Bronchiolitis Oral/Enteral Feeding Guidance Clinical Pathway — Emergency Department and Inpatient

Emergency Department and Inpatient
Clinical Pathway for Oral or Enteral Feeding in Children with Bronchiolitis

Goals and Metrics
Patient Education
Provider Resources
Related Pathways
  • Assess
    Feeding history, hydration status and degree of respiratory distress
Mild/mod respiratory distress
Mod/severe respiratory distress and Stable for oral/enteral feeding
Severe respiratory distress and Not stable for oral/enteral feeding
  • Mental status
    • Alert and consolable
  • Improved respiratory distress, stable on HFNC
  • Weaning on high-flow NC
  • Mental status
    • Sleepy, lethargic or inconsolable
  • Severe respiratory distress
    • No improvement on HFNC
  • Escalating treatments
    • Increasing HFNC setting
    • Increasing need for suctioning NIPPV, etc.
  • Any patient going to an ICU
Low concern for dehydration/adequate PO
Concern for dehydration/inadequate PO
Low concern for dehydration/adequate PO
PO feeding
PO or enteral feeding
PO feeding
NPO, IV hydration
If poor PO, consider NG placement after discussion with family
Continuous IV fluids, inpatient pathway
NG not placed
NG placed
  • Begin NG hydration/feeding
  • Encourage PO as tolerated

Assess hydration

  • Low concern
  • History of adequate PO feeds and/or good urine output
  • Tolerates PO feeding in ED
  • No signs of dehydration on exam
  • Concern
  • History of inadequate PO feeds and poor urine output
  • Unable to tolerate PO feeds in ED
  • Signs of dehydration on exam

Maintenance IV fluid rate
4-2-1 Rule

  • Use patient weight in kg
  • 4 mL/kg/hr for 1st 10 kg +
  • 2 mL/kg/hr for 2nd 10 kg +
  • 1 mL/kg/hr for each kg over 20 kg
  • MAX rate 120 mL/hr

Continuous IV fluids, inpatient pathway

Begin NG hydration/feeding
  • Fluid bolus needed for rehydration
    • Bolus with 10 ml/kg of Pedialyte®, may be given via gravity
    • Consider slowing feed over 1-2 hours if not tolerating initial gravity feed
  • Ongoing hydration/nutrition needed
    • Consider starting at 0.5 maintenance to ensure tolerance, increase to maintenance as tolerated
    • Give continuous or 6-8 bolus feeds per day, based on patient circumstances
      • h/o GERD, vomiting bolus feeds etc.
    • Provide breast milk or age-appropriate formula
    • Pedialyte may be considered if not tolerating feeds
  • Transition to full PO feeding
    • Improved PO intake documented and can adequately maintain hydration
  • Consult nutrition
    • If intolerance occurs or patient is anticipated to require NG feeds > 72 hrs
  • Consider speech consult
    • If prolonged issues with PO feeding or concerns for safety of PO feeding
Age Formula choices
0-12 months Breast milk or home formula
12-24 months Standard formula (Pediasure®/Nutren Junior®)
or
Allergen free (EleCare Jr®/Alfamino Junior™) as indicated
Posted: June 2018
Reviewed: January 2023
Authors: E. Becker, RN; D. Whitney, MD; M. Dunn, MD; J. Cockerham, RN; M. McCloskey, RN; M. Nitka, RN; J. Ronan, MD; K. Palm, RD; A. Reardon, NP; R. Abaya, MD;