Australasian Bronchiolitis Guideline: 2025 Update

Summary of guideline

Clinical Contents:

Technical Contents:

Download Bedside Version Download Full Guideline Download Guideline Annexes

Summary of all guideline recommendations Download initial illness severity assessment table Download evidence based approach to the use of respiratory support flow chart Download criteria for safe discharge flow chart

SUMMARY

Bronchiolitis is one of the most common reasons for hospital admission in Australian and Aotearoa New Zealand infants. The Australasian Bronchiolitis Guideline aims to provide evidence-based clinical guidance on the management of infants (<12 months) presenting or admitted to hospital with bronchiolitis. The recommendations are applicable to emergency departments (EDs), general paediatric wards, and intensive care units (ICUs) in Australasian hospitals. The guidance has been developed for clinicians working within these settings.

The Guideline recommendations are presented in the table below and can also be downloaded in three documents as above; (1) a detailed Full Guideline summarising the evidence underlying each recommendation, (2) Annexes to the Full Guideline, and (3) a Bedside Summary.

Summary of recommendations

Legend

× Strong against
Conditional/weak (for or against)
✓ Strong for
Consensus based

Topic	Recommendation	Recommendation strength
DIAGNOSIS
Physical examination and history (R1)	1. Consider a diagnosis of bronchiolitis in an infant if they have an upper respiratory tract infection (rhinorrhoea/nasal congestion, and/or cough), followed by the onset of a lower respiratory tract infection with one or more of the following: respiratory distress (tachypnoea and/or retractions) or the presence of diffuse crackles and/or wheeze, with or without fever. Additional signs and symptoms can include feeding difficulties, vomiting, dehydration, hypoxaemia, lethargy, uncommonly (<5%) diarrhoea, and rarely (<2%) apnoea.	1. Weak
Risk factors (R2)	2. Clinicians should take into account the following risk factors for more serious illness when assessing and managing infants with bronchiolitis: • Gestational age <37 weeks* • Younger chronological age at presentation* • Prenatal and/or postnatal exposure to tobacco smoke* • Reduced breastfeeding exposure* • Faltering growth/slow weight gain (failure to thrive) • Comorbidities (e.g., congenital heart disease, chronic lung disease, chronic neurological condition, congenital diaphragmatic hernia, trisomy 21, and other genetic disorders) • Being an Indigenous infant† • Being an economically disadvantaged infant • Timing and severity of illness onset at hospital presentation. *Risk factors should be judged on a continuous scale. †Indigenous status itself is unlikely to confer risk but may correlate with severe outcomes.	2. Strong ✓
CXR (R3a-c)	3a. Do not routinely use CXR in infants presenting or admitted with bronchiolitis.	3a. Conditional
	3b. Consider CXR in infants with an unexpected deterioration* or a clinical course not consistent with bronchiolitis (e.g., concerns for sepsis, pneumonic consolidation, pneumothorax, empyema, immunodeficiency, pleural effusion, or significant cardiac abnormalities).	3b. Consensus based
	3c. Consider CXR in infants in high dependency/intensive care settings where there is diagnostic concern (e.g., possible complications such as heart failure with congenital heart disease) to guide treatment options.	3c. Consensus based
Laboratory tests (R4a-c)	4a. i) Do not routinely use laboratory tests (including bacteriological testing of urine or blood) for infants presenting to hospital or hospitalised with bronchiolitis.	4a. i) Conditional
	4a. ii) Consider measuring glucose and/or sodium levels in infants with bronchiolitis who have poor feeding, dehydration, or altered mental state.	4a. ii) Consensus based
	4b. Consider using biomarkers (e.g., full blood count, CRP, PCT), urine testing, and blood cultures to diagnose serious bacterial co-infection in infants with unexpected deterioration during hospitalisation.	4b. Consensus based
