Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
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 rst 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 signicant 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 dened 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 rst (Evidence Quality: B; Recommen-
dation [based on low level evidence 28 days of life (Evidence Quality: dation Strength: Moderate Rec-
and reasoning from rst 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 rst year of life (Evidence Quality: tion).
rst 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 benet-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 signicant 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 uids 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 identied by the subcom-
dence in support of a policy be identied, mittee as experts in the eld. 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 dened. Evidence-
committee included primary care physi- line.
based recommendations reect the
cians, including general pediatricians,
quality of evidence and the balance of This clinical practice guideline is not
a family physician, and pediatric sub-
benet 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-
Practice14 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 Conict
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 conicts. Any conicts 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 identied by database searches
were also reviewed by 1 of 4 members
of the committee, and references iden-
tied 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 benets
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 rst oxemia not suspected on physical
ical signs and symptoms occurring in year of life.2225 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 signicant viral ventilation.16,34,41 Among outpatients,
nasal aring, 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),2729 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- specic ndings 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, immunodeciency, 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 identied. 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-
signicant congenital heart disease, to detect clinically important risk fac- ciation between the specic viral agent
chronic lung disease (bronchopulmonary tors associated with disease pro- and risk of apnea in bronchiolitis.42
dysplasia), congenital anomalies,1517 gression.16,34,35 Tachypnea, dened 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 studies3537 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
childs status. Upper airway obstruction poral variability in physical ndings 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 dene 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 hosts dation). or other inpatient outcomes. A recent,
airway, and the clinical assessments, par-
large multicenter trial found a similar
ticularly scoring, would limit the clinicians Action Statement Prole KAS 3 lack of efcacy 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 Benets Avoiding adverse effects, lower on a xed schedule compared with an
literature on use of -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 benet of
current wheezing. At the time of that drug used in children hospitalized for bron-
review, there were 3 studies in the Benet-harm Benets 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 benet mendation for the use of epinephrine
Intentional None in this setting.
were no clear benets from the use vagueness
of -agonists in this population. The Role of patient None The role of epinephrine in the out-
authors noted some conicting 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 dened and meaningful out-
Differences of None chiolitis Epinephrine Steroid Trial.68
opinion
This multicenter randomized trial
come measures could be identied.
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 - and -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 puried
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 nicant after adjusting for multiple
buterol in another group, but therapy difference in efcacy on the basis of comparisons.
was accompanied by clinically signi- preparation,63 although the compari- The systematic review by Hartling
cant tachycardia.62 This small clinical son has not been specically studied et al64 concluded that epinephrine
change occurring with signicant 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,8284 the evidence on corti- these drugs could be synergistic.8992
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 xed simultaneous bronchodila-
studied in intensive care settings, steroids do not signicantly reduce tor regimens have not consistently
and most trials have included only outpatient admissions when compared shown benet9397; hence, a recommen-
patients with mild to moderate dis- with placebo (pooled risk ratio, 0.92; dation regarding the benet 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 nd 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 signicant benet to
however, did show a reduction in hos- children with bronchiolitis. Evidence
CORTICOSTEROIDS pitalizations 7 days after treatment with for potential benet of combined
Key Action Statement 5 combined nebulized epinephrine and corticosteroid and agents with both
Clinicians should not administer oral dexamethasone as compared with - and -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 Prole KAS 5 result insignicant (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
Benets No clinical benet, avoiding standard recognized rationale for why of safety.
adverse effects
Risk, harm, cost None
combination epinephrine and dexa-
Benet-harm Benets 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 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 agonists and corticosteroids low-level evidence and reasoning
benet from corticosteroids in other have shown potential mechanisms for from rst principles]).
rst 2 days of hospitalization. AOM did chiolitis. One study found that food in- signicant. In a larger open ran-
not inuence the clinical course or take at less than 50% of normal for the domized trial including infants be-
laboratory ndings 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 signicant
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 aring, retractions, cally signicant. 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 uid replacement.183 One These studies suggest that infants
case series184 and 2 randomized who have difculty 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 efcacy and safety of the in-
gastric or intravenous uids for gastric uid replacement; however,
travenous and nasogastric routes
infants with a diagnosis of bron-
for uid 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 uid retention re-
Recommendation Strength: Strong
strated no signicant 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.187189 Therefore,
Action Statement Prole KAS 9
receipt of hypotonic uid replace-
Aggregate evidence quality X ment and maintenance uids may
Benets Maintaining hydration increase the risk of iatrogenic hypo-
Risk, harm, cost Risk of infection, risk of aspiration with nasogastric tube, discomfort,
hyponatremia, intravenous inltration, overhydration natremia in these infants. A recent
Benet-harm assessment Benets 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 uids, the use of hypotonic
Exclusions None uids was associated with signicant
Strength Strong recommendation hyponatremia compared with iso-
Differences of opinion None
tonic uids in older children.190 Use
of isotonic uids, in general, appears
to be safer.
