturation moglobin dissociation curve (Fig 3) gen is unreliable with this method.109
>89% is adequate to
demonstrate that small increases in Pulse oximetry is a convenient method
oxygenate tissues; the risk
of hypoxemia with arterial partial pressure of oxygen are to assess the percentage of hemo-
oxyhemoglobin saturation associated with marked improvement globin bound by oxygen in children.
>89% is minimal Pulse oximetry has been erroneously
in pulse oxygen saturation when the
Intentional None
vagueness latter is less than 90%; with pulse oxy- used in bronchiolitis as a proxy for
Role of patient Limited gen saturation readings greater than respiratory distress. Accuracy of pulse
preferences oximetry is poor, especially in the 76%
Exclusions Children with acidosis or fever
90% it takes very large elevations in
Strength Weak recommendation (based arterial partial pressure of oxygen to to 90% range.110 Further, it has been
on low-level evidence/ affect further increases. In infants and well demonstrated that oxygen satu-
reasoning from first ration has much less impact on re-
principles)
children with bronchiolitis, no data exist
to suggest such increases result in any spiratory drive than carbon dioxide
Differences of None
opinion clinically significant difference in physi- concentrations in the blood.111 There
is very poor correlation between re-
ologic function, patient symptoms, or
Key Action Statement 6b spiratory distress and oxygen satu-
clinical outcomes. Although it is well
rations among infants with lower
Clinicians may choose not to use understood that acidosis, temperature,
respiratory tract infections.112 Other
continuous pulse oximetry for in- and 2,3-diphosphoglutarate influence
than cyanosis, no published clinical
fants and children with a diagnosis the oxyhemoglobin dissociation curve,
sign, model, or score accurately iden-
of bronchiolitis (Evidence Quality: there has never been research to tifies hypoxemic children.113
C; Recommendation Strength: Weak demonstrate how those influences
Recommendation [based on lower- Among children admitted for bronchi-
practically affect infants with hypox-
level evidence]). olitis, continuous pulse oximetry mea-
emia. The risk of hypoxemia must be
surement is not well studied and
weighed against the risk of hospitali-
Action Statement Profile KAS 6b potentially problematic for children who
zation when making any decisions
do not require oxygen. Transient desa-
Aggregate C about site of care. One study of hospi-
evidence turation is a normal phenomenon in
quality
talized children with bronchiolitis, for healthy infants. In 1 study of 64 healthy
Benefits Shorter LOS, decreased alarm example, noted a 10% adverse error or infants between 2 weeks and 6 months
fatigue, decreased cost near-miss rate for harm-causing inter-
Risk, harm, cost Delayed detection of hypoxemia,
of age, 60% of these infants exhibited
delay in appropriate weaning
ventions.103 There are no studies on the a transient oxygen desaturation below
of oxygen effect of short-term, brief periods of 90%, to values as low as 83%.105 A ret-
Benefit-harm Benefits outweigh harms hypoxemia such as may be seen in
assessment
rospective study of the role of continu-
Value judgments None bronchiolitis. Transient hypoxemia is ous measurement of oxygenation in
Intentional None common in healthy infants.104 Travel of infants hospitalized with bronchiolitis
vagueness healthy children even to moderate alti- found that 1 in 4 patients incur unnec-
Role of patient Limited
preferences tudes of 1300 m results in transient essarily prolonged hospitalization as
Exclusions None sleep desaturation to an average of a result of a perceived need for oxygen
Strength Weak recommendation (based 84% with no known adverse con- outside of other symptoms40 and no
on lower level of evidence)
Differences of None sequences.105 Although children with evidence of benefit was found.
opinion chronic hypoxemia do incur devel- Pulse oximetry is prone to errors of
opmental and behavioral problems, measurement. Families of infants hospi-
Although oxygen saturation is a poor children who suffer intermittent hyp- talized with continuous pulse oximeters
predictor of respiratory distress, it is oxemia from diseases such as asthma are exposed to frequent alarms that

continuous positive airway pressure

in bronchiolitis.127–130 Clinical evidence
suggests it reduces work of breath-
ing131,132 and may decrease need for
intubation,133–136 although studies are
generally retrospective and small. The
therapy has been studied in the ED136,137
and the general inpatient setting,134,138
as well as the ICU. The largest and most
rigorous retrospective study to date
was from Australia,138 which showed
a decline in intubation rate in the sub-
group of infants with bronchiolitis (n =
330) from 37% to 7% after the intro-
duction of high-flow nasal cannula,
while the national registry intubation
rate remained at 28%. A single pilot
for a randomized trial has been pub-
FIGURE 3
Oxyhemoglobin dissociation curve showing percent saturation of hemoglobin at various partial
lished to date.139 Although promising,
pressures of oxygen (reproduced with permission from the educational Web site www.anaesthesiauk. the absence of any completed ran-
com).102 domized trial of the efficacy of high-flow
nasal cannula in bronchiolitis precludes
specific recommendations on it use at
may negatively affect sleep. Alarm fa- cluding 2 randomized trials.118,119 Most present. Pneumothorax is a reported
tigue is recognized by The Joint of the studies have been performed in complication.
Commission as a contributor toward areas of higher altitude, where pro-
in-hospital morbidity and mortality.114 longed hypoxemia is a prime deter-
One adult study demonstrated very minant of LOS in the hospital.120,121
CHEST PHYSIOTHERAPY
poor documentation of hypoxemia al- Readmission rates may be moderately
erts by pulse oximetry, an indicator higher in patients discharged with Key Action Statement 7
of alarm fatigue.115 Pulse oximetry home oxygen; however, overall hospital Clinicians should not use chest phys-
probes can fall off easily, leading to use may be reduced,122 although not in iotherapy for infants and children
inaccurate measurements and alarms.116 all settings.123 Concerns have been with a diagnosis of bronchiolitis (Evi-
False reliance on pulse oximetry may raised that home pulse oximetry may dence Quality: B; Recommendation
lead to less careful monitoring of re- complicate care or confuse families.124 Strength: Moderate Recommendation).
spiratory status. In one study, contin- Communication with follow-up physi-
uous pulse oximetry was associated cians is important, because primary Action Statement Profile KAS 7
with increased risk of minor adverse care physicians may have difficulty de-
Aggregate B
events in infants admitted to a gen- termining safe pulse oximetry levels
evidence
eral ward.117 The pulse oximetry– for discontinuation of oxygen.125 Addi- quality
monitored patients were found to tionally, there may be an increased Benefits Decreased stress from
have less-effective surveillance of their demand for follow-up outpatient visits therapy, reduced cost
severity of illness when controlling for associated with home oxygen use.124 Benefit-harm Benefits outweigh harms
other variables. Use of humidified, heated, high-flow assessment
There are a number of new approaches nasal cannula to deliver air-oxygen Intentional None
to oxygen delivery in bronchiolitis, 2 mixtures provides assistance to in- vagueness
of which are home oxygen and high- fants with bronchiolitis through mul- Role of patient None
preferences
frequency nasal cannula. There is tiple proposed mechanisms.126 There
Exclusions None
emerging evidence for the role of home is evidence that high-flow nasal can- Strength Moderate recommendation
oxygen in reducing LOS or admission nula improves physiologic measures Differences of None
rate for infants with bronchiolitis, in- of respiratory effort and can generate opinion

