Management of bronchiolitis in children aged 1 to 23 months no longer requires testing for specific viruses or a trial dose of a bronchodilator, according to new guidelines issued by the American Academy of Pediatrics (AAP) and published online October 27 in Pediatrics.
According to a comprehensive evidence review, the new AAP guideline on diagnosing, treating, and preventing bronchiolitis updates their previous recommendations published in 2006. It targets pediatricians, family physicians, emergency medicine specialists, hospitalists, nurse practitioners, and physician assistants who care for children.
Bronchiolitis is the most common cause of hospitalization among infants younger than 1 year. The new guideline emphasizes that only supportive care, including oxygen and hydration, is strongly recommended for young children with bronchiolitis.
"Bronchiolitis is a disorder commonly caused by viral lower respiratory tract infection in infants," write Shawn L. Ralston, MD, and colleagues from the AAP. "Bronchiolitis is characterized by acute inflammation, edema, and necrosis of epithelial cells lining small airways, and increased mucus production. Signs and symptoms typically begin with rhinitis and cough, which may progress to tachypnea, wheezing, rales, use of accessory muscles, and/or nasal flaring."
Changes from the 2006 guideline include that testing for specific viruses is no longer needed, because multiple viruses may cause bronchiolitis. Routine radiographic or laboratory studies are also unnecessary, and clinicians should diagnose bronchiolitis and assess its severity on the basis of history and physical examination.
The AAP also no longer recommends a trial dose of a bronchodilator, such as albuterol or salbutamol, because evidence to date shows that bronchodilators are ineffective in changing the course of bronchiolitis (evidence quality: B, strong recommendation). In addition, in accordance with a policy statement published in July by the AAP, the new guideline updates recommendations for use of palivizumab to prevent respiratory syncytial virus infections: Otherwise-healthy infants with gestational age of 29 weeks or more should not receive palivizumab, but during the first year of life, infants with hemodynamically significant heart disease or chronic lung disease of prematurity should receive palivizumab (maximum of 5 monthly doses, 15 mg/kg per dose, during the respiratory syncytial virus season).
Other recommendations include that when making decisions about the assessment and management of children with bronchiolitis, clinicians should evaluate risk factors for severe disease, such as age less than 12 weeks, prematurity, underlying cardiopulmonary disease, or immunodeficiency. Finally, clinicians should not give epinephrine to infants and children diagnosed with bronchiolitis, nor should they receive chest physiotherapy.
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