will provide protection for most in- tion for a total of 5 doses will provide brosis 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 fth and nal because of RSV infection. Although this
CONGENITAL HEART DISEASE dose should be administered in Febru- study was not powered for efcacy, no
Despite the large number of subjects ary, and protection will last into March clinically meaningful differences in
enrolled, little benet from pal- for most children. outcome were reported.205 A survey of
ivizumab prophylaxis was found in cystic brosis 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 brosis.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 -
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 denition of
hospitalizations per 1000 prophylaxis ent. A patient with cystic brosis 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 rst 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 dened in children with pulmonary
dened as a requirement for 28 days abnormalities or neuromuscular dis-
of more than 21% oxygen beginning Insufcient 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 rst 24 months of children with Down syndrome, cystic cause of ineffective cough, recurrent
life and continues to require sup- brosis, pulmonary abnormality, neu- gastroesophageal tract reux, pulmo-
plemental oxygen, diuretic therapy, romuscular disease, or immune com- nary malformations, tracheoesophageal
or chronic corticosteroid therapy promise. stula, 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 rst 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 qualies 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 rst 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 20112012 bronchiolitis sea- in patients with cystic brosis 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 brosis 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 brosis. No ev- stem cell transplantation, receive
is not recommended within the conti- idence suggests a benet 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 brosis. 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.222225 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 Prole 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 Benets 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.227229 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 Benet-harm assessment Benets 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 Prole KAS 12a tobacco smoke dren from tobacco exposure is
prevention a recommendation that is primarily
Aggregate evidence quality C should begin in
Benets 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
benet 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
Benet-harm assessment Benets 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 rst delineated the
to deny tobacco childs 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 specic 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 icts)
chiolitis by using 2013 guideline Eneida A. Mendonca, MD, PhD, FAAP, FACMI:
QUALITY IMPROVEMENT AND PATIENT
denition SAFETY, 20132014) Informatician/Academic Pediatric Intensive
More studies on deep suction- Shawn L. Ralston, MD, FAAP: Chair, Pediatric Care Physician, Partnership for Policy Imple-
Hospitalist (no nancial conicts; published mentation Representative (no conicts)
ing and nasopharyngeal suction- Kieran J. Phelan, MD, MSc: General Pedia-
research related to bronchiolitis)
ing trician (no conicts)
Allan S. Lieberthal, MD, FAAP: Chair, General
Strategies for monitoring oxygen Pediatrician with Expertise in Pulmonology (no Joseph J. Zorc, MD, MSCE, FAAP: Pediatric
conicts) Emergency Physician, AAP Section on Emergency
saturation Medicine Representative (no nancial conicts;
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 conicts) Danette Stanko-Lopp, MA, MPH: Methodolo-
gist, Epidemiologist (no conicts)
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-ow na- born Representative (no conicts) American Thoracic Society Liaison (no conicts)
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 nancial
RSV vaccine and antiviral agents conicts; published research related to bronchi- Liaison (no conicts)
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 b- gency Medicine Physician (no nancial conicts; cians liaison (no conicts).
rosis, neuromuscular diseases, published research related to bronchiolitis) Stephen Sayles, III, MD, FACEP: Emergency
Down syndrome, immune de- Michael J. Light, MD, FAAP: Pediatric Pulmo- Medicine Physician, American College of
nologist, AAP Section on Pediatric Pulmonology Emergency Physicians Liaison (no conicts)
ciency Sinsi Hernndez-Cancio, JD: Parent/Consumer
Representative (no conicts)
Emphasis on parent satisfaction/ Nizar F. Maraqa, MD, FAAP: Pediatric In- Representative (no conicts)
patient-centered outcomes in all fectious Disease Physician, AAP Section on In-
research (ie, not LOS as the only fectious Diseases Representative (no conicts) STAFF
H. Cody Meissner, MD, FAAP: Pediatric In- Caryn Davidson, MA
measure) fectious Disease Physician, AAP Committee on Linda Walsh, MAB
REFERENCES
1. American Academy of Pediatrics Sub- talisation for RSV infection. Arch Dis Child. bronchiolitis hospitalizations in the United
committee on Diagnosis and Management 2001;85(6):463468 States, 2000-2009. Pediatrics. 2013;132(1):
of Bronchiolitis. Diagnosis and manage- 6. Parrott RH, Kim HW, Arrobio JO, et al. 2836
ment of bronchiolitis. Pediatrics. 2006;118 Epidemiology of respiratory syncytial vi- 11. Hall CB, Weinberg GA, Blumkin AK, et al.
