Aims Recent conclusive evidence has suggested that, contrary to previous limited evidence, there is no benefit to the use of 3% hypertonic saline (3% HS) in the treatment of bronchiolitis in infants.^1,2 This led to a change in the clinical guideline during the 2015/2016 bronchiolitis season. We hypothesised that the use of hypertonic saline was preventing the use of other un-necessary treatments and that inappropriate prescribing would increase following the advice not to give hypertonic saline.

The primary aim of the study was to determine if the removal of 3% hypertonic saline from the institutional clinical guideline would result in reduced prescribing patterns. A secondary aim was to evaluate the overall prescribing compliance with the guideline including in the prescribing of antibiotics and bronchodilators, and identify if the change in the clinical guideline impacted the prescribing of other agents in children admitted with a diagnosis of bronchiolitis.

Methods Data on medical treatments and hospital outcomes were prospectively collected on all infants in the 2015/2016 season both before and after the change in guideline. Details of all medicines prescribed on the patients Medication Record particularly bronchodilators, antimicrobials and inhaled agents were collected. Patient demographics were collected from medical notes. Results were analysed using chi square and Mann Whitney in Excel and Stata.

Results 128 children (86 before, 42 after the change in guideline) were recruited to the study. Baseline demographics were similar except for a higher proportion of children with RSV in the pre-group. Overall guideline compliance was achieved by 2 infants pre, and 3 infants post guideline change (4%). The use of hypertonic saline decreased significantly after the change in guideline but did not cease (90% pre, 71% post p<0.01). Bronchodilators were used in one in 4 infants and antibiotics in one in 3 infants, and there was no significant difference in these rates before or after the change in guidelines.

Conclusion The change to the guideline reduced the use of 3%HS, however overall guideline compliance in children with bronchiolitis is poor. Hypertonic saline use decreased when the guideline changed but a significant portion of children before and after the guideline change received medications not indicated in the treatment of bronchiolitis, including bronchodilators and antibiotics. It appears that it remains difficult to ‘do nothing’ for bronchiolitis. Poor clinical practice remains and education of clinical staff is necessary in this regard.

References

1. Guidance: Bronchiolitis in children: diagnosis and management, NICE (NG9) Published date: June 2015.

2. Silver AH, Esteban-Cruciani N, Azzarone G, et al. 3% hypertonic saline versus normal saline in inpatient bronchiolitis: A randomised controlled trial. Paediatrics2015;136:1036–1043.