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Hospital course and discharge criteria for children hospitalized with bronchiolitis
Jonathan M Mansbach1, Sunday Clark, Pedro A Piedra
1Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
Insights
Most children hospitalized with bronchiolitis improve within 4 days, with only 4% worsening after initial recovery. This study provides data to help establish evidence-based discharge criteria for pediatric bronchiolitis care.
Area of Science:
- Pediatrics
- Infectious Diseases
- Respiratory Medicine
Background:
- Uncertainty exists regarding the typical clinical course and safe discharge timing for hospitalized children with bronchiolitis.
- Developing clear discharge criteria is crucial for optimizing patient care and resource utilization.
Purpose of the Study:
- To analyze the time to clinical improvement in pediatric bronchiolitis.
- To identify risk factors associated with clinical worsening after initial improvement.
- To inform the development of evidence-based discharge criteria for hospitalized children with bronchiolitis.
Main Methods:
- Prospective, multiyear cohort study conducted across sixteen US hospitals.
- Involved consecutive hospitalized children under 2 years of age diagnosed with bronchiolitis.
- Clinical improvement was assessed using retraction severity, respiratory rate, oxygen saturation, and hydration status.
Main Results:
- The median time to clinical improvement was 4 days (IQR: 3-7.5 days) among 1916 children.
- 88% of children met clinical improvement criteria, with only 4% experiencing clinical worsening (3% requiring intensive care).
- Factors associated with worsening included younger age (<2 months), prematurity (<37 weeks gestation), severe retractions, inadequate oral intake, and apnea.
Conclusions:
- While recovery times for bronchiolitis vary, clinical worsening after initial improvement is uncommon (4%).
- Younger, premature infants presenting with severe respiratory distress are at higher risk of worsening.
- These findings support the development of evidence-based discharge criteria to standardize care and potentially reduce hospital length of stay.
Background:
For children hospitalized with bronchiolitis, there is uncertainty about the expected inpatient clinical course and when children are safe for discharge.
Objectives:
Examine the time to clinical improvement, risk of clinical worsening after improvement, and develop discharge criteria.
Design:
Prospective multiyear cohort study.
Setting:
Sixteen US hospitals.
Participants:
Consecutive hospitalized children age <2 years with bronchiolitis.
Measurement:
We defined clinical improvement using: (1) retraction severity, (2) respiratory rate, (3) room air oxygen saturation, and (4) hydration status. After meeting improvement criteria, children were considered clinically worse based on the inverse of ≥1 of these criteria or need for intensive care.
Results:
Among 1916 children, the median number of days from onset of difficulty breathing until clinical improvement was 4 (interquartile range, 3-7.5 days). Of the total, 1702 (88%) met clinical improvement criteria, with 4% worsening (3% required intensive care). Children who worsened were age <2 months (adjusted odds ratio [AOR]: 3.51; 95% confidence interval [CI]: 2.07-5.94), gestational age <37 weeks (AOR: 1.94; 95% CI: 1.13-3.32), and presented with severe retractions (AOR: 5.55; 95% CI: 2.12-14.50), inadequate oral intake (AOR: 2.54; 95% CI: 1.39-4.62), or apnea (AOR: 2.87; 95% CI: 1.45-5.68). Readmissions were similar for children who did and did not worsen.
Conclusions:
Although children hospitalized with bronchiolitis had wide-ranging recovery times, only 4% worsened after initial improvement. Children who worsened were more likely to be younger, premature infants presenting in more severe distress. For children hospitalized with bronchiolitis, these data may help establish more evidence-based discharge criteria, reduce practice variability, and safely shorten hospital length-of-stay.
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