(4):17741793 rus infection in Washington, D.C. II. In- Respiratory syncytial virus-associated
2. Agency for Healthcare Research and fection and disease with respect to age, hospitalizations among children less
Quality. Management of Bronchiolitis in immunologic status, race and sex. Am J than 24 months of age. Pediatrics. 2013;
Infants and Children. Evidence Report/ Epidemiol. 1973;98(4):289300 132(2). Available at: www.pediatrics.org/
Technology Assessment No. 69. Rockville, 7. Meissner HC. Selected populations at in- cgi/content/full/132/2/e341
MD: Agency for Healthcare Research and creased risk from respiratory syncytial 12. Hall CB. Nosocomial respiratory syncy-
Quality; 2003. AHRQ Publication No. 03- virus infection. Pediatr Infect Dis J. 2003; tial virus infections: the Cold War has
E014 22(suppl 2):S40S44, discussion S44S45 not ended. Clin Infect Dis. 2000;31(2):
3. Mullins JA, Lamonte AC, Bresee JS, 8. Shay DK, Holman RC, Roosevelt GE, Clarke 590596
Anderson LJ. Substantial variability in MJ, Anderson LJ. Bronchiolitis-associated 13. Stevens TP, Sinkin RA, Hall CB, Maniscalco
community respiratory syncytial virus mortality and estimates of respiratory WM, McConnochie KM. Respiratory syncy-
season timing. Pediatr Infect Dis J. 2003; syncytial virus-associated deaths among tial virus and premature infants born at
22(10):857862 US children, 1979-1997. J Infect Dis. 2001; 32 weeks gestation or earlier: hospitali-
4. Centers for Disease Control and Pre- 183(1):1622 zation and economic implications of pro-
vention. Respiratory syncytial virus activ- 9. Miller EK, Gebretsadik T, Carroll KN, et al. phylaxis. Arch Pediatr Adolesc Med. 2000;
ityUnited States, July 2011-January Viral etiologies of infant bronchiolitis, 154(1):5561
2013. MMWR Morb Mortal Wkly Rep. 2013; croup and upper respiratory illness dur- 14. American Academy of Pediatrics Steering
62(8):141144 ing 4 consecutive years. Pediatr Infect Dis Committee on Quality Improvement and
5. Greenough A, Cox S, Alexander J, et al. J. 2013;32(9):950955 Management. Classifying recommendations
Health care utilisation of infants with 10. Hasegawa K, Tsugawa Y, Brown DF, Man- for clinical practice guidelines. Pediatrics.
chronic lung disease, related to hospi- sbach JM, Camargo CA Jr. Trends in 2004;114(3):874877
54. Walsh P, Caldwell J, McQuillan KK, Friese S, 67. Skjerven HO, Hunderi JO, Brgmann- bronchodilators for children with bron-
Robbins D, Rothenberg SJ. Comparison of Pieper SK, et al. Racemic adrenaline and chiolitis. Pediatrics. 2010;126(3). Available
nebulized epinephrine to albuterol in inhalation strategies in acute bronchioli- at: www.pediatrics.org/cgi/content/full/
bronchiolitis. Acad Emerg Med. 2008;15 tis. N Engl J Med. 2013;368(24):22862293 126/3/e520
(4):305313 68. Plint AC, Johnson DW, Patel H, et al; Pedi- 80. Luo Z, Liu E, Luo J, et al. Nebulized hyper-
55. Scarlett EE, Walker S, Rovitelli A, Ren CL. atric Emergency Research Canada (PERC). tonic saline/salbutamol solution treatment
Tidal breathing responses to albuterol Epinephrine and dexamethasone in chil- in hospitalized children with mild to mod-
and normal saline in infants with viral dren with bronchiolitis. N Engl J Med. erate bronchiolitis. Pediatr Int. 2010;52(2):
bronchiolitis. Pediatr Allergy Immunol 2009;360(20):20792089 199202
Pulmonol. 2012;25(4):220225 69. Wark PA, McDonald V, Jones AP. Nebulised 81. Sarrell EM, Tal G, Witzling M, et al. Nebu-
56. Gadomski AM, Scribani MB. Bronchodila- hypertonic saline for cystic brosis. Cochrane lized 3% hypertonic saline solution treat-
tors for bronchiolitis. Cochrane Database Database Syst Rev. 2005;(3):CD001506 ment in ambulatory children with viral
Syst Rev. 2014;(6):CD001266 70. Daviskas E, Anderson SD, Gonda I, et al. bronchiolitis decreases symptoms. Chest.
