The dos and don’ts of managing bronchiolitis in infants in primary care settings

Bronchiolitis, the most common viral respiratory disease in infants, is frequently encountered in primary care settings. It primarily affects children younger than two years and is typically caused by respiratory syncytial virus, although any virus can be responsible. Healthcare providers often order nonevidence-based interventions that have no impact on the disease, feeling that they need to “do something” when faced with these infants and their anxious parents and caregivers.To assist healthcare providers, Choosing Wisely Canada authors have outlined an approach to the diagnosis and management of bronchiolitis in infants in primary care settings. The aim is to optimize management and avoid unnecessary treatments, investigations and healthcare costs.Diagnosis Bronchiolitis is diagnosed clinically. It usually presents in infants up to 24 months of age. Patients typically have a history of upper respiratory illness prodrome, and develop bilateral wheezing or crepitations, increased difficulty in breathing (grunting, nasal flaring, retractions) or increased respiratory rate. No investigations (e.g., chest x-ray, laboratory testing) are needed for diagnosis, regardless of whether the infant is seen at the start, middle or end of disease, or if the infant has ongoing cough after a few weeks.Differential diagnoses to consider include:Asthma, which cannot reliably be diagnosed in children younger than 12 months but can be considered in those with a history of atopy or recurrent wheezePneumonia (unilateral findings, fever > 39°C)Croup (stridor or barking cough)Foreign body aspiration (unilateral sign, no prodrome)Laryngomalacia (stridor with positional changes).Infants at high risk of severe disease are those who were born at less than 35 weeks’ gestation, are younger than three months at presentation, have hemodynamically substantial cardiopulmonary disease or have immunodeficiency.Management is based on illness severity:Mild cases have no or mild respiratory distress, are well hydrated and feeding adequately. These children can usually be managed as an outpatient and at home.Moderate cases show moderate respiratory distress (tachypnea with respiratory rate > 60 breaths/min), inadequate feeding and brief apnea. These children often need observation, including assessment in the emergency department. Hospitalization may be required; indications for admission include severe respiratory distress, dehydration or poor fluid intake, cyanosis or apnea, family unable to cope, and infants at risk of severe disease.Severe cases exhibit severe respiratory distress, are unable to feed or are clinically dehydrated, lethargic, with frequent apnea. Emergency department assessment and hospitalization are required.Dos and don’ts of managementThings to do. Supportive management:Ensure adequate fluid intake: encourage families to feed the infant small amounts frequently.Suction: suctioning nasal passages with any commercial device may be beneficial, especially before feeding.Manage fever: treat fever with antipyretics.Empower families: provide resources for home management and clear instructions about when to seek further care. Provide a “viral prescription” that outlines how caregivers can help the child feel better and manage symptoms (viral prescription sample is available in the toolkit below).Toolkit: refer to and use the Choosing Wisely Canada bronchiolitis toolkit (https://choosingwiselycanada.org/primary-care/bronchiolitis/). It includes an information sheet for families, as well as posters and screensavers that can be used to educate families and set expectations before and during a visit. It also outlines symptoms that warrant returning to the healthcare provider or seeking more immediate medical care (e.g., child has a persistent fever > 38°C for days; symptoms do not improve in day[s] or worsen at any time; child has trouble breathing, persistent vomiting or is not drinking). Follow up: arrange close follow-up as needed.Things not to do.Do not measure oxygen saturation if the child appears well and has mild disease.Do not order chest x-rays.Do not order routine bloodwork unless clinically indicated (e.g., dehydration, febrile young infant). Do not prescribe salbutamol, corticosteroids (inhaled or oral) or epinephrine.Do not order comprehensive respiratory viral testing.Do not prescribe antibiotics.Overall, healthcare providers and families should focus on symptom management, avoid nonevidence-based interventions, and understand warning signs that warrant further evaluation.Reference1. Lirette MP, Müller MJC, Young J; Choosing Wisely Canada. Management of bronchiolitis in infants in primary care settings. What to do and what not to do. Can Fam Physician 2023;69:845-7. (accessed January 4, 2024).

The dos and don’ts of managing bronchiolitis in infants in primary care settings

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