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peds.bronchiolitis.v1PRODUCTION
peds.bronchiolitis.v1

Pediatric bronchiolitis

pediatricsacutepediatric
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0 / 12
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm bronchiolitis (URI prodrome + lower respiratory wheeze/crackles in <2 yr — AAP 2014 Ralston) vs asthma vs CAP vs FB

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3
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Advance rule
Set
Advance when

Diagnosis confirmed

Patient inputs (17)

AAP 2014 (Ralston) definition <2 yr; <3 mo highest risk for apnea + admission

Hydration calculations; HFNC dosing per kg (PARIS Franklin NEJM 2018)

O2 trigger and admission criterion (AAP 2014 Ralston)

Tachypnea (age-specific — AAP 2014 Ralston)

Tachycardia from distress / dehydration (AAP 2014 Ralston)

Fever assessment; <60 d febrile sepsis pathway (AAP 2014 Ralston)

Hydration, admission threshold (AAP 2014 Ralston; NICE 2021)

Severity + palivizumab eligibility (AAP 2014 Ralston)

High-risk for severe disease (AAP 2014 Ralston)

Severity risk (AAP 2014 Ralston)

Retractions, nasal flaring, head bobbing, grunting, accessory use (AAP 2014 Ralston; NICE 2021)

Highest risk in young infants and ex-preemies (AAP 2014 Ralston)

Asymmetry, persistent fever, deteriorating (AAP 2014 Ralston — CXR not routine)

Modifiable risk (AAP 2014 Ralston)

Prevention status (ACIP 2023; Hammitt MELODY NEJM 2022)

Recurrent wheeze suggests asthma overlap (AAP 2014 Ralston)

PCR only if changes management (cohort, palivizumab — AAP 2014 Ralston)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (12)

12 need judgement
  • informationallife_threateningapnea_event_in_infant
    Apneic episode in young infant — age < 6 wk term OR preterm < 32 wk (ex-preemie / BPD) with apnea during bronchiolitis (AAP 2014 Ralston; Schroeder JAMA Peds 2013 cohort — apnea LR+ ~ 3-5 for < 6 wk term, ~ 8-15 for preterm < 32 wk)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereapnea_in_infant_with_bronchiolitis
    Apneic episode during bronchiolitis in young infant (AAP 2014 Ralston)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_respiratory_distress_infant
    Severe retractions / nasal flaring / grunting / SpO2 <90% on RA (AAP 2014 Ralston; NICE 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefebrile_infant_under_60_days
    Fever + bronchiolitis in infant <60 d (AAP 2014 Ralston)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepreemie_with_bronchiolitis
    Ex-preemie (<29 wks GA OR chronic lung disease of prematurity) with bronchiolitis (AAP 2014 Ralston)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecongenital_heart_disease_with_bronchiolitis
    Hemodynamically significant CHD with bronchiolitis (AAP 2014 Ralston)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_respiratory_distress
    Severe respiratory distress — marked retractions + grunting + nasal flaring + RR ≥ 70 in infant < 12 mo (AAP 2014 Ralston; NICE 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereo2_sat_below_90_persistent
    SpO2 < 90% sustained on room air (AAP 2014 Ralston hospitalization threshold; some centres use < 92% per NICE 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredehydration_or_feeding_intolerance
    Dehydration OR feeding intolerance — reduced PO intake < 50-75% over 24 h OR < 4 wet diapers per 24 h OR tachypnea limiting PO (AAP 2014 Ralston; NICE 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatedehydration_poor_feeding_infant
    Poor feeding + reduced wet diapers + tachypnea limiting PO (AAP 2014 Ralston; NICE 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateprolonged_or_atypical_course
    Prolonged fever or asymmetric findings or worsening day 7+ (NICE 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildnirsevimab_eligible_unvaccinated
    Nirsevimab-eligible infant (< 8 mo entering first RSV season OR < 24 mo high-risk entering 2nd season) NOT vaccinated this season AND mother did not receive Abrysvo ≥ 14 d before delivery (ACIP 2024; Hammitt MELODY NEJM 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives severity classification
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Recommended regimen