57. Mallol J, Barrueto L, Girardi G, et al. Use of Inhalation of hypertonic saline aerosol 2002;122(6):20152020
nebulized bronchodilators in infants under 1 enhances mucociliary clearance in asth- 82. Rowe BH, Spooner C, Ducharme FM,
year of age: analysis of four forms of ther- matic and healthy subjects. Eur Respir J. Bretzlaff JA, Bota GW. Early emergency
apy. Pediatr Pulmonol. 1987;3(5):298303 1996;9(4):725732 department treatment of acute asthma
58. Lines DR, Kattampallil JS, Liston P. Efcacy 71. Sood N, Bennett WD, Zeman K, et al. In- with systemic corticosteroids. Cochrane
of nebulized salbutamol in bronchiolitis. creasing concentration of inhaled saline Database Syst Rev. 2001;(1):CD002178
Pediatr Rev Commun. 1990;5(2):121129 with or without amiloride: effect on 83. Smith M, Iqbal S, Elliott TM, Everard M,
59. Alario AJ, Lewander WJ, Dennehy P, Seifer mucociliary clearance in normal subjects. Rowe BH. Corticosteroids for hospitalised
R, Mansell AL. The efcacy of nebulized Am J Respir Crit Care Med. 2003;167(2): children with acute asthma. Cochrane
metaproterenol in wheezing infants and 158163 Database Syst Rev. 2003;(2):CD002886
young children. Am J Dis Child. 1992;146 72. Mandelberg A, Amirav I. Hypertonic saline 84. Russell KF, Liang Y, OGorman K, Johnson
(4):412418 or high volume normal saline for viral DW, Klassen TP. Glucocorticoids for croup.
60. Chavasse RJPG, Seddon P, Bara A, McKean bronchiolitis: mechanisms and rationale. Cochrane Database Syst Rev. 2011;(1):
MC. Short acting beta2-agonists for re- Pediatr Pulmonol. 2010;45(1):3640 CD001955
current wheeze in children under two 73. Zhang L, Mendoza-Sassi RA, Wainwright C, 85. Fernandes RM, Bialy LM, Vandermeer B,
years of age. Cochrane Database Syst Rev. Klassen TP. Nebulized hypertonic saline et al. Glucocorticoids for acute viral
2009;(2):CD002873 solution for acute bronchiolitis in infants. bronchiolitis in infants and young chil-
61. Totapally BR, Demerci C, Zureikat G, Nolan Cochrane Database Syst Rev. 2008;(4): dren. Cochrane Database Syst Rev. 2013;
B. Tidal breathing ow-volume loops in CD006458 (6):CD004878
bronchiolitis in infancy: the effect of 74. Jacobs JD, Foster M, Wan J, Pershad J. 7% 86. Corneli HM, Zorc JJ, Mahajan P, et al;
albuterol [ISRCTN47364493]. Crit Care. Hypertonic saline in acute bronchiolitis: Bronchiolitis Study Group of the Pediatric
2002;6(2):160165 a randomized controlled trial. Pediatrics. Emergency Care Applied Research Net-
62. Levin DL, Garg A, Hall LJ, Slogic S, Jarvis 2014;133(1). Available at: www.pediatrics. work (PECARN). A multicenter, random-
JD, Leiter JC. A prospective randomized org/cgi/content/full/133/1/e8 ized, controlled trial of dexamethasone
controlled blinded study of three bron- 75. Wu S, Baker C, Lang ME, et al. Nebulized for bronchiolitis [published correction
chodilators in infants with respiratory hypertonic saline for bronchiolitis: a ran- appears in N Engl J Med 2008;359(18):
syncytial virus bronchiolitis on mechani- domized clinical trial. JAMA Pediatr. 2014; 1972]. N Engl J Med. 2007;357(4):331339
cal ventilation. Pediatr Crit Care Med. 168(7):657663 87. Frey U, von Mutius E. The challenge of
2008;9(6):598604 76. Florin TA, Shaw KN, Kittick M, Yakscoe S, managing wheezing in infants. N Engl J
63. Bjornson C, Russell K, Vandermeer B, Zorc JJ. Nebulized hypertonic saline for Med. 2009;360(20):21302133
Klassen TP, Johnson DW. Nebulized epi- bronchiolitis in the emergency depart- 88. Gibson PG, Powell H, Ducharme F. Long-acting
nephrine for croup in children. Cochrane ment: a randomized clinical trial. JAMA beta2-agonists as an inhaled corticosteroid-
Database Syst Rev. 2013;(10):CD006619 Pediatr. 2014;168(7):664670 sparing agent for chronic asthma in adults
64. Hartling L, Fernandes RM, Bialy L, et al. 77. Sharma BS, Gupta MK, Rak SP. Hypertonic and children. Cochrane Database Syst Rev.
