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Australasian Bronchiolitis Guideline: 2025 Update

PREDICT (Australasia) · 2025 · Australia

Source and licence

Authors
Meredith L Borland, Kate Loveys, Franz E Babl et al.
Title
Australasian Bronchiolitis Guideline: 2025 Update
Journal
Journal of Paediatrics and Child Health, 2025
DOI
10.1111/jpc.70144
Licence
CC BY 4.0
Changes
Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC12397848

Licence statement of the original publication

This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.

Open the original publication →Full text on Europe PMC

Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Physical examination and history (Q1)

  • 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 respiratory distress (tachypnoea and/or retractions), or presence of diffuse crackles and/or wheeze, with or without the presence of fever. Additional signs and symptoms can include feeding difficulties, vomiting, dehydration, hypoxaemia, lethargy, uncommonly (< 5%) diarrhoea, and rarely (< 2%) apnoea.Recommendation strength: 1. Weak

Risk factors (Q2)

  • 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 including 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. *Clinicians should judge these as risk factors on a continuous scale; with higher risk of poor outcomes associated with lower gestational age, lower chronological age, fewer days of breastfeeding exposure, and greater tobacco smoke exposure. † Indigenous status, in itself, is unlikely to confer risk but there remains a correlation in Australia and Aotearoa New Zealand with ethnicity and severe bronchiolitis outcomes, independent of socioeconomic status, potentially reflecting the ongoing impacts of colonisation, remote geographic isolation, and the institutional racism in our health systems.Recommendation strength: 2. Strong

CXR (Q3a–c)

  • 3a. Do not routinely use CXR in infants presenting or admitted to hospital with bronchiolitis. 3b. Consider CXR in infants with an unexpected deterioration* and/or a clinical course not consistent with bronchiolitis, including concerns regarding the presence of sepsis, pneumonic consolidation, pneumothorax, empyema, immunodeficiency, pleural effusion, or significant cardiac abnormalities. *Unexpected deterioration refers to an unexpected requirement for an escalation of care. 3c. Consider CXR in infants with bronchiolitis in high dependency/intensive care settings, where there is clinician diagnostic concern regarding possible sepsis, pneumonic consolidation, pneumothorax, empyema, immunodeficiency, pleural effusion or significant complication of other diseases (e.g., heart failure with congenital heart disease), in order to guide treatment options.Recommendation strength: 3a. Conditional 3b. Consensus‐based 3c. Consensus‐based

Laboratory tests (Q4a–c)

  • 4a. (i) Do not routinely use laboratory tests for infants presenting to hospital or hospitalised with bronchiolitis, including bacteriological testing of urine or blood. (ii) Consider glucose and/or sodium levels during assessment in infants with bronchiolitis and poor feeding, evidence of dehydration or altered mental state. 4b. Consider use of biomarkers (e.g., FBC, CRP, PCT), urine testing, and blood cultures for the diagnosis of serious bacterial co‐infection for infants with unexpected deterioration during hospitalisation with bronchiolitis. 4c. Consider use of biomarkers (e.g., FBC, CRP, PCT) and blood cultures for diagnosis of serious bacterial co‐infection for infants being admitted to ICU with bronchiolitis.Recommendation strength: 4a. (i) Conditional (ii) Consensus‐based 4b. Consensus‐based 4c. Weak

Virological investigations (Q5)

  • 5. Do not routinely use viral testing in infants presenting to hospital or hospitalised with bronchiolitis, including testing undertaken solely for cohorting of patients.Recommendation strength: 5. Conditional

Bronchiolitis scoring systems (Q6)

  • 6. Do not routinely use a formal bronchiolitis severity scoring system to predict need for admission or hospital length of stay in infants presenting or admitted to hospital with bronchiolitis.Recommendation strength: 6. Weak

Criteria for safe discharge (Q7)

