To the Editors:
In a recent issue of the journal, Garcia-Mauriño et al1 published their interesting results on the impact on clinical outcomes of a discharge protocol for children <24 months of age hospitalized with bronchiolitis. As the authors discussed, numerous guidelines are available on the management of bronchiolitis, but guidance regarding discharge is limited.
The authors implemented a protocol to standardize the discharge of children with bronchiolitis at the pediatric infectious diseases ward (ID) but not at the general pediatrics or pediatric pulmonology wards (non-ID) in 1 tertiary hospital. The protocol included objective clinical criteria and a standardized oxygen weaning pathway, and the outcomes were length of stay (LOS) in hospital and readmission rate within 2 weeks.
The median age (25%–75%) of the 1118 patients in the ID unit was 4.0 (1.8–8.5) and in the non-ID units 6.5 (2.5–12) months. The median LOS in hospital was shorter in the ID than in the non-ID units: 2.0 (1.4–3.8) versus 2.8 (1.7–4.9) days. The difference was significant when analyzed as adjusted for age, gender, comorbidities and viral etiology and when patients <12-months-old were analyzed separately. Readmission rates were similar: 2.9% in the ID and 2.6% in the non-ID group.
In most European countries, the use of bronchiolitis diagnosis has been limited to <12-month-old infants who experience the first infection-associated respiratory distress, with or without wheezing.2 Many pediatricians think that the limit should be even lower, such as 6 months. In these young infants, the improvement may be slower, because there seems to be a 5-day or longer deterioration phase, thereafter a plateau, after which the recovery starts.3 Garcia-Mauriño et al1 took the age into account by 3 ways. The data of the patients younger than 12 months were also analyzed separately, the age was included as a confounder in all multivariate analyses and the discharge criteria concerning respiratory rate and fluid intake were age specific. In addition, having adequate follow-up was a mandatory condition for the discharge. Despite these safety aspects, the age-specific results of <6-month-old patients would be of interest.
Currently, high-flow nasal cannula (HFNC) therapy for oxygen administration in bronchiolitis is widely used but poorly studied. HFNC is an example of interventions that influence the LOS in hospital and need research-based criteria not only for starting but also for weaning from the therapy. In our recent nation-wide questionnaire study in Finland, we found that the guidelines were present for starting of HFNC in 71% and for weaning from HFNC in only 61% of hospitals, and the presence of the guideline was associated with shorter weaning times.4
Garcia-Mauriño et al1 propose a standardized protocol for the discharge of children with bronchiolitis to decrease unnecessary hospital days. It is easy to agree with their proposal. The discharge criteria should be based on clinical research, and the data of the youngest infants with bronchiolitis, those of <12-months-old and even those of <6-months-old, need to be analyzed separately.
Matti Korppi, MD, PhD
Department of Pediatrics
Center for Child Health
Tampere University and University Hospital
1. Garcia-Mauriño C, Moore-Clingenpeel M, Wallihan R, et al. Discharge criteria for bronchiolitis: an unmet need [published online ahead of print November 20, 2017]. Pediatr Infect Dis J.
2. Tapiainen T, Aittoniemi J, Immonen J, et al. Finnish guidelines for the treatment of laryngitis, wheezing bronchitis and bronchiolitis in children. Acta Paediatr. 2016;105:4449.
3. Pruikkonen H, Uhari M, Dunder T, et al. Infants under 6 months with bronchiolitis are most likely to need major medical interventions in the 5 days after onset. Acta Paediatr. 2014;103:10891093.
4. Sokuri P, Heikkilä P, Korppi M. National high-flow nasal cannula and bronchiolitis survey highlights need for further research and evidence-based guidelines. Acta Paediatr. 2017;106:19982003.