Steroids and bronchodilators for acute (3%) saline vs 0.93% saline nebulization for 2005;(4):CD005076
bronchiolitis in the rst two years of life: acute viral bronchiolitis: a randomized 89. Barnes PJ. Scientic rationale for using
systematic review and meta-analysis. BMJ. controlled trial. Indian Pediatr. 2013;50(8): a single inhaler for asthma control. Eur
2011;342:d1714 743747 Respir J. 2007;29(3):587595
65. Wainwright C, Altamirano L, Cheney M, 78. Silver AH. Randomized controlled trial of 90. Giembycz MA, Kaur M, Leigh R, Newton R.
et al. A multicenter, randomized, double- the efcacy of nebulized 3% saline without A Holy Grail of asthma management: to-
blind, controlled trial of nebulized epineph- bronchodilators for infants admitted with ward understanding how long-acting beta
rine in infants with acute bronchiolitis. N bronchiolitis: preliminary data [abstr E- (2)-adrenoceptor agonists enhance the
Engl J Med. 2003;349(1):2735 PAS2014:2952.685]. Paper presented at: clinical efcacy of inhaled corticosteroids.
66. Patel H, Gouin S, Platt RW. Randomized, Pediatric Academic Societies Annual Meet- Br J Pharmacol. 2008;153(6):10901104
double-blind, placebo-controlled trial of ing; May 36, 2014; Vancouver, British Co- 91. Kaur M, Chivers JE, Giembycz MA, Newton
oral albuterol in infants with mild-to- lumbia, Canada R. Long-acting beta2-adrenoceptor agonists
moderate acute viral bronchiolitis. J 79. Ralston S, Hill V, Martinez M. Nebulized synergistically enhance glucocorticoid-
Pediatr. 2003;142(5):509514 hypertonic saline without adjunctive dependent transcription in human airway
128. Arora B, Mahajan P, Zidan MA, Sethuraman 140. Roqu i Figuls M, Gin-Garriga M, Granados 153. Field CM, Connolly JH, Murtagh G, Slattery
U. Nasopharyngeal airway pressures in Rugeles C, Perrotta C. Chest physiother- CM, Turkington EE. Antibiotic treatment of
bronchiolitis patients treated with high-ow apy for acute bronchiolitis in paediatric epidemic bronchiolitisa double-blind
nasal cannula oxygen therapy. Pediatr patients between 0 and 24 months old. trial. BMJ. 1966;1(5479):8385
Emerg Care. 2012;28(11):11791184 Cochrane Database Syst Rev. 2012;(2): 154. Antonow JA, Hansen K, McKinstry CA,
129. Spentzas T, Minarik M, Patters AB, Vinson B, CD004873 Byington CL. Sepsis evaluations in hospi-
Stidham G. Children with respiratory dis- 141. Aviram M, Damri A, Yekutielli C, Bearman talized infants with bronchiolitis. Pediatr
tress treated with high-ow nasal cannula. J, Tal A. Chest physiotherapy in acute Infect Dis J. 1998;17(3):231236
J Intensive Care Med. 2009;24(5):323328 bronchiolitis [abstract]. Eur Respir J. 1992; 155. Friis B, Andersen P, Brene E, et al. Anti-
130. Hegde S, Prodhan P. Serious air leak 5(suppl 15):229230 biotic treatment of pneumonia and bron-
syndrome complicating high-ow nasal 142. Webb MS, Martin JA, Cartlidge PH, Ng YK, chiolitis. A prospective randomised study.
cannula therapy: a report of 3 cases. Pe- Wright NA. Chest physiotherapy in acute Arch Dis Child. 1984;59(11):10381045
diatrics. 2013;131(3). Available at: www. bronchiolitis. Arch Dis Child. 1985;60(11): 156. Greenes DS, Harper MB. Low risk of bac-
pediatrics.org/cgi/content/full/131/3/e939 10781079 teremia in febrile children with recogniz-
131. Pham TM, OMalley L, Mayeld S, Martin S, 143. Nicholas KJ, Dhouieb MO, Marshal TG, able viral syndromes. Pediatr Infect Dis J.
Schibler A. The effect of high ow nasal Edmunds AT, Grant MB. An evaluation of 1999;18(3):258261
cannula therapy on the work of breathing chest physiotherapy in the management 157. Spurling GK, Doust J, Del Mar CB, Eriksson
in infants with bronchiolitis [published of acute bronchiolitis: changing clinical L. Antibiotics for bronchiolitis in children.
online ahead of print May 21, 2014]. Pediatr practice. Physiotherapy. 1999;85(12):669674 Cochrane Database Syst Rev. 2011;(6):
Pulmonol. doi:doi:10.1002/ppul.23060 144. Boh L, Ferrero ME, Cuestas E, Polliotto L, CD005189
132. Bressan S, Balzani M, Krauss B, Pettenazzo Genoff M. Indications of conventional 158. Ralston S, Hill V, Waters A. Occult serious
A, Zanconato S, Baraldi E. High-ow nasal chest physiotherapy in acute bronchiolitis bacterial infection in infants younger than
cannula oxygen for bronchiolitis in a pe- [in Spanish]. Medicina (B Aires). 2004;64 60 to 90 days with bronchiolitis: a sys-
diatric ward: a pilot study. Eur J Pediatr. (3):198200 tematic review. Arch Pediatr Adolesc Med.