  • 7. Safe discharge from hospital (either from the ED or ward) for infants with bronchiolitis should take into account risk factors (R2), the distance of the family's residence from the hospital and their ability to return, parental health literacy, and the timing of the hospital presentation relative to the natural history of bronchiolitis (R1). Consider patients suitable for safe discharge from hospital when the following criteria are met: 1. Infant is clinically stable (defined as with mild to moderate stable respiratory effort). 2. For an infant who has not received oxygen/respiratory support and/or with SpO2 ≥ 95%, there is no need to continue to observe for maintenance of oxygen saturations and may be considered for discharge based on criteria below. For an infant who has received oxygen/respiratory support and/or with SpO2 ≤ 94%, they should be observed for maintenance of oxygen saturations in air at the following levels for 3–4 h, including a period of sleep: i. for infants aged ≥ 6 weeks with no underlying health conditions, for maintenance of SpO2 ≥ 90%; ii. for infants aged < 6 weeks, or infants aged < 12 months with an underlying health condition, for maintenance of SpO2 ≥ 92%. 3. All Infants irrespective of presentation to ED or on inpatient ward should be maintaining adequate oral intake of fluids and feeds of at least 1/2 of usual volume with adequate output (> 1/2 of usual wet nappies). 4. Parents and/or caregivers should feel confident to manage the infant with bronchiolitis at home. 5. Parents and/or caregivers are educated and provided with written information on possible deterioration and when to return for healthcare review. 6. Social situation allows discharge to home. The following factors should be considered: social factors, the time of day and suitable transport availability. 7. Arrange local follow‐up where appropriate.Recommendation strength: 7. Weak

Beta2 agonists (Q8a–b)

  • 8a. Do not use beta2 agonists in infants (< 12 months of age) presenting to hospital or hospitalised with bronchiolitis. 8b. Do not use beta2 agonists in infants (< 12 months of age) presenting to hospital or hospitalised with bronchiolitis, with a personal or family history of atopy outside of a RCT.Recommendation strength: 8a. Strong 8b. Strong

Adrenaline/epinephrine (Q9)

  • 9. Do not use adrenaline/epinephrine in infants presenting to hospital or hospitalised with bronchiolitis.Recommendation strength: 9. Strong

Hypertonic saline (Q10)

  • 10. Do not routinely use nebulised hypertonic saline in infants presenting to hospital or hospitalised with bronchiolitis outside of an RCT.Recommendation strength: 10. Weak

Glucocorticoids (Q11a–c)

  • 11a. Do not use systemic or local glucocorticoids in infants with bronchiolitis*. *For guidance on the use of glucocorticoids when SARS‐CoV‐2 infection is present, refer to R22b ‘SARS‐CoV‐2 treatment.’ 11b. Do not use glucocorticoids for the routine treatment of infants with bronchiolitis with a positive response to beta2 agonists or other markers of a latter asthmatic phenotype outside of a RCT. Beta2 agonists should not be used in infants aged < 12 months (see Q8a,b). 11c. (i) Do not routinely use a combination of systemic or local corticosteroids and adrenaline/epinephrine in infants presenting to or hospitalised with moderate bronchiolitis outside of the ICU setting. (ii) Consider using a combination of systemic or local corticosteroids and adrenaline/epinephrine in infants with severe bronchiolitis requiring ICU level care.Recommendation strength: 11a. Strong 11b. Strong 11c. (i) Conditional (ii) Conditional

Supplemental oxygen and saturation targets (Q12a–b)

  • 12a. Consider the use of supplemental oxygen in the treatment of hypoxaemic* infants with bronchiolitis. *For definitions of hypoxaemic and target oxygen saturation levels, see Q12b (‘Oxygen saturation targets’). 12b. Consider the use of supplemental oxygen in infants with bronchiolitis if their oxygen saturation is: Persistently < 90%, for infants aged ≥ 6 weeks; Persistently < 92%, for infants aged < 6 weeks, or infants aged < 12 months with an underlying health condition.Recommendation strength: 12a. Conditional 12b. Weak

Continuous pulse oximetry (Q13)

  • 13. Do not routinely use continuous pulse oximetry for medical management of non‐hypoxaemic infants (SpO2 ≥ 90% for infants ≥ 6 weeks age, or SpO2 ≥ 92% for infants < 6 weeks age, or infants aged < 12 months an underlying health condition), with bronchiolitis not receiving oxygen, or stable infants receiving low‐flow oxygen, who are not at risk of apnoea.Recommendation strength: 13. Conditional

