Pediatric bronchiolitis
NEW pediatric dossier — no manifest / atoms / package on disk yet (manifest field intentionally empty). NEXT STEPS: (1) author manifest at prisma/seed/manifests/peds.bronchiolitis.v1.ts; (2) RxCUI validation for albuterol, dexamethasone, epinephrine, palivizumab, nirsevimab (some long-acting mAb RxCUIs variable); (3) calculator gaps — bronchiolitis severity (Modified Tal, Wang, RDAI) absent (PRAM and AIR present). AAP 2014 supportive-care emphasis explicit: NO routine albuterol/dex/epi/abx. Nirsevimab supersedes palivizumab for most infants per ACIP 2024 universal-infant recommendation. Sibling differentiation from pulm.asthma.peds.v1 covers 5 features and recurrent wheeze handling. Deepened 2026-05-15 (shard-5-obped-id depth-pass-1): added co-located _briefs/peds.bronchiolitis.v1.depth.md (companion to existing 2026-04-27 brief) + _research-bundles/peds.bronchiolitis.v1.md. Added outpatient setting playbook (24-72 h phone + clinic follow-up for mild + low-risk-age + tolerating-feeds infants; nasal-suction technique education; feeding maintenance; return precautions; nirsevimab + maternal-RSV-vaccine prevention counseling for next season + future pregnancies; breastfeeding promotion; tobacco-smoke-exposure cessation; daycare guidance). Added 5 severity triggers: apnea_event_in_infant (life_threatening — < 6 wk term OR preterm < 32 wk apnea → admit + continuous cardiorespiratory monitoring + RSV PCR + cardiac monitoring + PICU consideration; Schroeder JAMA Peds 2013 cohort LR+ ~ 3-5 term / ~ 8-15 preterm), severe_respiratory_distress (severe — retractions + grunting + nasal flaring + RR ≥ 70 → HFNC 1-2 L/kg/min + ICU evaluation per PARIS Franklin NEJM 2018), o2_sat_below_90_persistent (severe — AAP 2014 hospitalization threshold; admit + supplemental O2), dehydration_or_feeding_intolerance (severe — < 50-75% PO intake over 24 h OR < 4 wet diapers per 24 h OR tachypnea limiting PO; admit + IV/NG fluids per Oakley 2013), nirsevimab_eligible_unvaccinated (mild — counsel nirsevimab at this visit OR next RSV season + maternal Abrysvo for future pregnancies + breastfeeding + tobacco cessation per ACIP 2024 + Hammitt MELODY/MEDLEY NEJM 2022). Appended 1 alternate-index PMID (35891114 MEDLEY Hammitt) alongside the existing 35235726 (both indexings point to the same MEDLEY trial in preterm + CHD + BPD; verify at next research:pubmed loop). Bumped evidence.last_reconciled to 2026-05-15. Phenotype matrix (age-band × severity × etiology × host × prevention-status — 480-cell collapsed cross-product) encoded indirectly via severity_triggers (apnea_in_infant_with_bronchiolitis, apnea_event_in_infant, severe_respiratory_distress_infant, severe_respiratory_distress, o2_sat_below_90_persistent, dehydration_poor_feeding_infant, dehydration_or_feeding_intolerance, febrile_infant_under_60_days, preemie_with_bronchiolitis, congenital_heart_disease_with_bronchiolitis, prolonged_or_atypical_course, nirsevimab_eligible_unvaccinated) + per-setting playbook logic (outpatient prevention + follow-up; ED triage + admit-vs-discharge; inpatient ward; PICU respiratory failure). First-class TS field for phenotype matrix is schema-blocked. Bayesian linkage (pre-test severe-bronchiolitis priors ~ 2-3% term healthy ≥ 6 wk, stratified to ~ 10-20% preterm < 32 wk / CHD / immunocompromised; LRs: SpO2 < 90% LR+ ~ 4-5, RR ≥ 70 LR+ ~ 3-4, RSV-PCR LR+ ~ 1.2-1.5 modest, apnea-age coupling LR+ ~ 3-5 term < 6 wk / ~ 8-15 preterm < 32 wk; aggregate SpO2 < 90% + severe WOB + poor feeding + age < 2 mo LR+ ~ 15-20 for admit; T_treat ~ 30% post-test OR overt features; T_test ~ 15% post-test for RSV-PCR cohort isolation; T_monitor ~ 5% post-test for continuous SpO2 + apnea alarm; routing edges to peds.febrile-infant.core.v1 / pulm.asthma.peds.v1 / id.cap.peds.v1 placeholder) documented in _research-bundles/peds.bronchiolitis.v1.md. ROS/DDx LR seed data audited by npm run audit:ros-ddx-coverage (cross-cutting; not touched by this shard). Prehospital recognition is currently encoded implicitly via flow.entry_points; a first-class "prehospital" DossierSetting value is schema-blocked. Schroeder JAMA Peds 2013 (apnea-LR cohort) + Madhi MELODY 2022 + Muller HARMONIE 2023 + Kampmann MATISSE 2023 + Oakley 2013 PMID lookups deferred to next research:pubmed loop.
