The Good, the Bad, and the Bronchiolitic Baby
In October, the AAP released its revised practice guideline for the diagnosis, management, and prevention of bronchiolitis, the most common cause of hospitalization among infants younger than 1 year and a very common diagnosis in the emergency department and outpatient setting. There have been several changes from the previous 2006 recommendations.
The most significant departures are in what is no longer recommended: viral or laboratory testing; radiographic imaging; use of a trial dose of a bronchodilator, such as albuterol; use of epinephrine; and chest physiotherapy. Allan Lieberthal, MD, an author on the guideline and a pulmonologist at Kaiser Permanente in Panorama City, California, told Medscape that "none of the treatments that have been tested have been shown to affect the outcome of the illness."
In an interview with Medscape, the lead author, Shawn Rawlson, a pediatric hospitalist at Dartmouth-Hitchcock Medical Center in New Hampshire, acknowledged that the evidence with regard to many common interventions for bronchiolitis was "overwhelmingly negative. ...Bronchiolitis is a frustrating disease for physicians because of the lack of any truly effective therapy."
As for positive or active recommendations, there are three. The first, and the most significant, is in the area of prevention: Palivizumab is now no longer recommended for patients at 29 weeks' gestation or older, unless there is chronic lung disease of prematurity or a hemodynamically significant cardiac condition. This statement is a supplement to the AAP guideline on the use of palivizumab, which was also issued this year.
On the treatment side, there is a recommendation to consider using nebulized hypertonic saline for hospitalized patients (not children in the outpatient setting or emergency department), though the evidence is considered weak. Finally, for outpatient clinicians, there is a recommendation that they should continue to advise parents to avoid exposure to tobacco smoke.
The guideline could be summed up by saying: Don't just stand there; be supportive! The full 28 pages of the guidelines can be found online.
Having a guideline of what not to do is intellectually helpful. Under the guise of "first, do no harm," these recommendations are all little versions of this tenet. It says, essentially, "Here are a bunch of clinically ascertained suggestions so that you don't make things worse." However, when it's just you and that coughing, rhinorrheic, miserable 18-month-old and that fatigued, frustrated, and frayed parent, this guideline doesn't do much to make anybody feel better.
Pediatricians understand the science underpinning the guideline, but it remains to be seen whether we can effectively convey the art of medicine as we speak with the parents of a sick child. We understand the desire to "just do something," but will we be able to reassure the parents that this "something" is probably not in their child's best interest? We can probably understand what it's like to have sat up for several nights with bronchiolitic children, but will that be enough? Time will tell, but the more clinicians understand the evidence and strive to practice according to the guidelines of what not to do, the more consistent we will be in approaching this admittedly frustrating diagnosis.
Medscape Pediatrics © 2014 WebMD, LLC
Cite this: L. Gregory Lawton. 2014's Pediatric 'Great Eight': The News You Need to Know - Medscape - Dec 19, 2014.