HF therapy (Q14)

  • 14. (i) Do not routinely use HF therapy in infants with mild or moderate bronchiolitis who are not hypoxaemic.* (ii) Do not routinely use HF therapy as a first‐line therapy in infants with moderate bronchiolitis who are hypoxaemic.* (iii) Consider HF therapy in infants with bronchiolitis who are hypoxaemic, * and who have failed low flow oxygen. (iv) Consider HF therapy in infants with bronchiolitis with severe disease prior to CPAP. * For otherwise healthy infants aged ≥ 6 weeks: SpO2 persistently < 90%. For infants aged < 6 weeks, or infants aged < 12 months with an underlying health condition: SpO2 persistently < 92%.Recommendation strength: 14. (i) Conditional (ii) Conditional (iii) Conditional (iv) Conditional

Chest physiotherapy (Q15)

  • 15. Do not routinely use chest physiotherapy in infants with bronchiolitis.Recommendation strength: 15. Conditional

Suctioning (Q16a–b)

  • 16a (i). Do not routinely use nasal suction in the management of infants with bronchiolitis. (ii). Consider using superficial suctioning in infants who have respiratory distress or feeding difficulties due to upper airway secretions. 16b. Do not routinely use deep nasal suctioning for the management of infants with bronchiolitis.Recommendation strength: 16a (i). Conditional (ii). Conditional 16b. Weak

Nasal saline (Q17)

  • 17 (i). Do not routinely use nasal saline drops in the management of infants with bronchiolitis. (ii). Consider a trial of intermittent nasal saline drops at time of feeding in infants with reduced feeding.Recommendation strength: 17 (i). Conditional (ii). Conditional

CPAP (Q18)

  • 18. Consider using CPAP therapy in infants with bronchiolitis and impending or severe respiratory failure, and/or with severe illness.Recommendation strength: 18. Conditional

Antibiotic medication (Q19a–c)

  • 19a. Do not routinely use antibiotics for the treatment of infants with bronchiolitis. 19b. Do not routinely use azithromycin for treatment of bronchiolitis in infants admitted to hospital. 19c. Do not routinely use antibiotics for the treatment of bronchiolitis in infants who are at risk of developing bronchiectasis (due to known risk factors such as virus type (e.g., Adenovirus), Indigenous ethnicity, socioeconomic disadvantage).Recommendation strength: 19a. Conditional 19b. Weak 19c. Weak

Non‐oral hydration (Q20a–e)

  • 20a. Use supplemental hydration for infants with bronchiolitis who cannot maintain hydration orally. 20b. (i) Use either NG or IV routes for non‐oral hydration in infants admitted to hospital with bronchiolitis requiring supplemental hydration. (ii) Consider NG as the preferred first method of non‐oral hydration in infants with moderate bronchiolitis requiring supplemental hydration. (iii) 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. 20c. Consider fluid restriction at 50%–75% of recommended maintenance due to the risk of fluid overload from syndrome of inappropriate antidiuretic hormone secretion, and hyponatremia in bronchiolitis. Monitor for signs of overhydration. 20d. Consider using either 0.9% sodium chloride (normal saline) with 5% glucose, or balanced fluid (e.g., Plasma‐lyte 148 or Hartmann's solution) with 5% glucose, for use as maintenance fluid in infants admitted to hospital with bronchiolitis requiring IV hydration. For younger infants aged up to 4 weeks corrected with bronchiolitis, consider 10% glucose, or monitoring of blood sugar levels if receiving 5% glucose. 20e. (i) Consider enteral feeding (NG or oral), if tolerated, in infants receiving high flow. (ii) Consider continuous NG feeding in infants receiving CPAP who are not judged at imminent risk of intubation.Recommendation strength: 20a. Strong 20b. (i) Strong (ii) Weak (iii) Conditional 20c. Consensus‐based 20d. Consensus‐based 20e. (i) Weak (ii) Consensus‐based

Infection control practices (Q21)

  • 21. (i) Use hand hygiene practices for the management of infants with bronchiolitis. (ii) Consider multicomponent infection control practices for the management of infants with bronchiolitis. (iii) Consider cohorting of infants admitted to inpatient wards with bronchiolitis.Recommendation strength: 21. (i) Strong (ii) Weak (iii) Weak