2013;172(12):16491656 145. De Crdoba F, Rodrigues M, Luque A, 2011;165(10):951956
133. Ganu SS, Gautam A, Wilkins B, Egan J. In- Cadrobbi C, Faria R, Sol D. Fisioterapia 159. Purcell K, Fergie J. Lack of usefulness of
crease in use of non-invasive ventilation respiratria em lactentes com bronquio- an abnormal white blood cell count for
for infants with severe bronchiolitis is lite: realizar ou no? Mundo Sade. 2008; predicting a concurrent serious bacterial
associated with decline in intubation 32(2):183188 infection in infants and young children
rates over a decade. Intensive Care Med. 146. Gajdos V, Katsahian S, Beydon N, et al. hospitalized with respiratory syncytial vi-
2012;38(7):11771183 Effectiveness of chest physiotherapy in rus lower respiratory tract infection.
134. Wing R, James C, Maranda LS, Armsby CC. infants hospitalized with acute bronchi- Pediatr Infect Dis J. 2007;26(4):311315
Use of high-ow nasal cannula support in olitis: a multicenter, randomized, controlled 160. Purcell K, Fergie J. Concurrent serious
the emergency department reduces the trial. PLoS Med. 2010;7(9):e1000345 bacterial infections in 2396 infants and
need for intubation in pediatric acute re- 147. Rochat I, Leis P, Bouchardy M, et al. Chest children hospitalized with respiratory
spiratory insufciency. Pediatr Emerg Care. physiotherapy using passive expiratory syncytial virus lower respiratory tract
2012;28(11):11171123 techniques does not reduce bronchiolitis infections. Arch Pediatr Adolesc Med.
135. McKiernan C, Chua LC, Visintainer PF, Allen severity: a randomised controlled trial. 2002;156(4):322324
H. High ow nasal cannulae therapy in Eur J Pediatr. 2012;171(3):457462 161. Purcell K, Fergie J. Concurrent serious
infants with bronchiolitis. J Pediatr. 2010; 148. Postiaux G, Louis J, Labasse HC, et al. bacterial infections in 912 infants and
156(4):634638 Evaluation of an alternative chest physio- children hospitalized for treatment of re-
136. Schibler A, Pham TM, Dunster KR, et al. therapy method in infants with respira- spiratory syncytial virus lower respiratory
Reduced intubation rates for infants after tory syncytial virus bronchiolitis. Respir tract infection. Pediatr Infect Dis J. 2004;
introduction of high-ow nasal prong ox- Care. 2011;56(7):989994 23(3):267269
ygen delivery. Intensive Care Med. 2011;37 149. Snchez Bayle M, Martn Martn R, Cano 162. Kuppermann N, Bank DE, Walton EA, Senac
(5):847852 Fernndez J, et al. Chest physiotherapy MO Jr, McCaslin I. Risks for bacteremia
137. Kelly GS, Simon HK, Sturm JJ. High-ow and bronchiolitis in the hospitalised in- and urinary tract infections in young fe-
nasal cannula use in children with respira- fant. Double-blind clinical trial [in Span- brile children with bronchiolitis. Arch
tory distress in the emergency department: ish]. An Pediatr (Barc). 2012;77(1):511 Pediatr Adolesc Med. 1997;151(12):1207
predicting the need for subsequent in- 150. Mussman GM, Parker MW, Statile A, 1214
tubation. Pediatr Emerg Care. 2013;29(8): Sucharew H, Brady PW. Suctioning and 163. Titus MO, Wright SW. Prevalence of serious
888892 length of stay in infants hospitalized with bacterial infections in febrile infants with
138. Kallappa C, Hufton M, Millen G, Ninan TK. bronchiolitis. JAMA Pediatr. 2013;167(5): respiratory syncytial virus infection. Pe-
Use of high ow nasal cannula oxygen 414421 diatrics. 2003;112(2):282284
(HFNCO) in infants with bronchiolitis on 151. Weisgerber MC, Lye PS, Li SH, et al. Factors 164. Melendez E, Harper MB. Utility of sepsis
a paediatric ward: a 3-year experience. predicting prolonged hospital stay for evaluation in infants 90 days of age or
Arch Dis Child. 2014;99(8):790791 infants with bronchiolitis. J Hosp Med. younger with fever and clinical bronchi-
139. Hilliard TN, Archer N, Laura H, et al. Pilot 2011;6(5):264270 olitis. Pediatr Infect Dis J. 2003;22(12):
study of vapotherm oxygen delivery in 152. Nichol KP, Cherry JD. Bacterial-viral inter- 10531056
moderately severe bronchiolitis. Arch Dis relations in respiratory infections of chil- 165. Hall CB, Powell KR, Schnabel KC, Gala CL,
Child. 2012;97(2):182183 dren. N Engl J Med. 1967;277(13):667672 Pincus PH. Risk of secondary bacterial
heart disease. Arch Dis Child. 2004;89:961 preterm infants. Pediatrics. 2013;132(5): 222. Bradley JP, Bacharier LB, Bonglio J, et al.
