Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis
Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis
Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis
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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,
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.
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
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 bron- chiolitis 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
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]).
first 2 days of hospitalization. AOM did chiolitis. One study found that food in- significant. 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-
Differences of opinion None
tonic fluids in older children.190 Use
of isotonic fluids, in general, appears
to be safer.
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, admin- is 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
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
Intentional vagueness 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
Value judgments None
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).
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)”)
Updated Information & including high resolution figures, can be found at:
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References This article cites 232 articles, 69 of which you can access for 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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mprovement_and_patient_safety
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