Clinical judgment remains the gold standard for hospital admission of infants with bronchiolitis, and it cannot be replaced by objective criteria (strength of recommendation [SOR]: B, based on prospective and retrospective cohort and retrospective case-control studies). Oxygen saturation (SaO2) is the most consistent clinical predictor of deterioration, though different investigators vary cutoffs from 90% to 95% SaO2 and the vast majority of infants with saturations in this range do well (SOR: B, based upon prospective cohort studies)

Calabretta, Nancy

Gill, John H.

Lind, Isabel

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VOL 55, NO 1 / JANUARY 2006 67w w w. j f p o n l i n e . c o mWhat are hospital admission criteria for infants with bronchiolitis?n Evidence summaryBronchiolitis is the most common diagno-sis among hospitalized infants aged <1 yearin the US.1 It is usually mild with a self-limited course. A 1997 study following1113 healthy full-term infants through 20consecutive winter seasons showed a 5%hospitalization rate of all infants with apositive respiratory syncytial virus (RSV)culture (hospitalization rates with otherpathogens were not reported), confirmingthe mild nature of most cases of bronchioli-tis.2 RSV accounts for 50% to 80% ofbronchiolitis, along with other pathogenssuch as parainfluenza virus, influenzavirus, and human metapneumovirus. Arecent analysis of Centers for DiseaseControl and Prevention data from 1979to 1997 showed that an average of 95children died annually in the US frombronchiolitis, and 77% of these wereaged <1 year (median age at death was 3 months).3When discrete measures such as vitalsigns and scoring scales for respiratorydistress are compared, infants who haveClinical judgment remains the gold standard forhospital admission of infants with bronchiolitis,and it cannot be replaced by objective criteria(strength of recommendation [SOR]: B, based on prospective and retrospective cohort and retrospective case-control studies). Oxygen saturation (SaO2) is the most consistent clinicalpredictor of deterioration, though different investigators vary cutoffs from 90% to 95% SaO2and the vast majority of infants with saturations in this range do well (SOR: B, based upon prospective cohort studies).E V I D E N C E - B A S E D A N S W E RThe key is being able to identify a “sick” childAs a medical student I was taught that one of themost important skills I could develop is the abilityto look at a child and know whether he or she is“really sick” or “not so sick.” In determining whichpatients with bronchiolitis I admit to the hospital, I look at findings such as age (<3 months), medicalhistory, oxygen saturation, and respiratory rateand effort. I also evaluate less tangible data,including the parents’ level of comfort taking theirchild home, and the number of visits they havealready made to the emergency department orclinic for this same problem. For me, a pulseoximetry reading of 93% (or any other individualfinding) does not mandate admission. Althoughone might hope for more objective evidence uponwhich to base decisions, those of us who are comfortable using this type of gestalt will find theresults of this inquiry reassuring.Mike Polizzotto, MDRockford Family Medicine Residency Program, Rockford, IllC L I N I C A L C O M M E N T A R YIsabel Lind, MD, John H. Gill, MDWaco Family Medicine Residency Program, Waco, TexNancy Calabretta, MS, MEdUMDNJ Camden Campus Library at Cooper, Cooper University Hospital, Camden, NJCLINICAL INQUIRIESCopyright® Dowden He lth Media  For personal use onlyFor mass reproduction, content licensing and permissions contact Dowden Health Media.“toxic” appearance, and age <3 monthswere associated with more severe illness(defined as inability to remain alert andactive or well hydrated throughout theirillness). Oxygen saturation (SaO2)<95% was the most objective predictorof severity (positive predictive value =87%; negative predictive value = 73%).The study population was more ill thanwhat is typical in outpatient settings(42% required admission and 11%required mechanical ventilation); there-fore the positive predictive value wouldbe lower in a milder, more typical out-patient population.In a retrospective case-control studyof 542 otherwise healthy full-terminfants aged <1 year admitted for bron-chiolitis with positive RSV tests, tachyp-nea (rate >80) and hypoxia (SaO2<85%) were predictive of the need forpediatric ICU–level care (the specificityfor predicting deterioration was 97%,but the sensitivity was only 30%).4 Theauthors concluded that the use of anyspecific variable for a single patient islimited because of its low sensitivity fordetecting the risk of an adverse out-come.Several studies have attempted todefine admission criteria or decision-making tools for admission of theseinfants, but all used the clinical opinionof the attending pediatrician as theirgold standard and many excludedinfants discharged within 24 hours, thuslimiting their applicability to an outpa-tient population.4,7–10 Common criteriain these studies were an SaO2 ≤93% orhistory