NICE vs RCPCH: Management of Bronchiolitis (2025) - A Clinical Comparison
Bronchiolitis remains the most common lower respiratory tract infection in infants and a leading cause of hospitalisation in the UK. For clinicians, two key national guidelines inform practice: the National Institute for Health and Care Excellence (NG239, published May 2021) and the Royal College of Paediatrics and Child Health (RCPCH, published 2022, with a 2025 update confirming core principles). While aligned on fundamental principles of supportive, minimally invasive care, there are nuanced differences in emphasis and practical application that are crucial for day-to-day clinical management. This comparison provides a detailed, factual analysis for UK clinicians.
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Diagnosis and Clinical Assessment
NICE (NG239)
NICE provides a structured, criteria-based approach to diagnosis. It emphasises that bronchiolitis is a clinical diagnosis.
- Diagnostic Criteria: Typically a child under 2, with a coryzal prodrome followed by:
- Persistent cough and
- Either tachypnoea, wheeze, crackles, or recessions.
- Assessment Tools: Recommends using a clinical score, such as the Bronchiolitis Severity Score (BSS), to aid in objective assessment and monitoring of progression.
- Investigations: Explicitly advises against routine chest X-ray (CXR) or blood tests. CXR should only be considered if diagnosis is uncertain or if there is unexpected clinical deterioration.
RCPCH
The RCPCH guideline also reinforces clinical diagnosis but adopts a more descriptive, pragmatic tone focused on the typical disease course.
- Diagnostic Focus: Highlights the classic pattern of upper respiratory tract infection (URTI) symptoms progressing to lower respiratory tract involvement with increased respiratory effort and wheeze/crackles.
- Assessment Tools: Less prescriptive about specific scoring systems. Emphasises the importance of continuous clinical assessment, particularly observing for signs of impending respiratory failure (e.g., grunting, marked recessions, hypoxia).
- Investigations: Aligns with NICE in discouraging routine investigations. Strongly emphasises that CXR findings (e.g., patchy collapse/consolidation) often do not correlate with clinical severity and can lead to unnecessary antibiotic use.
Key Difference: NICE is more formalised, recommending the use of a specific clinical score (BSS), whereas RCPCH focuses on the overall clinical picture and pattern recognition without mandating a specific tool.
Treatment and Management
Both guidelines champion supportive care as the cornerstone of management. The key differences lie in the specifics of hydration and respiratory support.
NICE (NG239)
- Feeding & Hydration: Advises considering nasogastric (NG) or intravenous (IV) fluids if an infant cannot take oral feeds to maintain hydration. The threshold for intervention is clearly linked to inadequate oral intake.
- Oxygen: Recommends oxygen saturation targets of 90% and above for acutely ill infants. Suggests considering 92% and above for those with co-morbidities like congenital heart disease.
- Pharmacotherapy (Firmly Against):
- Bronchodilators: Do not use salbutamol or ipratropium bromide.
- Montelukast: Do not use.
- Corticosteroids: Do not use systemic or inhaled corticosteroids.
- Antibiotics: Do not use unless there is strong evidence of a concurrent bacterial infection.
- Hypertonic Saline: Do not use.
- High-Flow Oxygen: Recommends high-flow humidified oxygen therapy for infants with impending respiratory failure, noting it may reduce the need for continuous positive airway pressure (CPAP) or intubation.
RCPCH
- Feeding & Hydration: Strongly promotes nasogastric (NG) tube feeding as the preferred method for nutritional and fluid support if oral intake is insufficient. Frames IV fluids as an alternative if NG feeding is not tolerated or contraindicated.
- Oxygen: Similarly recommends a target saturation of 90% and above. Its guidance is slightly more flexible, acknowledging that transient dips below 90% in a well-perfused, feeding infant may be acceptable.
- Pharmacotherapy (Firmly Against): The RCPCH list is identical to NICE's in practice, firmly rejecting the use of bronchodilators, corticosteroids, montelukast, and routine antibiotics.
- High-Flow Oxygen: Also endorses the use of high-flow therapy but provides more detailed practical guidance on its implementation, weaning, and safety monitoring within a clinical setting.
