Bronchiolitis Clinical Pathway – Emergency Department and Inpatient – Oral/Enteral Feeding Recommendations

Bronchiolitis Clinical Pathway – Emergency Department and Inpatient – Oral/Enteral Feeding Recommendations

Oral/Enteral Feeding Recommendations

Evidence has shown that most infants with bronchiolitis, including those requiring HFNC, are safe to feed by mouth or NG tube, with minimal risk of aspiration, unless they have impending respiratory failure or one of the following exclusions:

  • Severe respiratory distress
  • NPO, potential need for care escalation
  • Concern for possible severe sepsis
  • Risk for feeding intolerance
  • IV fluids for shock
  • Persistent emesis, severe GERD, aspiration risk
  • Craniofacial abnormalities that will make placing an NG tube difficult
  • Critical airway

Assess degree of respiratory distress, hydration status and feeding history.

Degree of Respiratory Distress

The highest rating in any of the categories below determines the child's starting position on the pathway. A severe rating in any category indicates a starting position in the Severe classification. All Moderate assessments, or a mix of Mild and Moderate would indicate a starting position in the Moderate classification. When in doubt, err on the side of classifying a child as more severe.

    Mild (0) Moderate (1) Severe (2)
RR < 3 mos 30-60 61-80 > 80
3 - < 12 mos 25-50 51-70 > 70
1 yr - 2 yrs 20-40 41-60 > 60
WOB None or mild Intercostal retractions Nasal flaring, grunting, head bobbing
Mental Status Baseline Fussy or anxious Lethargic or inconsolable
Oxygen Requirement None < 1.5 L > 1.5 L
Suctioning Bulb Wall/Bulb Wall
Breath Sounds Clear Crackles, Wheezing Diminished breath sounds or significant crackles, wheezing
Cough Absent or mild Moderate Severe

Hydration Status/Feeding History

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

Hydration/Feeding Recommendations

Age Formula Choices
0-12 mos Breast milk or home formula
12-24 mos
  • Standard formula (Pediasure/Nutren Junior)
  • or
  • Allergen free (EleCare Jr/Alfamino Junior) as indicated
Fluid Bolus Needed for Rehydration
  • Bolus with 10 ml/kg of Pedialyte, may be given via gravity
  • Consider slowing feed over 1-2 hrs 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
    • History of 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 Considerations

Nutrition
  • Intolerance to feeds
  • Anticipated to require NG feeds > 72 hrs
Speech
  • Prolonged issues with PO feeding
  • Concerns for safety of PO feeding