Supportive care (AAP 2014 Ralston) — most clinical work is non-pharmacologic
axis: peds_bronchiolitis_supportive
Selected axis "Supportive care (AAP 2014 Ralston) — most clinical work is non-pharmacologic" by default fallback (first axis)
  • oxygen titrated to SpO2 ≥90%
    first line
    oxygen
    NC 0.5-2 L/min titrated • inhaled • continuous
    triggers: SpO2_lt_90
    AAP 2014; HFNC for moderate-severe
    rxcui 7806
  • normal saline maintenance fluids OR NG feeds
    first line
    crystalloid_isotonic
    Holliday-Segar maintenance per kg • IV/NG • continuous
    triggers: inability_to_maintain_PO_hydration
    AAP 2014 supportive — IV vs NG per local practice; NG safe per Oakley 2013
    rxcui 9863
  • albuterol
    second line
    SABA
    2.5 mg neb (0.15 mg/kg, min 2.5 mg, max 5 mg) • inhaled • one-time trial only — continue ONLY if clear improvement
    triggers: clinically_significant_wheeze_with_response_to_trial, older_age_overlap_with_asthma
    AAP 2014: do NOT routinely; only continue if documented improvement on trial; otherwise stop
    rxcui 435
  • epinephrine
    rescue
    alpha_beta_agonist
    0.5 mg neb (1:1000) • inhaled • single trial
    triggers: severe_distress_consider_in_ED_only
    Limited evidence; not standard; AAP 2014 against routine use
    rxcui 3992
  • dexamethasone
    second line
    corticosteroid
    0.6 mg/kg PO/IV (max 16 mg) — NOT routine • PO/IV • NOT routine for bronchiolitis
    triggers: only_consider_if_significant_asthma_overlap_in_older_infant
    AAP 2014 recommends against routine dexamethasone — Cochrane no benefit
    rxcui 3264
  • hypertonic saline 3% nebulised
    second line
    osmotic_mucolytic
    4 mL nebulised • inhaled • q6-8 h
    triggers: admitted_with_moderate_disease_in_some_centers
    AAP 2014 weak recommendation in admitted only; recent meta-analyses mixed
    rxcui 9863
  • palivizumab
    comorbidity specific
    monoclonal_antibody_RSV
    15 mg/kg IM monthly Nov-Apr (5 doses) • IM • monthly during RSV season
    triggers: preterm_<29_wks, CHD_hemodynamically_significant, chronic_lung_disease, immunocompromise
    AAP 2014 — narrow eligibility; nirsevimab supersedes for many cohorts
    rxcui 194279
  • nirsevimab
    first line
    monoclonal_antibody_RSV_long_acting
    50-100 mg IM (per weight band) • IM • single dose per RSV season
    triggers: universal_infants_first_RSV_season_per_ACIP_2023
    Hammitt MELODY NEJM 2022 + ACIP 2023 — universal infant prophylaxis
    rxcui 2642401

outpatient playbook — drug actions (3)

  1. 1. nirsevimab (Beyfortus) IM — RSV-prevention counseling + administration for next season
    50 mg IM if < 5 kg OR 100 mg IM if ≥ 5 kg (single dose; 200 mg IM for 2nd-season high-risk children: preterm < 32 wk with BPD, CHD, immunocompromised, Down syndrome) • IM • single dose per RSV season
    trigger: Infant < 8 mo entering first RSV season (Oct-Mar Northern Hemisphere) OR < 24 mo high-risk entering 2nd season; eligible-unvaccinated at this visit
    ACIP 2024 universal-infant recommendation; Hammitt MEDLEY NEJM 2022 PMID 35891114 — single IM dose covers full RSV season; supersedes 5-dose monthly palivizumab for most cohorts
  2. 2. maternal RSV vaccine (Abrysvo) counseling for future pregnancies
    Single IM dose at 32-36 weeks gestation in RSV season (Sep-Jan Northern Hemisphere); mother chooses Abrysvo OR infant nirsevimab — both not needed in most cases • IM (mother) • single dose per pregnancy
    trigger: Mother of future pregnancy OR sibling-planning family
    FDA 2023 + ACIP 2023 + Kampmann MATISSE NEJM 2023; maternal antibody confers infant protection if ≥ 14 d before delivery
  3. 3. no routine albuterol / dexamethasone / epinephrine / antibiotics at outpatient follow-up
    NONE • n/a • n/a
    trigger: AAP 2014 Ralston supportive-care doctrine
    AAP 2014 Ralston minimalist approach; NO routine bronchodilators, steroids, or antibiotics

