Summary of guideline
Clinical Contents:
- Diagnosis
- Initial illness severity assessment
- Risk factors for severe illness
- Investigations
- SARS-CoV-2 co-infection
- Monitoring
- Respiratory support
- Medication
- Nasal suction and clearance techniques
- Hydration and nutrition
- Discharge planning
- Prevention of RSV bronchiolitis
- Infection control
- Education modules
Technical Contents:
Summary of key changes in recommendations between the 2016 guideline and the 2025 update
This section presents a summary of key changes in the recommendations between the 2016 Australasian Bronchiolitis Guideline and the 2025 update. A summary of the changes and the original recommendations are presented.
| TOPIC | NO. | CHANGE | SUMMARY of CHANGES | 2016 RECOMMENDATION |
|---|---|---|---|---|
| Physical exam and history | 1 | ✓ | The key clinical signs and symptoms of bronchiolitis have not changed. However, additional clinical signs and symptoms have been added to the recommendation: feeding difficulties, vomiting, dehydration, hypoxaemia, lethargy, uncommonly (<5%) diarrhoea, and rarely (<2%) apnoea. | Infants can be diagnosed with bronchiolitis if they have an upper respiratory tract infection followed by onset of respiratory distress with fever, and one or more of: cough, tachypnoea, retractions and diffuse crackles or wheeze on auscultation. (NHMRC: C, GRADE: Weak) |
| Risk factors | 2 | ✓ | Additional risk factors have been added to the recommendation, including the presence of trisomy 21, economic disadvantage, CDH, other genetic disorders, and the timing of illness onset at hospital presentation. In the 2025 update, clinicians are encouraged to view gestational age, chronological age, breastfeeding and tobacco smoke exposure (pre and postnatal) as continuous risk factors (where risk of serious illness is increased with lower gestational or chronological age, less breastfeeding exposure, and more tobacco smoke exposure). |
Clinicians should consider as risk factors for more serious illness: gestational age <37 weeks; chronological age at presentation <10 weeks; exposure to cigarette smoke; breastfeeding for <2 months; failure to thrive; having chronic lung disease; having chronic heart and/or chronic neurological conditions; being Indigenous ethnicity, and should take these into account when managing infants with bronchiolitis. (NHMRC: C, GRADE: Conditional) |
| CXR | 3b | NA | New topic to the 2025 guideline update. | NA |
| 3c | NA | New topic to the 2025 guideline update. | NA | |
| Laboratory tests | 4a | ✓ | The recommendation to perform urine testing for suspected urinary tract infection in infants with bronchiolitis and a fever was removed to reflect the updated evidence. However, urine tests may be considered to inform diagnoses of serious bacterial co-infection in infants with unexpected deterioration (see R4b). The recommendation was updated to report that glucose and/or sodium levels may be considered during assessment in infants with bronchiolitis and poor feeding, evidence of dehydration or altered mental state. |
There is no role for blood tests in managing infants presenting to hospital and hospitalised with bronchiolitis. Routine bacteriological testing of blood and urine is not recommended. In infants <2 months of age presenting to hospital or hospitalised with bronchiolitis with a temperature >38 degrees, there is a low risk of UTI. If clinical uncertainty exists, clinicians may consider collecting a urine sample for microscopy, culture, and sensitivity looking for the concurrent presence of UTI. (NHMRC: D, GRADE: Conditional) |
| 4b | NA | New topic to the 2025 guideline update. | NA | |
| 4c | NA | New topic to the 2025 guideline update. | NA | |
| Criteria for safe discharge | 7 | ✓ | In the 2025 update, a prescriptive discharge criteria and flow chart was developed. The criteria for safe discharge were revised to include specific oxygen saturation targets and indicators of adequate feeding, and the criteria were tailored to ED and ward discharge. Additional detail on the social factors surrounding discharge, such as parent/caregiver education on bronchiolitis and confidence to manage bronchiolitis from home, transport, and arrangement of local follow-up (if needed) were added. . | Oxygen saturations, adequacy of feeding, age (infants <8 weeks), and lack of social support should be considered at the time of discharge as a risk for representation. There is insufficient evidence to recommend absolute discharge criteria for infants attending the ED, or hospitalised with bronchiolitis
(NHMRC: Practice Point, GRADE: Weak) |
| Glucocorticoids | 11c | ✓ | The 2025 update states that combined glucocorticoid and adrenaline/epinephrine therapy may be considered in infants with severe bronchiolitis who are requiring ICU level care. The 2025 guidance is otherwise consistent with the 2016 guideline in advising against the routine use of combined therapy in infants with moderate bronchiolitis outside of the ICU setting. |
Do not administer a combination of systemic or local glucocorticoids and adrenaline/epinephrine to infants presenting to hospital or hospitalised with bronchiolitis. (NHMRC: D, GRADE: Weak) |
| Saturation targets | 12b | ✓ | In the 2025 update, it is recommended to use supplemental oxygen in infants with bronchiolitis if SpO2 is persistently <90% in infants aged ≥6 weeks. For infants <6 weeks of age, or <12 months of age with an underlying health condition, supplemental oxygen should be used if SpO2 is persistently <92%. |
In uncomplicated bronchiolitis oxygen supplementation should be commenced if the oxygen saturation level is sustained at a level <92%. At oxygen saturation levels of 92% or greater, oxygen therapy should be discontinued.
