The levels of evidence (A-D, X) and the strength of the recommendations (strong recommendation, recommendation, option, or no recommendation) are defined at the end of the "Major Recommendations" field.
Recommendation 1a
Clinicians should diagnose bronchiolitis and assess disease severity on the basis of history and physical examination. Clinicians should not routinely order laboratory and radiologic studies for diagnosis (recommendation: evidence level B).
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 (recommendation: evidence level B).
Recommendation 2a
Bronchodilators should not be used routinely in the management of bronchiolitis (recommendation: evidence level B).
Recommendation 2b
A carefully monitored trial of alpha-adrenergic or beta-adrenergic medication is an option. Inhaled bronchodilators should be continued only if there is a documented positive clinical response to the trial using an objective means of evaluation (option: evidence level B).
Recommendation 3
Corticosteroid medications should not be used routinely in the management of bronchiolitis (recommendation: evidence level B).
Recommendation 4
Ribavirin should not be used routinely in children with bronchiolitis (recommendation: evidence level B).
Recommendation 5
Antibacterial medications should be used only in children with bronchiolitis who have specific indications of the coexistence of a bacterial infection. When present, bacterial infection should be treated in the same manner as in the absence of bronchiolitis (recommendation: evidence level B).
Recommendation 6a
Clinicians should assess hydration and ability to take fluids orally (strong recommendation: evidence level X).
Recommendation 6b
Chest physiotherapy should not be used routinely in the management of bronchiolitis (recommendation: evidence level B).
Recommendation 7a
Supplemental oxygen is indicated if oxyhemoglobin saturation (SpO2) falls persistently below 90% in previously healthy infants. If the SpO2 does persistently fall below 90%, adequate supplemental oxygen should be used to maintain SpO2 at or above 90%. Oxygen may be discontinued if SpO2 is at or above 90% and the infant is feeding well and has minimal respiratory distress (option: evidence level D).
Recommendation 7b
As the child's clinical course improves, continuous measurement of SpO2 is not routinely needed (option: evidence level D).
Recommendation 7c
Infants with a known history of hemodynamically significant heart or lung disease and premature infants require close monitoring as the oxygen is being weaned (strong recommendation: evidence level B).
Recommendation 8a
Clinicians may administer palivizumab prophylaxis to selected infants and children with chronic lung disease (CLD)or a history of prematurity (less than 35 weeks' gestation) or with congenital heart disease (recommendation: evidence level A).
Recommendation 8b
When given, prophylaxis with palivizumab should be given in 5 monthly doses, usually beginning in November or December, at a dose of 15 mg/kg per dose administered intramuscularly (recommendation: evidence level C).
Recommendation 9a
Hand decontamination is the most important step in preventing nosocomial spread of respiratory syncytial virus (RSV). Hands should be decontaminated before and after direct contact with patients, after contact with inanimate objects in the direct vicinity of the patient, and after removing gloves (strong recommendation: evidence level B).
Recommendation 9b
Alcohol-based rubs are preferred for hand decontamination. An alternative is hand-washing with antimicrobial soap (recommendation: evidence level B).
Recommendation 9c
Clinicians should educate personnel and family members on hand sanitation (recommendation: evidence level C).
Recommendation 10a
Infants should not be exposed to passive smoking (strong recommendation: evidence level B).
Recommendation 10b
Breastfeeding is recommended to decrease a child's risk of having lower respiratory tract disease (LRTD) (recommendation: evidence level C).
Recommendation 11
Clinicians should inquire about use of complementary and alternative medicine (CAM) (option: evidence level D).
Definitions:
Evidence Based Grading Scale
A: Well designed randomized controlled trials (RCTs) or diagnostic studies on relevant populations
B: RCTs or diagnostic studies with minor limitations; overwhelming consistent evidence from observational studies
C: Observational studies (Case-control and cohort design)
D: Expert opinion, case reports, reasoning from first principles
X: Exceptional situations in which validating studies cannot be performed and there is a clear preponderance of benefit or harm
Strength of Recommendations
Strong recommendation: A strong recommendation in favor of a particular action is made when the anticipated benefits of the recommended intervention clearly exceed the harms (as a strong recommendation against an action is made when the anticipated harms clearly exceed the benefits) and the quality of the supporting evidence is excellent. In some clearly identified circumstances, strong recommendations may be made when high-quality evidence is impossible to obtain and the anticipated benefits strongly outweigh the harms.
Recommendation: A recommendation in favor of a particular action is made when the anticipated benefits exceed the harms but the quality of evidence is not as strong. Again, in some clearly identified circumstances, recommendations may be made when high quality evidence is impossible to obtain but the anticipated benefits outweigh the harms.
Option: Options define courses that may be taken when either the quality of evidence is suspect or carefully performed studies have shown little clear advantage to one approach over another.
No recommendation: No recommendation indicates that there is a lack of pertinent published evidence and that the anticipated balance of benefits and harms is presently unclear.