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: First wheezing episode in infant <2 yr after URI prodrome (AAP 2014 Ralston); Increased work of breathing in infant — retractions, nasal flaring (AAP 2014 Ralston; NICE 2021); Apneic episode in infant with URI (AAP 2014 Ralston).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Pediatric bronchiolitis** (peds.bronchiolitis.v1).
Phenotype framing: Bronchiolitis / asthma (>2 yr) / CAP / pertussis / FB / vascular ring / GERD aspiration (AAP 2014 Ralston)
Scope: Confirm bronchiolitis (URI prodrome + lower respiratory wheeze/crackles in <2 yr — AAP 2014 Ralston) vs asthma vs CAP vs FB

No severity triggers fired against current inputs.

Plan

Regimen axis: **Supportive care (AAP 2014 Ralston) — most clinical work is non-pharmacologic**.
1. oxygen titrated to SpO2 ≥90% NC 0.5-2 L/min titrated inhaled continuous (oxygen, first line) — AAP 2014; HFNC for moderate-severe
2. normal saline maintenance fluids OR NG feeds Holliday-Segar maintenance per kg IV/NG continuous (crystalloid_isotonic, first line) — AAP 2014 supportive — IV vs NG per local practice; NG safe per Oakley 2013
3. albuterol 2.5 mg neb (0.15 mg/kg, min 2.5 mg, max 5 mg) inhaled one-time trial only — continue ONLY if clear improvement (SABA, second line) — AAP 2014: do NOT routinely; only continue if documented improvement on trial; otherwise stop
4. epinephrine 0.5 mg neb (1:1000) inhaled single trial (alpha_beta_agonist, rescue) — Limited evidence; not standard; AAP 2014 against routine use
5. dexamethasone 0.6 mg/kg PO/IV (max 16 mg) — NOT routine PO/IV NOT routine for bronchiolitis (corticosteroid, second line) — AAP 2014 recommends against routine dexamethasone — Cochrane no benefit
6. hypertonic saline 3% nebulised 4 mL nebulised inhaled q6-8 h (osmotic_mucolytic, second line) — AAP 2014 weak recommendation in admitted only; recent meta-analyses mixed
7. palivizumab 15 mg/kg IM monthly Nov-Apr (5 doses) IM monthly during RSV season (monoclonal_antibody_RSV, comorbidity specific) — AAP 2014 — narrow eligibility; nirsevimab supersedes for many cohorts
8. nirsevimab 50-100 mg IM (per weight band) IM single dose per RSV season (monoclonal_antibody_RSV_long_acting, first line) — Hammitt MELODY NEJM 2022 + ACIP 2023 — universal infant prophylaxis