Airway edema, sloughing of respiratory Quality: B; Recommendation Strength: Enteritis was not evaluated. Urinary tract
epithelium into airways, and general- Strong Recommendation). infection occurred at a rate of approxi-
ized hyperinflation of the lungs, coupled mately 1%, but asymptomatic bacteri-
with poorly developed collateral venti- Action Statement Profile KAS 8 uria may have explained this finding. The
lation, put infants with bronchiolitis at Aggregate B authors concluded routine screening for
risk for atelectasis. Although lobar at- evidence SBI among hospitalized febrile infants
electasis is not characteristic of this quality with bronchiolitis between 30 and 90
Benefits Fewer adverse effects, less
disease, chest radiographs may show resistance to days of age is not justified. Limited data
evidence of subsegmental atelectasis, antibacterial agents, suggest the risk of bacterial infection in
prompting clinicians to consider or- lower cost hospitalized infants with bronchiolitis
dering chest physiotherapy to promote Benefit-harm Benefits outweigh harms younger than 30 days of age is similar to
airway clearance. A Cochrane Review140 assessment the risk in older infants. An abnormal
found 9 randomized controlled trials Value judgments None white blood cell count is not useful for
Intentional Strong suspicion is not
that evaluated chest physiotherapy in predicting a concurrent SBI in infants
vagueness specifically defined
hospitalized patients with bronchiolitis. and requires clinician and young children hospitalized with RSV
No clinical benefit was found by using judgment. An evaluation lower respiratory tract infection.159 Sev-
vibration or percussion (5 trials)141–144 for the source of possible
serious bacterial infection
eral retrospective studies support this
or passive expiratory techniques (4 tri- should be completed conclusion.160–166 Four prospective stud-
als).145–148 Since that review, a study149 before antibiotic use ies of SBI in patients with bronchiolitis
of the passive expiratory technique Role of patient None
preferences
and/or RSV infections also demonstrated
found a small, but significant reduction Exclusions None low rates of SBI.167–171
in duration of oxygen therapy, but no Strength Strong recommendation
Approximately 25% of hospitalized in-
other benefits. Differences of None
opinion fants with bronchiolitis have radio-
Suctioning of the nasopharynx to re- graphic evidence of atelectasis, and it
move secretions is a frequent practice may be difficult to distinguish between
in infants with bronchiolitis. Although atelectasis and bacterial infiltrate or
Infants with bronchiolitis frequently re-
suctioning the nares may provide consolidation.169 Bacterial pneumonia
ceive antibacterial therapy because of
temporary relief of nasal congestion in infants with bronchiolitis without
fever,152 young age,153 and concern for
or upper airway obstruction, a retro- consolidation is unusual.170 Antibiotic
secondary bacterial infection.154 Early
spective study reported that deep therapy may be justified in some chil-
randomized controlled trials 155,156
suctioning150 was associated with dren with bronchiolitis who require
showed no benefit from routine anti-
longer LOS in hospitalized infants 2 intubation and mechanical ventilation
bacterial therapy for children with
to 12 months of age. The same study for respiratory failure.172,173
bronchiolitis. Nonetheless, antibiotic
also noted that lapses of greater
therapy continues to be overused in Although acute otitis media (AOM) in
than 4 hours in noninvasive, external
young infants with bronchiolitis because infants with bronchiolitis may be at-
nasal suctioning were also associ-
of concern for an undetected bacterial tributable to viruses, clinical features
ated with longer LOS. Currently, there
infection. Studies have shown that febrile generally do not permit differentiation of
are insufficient data to make a rec-
infants without an identifiable source of viral AOM from those with a bacterial
ommendation about suctioning, but
fever have a risk of bacteremia that may component.174 Two studies address the
it appears that routine use of “deep”
be as high as 7%. However, a child with frequency of AOM in patients with
suctioning151,153 may not be beneficial.
a distinct viral syndrome, such as bronchiolitis. Andrade et al175 pro-
bronchiolitis, has a lower risk (much spectively identified AOM in 62% of 42
ANTIBACTERIALS
less than 1%) of bacterial infection of the patients who presented with bronchi-
Key Action Statement 8 cerebrospinal fluid or blood.157 olitis. AOM was present in 50% on entry
Clinicians should not administer Ralston et al158 conducted a systematic to the study and developed in an addi-
antibacterial medications to infants review of serious bacterial infections tional 12% within 10 days. A subsequent
and children with a diagnosis of (SBIs) occurring in hospitalized febrile report176 followed 150 children hospi-
bronchiolitis unless there is a con- infants between 30 and 90 days of age talized for bronchiolitis for the de-
comitant bacterial infection, or a with bronchiolitis. Instances of bacter- velopment of AOM. Seventy-nine (53%)
strong suspicion of one. (Evidence emia or meningitis were extremely rare. developed AOM, two-thirds within the