965 811818 Severity of respiratory syncytial virus
200. Geskey JM, Thomas NJ, Brummel GL. Pal- 212. Hall CB, Douglas RG Jr, Geiman JM. Pos- bronchiolitis is affected by cigarette
ivizumab in congenital heart disease: sible transmission by fomites of re- smoke exposure and atopy. Pediatrics.
should international guidelines be re- spiratory syncytial virus. J Infect Dis. 1980; 2005;115(1). Available at: www.pediatrics.
vised? Expert Opin Biol Ther. 2007;7(11): 141(1):98102 org/cgi/content/full/115/1/e7
16151620 213. Sattar SA, Springthorpe VS, Tetro J, 223. Al-Shawwa B, Al-Huniti N, Weinberger M,
201. Robbie GJ, Zhao L, Mondick J, Losonsky Vashon R, Keswick B. Hygienic hand anti- Abu-Hasan M. Clinical and therapeutic
G, Roskos LK. Population pharmacoki- septics: should they not have activity and variables inuencing hospitalisation for
netics of palivizumab, a humanized anti- label claims against viruses? Am J Infect bronchiolitis in a community-based pae-
respiratory syncytial virus monoclonal Control. 2002;30(6):355372 diatric group practice. Prim Care Respir J.
antibody, in adults and children. Anti- 214. Picheansathian W. A systematic review on 2007;16(2):9397
microb Agents Chemother. 2012;56(9): the effectiveness of alcohol-based so- 224. Carroll KN, Gebretsadik T, Grifn MR, et al.
49274936 lutions for hand hygiene. Int J Nurs Pract. Maternal asthma and maternal smoking
202. Megged O, Schlesinger Y. Down syndrome 2004;10(1):39 are associated with increased risk of
and respiratory syncytial virus infection. 215. Hall CB. The spread of inuenza and other bronchiolitis during infancy. Pediatrics.
Pediatr Infect Dis J. 2010;29(7):672673 respiratory viruses: complexities and con- 2007;119(6):11041112
203. Robinson KA, Odelola OA, Saldanha IJ, jectures. Clin Infect Dis. 2007;45(3):353 225. Semple MG, Taylor-Robinson DC, Lane S,
Mckoy NA. Palivizumab for prophylaxis 359 Smyth RL. Household tobacco smoke and
against respiratory syncytial virus infection 216. Boyce JM, Pittet D; Healthcare Infection admission weight predict severe bron-
in children with cystic brosis. Cochrane Control Practices Advisory Committee; chiolitis in infants independent of depri-
Database Syst Rev. 2012;(2):CD007743 HICPAC/SHEA/APIC/IDSA Hand Hygiene Task vation: prospective cohort study. PLoS
204. Winterstein AG, Eworuke E, Xu D, Schuler P. Force; Society for Healthcare Epidemiol- ONE. 2011;6(7):e22425
Palivizumab immunoprophylaxis effective- ogy of America/Association for Profes- 226. Best D; Committee on Environmental
ness in children with cystic brosis. sionals in Infection Control/Infectious Health; Committee on Native American
Pediatr Pulmonol. 2013;48(9):874884 Diseases Society of America. Guideline for Child Health; Committee on Adolescence.
205. Cohen AH, Boron ML, Dingivan C. A phase Hand Hygiene in Health-Care Settings. From the American Academy of Pediatrics:
IV study of the safety of palivizumab for Recommendations of the Healthcare In- Technical reportSecondhand and pre-
prophylaxis of RSV disease in children fection Control Practices Advisory Com- natal tobacco smoke exposure. Pediatrics.
with cystic brosis [abstract]. American mittee and the HICPAC/SHEA/APIC/IDSA 2009;124(5). Available at: www.pediatrics.
