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AAP-Bronchiolitis-Guidelines.Pdf Guidance for the Clinician in Rendering Pediatric Care CLINICAL PRACTICE GUIDELINE Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis Shawn L. Ralston, MD, FAAP, Allan S. Lieberthal, MD, FAAP, abstract H. Cody Meissner, MD, FAAP, Brian K. Alverson, MD, FAAP, Jill E. This guideline is a revision of the clinical practice guideline, “Diagnosis Baley, MD, FAAP, Anne M. Gadomski, MD, MPH, FAAP, ” 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 — about evaluation and management of children with bronchiolitis RSV respiratory syncytial virus 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- ment (Evidence Quality: B; Recommendation Strength: Moderate PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Recommendation). Copyright © 2014 by the American Academy of Pediatrics 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 Downloaded from http://pediatrics.aappublications.org/ by guest on April 27, 2018 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 Downloaded from http://pediatrics.aappublications.org/ by guest on April 27, 2018 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
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