first 2 days of hospitalization. AOM did chiolitis. One study found that food insignificant. In a larger open ran-
not influence the clinical course or take at less than 50% of normal for the domized trial including infants be-
laboratory findings of bronchiolitis. The previous 24 hours is associated with tween 2 and 12 months of age and
current AAP guideline on AOM177 rec- a pulse oximetry value of <95%.180 conducted in Australia and New
ommends that a diagnosis of AOM Infants with mild respiratory distress Zealand, there were no significant
should include bulging of the tympanic may require only observation, particu- differences in rates of admission to
membrane. This is based on bulging larly if feeding remains unaffected. ICUs, need for ventilatory support,
being the best indicator for the pres- When the respiratory rate exceeds 60 and adverse events between 381
ence of bacteria in multiple tympano- to 70 breaths per minute, feeding may infants assigned to nasogastric hy-
centesis studies and on 2 articles be compromised, particularly if nasal dration and 378 infants assigned to
comparing antibiotic to placebo ther- secretions are copious. There is limited intravenous hydration.188 There was
apy that used a bulging tympanic evidence to suggest coordination of a difference of 4 hours in mean LOS
membrane as a necessary part of the breathing with swallowing may be between the intravenous group (82.2
diagnosis.178,179 New studies are needed impaired among infants with bron- hours) and the nasogastric group
to determine the incidence of AOM in chiolitis.181 These infants may develop (86.2 hours) that was not statisti-
bronchiolitis by using the new criterion increased nasal flaring, retractions, cally significant. The nasogastric
of bulging of the tympanic membrane. and prolonged expiratory wheezing route had a higher success rate of
Refer to the AOM guideline180 for rec- when fed and may be at increased risk insertion than the intravenous
ommendations regarding the manage- of aspiration.182 route. Parental satisfaction scores
ment of AOM. One study estimated that one-third of did not differ between the in-
infants hospitalized for bronchiolitis travenous and nasogastric groups.
NUTRITION AND HYDRATION require fluid replacement.183 One These studies suggest that infants
case series184 and 2 randomized who have difficulty feeding safely
Key Action Statement 9
trials,185,186 examined the compara- because of respiratory distress can
Clinicians should administer naso- receive either intravenous or naso-
tive efficacy and safety of the in-
gastric or intravenous fluids for gastric fluid replacement; however,
travenous and nasogastric routes
infants with a diagnosis of bron-
for fluid replacement. A pilot trial more evidence is needed to increase
chiolitis who cannot maintain hy- the strength of this recommendation.
in Israel that included 51 infants
dration orally (Evidence Quality: X;
younger than 6 months demon- The possibility of fluid retention re-
Recommendation Strength: Strong
strated no significant differences in lated to production of antidiuretic
Recommendation).
the duration of oxygen needed or hormone has been raised in patients
time to full oral feeds between with bronchiolitis.187–189 Therefore,
Action Statement Profile KAS 9
receipt of hypotonic fluid replace-
Aggregate evidence quality X ment and maintenance fluids may
Benefits Maintaining hydration increase the risk of iatrogenic hypo-
Risk, harm, cost Risk of infection, risk of aspiration with nasogastric tube, discomfort,
hyponatremia, intravenous infiltration, overhydration natremia in these infants. A recent
Benefit-harm assessment Benefits outweigh harms meta-analysis demonstrated that among
Value judgments None hospitalized children requiring main-
Intentional vagueness None
Role of patient preferences Shared decision as to which mode is used
tenance fluids, the use of hypotonic
Exclusions None fluids was associated with significant
Strength Strong recommendation hyponatremia compared with iso-
tonic fluids in older children.190 Use
of isotonic fluids, in general, appears
to be safer.
The level of respiratory distress infants receiving intravenous 5%

attributable to bronchiolitis guides dextrose in normal saline solution PREVENTION
the indications for fluid replacement. or nasogastric breast milk or for-
Conversely, food intake in the previous mula.187 Infants in the intravenous Key Action Statement 10a
24 hours may be a predictor of oxygen group had a shorter LOS (100 vs 120 Clinicians should not administer
saturation among infants with bron- hours) but it was not statistically palivizumab to otherwise healthy

infants with a gestational age of 29 Action Statement Profile KAS 10b Palivizumab was licensed by the US
weeks, 0 days or greater (Evidence Aggregate evidence quality B Food and Drug Administration in June
Quality: B; Recommendation Strength: Benefits Reduced risk of RSV 1998 largely on the basis of results of 1
Strong Recommendation). hospitalization clinical trial.193 The results of a second
Risk, harm, cost Injection pain;
increased risk of
clinical trial among children with con-
Action Statement Profile KAS 10a illness from genital heart disease were reported in
Aggregate evidence B
increased visits to December 2003.194 No other prospec-
clinician office or
quality tive, randomized, placebo-controlled
clinic; cost; side
Benefits Reduced pain of trials have been conducted in any
effects from
injections, reduced
palivizumab subgroup. Since licensure of pal-
use of a medication
Benefit-harm assessment Benefits outweigh ivizumab, new peer-reviewed pub-
that has shown
harms
minimal benefit,
Value judgments None lications provide greater insight into
reduced adverse the epidemiology of disease caused by
effects, reduced
Role of patient preferences Parents may choose RSV.195–197 As a result of new data, the
visits to health care
to not accept
provider with less
palivizumab
Bronchiolitis Guideline Committee and
exposure to illness the Committee on Infectious Diseases
Exclusions None
Risk, harm, cost Minimal increase in risk
of RSV hospitalization
Strength Moderate have updated recommendations for
recommendation
Benefit-harm assessment Benefits outweigh use of prophylaxis.
harms
Notes This KAS is
harmonized with PREMATURITY
the AAP policy
Role of patient Parents may choose to Monthly palivizumab prophylaxis should
statement on
preferences not accept be restricted to infants born before 29
palivizumab191,192
palivizumab
weeks, 0 days’ gestation, except for
Exclusions Infants with chronic
lung disease of Key Action Statement 10c infants who qualify on the basis of
prematurity and Clinicians should administer a max- congenital heart disease or chronic
hemodynamically lung disease of prematurity. Data
significant cardiac imum 5 monthly doses (15 mg/kg/
disease (as described dose) of palivizumab during the show that infants born at or after 29
in KAS 10b) RSV season to infants who qualify weeks, 0 days’ gestation have an RSV
Strength Recommendation
for palivizumab in the first year hospitalization rate similar to the rate
Notes This KAS is harmonized of life (Evidence Quality: B, Recom- of full-term infants.11,198 Infants with
with the AAP policy mendation Strength: Moderate a gestational age of 28 weeks, 6 days
statement on or less who will be younger than 12
Recommendation).
palivizumab
months at the start of the RSV sea-
Action Statement Profile KAS 10c son should receive a maximum of 5
Aggregate evidence quality B

Benefits Reduced risk of hospitalization; reduced admission to ICU
Risk, harm, cost Injection pain; increased risk of illness from increased visits to clinician
office or clinic; cost; adverse effects of palivizumab
Benefit-harm assessment Benefits outweigh harms
Key Action Statement 10b Value judgments None
Clinicians should administer pal- Role of patient preferences None
ivizumab during the first year of Exclusions Fewer doses should be used if the bronchiolitis season ends before the
completion of 5 doses; if the child is hospitalized with a breakthrough RSV,
life to infants with hemodynami-
monthly prophylaxis should be discontinued
cally significant heart disease or Strength Moderate recommendation
chronic lung disease of prema- Differences of opinion None
turity defined as preterm infants Notes This KAS is harmonized with the AAP policy statement on palivizumab191,192
<32 weeks, 0 days’ gestation who

require >21% oxygen for at least Detailed evidence to support the policy monthly doses of palivizumab or until
the first 28 days of life (Evidence statement on palivizumab and this the end of the RSV season, whichever
Quality: B; Recommendation Strength: palivizumab section can be found in the comes first. Depending on the month
Moderate Recommendation). technical report on palivizumab.192 of birth, fewer than 5 monthly doses