(NHMRC: C, GRADE: Conditional) |
| Non-oral hydration | 20b | ✓ | In the updated recommendation, further detail was provided on the types of NG hydration that may be given. Clinicians can consider either continuous or bolus methods of NG non-oral hydration with oral rehydration solution, breast milk, or formula in infants admitted to hospital with bronchiolitis requiring an NG. NG is the preferred first method of non-oral hydration in infants with moderate bronchiolitis requiring supplemental hydration. | Both NG and IV routes are acceptable means for non-oral hydration in infants admitted to hospital with bronchiolitis. (NHMRC: B, GRADE: Strong). |
| 20c | ✓ | The recommendation has been updated to provide more specific guidance on fluid restriction. Clinicians can consider fluid restriction at 50-75% of recommended maintenance due to the risk of fluid overload from SiADH, and hyponatremia in bronchiolitis. Clinicians are also encouraged to monitor for signs of overhydration. | There is insufficient evidence to recommend a specific proportion of maintenance fluid. There is a risk of fluid overload therefore judicious and vigilant use of hydration fluid is required and regular review is recommended (NHMRC: Practice point, GRADE: Weak). |
|
| 20d | NA | New topic to the 2025 guideline update. | NA | |
| 20e | NA | New topic to the 2025 guideline update. | NA | |
| Infection control practices | 21 | ✓ | In addition to hand hygiene practices and cohorting of patients in wards, the 2025 update recommends that multicomponent infection control measures may be considered while managing infants with bronchiolitis (e.g., use of gowns, masks). | Hand hygiene is the most effective intervention to reduce hospital acquired infections and is recommended. There is inadequate evidence for benefits in cohorting infants with bronchiolitis. (NHMRC: D, GRADE: Weak) |
| SARS-CoV-2 co-infection | 22a | NA | New topic to the 2025 guideline update. | NA |
| SARS-CoV-2 treatment | 22b | NA | New topic to the 2025 guideline update. | NA |
| Monoclonal antibody therapy | 23 | NA | New topic to the 2025 guideline update. | NA |
| Maternal RSV immunisation | 24 | NA | New topic to the 2025 guideline update. | NA |
| Infant RSV immunisation | 25 | NA | New topic to the 2025 guideline update. | NA |
Note. The recommendations were not reported as changed in instances where there were minor changes to the wording of the recommendation, but the recommended action had not changed. For details of all recommendations, refer to the main report (Table 6: recommendations from the 2025 Australasian Bronchiolitis Guideline update).
CDH = Congenital diaphragmatic hernia; ED = Emergency department; GRADE = Grading of Recommendations Assessment, Development and Evaluation; ICU = Intensive care unit; IM = Intramuscular; IV = Intravenous; NG = Nasogastric; NHMRC = National Health and Medical Research Council; RSV = Respiratory syncytial virus; SARS-CoV-2 = Severe acute respiratory syndrome coronavirus 2; UTI = Urinary tract infection.