	4c. Consider using biomarkers and blood cultures for diagnosing serious bacterial co-infection in infants admitted to ICU.	4c. Weak
Virological investigations (R5)	5. Do not routinely use viral testing in infants presenting or hospitalised with bronchiolitis (including tests undertaken solely for cohorting purposes).	5. Conditional
MANAGEMENT
Bronchiolitis scoring systems (R6)	6. Do not routinely use a formal bronchiolitis severity scoring system to predict the need for admission or hospital length of stay.	6. Weak
Criteria for safe discharge (R7)	7. Safe discharge from hospital (ED or ward) should consider: • Risk factors (see R2) • Distance from hospital and ability to return • Parental health literacy • Timing of presentation relative to bronchiolitis’ natural history Discharge is considered when: 1. The infant is clinically stable (mild to moderate stable respiratory effort). 2. For infants without oxygen support (or SpO₂ ≥95%), observation beyond initial assessment is not required; for those with oxygen support (or SpO₂ ≤94%), observe for 3–4 hours (including during sleep) with defined SpO₂ targets. 3. The infant maintains adequate oral intake (at least half of the usual volume, with adequate wet nappies). 4. Parents/caregivers feel confident managing at home and are provided with written information on when to seek help. 5. Social factors and transport availability support discharge. 6. Local follow-up is arranged where appropriate.	7. Weak
Beta2 agonists (R8a-b)	8a. Do not use beta2 agonists in infants (<12 months) presenting or hospitalised with bronchiolitis.	8a. Strong ×
Beta2 agonists (R8a-b)	8b. Do not use beta2 agonists in infants with a personal or family history of atopy (outside of an RCT).	8b. Strong ×
Adrenaline/ epinephrine (R9)	9. Do not use adrenaline/ epinephrine in infants presenting or hospitalised with bronchiolitis.	9. Strong ×
Hypertonic saline (R10)	10. Do not routinely use nebulised hypertonic saline in infants with bronchiolitis outside of an RCT.	10. Weak
Glucocorticoids (R11a-c)	11a. Do not use systemic or local glucocorticoids in infants with bronchiolitis*.	11a. Strong ×
	11b. Do not use glucocorticoids for routine treatment in infants with bronchiolitis who respond to beta2 agonists or display a later asthmatic phenotype.	11b. Strong ×
	11c. i) Do not routinely use a combination of corticosteroids and adrenaline/ epinephrine in infants with moderate bronchiolitis outside the ICU.	11c. i) Conditional/weak
	11c. ii) Consider combination therapy in infants with severe bronchiolitis requiring ICU care.	11c. ii) Conditional/weak
Supplemental oxygen and saturation targets (R12a-b)	12a. Consider the use of supplemental oxygen in hypoxaemic infants with bronchiolitis. (*See R12b for definitions.)	12a. Conditional
Supplemental oxygen and saturation targets (R12a-b)	12b. Use supplemental oxygen if SpO₂ is persistently: – <90% for infants aged ≥6 weeks – <92% for infants aged <6 weeks or with underlying conditions.	12b. Weak
Continuous pulse oximetry (R13)	13. Do not routinely use continuous pulse oximetry for non‑hypoxaemic infants (SpO₂ ≥90% for infants ≥6 weeks, or SpO₂ ≥92% for infants <6 weeks/with underlying conditions) who are not at risk of apnoea.	13. Conditional
HF therapy (R14)	14 i) Do not routinely use HF therapy in infants with mild/moderate bronchiolitis who are not hypoxaemic.	14 i) Conditional
	14 ii) Do not routinely use HF therapy as first‑line in infants with moderate bronchiolitis who are hypoxaemic.	14 ii) Conditional
	14 iii) Consider HF therapy in infants who are hypoxaemic and have failed low‑flow oxygen.	14 iii) Conditional
	14 iv) Consider HF therapy in infants with severe disease prior to CPAP.	14 iv) Conditional
Chest physiotherapy (R15)	15. Do not routinely use chest physiotherapy in infants with bronchiolitis.	15. Conditional
Suctioning (R16a-b)	16a i). Do not routinely use nasal suction in infants with bronchiolitis.	16a i) Conditional
	16a ii). Consider superficial suctioning in infants with respiratory distress or feeding difficulties due to upper airway secretions.	16a ii) Conditional