will provide protection for most in- tion for a total of 5 doses will provide fibrosis from 40 centers reported 1
fants for the duration of the season. protection into April.201 If prophylaxis is subject in each group was hospitalized
initiated in October, the fifth and final because of RSV infection. Although this
CONGENITAL HEART DISEASE dose should be administered in Febru- study was not powered for efficacy, no
Despite the large number of subjects ary, and protection will last into March clinically meaningful differences in
enrolled, little benefit from pal- for most children. outcome were reported.205 A survey of
ivizumab prophylaxis was found in cystic fibrosis center directors pub-
the industry-sponsored cardiac study SECOND YEAR OF LIFE lished in 2009 noted that palivizumab
among infants in the cyanotic group prophylaxis is not the standard of care
Because of the low risk of RSV hospi- for patients with cystic fibrosis.206 If
(7.9% in control group versus 5.6% in talization in the second year of life,
palivizumab group, or 23 fewer hos- a neonate is diagnosed with cystic fi-
palivizumab prophylaxis is not recom- brosis by newborn screening, RSV
pitalizations per1000 children; P = mended for children in the second year
.285).197 In the acyanotic group (11.8% prophylaxis should not be adminis-
of life with the following exception. tered if no other indications are pres-
vs 5.0%), there were 68 fewer RSV Children who satisfy the definition of
hospitalizations per 1000 prophylaxis ent. A patient with cystic fibrosis with
chronic lung disease of infancy and clinical evidence of chronic lung dis-
recipients (P = .003).197,199,200 continue to require supplemental oxy- ease in the first year of life may be
gen, chronic corticosteroid therapy, considered for prophylaxis.
CHRONIC LUNG DISEASE OF
or diuretic therapy within 6 months
PREMATURITY
of the onset of the second RSV sea-
Palivizumab prophylaxis should be son may be considered for a second Neuromuscular Disease and
administered to infants and children Pulmonary Abnormality
season of prophylaxis.
younger than 12 months who develop The risk of RSV hospitalization is not
chronic lung disease of prematurity, OTHER CONDITIONS well defined in children with pulmonary
defined as a requirement for 28 days abnormalities or neuromuscular dis-
of more than 21% oxygen beginning Insufficient data are available to rec- ease that impairs ability to clear
at birth. If a child meets these cri- ommend routine use of prophylaxis in secretions from the lower airway be-
teria and is in the first 24 months of children with Down syndrome, cystic cause of ineffective cough, recurrent
life and continues to require sup- fibrosis, pulmonary abnormality, neu- gastroesophageal tract reflux, pulmo-
plemental oxygen, diuretic therapy, romuscular disease, or immune com- nary malformations, tracheoesophageal
or chronic corticosteroid therapy promise. fistula, upper airway conditions, or
within 6 months of the start of the conditions requiring tracheostomy. No
RSV season, monthly prophylaxis should Down Syndrome data on the relative risk of RSV hospi-
be administered for the remainder of Routine use of prophylaxis for children talization are available for this cohort.
the season. in the first year of life with Down Selected infants with disease or con-
syndrome is not recommended unless genital anomaly that impairs their
NUMBER OF DOSES the child qualifies because of cardiac ability to clear secretions from the
disease or prematurity.202 lower airway because of ineffective
Community outbreaks of RSV disease
cough may be considered for pro-
usually begin in November or December,
Cystic Fibrosis phylaxis during the first year of life.
peak in January or February, and end by
late March or, at times, in April.4 Figure 1 Routine use of palivizumab prophylaxis
shows the 2011–2012 bronchiolitis sea- in patients with cystic fibrosis is not Immunocompromised Children
son, which is typical of most years. recommended.203,204 Available studies Population-based data are not avail-
Because 5 monthly doses will provide indicate the incidence of RSV hospital- able on the incidence or severity of RSV
more than 24 weeks of protective se- ization in children with cystic fibrosis hospitalization in children who un-
rum palivizumab concentration, adminis low and unlikely to be different from dergo solid organ or hematopoietic
istration of more than 5 monthly doses children without cystic fibrosis. No ev- stem cell transplantation, receive
is not recommended within the conti- idence suggests a benefit from pal- chemotherapy, or are immunocom-
nental United States. For infants who ivizumab prophylaxis in patients with promised because of other conditions.
qualify for 5 monthly doses, initiation of cystic fibrosis. A randomized clinical Prophylaxis may be considered for
prophylaxis in November and continua- trial involving 186 children with cystic hematopoietic stem cell transplant

patients who undergo transplantation Key Action Statement 11b caregivers.213 Studies have shown that
and are profoundly immunosup- All people should use alcohol-based health care workers have acquired in-
pressed during the RSV season.207 rubs for hand decontamination when fection by performing activities such as
caring for children with bronchioli- feeding, diaper change, and playing
MISCELLANEOUS ISSUES tis. When alcohol-based rubs are with the RSV-infected infant. Caregivers
not available, individuals should who had contact only with surfaces
Prophylaxis is not recommended for
wash their hands with soap and contaminated with the infants’ secre-
prevention of nosocomial RSV disease
water (Evidence Quality: B; Recom- tions or touched inanimate objects in
in the NICU or hospital setting.208,209
mendation Strength: Strong Rec- patients’ rooms also acquired RSV. In
No evidence suggests palivizumab is these studies, health care workers
ommendation).
a cost-effective measure to prevent contaminated their hands (or gloves)
recurrent wheezing in children. Pro- with RSV and inoculated their oral or
Action Statement Profile KAS 11b
phylaxis should not be administered conjunctival mucosa.214 Frequent hand
to reduce recurrent wheezing in later Aggregate evidence quality B
Benefits Less hand irritation washing by health care workers has
years.210,211 Risk, harm, cost If there is visible been shown to reduce the spread of
Monthly prophylaxis in Alaska Native dirt on the RSV in the health care setting.215
hands, hand
children who qualify should be de- The Centers for Disease Control and
washing is
termined by locally generated data necessary; Prevention published an extensive re-
regarding season onset and end. alcohol-based
view of the hand-hygiene literature and
rubs are not
Continuation of monthly prophylaxis effective for made recommendations as to indica-
for an infant or young child who ex- Clostridium tions for hand washing and hand
periences breakthrough RSV hospital- difficile, present
a fire hazard,
antisepsis.216 Among the recom-
ization is not recommended. and have a slight mendations are that hands should be
increased cost disinfected before and after direct
Benefit-harm assessment Benefits outweigh
contact with every patient, after con-
harms
HAND HYGIENE Value judgments None tact with inanimate objects in the di-
Key Action Statement 11a Intentional vagueness None rect vicinity of the patient, and before
Role of patient preferences None putting on and after removing gloves.
All people should disinfect hands Exclusions None
Strength Strong If hands are not visibly soiled, an
before and after direct contact
recommendation alcohol-based rub is preferred. In
with patients, after contact with Differences of opinion None guidelines published in 2009, the
inanimate objects in the direct vi-
cinity of the patient, and after re- World Health Organization also rec-
moving gloves (Evidence Quality: B; ommended alcohol-based hand-rubs
Recommendation Strength: Strong as the standard for hand hygiene in
Efforts should be made to decrease the
Recommendation). health care.217 Specifically, systematic
spread of RSV and other causative
reviews show them to remove organ-
agents of bronchiolitis in medical
Action Statement Profile KAS 11a isms more effectively, require less
settings, especially in the hospital.
time, and irritate skin less often than
Secretions from infected patients can
hand washing with soap or other anti-
be found on beds, crib railings, ta-
Benefits Decreased septic agents and water. The availability
transmission bletops, and toys.12 RSV, as well as
of bedside alcohol-based solutions in-
of disease many other viruses, can survive better creased compliance with hand hygiene
Risk, harm, cost Possible hand
on hard surfaces than on porous among health care workers.214
irritation
Benefit-harm assessment Benefits outweigh surfaces or hands. It can remain in-
When caring for hospitalized children
harms fectious on counter tops for ≥6 hours, with clinically diagnosed bronchioli-
Intentional vagueness None on gowns or paper tissues for 20 tis, strict adherence to hand de-
Role of patient preferences None to 30 minutes, and on skin for up to contamination and use of personal
Exclusions None
20 minutes.212 protective equipment (ie, gloves and
Strength Strong
recommendation It has been shown that RSV can be carried gowns) can reduce the risk of cross-
Differences of opinion None and spread to others on the hands of infection in the health care setting.215

