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Bronchiolitis
Diagnosis, Management, and Prevention

Clinical Practice Guideline 2014
Pediatrics; originally published online October 27, 2014;
Hernandez-Cancio A. Brown, Ian Nathanson, Elizabeth Rosenblum, Stephen Sayles III and Sinsi Eneida A. Mendonca, Kieran J. Phelan, Joseph J. Zorc, Danette Stanko-Lopp, Mark Baley, Anne M. Gadomski, David W. Johnson, Michael J. Light, Nizar F. Maraqa,

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ABSTRACT

This guideline is a revision of the clinical practice guideline, "Diagnosis and Management of Bronchiolitis," published by the American Academy of Pediatrics in 2006. The guideline applies to children from 1 through 23 months of age. Other exclusions are noted. Each key action statement indicates level of evidence, benefit-harm relationship, and level of recommendation. Key action statements are as follows: Pediatrics 2014;134:e1474-e1502

DIAGNOSIS

1a. Clinicians should diagnose bronchiolitis and assess disease severity on the basis of history and physical examination (Evidence Quality: B; Recommendation Strength: Strong Recommendation).

1b. Clinicians should assess risk factors for severe disease, such as age less than 12 weeks, a history of prematurity, underlying cardiopulmonary disease, or immunodeficiency, when making decisions about evaluation and management of children with bronchiolitis (Evidence Quality: B; Recommendation Strength: Moderate Recommendation).

1c. When clinicians diagnose bronchiolitis on the basis of history and physical examination, radiographic or laboratory studies should not be obtained routinely (Evidence Quality: B; Recommendation Strength: Moderate Recommendation).
TREATMENT
2. Clinicians should not administer albuterol (or salbutamol) to infants and children with a diagnosis of bronchiolitis (Evidence Quality: B; Recommendation Strength: Strong Recommendation).

3. Clinicians should not administer epinephrine to infants and children with a diagnosis of bronchiolitis (Evidence Quality: B; Recommendation Strength: Strong Recommendation).

4a. Nebulized hypertonic saline should not be administered to infants with a diagnosis of bronchiolitis in the emergency department (Evidence Quality: B; Recommendation Strength: Moderate Recommendation).

4b. Clinicians may administer nebulized hypertonic saline to infants and children hospitalized for bronchiolitis (Evidence Quality: B; Recommendation Strength: Weak Recommendation [based on randomized controlled trials with inconsistent findings]).

5. Clinicians should not administer systemic corticosteroids to infants with a diagnosis of bronchiolitis in any setting (Evidence Quality: A; Recommendation Strength: Strong Recommendation).

6a. Clinicians may choose not to administer supplemental oxygen if the oxyhemoglobin saturation exceeds 90% in infants and children with a diagnosis of bronchiolitis (Evidence Quality: D; Recommendation Strength: Weak Recommendation [based on low level evidence and reasoning from first principles]).

6b. Clinicians may choose not to use continuous pulse oximetry for infants and children with a diagnosis of bronchiolitis (Evidence Quality: D; Recommendation Strength: Weak Recommendation [based on lowlevel evidence and reasoning from first principles]).

7. Clinicians should not use chest physiotherapy for infants and children with a diagnosis of bronchiolitis (Evidence Quality: B; Recommendation Strength: Moderate Recommendation).

8. Clinicians should not administer antibacterial medications to infants and children with a diagnosis of bronchiolitis unless there is a concomitant bacterial infection, or a strong suspicion of one (Evidence Quality: B; Recommendation Strength: Strong Recommendation).

9. Clinicians should administer nasogastric or intravenous fluids for infants with a diagnosis of bronchiolitis who cannot maintain hydration orally (Evidence Quality: X; Recommendation Strength: Strong Recommendation).
PREVENTION
10a. Clinicians should not administer palivizumab to otherwise healthy infants with a gestational age of 29 weeks, 0 days or greater (Evidence Quality: B; Recommendation Strength: Strong Recommendation).

10b. Clinicians should administer palivizumab during the first year of life to infants with hemodynamically significant heart disease or chronic lung disease of prematurity defined as preterm infants <32 weeks 0 days' gestation who require >21% oxygen for at least the first 28 days of life (Evidence Quality: B; Recommendation Strength: Moderate Recommendation).

10c. Clinicians should administer a maximum 5 monthly doses (15 mg/kg/dose) of palivizumab during the respiratory syncytial virus season to infants who qualify for palivizumab in the first year of life (Evidence Quality: B; Recommendation Strength: Moderate Recommendation).

11a. All people should disinfect hands before and after direct contact with patients, after contact with inanimate objects in the direct vicinity of the patient, and after removing gloves (Evidence Quality: B; Recommendation Strength: Strong Recommendation).

11b. All people should use alcoholbased rubs for hand decontamination when caring for children with bronchiolitis. When alcoholbased rubs are not available, individuals should wash their hands with soap and water (Evidence Quality: B; Recommendation Strength: Strong Recommendation).

12a. Clinicians should inquire about the exposure of the infant or child to tobacco smoke when assessing infants and children for bronchiolitis (Evidence Quality: C; Recommendation Strength: Moderate Recommendation).

12b. Clinicians should counsel caregivers about exposing the infant or child to environmental tobacco smoke and smoking cessation when assessing a child for bronchiolitis (Evidence Quality: B; Recommendation Strength: Strong).

13. Clinicians should encourage exclusive breastfeeding for at least 6 months to decrease the morbidity of respiratory infections. (Evidence Quality: B; Recommendation Strength: Moderate Recommendation).

14. Clinicians and nurses should educate personnel and family members on evidence-based diagnosis, treatment, and prevention in bronchiolitis. (Evidence Quality: C; observational studies; Recommendation Strength: Moderate Recommendation
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