Thoracic Society Abstracts, 2005 In- Hand Hygiene Task Force. MMWR Recomm org/cgi/content/full/124/5/e1017
ternational Conference; 2005. p. A178 Rep. 2002;51(RR-16):145, quiz CE1CE4 227. Wilson KM, Wesgate SC, Best D, Blumkin
206. Giusti R. North American synagis pro- 217. World Health Organization. Guidelines on AK, Klein JD. Admission screening for
phylaxis survey. Pediatr Pulmonol. 2009;44 hand hygiene in health care. Geneva, secondhand tobacco smoke exposure.
(1):9698 Switzerland: World Health Organization; Hosp Pediatr. 2012;2(1):2633
207. El Saleeby CM, Somes GW, DeVincenzo HP, 2009. Available at: http://whqlibdoc.who. 228. Mahabee-Gittens M. Smoking in parents of
Gaur AH. Risk factors for severe re- int/publications/2009/9789241597906_eng. children with asthma and bronchiolitis in
spiratory syncytial virus disease in chil- pdf. Accessed July 15, 2014 a pediatric emergency department.
dren with cancer: the importance of 218. Karanl LV, Conlon M, Lykens K, et al. Re- Pediatr Emerg Care. 2002;18(1):47
lymphopenia and young age. Pediatrics. ducing the rate of nosocomially transmitted 229. Dempsey DA, Meyers MJ, Oh SS, et al.
2008;121(2):235243 respiratory syncytial virus. [published cor- Determination of tobacco smoke exposure
208. Berger A, Obwegeser E, Aberle SW, Lang- rection appears in Am J Infect Control. 1999; by plasma cotinine levels in infants and
gartner M, Popow-Kraupp T. Nosocomial 27(3):303] Am J Infect Control. 1999;27(2): children attending urban public hospital
transmission of respiratory syncytial vi- 9196 clinics. Arch Pediatr Adolesc Med. 2012;
rus in neonatal intensive care and in- 219. Macartney KK, Gorelick MH, Manning ML, 166(9):851856
termediate care units. Pediatr Infect Dis J. Hodinka RL, Bell LM. Nosocomial re- 230. Rosen LJ, Noach MB, Winickoff JP, Hovell
2010;29(7):669670 spiratory syncytial virus infections: the MF. Parental smoking cessation to protect
209. Ohler KH, Pham JT. Comparison of the cost-effectiveness and cost-benet of in- young children: a systematic review and
timing of initial prophylactic palivizumab fection control. Pediatrics. 2000;106(3): meta-analysis. Pediatrics. 2012;129(1):141152
dosing on hospitalization of neonates for 520526 231. Matt GE, Quintana PJ, Destaillats H, et al.
respiratory syncytial virus. Am J Health 220. Strachan DP, Cook DG. Health effects of Thirdhand tobacco smoke: emerging evi-
Syst Pharm. 2013;70(15):13421346 passive smoking. 1. Parental smoking and dence and arguments for a multidisciplin-
210. Blanken MO, Robers MM, Molenaar JM, lower respiratory illness in infancy and early ary research agenda. Environ Health
et al. Respiratory syncytial virus and re- childhood. Thorax. 1997;52(10):905914 Perspect. 2011;119(9):12181226
current wheeze in healthy preterm 221. Jones LL, Hashim A, McKeever T, Cook DG, 232. Section on Breastfeeding. Breastfeeding
infants. N Engl J Med. 2013;368(19):1794 Britton J, Leonardi-Bee J. Parental and and the use of human milk. Pediatrics.
1799 household smoking and the increased 2012;129(3). Available at: www.pediatrics.
211. Yoshihara S, Kusuda S, Mochizuki H, Okada risk of bronchitis, bronchiolitis and other org/cgi/content/full/129/3/e827
K, Nishima S, Simes EAF; C-CREW Inves- lower respiratory infections in infancy: sys- 233. Ip S, Chung M, Raman G, et al. Breast-
tigators. Effect of palivizumab prophylaxis tematic review and meta-analysis. Respir feeding and Maternal and Infant Health
on subsequent recurrent wheezing in Res. 2011;12:5 Outcomes in Developed Countries. Rockville,
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-benet 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, -2/ Oxygen
(MM Risk Factors)) OR exp Receptors, Adrenergic, / OR MedLine
exp Receptors, Adrenergic, -1/ OR ((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/
ammatory 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)) specications.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))
Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical Practice Guideline: The
Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics. 2014;134
(5):e1474e1502
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]:e1474e1502).
On page e1484, in the discussion after Key Action Statement 6b, in the fth
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
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 (9th12th Grade) and Younger Teens (6th8th Grade)
CAPS (n 5 57) IRC (n 5 62a) F (df ) Pb
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; 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/early/2014/10/21/peds.2014-2742