Other methods of infection control in child to environmental tobacco tis.222–225 The AAP issued a technical
viral bronchiolitis include education of smoke and smoking cessation report on the risks of secondhand
personnel and family members, surveil- when assessing a child for bron- smoke in 2009. The report makes rec-
lance for the onset of RSV season, and chiolitis (Evidence Quality: B; Rec- ommendations regarding effective ways
wearing masks when anticipating expo- ommendation Strength: Strong to eliminate or reduce secondhand
sure to aerosolized secretions while Recommendation). smoke exposure, including education of
performing patient care activities. Pro- parents.226
grams that implement the aforemen- Action Statement Profile KAS 12b Despite our knowledge of this impor-
tioned principles, in conjunction with Aggregate evidence quality B tant risk factor, there is evidence to
effective hand decontamination and Benefits Reinforces the suggest health care providers identify
cohorting of patients, have been shown detrimental fewer than half of children exposed to
to reduce the spread of RSV in the effects of
smoking, tobacco smoke in the outpatient, in-
health care setting by 39% to 50%.218,219 potential to patient, or ED settings.227–229 Further-
decrease more, there is evidence that
smoking
TOBACCO SMOKE Risk, harm, cost Time to counsel
counseling parents in these settings is
Key Action Statement 12a Benefit-harm assessment Benefits outweigh well received and has a measurable
harms impact. Rosen et al230 performed a
Clinicians should inquire about the Value judgments None
meta-analysis of the effects of inter-
exposure of the infant or child to
Role of patient preferences Parents may choose ventions in pediatric settings on pa-
tobacco smoke when assessing to ignore rental cessation and found a pooled
infants and children for bron- counseling risk ratio of 1.3 for cessation among
chiolitis (Evidence Quality: C; Rec- Exclusions None
Strength Moderate the 18 studies reviewed.
ommendation Strength: Moderate
recommendation In contrast to many of the other
Recommendation). Differences of opinion None
Notes Counseling for
recommendations, protecting chil-
Action Statement Profile KAS 12a tobacco smoke dren from tobacco exposure is
prevention a recommendation that is primarily
Aggregate evidence quality C should begin in
Benefits Can identify infants the prenatal
implemented outside of the clinical
and children at period and setting. As such, it is critical that
risk whose continue in parents are fully educated about the
family may family-centered importance of not allowing smoking
benefit from care and at all
counseling, well-infant visits in the home and that smoke lingers
predicting risk of on clothes and in the environment
severe disease for prolonged periods.231 It should
Risk, harm, cost Time to inquire
Benefit-harm assessment Benefits outweigh
be provided in plain language and
harms in a respectful, culturally effective
Tobacco smoke exposure increases the
manner that is family centered, en-
Intentional vagueness None risk and severity of bronchiolitis. Stra-
gages parents as partners in their
Role of patient preferences Parent may choose chan and Cook220 first delineated the
to deny tobacco child’s health, and factors in their
effects of environmental tobacco smoke
use even though literacy, health literacy, and primary
they are, in fact, on rates of lower respiratory tract dis-
language needs.
users ease in infants in a meta-analysis in-
Exclusions None cluding 40 studies. In a more recent
Strength Moderate
recommendation systematic review, Jones et al221 found BREASTFEEDING
Differences of opinion None a pooled odds ratio of 2.51 (95% CI 1.96
to 3.21) for tobacco smoke exposure Key Action Statement 13
and bronchiolitis hospitalization among Clinicians should encourage exclusive
the 7 studies specific to the condition. breastfeeding for at least 6 months
Other investigators have consistently to decrease the morbidity of respi-
Key Action Statement 12b reported tobacco smoke exposure ratory infections (Evidence Quality:
Clinicians should counsel care- increases both severity of illness and Grade B; Recommendation Strength:
givers about exposing the infant or risk of hospitalization for bronchioli- Moderate Recommendation).

Action Statement Profile KAS 13 with an increased risk for 2 or more Shared decision-making with parents
medical visits and hospital admission about diagnosis and treatment of
Benefits May reduce the risk for wheezing lower respiratory illness. bronchiolitis is a key tenet of patient-
of bronchiolitis In Japan, Nishimura et al236 looked centered care. Despite the absence of
and other
at 3 groups of RSV-positive infants effective therapies for viral bronchi-
illnesses;
multiple benefits defined as full, partial, or token breast- olitis, caregiver education by clinicians
of breastfeeding feeding. There were no significant may have a significant impact on care
unrelated to differences in the hospitalization rate patterns in the disease. Children with
bronchiolitis
Risk, harm, cost None among the 3 groups; however, there bronchiolitis typically suffer from
Benefit-harm assessment Benefits outweigh were significant differences in the symptoms for 2 to 3 weeks, and
risks duration of hospitalization and the parents often seek care in multiple
rate of requiring oxygen therapy, both settings during that time period.237
Role of patient preferences Parents may choose favoring breastfeeding. Given that children with RSV gener-
to feed formula ally shed virus for 1 to 2 weeks and
rather than
from 30% to 70% of family members
breastfeed
Exclusions None FAMILY EDUCATION may become ill,238,239 education about
Strength Moderate prevention of transmission of disease
recommendation
Key Action Statement 14
is key. Restriction of visitors to new-
Notes Education on Clinicians and nurses should edu-
breastfeeding borns during the respiratory virus
should begin in
cate personnel and family mem- season should be considered. Con-
the prenatal bers on evidence-based diagnosis, sistent evidence suggests that pa-
period treatment, and prevention in rental education is helpful in the
bronchiolitis (Evidence Quality: C; promotion of judicious use of anti-
observational studies; Recommen- biotics and that clinicians may mis-
In 2012, the AAP presented a general dation Strength; Moderate Recom- interpret parental expectations about
policy on breastfeeding.232 The policy mendation). therapy unless the subject is openly
statement was based on the proven discussed.240–242
benefits of breastfeeding for at least 6 Action Statement Profile KAS 14
months. Respiratory infections were
Aggregate evidence quality C
shown to be significantly less common Benefits Decreased FUTURE RESEARCH NEEDS
in breastfed children. A primary re- transmission of
source was a meta-analysis from the disease, benefits Better algorithms for predicting
Agency for Healthcare Research and
of breastfeeding, the course of illness
Impact of clinical score on patient
promotion of
Quality that showed an overall 72% judicious use of
reduction in the risk of hospitalization antibiotics, risks outcomes
secondary to respiratory diseases in of infant lung
damage
Evaluating different ethnic groups
infants who were exclusively breastfed attributable to and varying response to treat-
for 4 or more months compared with tobacco smoke ments
Risk, harm, cost Time to educate
those who were formula fed.233
properly Does epinephrine alone reduce ad-
The clinical evidence also supports Benefit-harm assessment Benefits outweigh mission in outpatient settings?
Additional studies on epinephrine
decreased incidence and severity of harms
illness in breastfed infants with bron- Intentional vagueness Personnel is not in combination with dexametha-
chiolitis. Dornelles et al234 concluded specifically sone or other corticosteroids
that the duration of exclusive breast- defined but
feeding was inversely related to the should include Hypertonic saline studies in the
all people who outpatient setting and in in hospi-
length of oxygen use and the length of enter a patient’s
tals with shorter LOS
hospital stay in previously healthy room
infants with acute bronchiolitis. In Role of patient preferences None More studies on nasogastric hy-
Exclusions None dration
a large prospective study in Australia, Strength Moderate
Oddy et al235 showed that breastfeeding recommendation More studies on tonicity of intrave-
for less than 6 months was associated Differences of opinion None nous fluids