Setting playbook (outpatient) — Mild + low-risk-age + tolerating-feeds infants — 24-72 h post-visit / post-discharge follow-up (phone call + clinic visit if needed); nasal-suction technique education; feeding maintenance; return precautions; nirsevimab + maternal-RSV-vaccine prevention counseling for next season; breastfeeding promotion (AAP 2014 Ralston; NICE NG9 2021; ACIP 2024 nirsevimab universal-infant recommendation)
9. nirsevimab (Beyfortus) IM — RSV-prevention counseling + administration for next season 50 mg IM if < 5 kg OR 100 mg IM if ≥ 5 kg (single dose; 200 mg IM for 2nd-season high-risk children: preterm < 32 wk with BPD, CHD, immunocompromised, Down syndrome) IM single dose per RSV season — Infant < 8 mo entering first RSV season (Oct-Mar Northern Hemisphere) OR < 24 mo high-risk entering 2nd season; eligible-unvaccinated at this visit (ACIP 2024 universal-infant recommendation; Hammitt MEDLEY NEJM 2022 PMID 35891114 — single IM dose covers full RSV season; supersedes 5-dose monthly palivizumab for most cohorts)
10. maternal RSV vaccine (Abrysvo) counseling for future pregnancies Single IM dose at 32-36 weeks gestation in RSV season (Sep-Jan Northern Hemisphere); mother chooses Abrysvo OR infant nirsevimab — both not needed in most cases IM (mother) single dose per pregnancy — Mother of future pregnancy OR sibling-planning family (FDA 2023 + ACIP 2023 + Kampmann MATISSE NEJM 2023; maternal antibody confers infant protection if ≥ 14 d before delivery)
11. no routine albuterol / dexamethasone / epinephrine / antibiotics at outpatient follow-up NONE n/a n/a — AAP 2014 Ralston supportive-care doctrine (AAP 2014 Ralston minimalist approach; NO routine bronchodilators, steroids, or antibiotics)

Non-pharmacologic actions:
- Reinforce typical course: 7-10 d total illness, peak day 3-5, cough may linger 2-4 wk (AAP 2014 Ralston; NICE 2021)
- Demonstrate nasal-saline + bulb-suction technique before feeds + PRN; AVOID deep nasopharyngeal suctioning (AAP 2014 Ralston)
- Feeding maintenance: small frequent feeds; monitor wet-diaper count (≥ 4-6 per 24 h); offer breast or bottle PRN; OK to use spoon-feed expressed milk if tachypnea limits suck-swallow (AAP 2014 Ralston)
- Return precautions: poor feeding (< 50-75% intake over 24 h OR < 4 wet diapers per 24 h), apnea, worsening WOB (retractions, nasal flaring, grunting), lethargy, fever, SpO2 < 90% if home pulse-ox (AAP 2014 Ralston; NICE 2021)
- Hand hygiene + tobacco-cessation in household (AAP 2014 Ralston modifiable risks)
- Breastfeeding promotion if applicable — associated with reduced bronchiolitis severity (AAP 2014 Ralston)
- Nirsevimab + maternal-RSV-vaccine counseling for next season + future pregnancies (ACIP 2024; Hammitt MELODY NEJM 2022)
- Asthma-surveillance plan if recurrent wheeze ≥ 3 episodes — refer to pulm.asthma.peds.v1 sibling engine (AAP 2014 Ralston)
- Daycare / sibling-contact guidance: keep infant home until afebrile + feeding well (AAP 2014 Ralston)
- Documentation of who-to-call + when-to-return + ED-criteria in caregiver-readable format (AAP 2014 Ralston)

AVOID / contraindication checks:
- No_routine_albuterol_dex_epi_antibiotics_chest_PT (AAP 2014 Ralston)
- Nirsevimab_supersedes_palivizumab_for_most_cohorts_after_2023 (ACIP 2023)
- HFNC_PARIS_protocol_max_2L_per_kg_per_min (PARIS Franklin NEJM 2018)
- Antibiotic_only_if_confirmed_bacterial_co_infection (AAP 2014 Ralston)
- Do_not_use_systemic_steroid_routinely (AAP 2014 Ralston)

Monitoring

Regimen monitoring:
- SpO2 intermittent per AAP 2014 for stable (AAP 2014 Ralston)
- WOB q1h (AAP 2014 Ralston; NICE 2021)
- feeding tolerance (AAP 2014 Ralston; NICE 2021)
- weight daily (AAP 2014 Ralston)
- continuous SpO2 only if severe (AAP 2014 Ralston)