SARS CoV‐2 co‐infection and treatment (Q22a–b)

  • 22a. Do not routinely use SARS‐CoV‐2 status to stratify increased risk for deterioration in infants with bronchiolitis. SARS CoV‐2 infection or co‐infection does not appear to place infants at increased risk of severe outcome from bronchiolitis. 22b. (i) Consider use of dexamethasone in hypoxic patients presenting with bronchiolitis who are also positive for SARS‐CoV‐2 co‐infection. (ii) Consider use of remdesivir in immunosuppressed infants who are also positive for SARS‐CoV‐2 infection.Recommendation strength: 22a. Weak 22b. (i) Consensus‐based (ii) Consensus‐based

Infant RSV monoclonal antibody prophylaxis (Q23)

  • 23. (i) Consider use of monoclonal antibodies (palivizumab or nirsevimab) during RSV season in infants at increased risk of severe complications with bronchiolitis; chronic lung disease, congenital heart disease, and infants born very preterm (< 32 wGA). (ii) Consider universal nirsevimab as a population‐based approach to reduce morbidity due to RSV bronchiolitis.Recommendation strength: 23. (i) Conditional (ii) Conditional

Maternal active RSV immunisation (Q24)

  • 24. Consider universal maternal antenatal immunisation with a RSV prefusion F protein‐based vaccine as a population‐based approach to reduce morbidity due to RSV bronchiolitis.Recommendation strength: 24. Conditional

Infant active RSV immunisation (Q25)

  • 25. Do not routinely use universal infant RSV immunisation.Recommendation strength: 25. Weak

Physical exam and history

  • 1Infants 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

  • 2Clinicians 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

Laboratory tests

  • 4aThere 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°, 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

Criteria for safe discharge

  • 7Oxygen 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 bronchiolitisNHMRC: Practice Point, GRADE: Weak

Glucocorticoids

  • 11cDo 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

  • 12bIn 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

  • 20bBoth NG and IV routes are acceptable means for non‐oral hydration in infants admitted to hospital with bronchiolitis.NHMRC: B, GRADE: Strong
  • 20cThere 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 recommendedNHMRC: Practice point, GRADE: Weak

Infection control practises

  • 21Hand 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

Abstract

Aim: To provide updated evidence‐based clinical guidance in the management of infants with bronchiolitis presenting to emergency departments (EDs), general paediatric, or intensive care units (ICUs) in Australia and Aotearoa New Zealand (AoNZ) following the first publication in 2016.

Method: The Paediatric Research in Emergency Departments International Collaborative (PREDICT) network guideline working group appraised, summarised, and updated evidence from 1 January 2000 to 24 January 2024 addressing 41 questions (30 from the 2016 guideline and 11 new questions for 2025). Recommendations were developed using GRADE methodology and revised after a period of external consultation.

Results: The literature search identified 26 467 citations with 431 included in 41 recommendations providing 11 new and 7 key updates. The key changes included: (i) refinement of the clinical features of bronchiolitis, (ii) addition of new risk factors for severity of illness, (iii) advice on the role of biomarkers for unexpected deterioration or admission to ICU, (iv) guidance on glucocorticoids in SARS‐CoV‐2 co‐infection, (v) guidance on combined glucocorticoids/inhaled epinephrine in severe bronchiolitis requiring ICU level care, (vi) refinement of oxygen saturation targets, (vii) guidance on humidified high flow therapy and continuous positive airway pressure, (viii) recommendation on use of RSV prevention therapies/immunisations for babies and mothers.

Conclusion: The updated Australasian Bronchiolitis Guideline provides clinicians across Australasian settings with the latest evidence‐based guidance on the management of the commonest condition in infancy requiring hospital admission.

Contents of the original publication

The section headings of the original.

  • Introduction
  • Aims and Objectives
  • Materials and Methods
  • Scope and Process
  • Results
  • Key Changes Between the 2016 and 2025 Guidance
  • Discussion
  • Updating the Guideline
  • Strengths and Limitations
  • Conclusions
  • Supporting information

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