Key Difference & Practical Takeaway: The most significant practical difference is the preference for NG feeding over IV fluids in the RCPCH guideline. RCPCH positions NG feeding as the primary supportive method for hydration, while NICE presents NG and IV fluids as more equal options. For many UK units, the RCPCH approach has become standard to avoid the complications of IV cannulation in infants.
Special Situations and High-Risk Groups
Both Guidelines
Both agree that infants with significant co-morbidities (e.g., chronic lung disease, congenital heart disease, neuromuscular disease, immunodeficiency, or prematurity < 32 weeks) require a lower threshold for admission and more cautious management due to a higher risk of severe disease.
Apnoea
- NICE: States that a history of apnoea warrants admission for monitoring.
- RCPCH: Provides more detailed stratification, noting that apnoea is more common in ex-preterm infants and those under 2 months. Emphasises the need for continuous cardiorespiratory monitoring in these cases.
Practical Takeaway: While both mandate admission for apnoea, RCPCH offers more nuanced context, which can help in risk-stratifying infants on the ward.
Practical Clinical Pathway: A Synthesis
For a clinician in an emergency department or assessment unit, a combined pathway incorporating both guidelines would look like this:
- Triage & Assessment: Clinical diagnosis based on history and examination. Use a score like the BSS (per NICE emphasis) for objective baseline measurement.
- Decision to Admit: Admit if: moderate-severe respiratory distress, SpO2 ≤ 90%, apnoea, inadequate oral intake (<50-75% of usual volume), or significant co-morbidity.
- Ward Management:
- Supportive Care: Position comfortably, minimal handling.
- Hydration: Offer small, frequent feeds. If inadequate, commence NG feeds as first-line (RCPCH preference). Use IV fluids if NG is not feasible.
- Oxygen: Target SpO2 ≥ 90%. Use low-flow via nasal prongs. Escalate to high-flow humidified oxygen for increasing work of breathing or persistent hypoxia.
- Monitoring: Continuous SpO2 and regular nursing observations. No routine CXR or blood tests.
- Discharge Criteria: Clinically improving, maintaining SpO2 ≥ 90% in air, taking adequate oral feeds, and parents feel confident to manage at home.
Frequently Asked Questions (FAQs) for Clinicians
1. A 4-month-old has an SpO2 of 91% in the ED but is otherwise well and feeding. Must I admit them?
Answer (Both): Yes, admission is strongly recommended. Both guidelines use 90% as a clear threshold for supplemental oxygen and inpatient management. An SpO2 of 91% indicates significant disease and warrants observation for potential deterioration.
2. The parents are asking for a "puffer" (salbutamol) as it helped their older asthmatic child. How should I respond?
Answer (Both): Explain that bronchiolitis is a viral illness causing inflammation and mucus plugging in the small airways, not bronchospasm like in asthma. Emphasise that multiple studies show bronchodilators provide no benefit and can cause tachycardia and other side effects. Supportive care is the only evidence-based treatment.
3. My patient on the ward is requiring 2L high-flow. When should I involve PICU?
Answer (RCPCH emphasis): Escalation should be based on clinical trajectory, not just flow rate. Key triggers include: increasing oxygen requirement (FiO2 > 40%), persistent or worsening respiratory acidosis on blood gas, apnoeas, or signs of fatigue (e.g., falling respiratory rate with increasing CO2). Early discussion with PICU is always advisable.
4. Is suctioning recommended to clear nasal secretions?
Answer (Both): Gentle nasal saline drops and suctioning may be considered before feeds if secretions are clearly obstructing the nasal airway and impairing feeding. However, deep oropharyngeal suction is not recommended as it is distressing and not proven to be beneficial.
5. An infant with bronchiolitis has a fever of 38.5°C. Should I start antibiotics?
Answer (Both): No. Fever is a common feature of viral bronchiolitis. Antibiotics are only indicated if there is strong evidence of a secondary bacterial infection (e.g., clinical signs of pneumonia, septic shock, or a positive bacterial culture from a normally sterile site). Routine use contributes to antimicrobial resistance.
Source Links
- NICE Guideline NG239 (May 2021): Bronchiolitis in children: diagnosis and management
- RCPCH Guideline (2022, reaffirmed 2025): Bronchiolitis: Guidance for the UK (Includes a useful clinical tool and parent information)