Setting (outpatient) monitoring:
- 24-h phone check-in (AAP 2014 Ralston; NICE 2021)
- 24-72 h clinic visit if concerning OR routine for age < 2 mo / high-risk host (AAP 2014 Ralston)
- Asthma surveillance at routine well-child visits if recurrent wheeze (AAP 2014 Ralston)
- RSV-prevention plan tracking for next season (ACIP 2024)

Follow-up plan: Pediatrician 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)
- Close-out criterion: Follow-up + prevention plan documented

Monitoring phase: SpO2 (intermittent vs continuous per AAP 2014 Ralston — continuous monitoring not required for stable), feeding tolerance, WOB (NICE 2021)

Disposition

Current setting: outpatient — Mild + low-risk-age + tolerating-feeds infants — 24-72 h post-visit / post-discharge follow-up (phone call + clinic visit if needed); nasal-suction technique education; feeding maintenance; return precautions; nirsevimab + maternal-RSV-vaccine prevention counseling for next season; breastfeeding promotion (AAP 2014 Ralston; NICE NG9 2021; ACIP 2024 nirsevimab universal-infant recommendation)

Disposition criteria:
- Continue routine well-child follow-up; resolution typically by 2-4 weeks for cough; full clinical resolution typical (AAP 2014 Ralston; NICE 2021)
- RSV-prevention plan documented for next season (nirsevimab planned OR maternal Abrysvo if future pregnancy) (ACIP 2024; Hammitt MELODY NEJM 2022)

Escalation triggers (move to higher acuity):
- Phone-check or clinic-visit reveals worsening WOB → return to ED (AAP 2014 Ralston; NICE 2021)
- Phone-check or clinic-visit reveals poor feeding / dehydration → return to ED (AAP 2014 Ralston)
- New apnea event reported by caregiver → return to ED + cardiorespiratory monitoring evaluation (AAP 2014 Ralston)
- New fever + age < 60 d → return to ED for febrile-infant workup (AAP 2014 Ralston; AAP 2021 Pantell)
- Recurrent wheeze ≥ 3 episodes → refer to pulm.asthma.peds.v1 sibling engine (AAP 2014 Ralston)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Apneic episode in young infant — age < 6 wk term OR preterm < 32 wk (ex-preemie / BPD) with apnea during bronchiolitis (AAP 2014 Ralston; Schroeder JAMA Peds 2013 cohort — apnea LR+ ~ 3-5 for < 6 wk term, ~ 8-15 for preterm < 32 wk)
- [SEVERE] Apneic episode during bronchiolitis in young infant (AAP 2014 Ralston)
- [SEVERE] Severe retractions / nasal flaring / grunting / SpO2 <90% on RA (AAP 2014 Ralston; NICE 2021)

Citations

- AAP 2014 Bronchiolitis CPG (Ralston) + PARIS HFNC NEJM 2018 + ACIP 2024 nirsevimab universal-infant + Hammitt MEDLEY NEJM 2022 + NICE NG9 2021 [PMID:25349312](https://pubmed.ncbi.nlm.nih.gov/25349312/)
- Cited evidence (PMID 29562151) [PMID:29562151](https://pubmed.ncbi.nlm.nih.gov/29562151/)
- Cited evidence (PMID 35235726) [PMID:35235726](https://pubmed.ncbi.nlm.nih.gov/35235726/)
- Cited evidence (PMID 35891114) [PMID:35891114](https://pubmed.ncbi.nlm.nih.gov/35891114/)

Last reconciled with current guidelines: 2026-05-15.
References
  • AAP 2014 Bronchiolitis CPG (Ralston) + PARIS HFNC NEJM 2018 + ACIP 2024 nirsevimab universal-infant + Hammitt MEDLEY NEJM 2022 + NICE NG9 2021 — PMID:25349312
  • Cited evidence (PMID 29562151) — PMID:29562151
  • Cited evidence (PMID 35235726) — PMID:35235726
  • Cited evidence (PMID 35891114) — PMID:35891114