Entry points (4)
- symptomFirst wheezing episode in infant <2 yr after URI prodrome (AAP 2014 Ralston)first_wheeze_in_infant_with_uri
- symptomIncreased work of breathing in infant — retractions, nasal flaring (AAP 2014 Ralston; NICE 2021)increased_work_of_breathing_infant
- symptomApneic episode in infant with URI (AAP 2014 Ralston)apneic_spell_infant
- symptomPoor feeding / dehydration during URI in infant (AAP 2014 Ralston; NICE 2021)poor_feeding_dehydration_infant
Required inputs (17)
- agerequireddemographic • used at CONTEXTAAP 2014 (Ralston) definition <2 yr; <3 mo highest risk for apnea + admission
- weightrequireddemographic • used at CONTEXTHydration calculations; HFNC dosing per kg (PARIS Franklin NEJM 2018)
- spo2requiredvital • used at CONTEXTO2 trigger and admission criterion (AAP 2014 Ralston)
- rrrequiredvital • used at CONTEXTTachypnea (age-specific — AAP 2014 Ralston)
- hrrequiredvital • used at CONTEXTTachycardia from distress / dehydration (AAP 2014 Ralston)
- temperaturerequiredvital • used at CONTEXTFever assessment; <60 d febrile sepsis pathway (AAP 2014 Ralston)
- work_of_breathingrequiredsymptom • used at RED_FLAGSRetractions, nasal flaring, head bobbing, grunting, accessory use (AAP 2014 Ralston; NICE 2021)
- feeding_statusrequiredsymptom • used at CONTEXTHydration, admission threshold (AAP 2014 Ralston; NICE 2021)
- apnea_historyrequiredsymptom • used at RED_FLAGSHighest risk in young infants and ex-preemies (AAP 2014 Ralston)
- prematurityrequiredhistory • used at CONTEXTSeverity + palivizumab eligibility (AAP 2014 Ralston)
- congenital_heart_diseaserequiredhistory • used at CONTEXTHigh-risk for severe disease (AAP 2014 Ralston)
- immunocompromiserequiredhistory • used at CONTEXTSeverity risk (AAP 2014 Ralston)
- prior_wheeze_episodeshistory • used at DIFFERENTIALRecurrent wheeze suggests asthma overlap (AAP 2014 Ralston)
- tobacco_exposurehistory • used at CONTEXTModifiable risk (AAP 2014 Ralston)
- rsv_vaccination_or_nirsevimabhistory • used at CONTEXTPrevention status (ACIP 2023; Hammitt MELODY NEJM 2022)
- rsv_or_respiratory_panellab • used at INITIAL_WORKUPPCR only if changes management (cohort, palivizumab — AAP 2014 Ralston)
- cxr_only_if_atypicalimaging • used at BRANCHING_WORKUPAsymmetry, persistent fever, deteriorating (AAP 2014 Ralston — CXR not routine)
12-phase flow (12)
- 1FRAMEConfirm bronchiolitis (URI prodrome + lower respiratory wheeze/crackles in <2 yr — AAP 2014 Ralston) vs asthma vs CAP vs FBinputs: age, rr, spo2advance: Diagnosis confirmed
- 2ENTRYWheeze + URI in toddler/infant, apneic spell, increased WOB, dehydration (AAP 2014 Ralston)inputs: weightadvance: Entry trigger captured
- 3CONTEXTAge, prematurity, CHD, immunocompromise, prior wheeze, tobacco, RSV prevention status (AAP 2014 Ralston; NICE 2021)inputs: prematurity, congenital_heart_disease, immunocompromise, feeding_statusadvance: Context complete
- 4RED_FLAGSApnea, severe respiratory distress, SpO2 <90%, dehydration, infants <3 mo with poor feeding, ex-preemie (AAP 2014 Ralston; NICE 2021)inputs: apnea_history, work_of_breathing, spo2advance: Severity assigned
- 5INITIAL_WORKUPClinical diagnosis; SpO2; consider RSV PCR if changes management; CXR not routine; UA/CBC only if febrile <60 d (AAP 2014 Ralston)inputs: spo2actions: workup.bronchiolitis, workup.pediatric_feveradvance: Bedside assessment complete
- 6BRANCHING_WORKUPCXR if asymmetry / persistent fever / atypical; blood/urine cultures + LP if neonatal sepsis pathway; FB if sudden onset (AAP 2014 Ralston; NICE 2021)inputs: cxr_only_if_atypicalactions: workup.aspiration_pneumoniaadvance: Atypical workup as needed
- 7DIFFERENTIALBronchiolitis / asthma (>2 yr) / CAP / pertussis / FB / vascular ring / GERD aspiration (AAP 2014 Ralston)advance: Differential narrowed
- 8RISK_STRATIFICATIONRisk factors (prematurity, CHD, immunocompromise, age <3 mo, apnea) + clinical severity (AAP 2014 Ralston)inputs: age, work_of_breathingadvance: Severity tier assigned
- 9TREATMENTSupportive: nasal suctioning, hydration (IV/NG if poor PO), supplemental O2 to SpO2 >=90% (AAP 2014 Ralston), HFNC for moderate-severe (PARIS Franklin NEJM 2018), CPAP/intubation for failure; NO routine albuterol/dex/epi/antibiotics (AAP 2014 Ralston; Cochrane 2023); targeted abx if confirmed bacterial co-infectioninputs: weight, spo2advance: Supportive plan documented
- 10DISPOSITIONHome for mild + tolerating PO + SpO2 >=90% + reliable f/u; admit for severe / apnea / poor feeding / age <3 mo / risk factors (AAP 2014 Ralston; NICE 2021)advance: Disposition documented
- 11MONITORINGSpO2 (intermittent vs continuous per AAP 2014 Ralston — continuous monitoring not required for stable), feeding tolerance, WOB (NICE 2021)advance: Monitoring orders documented
- 12FOLLOWUPPediatrician within 1-2 d post-discharge; RSV prevention plan next season (palivizumab high-risk OR nirsevimab universal — ACIP 2023; Hammitt MELODY NEJM 2022); asthma surveillance for recurrent (AAP 2014 Ralston)advance: Follow-up + prevention plan documented