	16b. Do not routinely use deep nasal suctioning.	16b. Weak
Nasal saline (R17)	17 i). Do not routinely use nasal saline drops in infants with bronchiolitis.	17 i) Conditional
Nasal saline (R17)	17 ii). Consider a trial of intermittent nasal saline drops at feeding time in infants with reduced feeding.	17 ii) Conditional
CPAP (R18)	18. Consider using CPAP therapy in infants with bronchiolitis and impending or severe respiratory failure and/or severe illness.	18. Conditional
Antibiotic medication (R19a-c)	19a. Do not routinely use antibiotics for bronchiolitis.	19a. Conditional
	19b. Do not routinely use azithromycin for bronchiolitis in hospitalised infants.	19b. Weak
	19c. Do not routinely use antibiotics for bronchiolitis in infants at risk of bronchiectasis.	19c. Weak
Non-oral hydration (R20a-e)	20a. Use supplemental hydration for infants unable to maintain hydration orally.	20a. Strong ✓
	20b. i) Use either NG or IV routes for non-oral hydration in infants requiring supplemental hydration.	20b. i) Strong ✓
	20b. ii) Consider NG as the preferred first method in infants with moderate bronchiolitis requiring hydration.	20b. ii) Weak
	20b. iii) Consider either continuous or bolus NG non-oral hydration with ORS, breast milk, or formula.	20b. iii) Conditional/weak
	20c. Consider fluid restriction at 50–75% of recommended maintenance due to risk of fluid overload from SiADH and hyponatremia; monitor for overhydration.	20c. Consensus based
	20d. Consider using either 0.9% sodium chloride with 5% glucose or a balanced fluid (e.g., Plasma‑lyte 148 or Hartmann’s solution) with 5% glucose for IV maintenance hydration. For infants up to 4 weeks corrected, consider 10% glucose or monitor blood sugar if using 5% glucose.	20d. Consensus based
	20e. i) Consider enteral (NG or oral) feeding if tolerated.	20e. i) Weak
	20e. ii) Consider continuous NG feeding in infants on CPAP not at imminent risk of intubation.	20e. ii) Consensus based
Infection control practices (R21)	21 i) Use hand hygiene practices.	21 i) Strong ✓
	21 ii) Consider multicomponent infection control practices.	21 ii) Weak
	21 iii) Consider cohorting of infants in inpatient wards.	21 iii) Weak
SARS CoV-2 co-infection and treatment (R22a-b)	22a. Do not routinely use SARS‑CoV‑2 status to stratify risk for deterioration in bronchiolitis; SARS‑CoV‑2 infection does not appear to increase severe outcomes.	22a. Weak
	22b. i) Consider dexamethasone in hypoxic bronchiolitis patients who are SARS‑CoV‑2 positive.	22b. i) Consensus based
	22b. ii) Consider remdesivir in immunosuppressed infants who are SARS‑CoV‑2 positive.	22b. ii) Consensus based
PREVENTION
Infant RSV monoclonal antibody prophylaxis (R23)	23 i) Consider use of monoclonal antibodies (palivizumab or nirsevimab) during RSV season in infants at increased risk of severe complications (e.g., chronic lung disease, congenital heart disease, and very preterm infants <32 wGA).	23 i) Conditional/weak
Infant RSV monoclonal antibody prophylaxis (R23)	23 ii) Consider universal nirsevimab as a population‑based approach to reduce RSV bronchiolitis morbidity.	23 ii) Conditional/weak
Maternal active RSV immunisation (R24)	24. Consider universal maternal antenatal immunisation with an RSV prefusion F protein‑based vaccine as a population‑based approach to reduce RSV bronchiolitis morbidity.	24. Conditional/weak
Infant active RSV immunisation (R25)	25. Do not routinely use universal infant RSV immunisation.	25. Weak

Disclaimer: The PREDICT Australasian Bronchiolitis Guideline aims to provide evidence-based clinical guidance for the management of infants (aged <12 months) with bronchiolitis, who have presented to an ED, or who have been admitted to a general paediatric ward or ICU (requiring treatment up to the point of mechanical ventilation) in an Australasian hospital. The content provided is not intended to replace personal consultation with, diagnosis and treatment by a qualified health care professional. Care should always be based on professional medical advice, appropriate for a patient’s specific circumstances.