Incidence of true AOM in bron- SUBCOMMITTEE ON BRONCHIOLITIS Infectious Diseases Representative (no con-
(OVERSIGHT BY THE COUNCIL ON flicts)
chiolitis by using 2013 guideline Eneida A. Mendonca, MD, PhD, FAAP, FACMI:
QUALITY IMPROVEMENT AND PATIENT
definition SAFETY, 2013–2014) Informatician/Academic Pediatric Intensive
More studies on deep suction- Shawn L. Ralston, MD, FAAP: Chair, Pediatric Care Physician, Partnership for Policy Imple-
Hospitalist (no financial conflicts; published mentation Representative (no conflicts)
ing and nasopharyngeal suction- Kieran J. Phelan, MD, MSc: General Pedia-
research related to bronchiolitis)
ing trician (no conflicts)
Allan S. Lieberthal, MD, FAAP: Chair, General
Strategies for monitoring oxygen Pediatrician with Expertise in Pulmonology (no Joseph J. Zorc, MD, MSCE, FAAP: Pediatric
conflicts) Emergency Physician, AAP Section on Emergency
saturation Medicine Representative (no financial conflicts;
Brian K. Alverson, MD, FAAP: Pediatric Hos-
Use of home oxygen pitalist, AAP Section on Hospital Medicine published research related to bronchiolitis)
Appropriate cutoff for use of oxy- Representative (no conflicts) Danette Stanko-Lopp, MA, MPH: Methodolo-
gist, Epidemiologist (no conflicts)
Jill E. Baley, MD, FAAP: Neonatal-Perinatal
gen in high altitude Medicine, AAP Committee on Fetus and New- Mark A. Brown, MD: Pediatric Pulmonologist,
Oxygen delivered by high-flow na- born Representative (no conflicts) American Thoracic Society Liaison (no conflicts)
Anne M. Gadomski, MD, MPH, FAAP: General Ian Nathanson, MD, FAAP: Pediatric Pulmo-
sal cannula nologist, American College of Chest Physicians
Pediatrician and Research Scientist (no financial
RSV vaccine and antiviral agents conflicts; published research related to bronchi- Liaison (no conflicts)
Use of palivizumab in special olitis including Cochrane review of bronchodilators) Elizabeth Rosenblum, MD: Academic Family
David W. Johnson, MD, FAAP: Pediatric Emer- Physician, American Academy of Family Physi-
populations, such as cystic fib- gency Medicine Physician (no financial conflicts; cians liaison (no conflicts).
rosis, neuromuscular diseases, published research related to bronchiolitis) Stephen Sayles, III, MD, FACEP: Emergency
Down syndrome, immune defi- Michael J. Light, MD, FAAP: Pediatric Pulmo- Medicine Physician, American College of
nologist, AAP Section on Pediatric Pulmonology Emergency Physicians Liaison (no conflicts)
ciency Sinsi Hernández-Cancio, JD: Parent/Consumer
Representative (no conflicts)
Emphasis on parent satisfaction/ Nizar F. Maraqa, MD, FAAP: Pediatric In- Representative (no conflicts)
patient-centered outcomes in all fectious Disease Physician, AAP Section on In-
research (ie, not LOS as the only fectious Diseases Representative (no conflicts) STAFF
H. Cody Meissner, MD, FAAP: Pediatric In- Caryn Davidson, MA
measure) fectious Disease Physician, AAP Committee on Linda Walsh, MAB
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APPENDIX 1 SEARCH TERMS BY *Upper Respiratory Infection Symp- Bronchiolitis AND (bronchodilator OR
TOPIC toms epinephrine OR albuterol OR salbuta-
mol OR corticosteroid OR steroid)
Introduction
MedLine *Hypertonic Saline
MedLine (exp Bronchiolitis/ OR exp Bronchioli-
((“bronchiolitis”[MeSH]) OR (“respira- tis, Viral/) AND exp *Respiratory Tract MedLine
tory syncytial viruses”[MeSH]) NOT Infections/ ((“bronchiolitis”[MeSH]) OR (“respira-
“bronchiolitis obliterans”[All Fields]) Limit to English Language tory syncytial viruses”[MeSH]) NOT
1. and exp Natural History/ Limit to “all infant (birth to 23 “bronchiolitis obliterans”[All Fields])
2. and exp Epidemiology/ months)” OR “newborn infant (birth AND (exp Saline Solution, Hypertonic/
to 1 month)” OR “infant (1 to 23 OR (aerosolized saline.mp. OR (exp
3. and (exp economics/ or exp
months)”) AEROSOLS/ AND exp Sodium Chloride/))
“costs and cost analysis”/ or
OR (exp Sodium Chloride/ AND exp
exp “cost allocation”/ or exp
CINAHL “Nebulizers and Vaporizers”/) OR neb-
cost-benefit analysis/ or exp
“cost control”/ or exp “cost of (MM “Bronchiolitis+”) AND (MM “Re- ulized saline.mp.)
illness”/ or exp “cost sharing”/ spiratory Tract Infections+”) Limit to English Language
or exp health care costs/ or Limit to “all infant (birth to 23
exp health expenditures/) The Cochrane Library months)” OR “newborn infant (birth to
4. and exp Risk Factors/ Bronchiolitis AND Respiratory Infection 1 month)” OR “infant (1 to 23 months)”)
Limit to English Language AND Humans
Inhalation Therapies CINAHL
AND (“all infant (birth to 23 months)”
or “newborn infant (birth to 1 month)” *Bronchodilators & Corticosteroids (MM “Bronchiolitis+”) AND (MM “Sa-
or “infant (1 to 23 months)”) line Solution, Hypertonic”)
MedLine
CINAHL ((“bronchiolitis”[MeSH]) OR (“respira- The Cochrane Library
(MM “Bronchiolitis+”) AND (“natural tory syncytial viruses”[MeSH]) NOT Bronchiolitis AND Hypertonic Saline
history” OR (MM “Epidemiology”) OR “bronchiolitis obliterans”[All Fields])
(MM “Costs and Cost Analysis”) OR AND (exp Receptors, Adrenergic, β-2/ Oxygen
(MM “Risk Factors”)) OR exp Receptors, Adrenergic, β/ OR MedLine
exp Receptors, Adrenergic, β-1/ OR β ((“bronchiolitis”[MeSH]) OR (“respira-
The Cochrane Library adrenergic*.mp. OR exp ALBUTEROL/ tory syncytial viruses”[MeSH]) NOT
Bronchiolitis AND (epidemiology OR OR levalbuterol.mp. OR exp EPINEPH- “bronchiolitis obliterans”[All Fields])
risk factor OR cost) RINE/ OR exp Cholinergic Antagonists/
OR exp IPRATROPIUM/ OR exp Anti-In- 1. AND (exp Oxygen Inhalation Therapy/
flammatory Agents/ OR ics.mp. OR in- OR supplemental oxygen.mp. OR ox-
Diagnosis/Severity
haled corticosteroid*.mp. OR exp ygen saturation.mp. OR *Oxygen/ad,
MedLine st [Administration & Dosage, Stand-
Adrenal Cortex Hormones/ OR exp Leu-
exp BRONCHIOLITIS/di [Diagnosis] OR kotriene Antagonists/ OR montelukast. ards] OR oxygen treatment.mp.)
exp Bronchiolitis, Viral/di [Diagnosis] mp. OR exp Bronchodilator Agents/) 2. AND (exp OXIMETRY/ OR oxi-
limit to English Language AND (“all Limit to English Language AND (“all meters.mp.) AND (exp “Reproduc-
infant (birth to 23 months)” or “new- infant (birth to 23 months)” or “new- ibility of Results”/ OR reliability.
born infant (birth to 1 month)” or born infant (birth to 1 month)” or mp. OR function.mp. OR technical
“infant (1 to 23 months)”) “infant (1 to 23 months)”) specifications.mp.) OR (percuta-
neous measurement*.mp. OR
CINAHL CINAHL exp Blood Gas Analysis/)
(MH “Bronchiolitis/DI”) (MM “Bronchiolitis+”) AND (MM Limit to English Language
“Bronchodilator Agents”) Limit to “all infant (birth to 23
The Cochrane Library months)” OR “newborn infant (birth to
Bronchiolitis AND Diagnosis The Cochrane Library 1 month)” OR “infant (1 to 23 months)”)

