Admit if: apnoea (observed or reported), persistent SpO2 under 90% (under 92% if under 6 weeks or comorbidity), poor feeding (under half of normal), severe respiratory distress, or clinician or parent concern.
Typical features
- Peak age 3 to 6 months, winter and RSV season
- Coryzal prodrome then cough, wheeze and fine crackles
- Feeding difficulty from work of breathing
- Diagnosis is clinical
What not to do (NICE)
- No salbutamol, ipratropium, adrenaline (nebulised) or montelukast
- No corticosteroids
- No antibiotics unless a bacterial infection is suspected
- No routine chest X-ray or blood tests
Mild
- Feeding over 75% of normal
- SpO2 92% or more in air
- Home with safety-net advice
Moderate
- Feeding 50 to 75%, some recession
- Raised respiratory rate
- Consider admission
Severe
- Grunting, marked recession, apnoea
- SpO2 under 92%, feeding under 50%
- Admit, oxygen, support feeding
Ward care
1
1. Support
Minimal handling, nasal suction if secretions block feeding, small frequent or NG feeds.
Minimal handling, nasal suction if secretions block feeding, small frequent or NG feeds.
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2
2. Oxygen
Supplemental oxygen if SpO2 is persistently under 90% (under 92% if under 6 weeks or comorbidity). Consider high-flow if not maintaining saturations.
Supplemental oxygen if SpO2 is persistently under 90% (under 92% if under 6 weeks or comorbidity). Consider high-flow if not maintaining saturations.
↓
3
3. Hydration
NG or orogastric fluids first-line if not feeding; IV fluids if not tolerated or impending respiratory failure.
NG or orogastric fluids first-line if not feeding; IV fluids if not tolerated or impending respiratory failure.
↓
4
4. Discharge and safety-net
Feeding adequately, stable in air, parents confident. Safety-net on worsening breathing, feeding under half, fewer wet nappies, apnoea or colour change.
Feeding adequately, stable in air, parents confident. Safety-net on worsening breathing, feeding under half, fewer wet nappies, apnoea or colour change.
Higher-risk infants
- Under 3 months, or prematurity
- Chronic lung disease, congenital heart disease
- Neuromuscular or immunodeficiency
Pitfalls
- Giving bronchodilators or steroids (not effective)
- Over-investigating a clinical diagnosis
- Missing apnoea in a young infant
- Discharging before feeding is adequate
MedPrep - www.medprep.uk - Educational revision aid only. Not clinical guidance. Doses are adult examples; check the BNF, current guidelines and local policy, and seek senior advice. Nov 2026