New AAP Bronchiolitis Guideline Drops Call for Certain Tests, Treatments

Updated Guidance Earns AAFP Endorsement

January 14, 2015 10:31 pm Chris Crawford

Bronchiolitis is the most common cause of hospitalization among infants during the first 12 months of life, according to a 2013 Pediatrics study(pediatrics.aappublications.org). That translates to about 100,000 bronchiolitis admissions a year in the United States, costing an estimated $1.73 billion.

[Unhappy infant getting breathing treatment]

To help physicians better approach the disorder, the American Academy of Pediatrics (AAP) released an updated guideline(pediatrics.aappublications.org) on diagnosing, managing and preventing bronchiolitis that was published Nov. 1 in Pediatrics. After careful evaluation, the AAFP endorsed it in December.

The guideline, which applies to children ages 1 to 23 months, includes several evidence-based updates to the AAP's 2006 guideline. It was developed by an AAP guideline subcommittee that included pediatricians, a family physician, hospitalists, pulmonologists, emergency physicians, a neonatologist and pediatric infectious disease physicians and was based on a literature review that research published between 2004 and May 2014, as well as some articles from the 2003 evidence report on which the 2006 guideline was based.

Story highlights
  • The AAFP has endorsed an evidence-based bronchiolitis guideline from the American Academy of Pediatrics that applies to children ages 1 to 23 months.
  • The new guideline was developed by a subcommittee that included pediatricians, a family physician, hospitalists, pulmonologists, emergency physicians, a neonatologist and pediatric infectious disease physicians.
  • Routine viral testing and a trial dose of a bronchodilator are no longer recommended, according to the guideline.

Guideline subcommittee member and family physician Elizabeth Rosenblum, M.D., of the University of California-San Diego, said major changes include:

  • no longer testing for specific viruses;
    no routine radiographic or laboratory studies;
  • not recommending a trial dose of a bronchodilator such as albuterol;
  • not administering epinephrine or corticosteroids to infants diagnosed with bronchiolitis;
  • not administering palivizumab for respiratory syncytial virus (RSV) prophylaxis to otherwise healthy infants with gestational age of 29 weeks or more, although it should be used for infants with hemodynamically significant heart disease or chronic lung disease of prematurity during the first year of life; and
  • administering either nasogastric or IV fluids as needed.

Rosenblum described the evidence and discussion behind some of the biggest changes from the previous guideline, including dropping the recommendation to test for specific viruses related to bronchiolitis. She said the testing once was thought to help predict disease severity and, therefore, guided management.

"Due to the availability of sensitive polymerase chain reaction assays, however, we now know that multiple viruses may cause bronchiolitis," Rosenblum told AAFP News. "In fact, up to one-third of infants have co-infections with several viruses. Testing for a specific virus, such as RSV, does not predict how severe the disease is likely to be and/or whether the child needs to be hospitalized."

So, although treatment for an infant with a viral lower respiratory tract infection does not change based on the identified virus, she noted, viral testing for RSV is still indicated for children on palivizumab prophylaxis with suspected breakthrough disease. For infants who test positive, prophylaxis can be discontinued.

In addition, said Rosenblum, the new guideline no longer recommends a trial dose of a bronchodilator because current evidence shows that bronchodilators are ineffective in changing the course of bronchiolitis.

"In clinical trials, bronchodilators have no impact on any meaningful outcome, such as risk for hospitalization, duration of illness or length of stay," she said. "It is important to understand the epidemiology of wheezing in young children. We know from longitudinal studies that 30 percent of all children will have wheezing episodes before age 3. Of these, only about 5 percent will go on to have asthma. Thus, there is a large cohort of patients who wheeze. Do you treat 100 percent of them with bronchodilators for the 5 percent who might respond?"

The use of bronchodilators in this population can cause significant side effects, Rosenblum added, such as irritability and tachycardia.

"The guideline does not recommend a trial dose of a bronchodilator because the harm of exposing a large cohort of patients to these medications far outweighs the potential benefit when applied across the entire population," she said.

For patients who require hospitalization, supportive care is recommended. According to the new guideline, clinicians may choose to not administer supplemental oxygen if oxyhemoglobin saturation exceeds 90 percent. Clinicians also may choose to not use continuous pulse oximetry, Rosenblum said. However, for infants who are unable to maintain hydration orally, either nasogastric or IV fluids should be administered.

Overall, said Rosenblum, the fact that the updated guideline incorporates all the relevant data from the past 10 years provides a compelling rationale for changing how physicians approach bronchiolitis.

"While it upends many 'usual practice' areas (e.g., don't swab for RSV; don't automatically try a bronchodilator), it provides guidance regarding the most scientifically sound health care practice for infants with bronchiolitis," she said. "All physicians who care for such infants would be well served by incorporating the guideline recommendations into their practice."


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