CINAHL NOT “bronchiolitis obliterans”[All “Urinary Tract Infections+”) OR (MM
(MM “Bronchiolitis+”) AND Fields]) “Bacteremia”))
((MM “Oxygen Therapy”) OR (MM “Ox- AND (exp Fluid Therapy/ AND (exp
The Cochrane Library
ygen+”) OR (MM “Oxygen Saturation”) infusions, intravenous OR exp admin-
OR (MM “Oximetry+”) OR (MM “Pulse istration, oral)) Bronchiolitis AND (serious bacterial
Oximetry”) OR (MM “Blood Gas Moni- Limit to English Language infection OR sepsis OR otitis media OR
toring, Transcutaneous”)) meningitis OR urinary tract infection or
Limit to (“all infant (birth to 23
bacteremia OR pneumonia OR anti-
months)” or “newborn infant (birth to
The Cochrane Library bacterial OR antimicrobial OR antibi-
1 month)” or “infant (1 to 23 months)”)
otic)
Bronchiolitis AND (oxygen OR oximetry)
CINAHL
Hand Hygiene, Tobacco,
Chest Physiotherapy and (MM “Bronchiolitis+”) AND Breastfeeding, Parent Education
Suctioning
((MM “Fluid Therapy+”) OR (MM “Hy-
MedLine
MedLine dration Control (Saba CCC)”) OR (MM
“Hydration (Iowa NOC)”)) ((“bronchiolitis”[MeSH]) OR (“respira-
((“bronchiolitis”[MeSH]) OR (“respira-
tory syncytial viruses”[MeSH]) NOT
tory syncytial viruses”[MeSH]) NOT
The Cochrane Library “bronchiolitis obliterans”[All Fields])
“bronchiolitis obliterans”[All Fields])
Bronchiolitis AND (hydrat* OR fluid*) 1. AND (exp Hand Disinfection/ OR
1. AND (Chest physiotherapy.mp. OR
hand decontamination.mp. OR
(exp Physical Therapy Techniques/
handwashing.mp.)
AND exp Thorax/)) SBI and Antibacterials
2. AND exp Tobacco/
2. AND (Nasal Suction.mp. OR (exp MedLine
Suction/)) 3. AND (exp Breast Feeding/ OR
((“bronchiolitis”[MeSH]) OR (“respira- exp Milk, Human/ OR exp Bottle
Limit to English Language tory syncytial viruses”[MeSH]) NOT Feeding/)
Limit to “all infant (birth to 23 “bronchiolitis obliterans”[All Fields]) Limit to English Language
months)” OR “newborn infant (birth to AND
1 month)” OR “infant (1 to 23 months)”) Limit to (“all infant (birth to 23
(exp Bacterial Infections/ OR exp Bac- months)” or “newborn infant (birth to
CINAHL terial Pneumonia/ OR exp Otitis Media/ 1 month)” or “infant (1 to 23 months)”)
OR exp Meningitis/ OR exp *Anti-bac-
(MM “Bronchiolitis+”) terial Agents/ OR exp Sepsis/ OR exp CINAHL
1. AND ((MH “Chest Physiotherapy Urinary Tract Infections/ OR exp Bac- (MM “Bronchiolitis+”)
(Saba CCC)”) OR (MH “Chest Phys- teremia/ OR exp Tracheitis OR serious
ical Therapy+”) OR (MH “Chest 1. AND (MH “Handwashing+”)
bacterial infection.mp.)
Physiotherapy (Iowa NIC)”)) 2. AND (MH “Tobacco+”)
Limit to English Language
2. AND (MH “Suctioning, Nasopharyn- 3. AND (MH “Breast Feeding+” OR
Limit to (“all infant (birth to 23
geal”) MH “Milk, Human+” OR MH “Bottle
months)” or “newborn infant (birth to
Feeding+”)
1 month)” or “infant (1 to 23 months)”)
The Cochrane Library
Bronchiolitis AND (chest physiotherapy The Cochrane Library
CINAHL
OR suction*) Bronchiolitis
(MM “Bronchiolitis+”) AND
1. AND (Breast Feeding OR breast-
Hydration ((MM “Pneumonia, Bacterial+”) OR
feeding)
(MM “Bacterial Infections+”) OR (MM
MedLine “Otitis Media+”) OR (MM “Meningitis, 2. AND tobacco
((“bronchiolitis”[MeSH]) OR (“respi- Bacterial+”) OR (MM “Antiinfective 3. AND (hand hygiene OR handwash-
ratory syncytial viruses”[MeSH]) Agents+”) OR (MM “Sepsis+”) OR (MM ing OR hand decontamination)

