guideline is a revision of the clinical practice guideline, "Diagnosis and Management of Bronchiolitis," published by the American Academy of Pediatrics in 2006. The guideline applies to children from 1 through 23 months of age. Other exclusions are noted. Each key action state- ment indicates level of evidence, benefit-harm relationship, and level of recommendation. Key action statements are as follows: Pediatrics 2014;134:e1474-e1502

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Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis

bronchiolitis is a leading cause of acute illness and hospitaliza- tion of young children. Research into the variation in treatment and outcomes for bronchiolitis across different settings has led to evidence-based clinical practice guidelines. Ongoing investigation con- tinues to expand this body of evidence. Authors of recent surveillance studies have defined the presence of coinfections with multiple viruses in some cases of bronchiolitis. Underlying comorbidities and young age remain the most important predictors for severe bronchiolitis. Pulse oximetry plays an important role in driving use of health care resources. Evidence-based reviews have suggested a limited role for diagnostic laboratory or radiographic tests in typical cases of bronchi- olitis. Several large, recent trials have revealed a lack of efficacy for routine use of either bronchodilators or corticosteroids for treatment of bronchiolitis. Preliminary evidence suggests a potential future role for a combination of these therapies and other novel treatments such as nebulized hypertonic saline. Pediatrics 2010;125:342-349

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Bronchiolitis: recent evidence on diagnosis and management.

BACKGROUND
In an effort to lead physicians in addressing the problem of overuse of medical tests and treatments, the American Board of Internal Medicine Foundation developed the Choosing Wisely campaign. The Society of Hospital Medicine (SHM) joined the initiative to highlight the need to critically appraise resource utilization in hospitals.

METHODS
The SHM employed a staged methodology to develop the adult Choosing Wisely list. This included surveys of the organization's leaders and general membership, a review of the literature, and Delphi panel voting.

RESULTS
The 5 recommendations that were subsequently approved by the SHM Board are: (1) Do not place, or leave in place, urinary catheters for incontinence or convenience or monitoring of output for non–critically ill patients (acceptable indications: critical illness, obstruction, hospice, perioperatively for <2 days for urologic procedures; use weights instead to monitor diuresis). (2) Do not prescribe medications for stress ulcer prophylaxis to medical inpatients unless at high risk for gastrointestinal complications. (3) Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit thresholds and in the absence of symptoms or active coronary disease, heart failure, or stroke. (4) Do not order continuous telemetry monitoring outside of the intensive care unit without using a protocol that governs continuation. (5) Do not perform repetitive complete blood count and chemistry testing in the face of clinical and lab stability.

CONCLUSIONS
Hospitalists have many opportunities to impact overutilization of care. The adult hospital medicine Choosing Wisely recommendations offer an explicit starting point for eliminating waste in the hospital. Journal of Hospital Medicine 2013;8:486–492. © 2013 Society of Hospital Medicine

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Choosing wisely in pediatric hospital medicine: Five opportunities for improved healthcare value

Bronchiolitis: Recommendations for diagnosis, monitoring and management of children one to 24 months of age.

Acute bronchiolitis is the leading cause of lower respiratory t ract infection and hospitalization in children less than 1y ear of age worldwide. It is usually a mild disease, but some children may develop severe symptoms, requiring hospital admission and ventilatory support in the ICU. Infants with pre-existing risk factors (prematurity, bronchopulmonary dysplasia, congenital heart diseases and immunodeficiency) may be predisposed to a severe form of the disease. Clinical diagnosis of bronchiolitis is manly based on medical history and physical examination (rhinorrhea, cough, crackles, wheezing and signs of respiratory distress). Etiological diagnosis, with antigen or genome detection to identify viruses involved, may have a role in reducing hospital transmission of the infection. Criteria for hospitalization include low oxygen saturation (<90-92%), moderate-to-severe respiratory distress, dehydration and presence of apnea. Children with pre-existing risk factors should be carefully assessed. To date, there is no specific treatment for viral bronchiolitis, and the mainstay of therapy is supportive care. This consists of nasal suctioning and nebulized 3% hypertonic saline, assisted feeding and hydration, humidified O2 delivery. The possible role of any pharmacological approach is still debated, and till now there is no evidence to support the use of bronchodilators, corticosteroids, chest physiotherapy, antibiotics or antivirals. Nebulized adrenaline may be sometimes useful in the emergency room. Nebulized adrenaline can be useful in the hospital setting for treatment as needed. Lacking a specific etiological treatment, prophylaxis and prevention, especially in children at high risk of severe infection, have a fundamental role. Environmental preventive measures minimize viral transmission in hospital, in the outpatient setting and at home. Pharmacological prophylaxis with palivizumab for RSV bronchiolitis is indicated in specific categories of children at risk during the epidemic period. Viral bronchiolitis, especially in the case of severe form, may correlate with an increased incidence of recurrent wheezing in pre-schooled children and with asthma at school age. The aim of this document is to provide a multidisciplinary update on the current recommendations for the management and prevention of bronchiolitis, in order to share useful indications, identify gaps in knowledge and drive future research.

/pdf/inter-society-consensus-document-on-treatment-and-prevention-5av6srn6vd.pdf

Inter-society consensus document on treatment and prevention of bronchiolitis in newborns and infants.

Evaluation of the utility of radiography in acute bronchiolitis.

1Departments of Pediatrics and Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada 2Department of Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada 3Division of Pediatric Emergency Medicine, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada 4Departments of Pediatrics and Emergency Medicine, University of Alberta, Women's and Children's Health Research Institute, Alberta, Canada 5Department of Pediatric Emergency Medicine, Max Rady School of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada 6Department of Pediatrics and Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada 7Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada 8Division of Pediatric Emergency Medicine, Department of Pediatrics, The Hospital for SickKids Research Institute, University of Toronto, Toronto, Ontario, Canada 9Departments of Pediatrics, Emergency Medicine, and Physiology & Pharmacology, Cumming School of Medicine, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Onbtario, Canada

Epinephrine metered‐dose inhaler for pediatric croup

The authors declare no potential conflict of interest. Appendix 1 Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article. 

Shannon MacPhee

Papers

Evaluation of the utility of radiography in acute bronchiolitis.

Epinephrine metered‐dose inhaler for pediatric croup

Epinephrine MDI for Pediatric Croup.