of complicating illness such ascongenital heart disease, prematurity, orlung disease, plus the clinical impressionof the attending physician.Recommendations from othersThe American Academy of Pediatricsdoes not have a guideline addressing thisissue. The only guideline listed at theNational Guidelines Clearinghouse was a2005 Cincinnati Children’s HospitalMedical Center guideline for managingSaO2 is the mostconsistent clinicalpredictor of deterioration in infants withbronchiolitis, but physician judgment remainsthe gold standard68 VOL 55, NO 1 / JANUARY 2006  THE JOURNAL OF FAMILY PRACTICECLINICAL INQUIRIESFAST TRACKmild disease courses are very similar tothose who subsequently have a moresevere illness. This, combined with thelow incidence of serious illness, lowersthe predictive value of any single clinicalcriteria for hospital admission (includingoxygen saturation, respiratory rate,apparent respiratory distress, and day ofillness) to the degree that no objective cri-teria are useful to make a decision for oragainst hospitalization.4,5In 2 good-quality retrospective case-control studies, which enrolled infantswith milder disease discharged fromemergency departments, no infantsreturned with illness severe enough torequire admission to an intensive careunit (ICU).5,6 No criteria were found thatcould predict subsequent severe courseand need for admission. One good-quality prospective studythat enrolled 213 infants, younger than13 months and presenting with bronchi-olitis as outpatients found that physicianimpression of appearance was a betterpredictor of severe illness than numericscoring systems such as the YaleObservation Scale or the Clinical AsthmaScore.7 Pulse oximetry (<95%), prematu-rity (<34 weeks gestational age), respira-tory rate >70/minute, atelectasis, “ill” orT A B L EInitial presentation 1. Tachypnea (respiratory rate >60–80) or retractions2. Hypoxia: cutoffs ranging from SaO2<90% to <95%3. Difficulty feeding or dehydration Age Age <12 monthsThe lower the age, the higher the riskComorbidities Bronchopulmonary dysplasia Cystic fibrosisCongenital heart disease Prematurity Gestational age at birth <36 weeksOther Lower annual family income4Risk factors for deterioration in infants with bronchiolitisC O N T I N U E D  O N  P A G E  6 9 infants with bronchiolitis; it is groundedin assuring good patient oxygenation andhydration.11 This guideline does not givespecific criteria for admission but leavesthis decision to the judgment of thephysician. It also notes that the benefitsof hospitalization center on the ability toclosely monitor clinical status (includingairway maintenance and hydration) andeducating parents. The guideline recom-mends starting supplemental oxygenwhen SaO2 is consistently less than 91%and weaning when higher than 94%.R E F E R E N C E S1. Leader S, Kohlhase MS. Recent trends in severe respi-ratory syncytial virus (RSV) among US infants, 1997 to2000. J Pediatr 2003; 143:S127–S132. 2. Fisher RG, Gruber WC, Edwards KM, et al. Twentyyears of outpatient respiratory syncytial virus infec-tion: a framework for vaccine efficacy trials. Pediatrics1997; 99(2):E7. 3. Shay DK, Holman RC, Roosevelt GE, Clarke MJ,Anderson LJ. Bronchiolitis-associated mortality andestimates of respiratory syncytial virus–associateddeaths among US children, 1979–1997. J Infect Dis2001; 183:16–22. 4. Brooks AM, McBride JT, McConnochie KM, Aviram M,Long C, Hall CB. Predicting deterioration in previouslyhealthy infants hospitalized with respiratory syncytialvirus infection. Pediatrics 1999; 104:463–467. 5. Roback MG, Baskin MN. Failure of oxygen saturationand clinical assessment to predict which patients withbronchiolitis discharged from the emergency depart-ment will return requiring admission. Pediatr EmergCare 1997; 13:9–11. 6. Johnson DW, Adair C, Brant R, Holmwood J, MitchellI. Differences in admission rates of children with bron-chiolitis by pediatric and general emergency depart-ments. Pediatrics 2002; 110:E49.7. Shaw KN, Bell LM, Sherman NH. Outpatient assess-ment of infants with bronchiolitis. Am J Dis Child 1991;145:151–155. 8. Mulholland EK, Olinsky A, Shann FA. Clinical findingsand severity of acute bronchiolitis. Lancet 1990;335:1259–1261.  9. Mai TV, Selby AM, Simpson JM, Isaacs D. Use of sim-ple clinical parameters to assess severity of bronchioli-tis. J Paediatr Child Health 1995; 31:465–468.  10. Walsh P, Rothenberg SJ, O’Doherty S, Hoey H, Healy R.A validated clinical model to predict the need foradmission and length of stay in children with acutebronchiolitis. Eur J Emerg Med 2004; 11:265–272.  11. Cincinnati Children’s Hospital Medical Center website.Evidence-based clinical practice guideline: Bronchiolitisin infants less than 1 year of age presenting with a firsttime episode. Last updated 2005. Available at:www.cincinnatichildrens.org/NR/rdonlyres/06A32FA0-503A-461E-BD71216097583923/0/BronchGL.pdf.Accessed on December 7, 2005VOL 55, NO 1 / JANUARY 2006 69CLINICAL INQUIRIES

What are hospital admission criteria for infants with bronchiolitis?

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