Recommendations

RACP Paediatrics & Child Health Division

2.
Do not routinely undertake chest X-rays for the diagnosis of bronchiolitis in children or routinely prescribe salbutamol or systemic corticosteroids to treat bronchiolitis in children

Chest X-rays: Chest X-rays for patients with acute lower respiratory tract infections rarely affect clinical treatments and outcomes. Chest X-ray films do not discriminate well between bronchiolitis and other forms of lower respiratory tract infection and in mild cases do not offer information that is likely to affect treatment. It is estimated that 133 children with typical bronchiolitis would have to undergo radiography to identify one radiograph that is suggestive of an alternate diagnosis.

Salbutamol: With the exception of improving clinical scores in infants treated as outpatients, the evidence overwhelmingly shows that bronchodilators, including salbutamol, do not improve oxygen saturation, reduce hospital admissions or shorten the duration of hospitalisation and time to resolution of illness in children with bronchiolitis. Compared with these minimal benefits, salbutamol is associated with adverse impacts such as tachycardia, oxygen desaturation and tremors. If a bronchodilator is required, epinephrine appears to be a superior alternative to salbutamol in reducing the severity of bronchiolitis.

Steroids: The majority of randomised controlled trials have not found a clinically relevant, sustained impact of systemic or inhaled glucocorticoids on admissions or length of hospitalisation in children with bronchiolitis or other forms of lower respiratory tract infection.

Supporting evidence
  • Beigelman A, King TS, Mauger D, et al. Do oral corticosteroids reduce the severity of acute lower respiratory tract illnesses in preschool children with recurrent wheezing? Journal of Allergy and Clinical Immunology 2013; 131(6):1518-25.
  • Bordley WC, Viswanathan M, King VJ, et al. Diagnosis and testing in bronchiolitis: a systematic review. Archives of Pediatric Adolescent Medicine. 2004; 158(2):119-26.
  • Cao AY, Choy JP, Mohanakrishnan L, et al. Chest radiographs for acute lower respiratory tract infections. Cochrane Database of Systematic Reviews 2013; 12: CD009119.
  • Fernandes RM, Bialy LM, Vandermeer B, et al. Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Database of Systematic Reviews 2013; 6:CD004878.
  • Gadomski AM, Scribani MB. Bronchodilators for bronchiolitis. Cochrane Database of Systematic Reviews 2014; 6:CD001266.
  • Hartling L, Fernandes RM, Bialy L, et al. Steroids and bronchodilators for acute bronchiolitis in the first two years of life: systematic review and meta-analysis. British Medical Journal 2011; 342:d171.
  • Modaressi MR, Asadian A, Faghihinia J, et al. Comparison of epinephrine to salbutamol in acute bronchiolitis. Iranian Journal of Pediatrics 2012; 22(2):241-4.
  • Schuh S, Lalani A, Allen U, et al. Evaluation of the utility of radiography in acute bronchiolitis. Journal of Pediatrics 2007; 150(4):429-33.
  • Yong JH, Schuh S, Rashidi R et al. A cost effectiveness analysis of omitting radiography in diagnosis of acute bronchiolitis. Pediatric Pulmonology 2009; 44(2):122-7.
How this list was made How this list was made

The Paediatrics & Child Health Division (PCHD) formed a group of interested Fellows to comprise a General Paediatrics EVOLVE Working Group. A review of low-value practices relevant to general paediatrics was conducted drawing on lists published by Choosing Wisely US and Canada, contributions to Choosing Wisely Australia by other medical colleges and published EVOLVE lists developed by other specialties in order to identify low-value practices of relevance while avoiding duplicating the mention of practices already identified in other EVOLVE lists. Based on this review, the Working Group shortlisted 15 items for further consideration. 

These 15 items were then reviewed and discussed by participants at a workshop held at the RACP Annual Congress 2016. Following these deliberations, the list was further narrowed down to 10 items. These 10 items were incorporated into an online survey which also summarised the recent evidence on each of these items. A link to the survey was distributed to all Fellows and advanced trainees of the RACP Paediatrics & Child Health Division. 

Survey respondents were asked whether they agreed, disagreed or were unsure about whether each item was undertaken in a significant number of paediatric patients, whether there was good evidence that the item should be undertaken less often and whether reducing use of the item was important in terms of reducing harm and/or costs to the healthcare system. Each item was assigned a score based on respondents’ answers to these three questions on each item. There were 269 respondents representing a survey response rate of approximately 22 per cent. The five highest scoring items were selected to be on this ‘top-five’ list.