2. On page e1358, in the section on Spinosad (0.9% Suspension), the second sentence
should have read: “It is not recommended for children younger than 6 months
because it also contains benzyl alcohol.” (instead of “It is contraindicated…”).
3. On page e1358, in the section on Spinosad (0.9% Suspension), the last

sentence, which read, “Safety in children younger than 4 years has not been
established.” should have been deleted.
doi:10.1542/peds.2015-2696
Campbell et al. Critical Elements in the Medical Evaluation of Suspected Child

Physical Abuse. Pediatrics. 2015;136(1):35–43
An error occurred in the article by Campbell et al, titled “Critical Elements in the
Medical Evaluation of Suspected Child Physical Abuse” published in the July 2015
issue of Pediatrics (2015;136[1]:35–43; doi:10.1542/peds.2014-4192). On page 41,
in Table 2, under “Radiology” and “Skull Fracture,” this reads: “Head CT,a skeletal
surveya.” This text should have read: “Head CT,b skeletal surveyb” (footnotes were
incorrectly assigned).
doi:10.1542/peds.2015-2823
Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical Practice Guideline: The
Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics. 2014;134
(5):e1474–e1502
An error occurred in the American Academy of Pediatrics article, titled “Clinical
Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis
published in the November 2014 issue of Pediatrics (2014;134[5]:e1474–e1502).
On page e1484, in the discussion after Key Action Statement 6b, in the fifth
paragraph, the sentence reading “In 1 study of 64 healthy infants between 2 weeks
and 6 months of age, 60% of these infants exhibited a transient oxygen desaturation
below 90%, to values as low as 83%.” should have been attributed to reference
104 (Hunt CE et al) instead of 105.
doi:10.1542/peds.2015-2862
Kurowski et al. Online Problem-Solving Therapy for Executive Dysfuntion After

Child Traumatic Brain Injury. Pediatrics. 2013;132(1):e158–e166
An error occurred in the article by Kurowski et al, titled “Online Problem-Solving
Therapy for Executive Dysfunction After Child Traumatic Brain Injury” published in the
July 2013 issue of Pediatrics (2013;132[1]:e158–e166; doi: 10.1542/peds.2012-4040). On
page e163, under the Results section, in Tables 3 and 4, the baseline and 6 month
TABLE 3 Improvements From Baseline to Follow-up on the Global Executive Composite (GEC) in the CAPS Versus IRC Treatments in the Entire Sample
Older Teens (9th–12th Grade) and Younger Teens (6th–8th Grade)
CAPS (n 5 57) IRC (n 5 62a) F (df ) Pb
Mean (SD) Mean (SD)
Baseline 6 Month Change Baseline 6 Month Change

Entire Samplea 58.53 (10.11) 57.00 (11.40) 21.53 (8.75) 61.56 (10.74) 60.16 (12.16) 21.40 (7.43) 0.17 (118) 0.68
Older Teensa 60.15 (10.51) 55.37 (11.44) 24.78 (6.66) 61.54 (10.98) 60.69 (10.94) 20.86 (5.98) 6.74 (61) 0.01
Younger Teens 57.07 (9.69) 58.47 (11.37) 1.40 (9.46) 61.59 (10.63) 59.48 (13.77) 22.11 (9.06) 1.27 (56) 0.27
CAPS 5 Counselor Assisted Problem Solving, IRC 5 Internet Resource Comparison
a
The total study participants for IRC was 63; however, one participant did not completed the Behavioral Rating Inventory (BRIEF)-Behavioral Regulation Index (BRI) Inhibit subscale, so the
GEC could not calculated for this participant and they were excluded from this analysis.
b
P values apply to differences between CAPS and IRC groups as measured by general linear models after controlling for baseline scores.
782 ERRATA
Clinical Practice Guideline: The Diagnosis, Management, and Prevention of
Bronchiolitis
Shawn L. Ralston, Allan S. Lieberthal, H. Cody Meissner, Brian K. Alverson, Jill E.
Baley, Anne M. Gadomski, David W. Johnson, Michael J. Light, Nizar F. Maraqa,
Eneida A. Mendonca, Kieran J. Phelan, Joseph J. Zorc, Danette Stanko-Lopp, Mark
A. Brown, Ian Nathanson, Elizabeth Rosenblum, Stephen Sayles III and Sinsi
Hernandez-Cancio
Pediatrics 2014;134;e1474; originally published online October 27, 2014;
DOI: 10.1542/peds.2014-2742
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/134/5/e1474.full.html
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2014 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Clinical Practice Guideline: The Diagnosis, Management, and Prevention of
Bronchiolitis
Shawn L. Ralston, Allan S. Lieberthal, H. Cody Meissner, Brian K. Alverson, Jill E.
Baley, Anne M. Gadomski, David W. Johnson, Michael J. Light, Nizar F. Maraqa,
Eneida A. Mendonca, Kieran J. Phelan, Joseph J. Zorc, Danette Stanko-Lopp, Mark
A. Brown, Ian Nathanson, Elizabeth Rosenblum, Stephen Sayles III and Sinsi
Hernandez-Cancio
Pediatrics 2014;134;e1474; originally published online October 27, 2014;
DOI: 10.1542/peds.2014-2742
Updated Information & including high resolution figures, can be found at:
Services /content/134/5/e1474.full.html
References This article cites 232 articles, 76 of which can be accessed

free at:
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Subspecialty Collections This article, along with others on similar topics, appears in
the following collection(s):
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Bronchiolitis
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

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Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis

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Guidance for the Clinician in

Rendering Pediatric Care

CLINICAL PRACTICE GUIDELINE

Clinical Practice Guideline: The Diagnosis, Management,

abstract Shawn L. Ralston, MD, FAAP, Allan S. Lieberthal, MD, FAAP,

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DIAGNOSIS uation and management of children Action Statement Proﬁle KAS 1b

The main goals in the history and

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continuous positive airway pressure

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The level of respiratory distress infants receiving intravenous 5%

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Aggregate evidence quality B

<32 weeks, 0 days’ gestation who

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3. On page e1358, in the section on Spinosad (0.9% Suspension), the last

Campbell et al. Critical Elements in the Medical Evaluation of Suspected Child

Kurowski et al. Online Problem-Solving Therapy for Executive Dysfuntion After

Mean (SD) Mean (SD)

Baseline 6 Month Change Baseline 6 Month Change

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

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References This article cites 232 articles, 76 of which can be accessed

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

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