A recent study titled “Racial/Ethnic differences in the presentation and management of severe bronchiolitis” investigates the multiple factors related to the presentation and management of bronchiolitis in the United States and hypothesizes that there are disparities among ethnic groups.

The study also expands on the concerns that the 2006 Academy of Pediatrics Bronchiolitis guidelines are not being followed (Pediatrics 2006;118:1774-93). The study brings up important topics for practitioners, epidemiologists, and insurance companies. Jonathan Santiago, MPH, and his colleagues at Yale University, New Haven, Conn., conclude that non-Hispanic black children were more likely to receive albuterol before admission and less likely to receive chest radiographs during hospitalization while Hispanic children are most likely to be discharged on inhaled corticosteroids.

However, it is important to review the study to understand the potential implications:

The study by Mr. Santiago, a medical student at Yale, and his colleagues has significant flaws with the inclusion and exclusion criteria. These flaws could have significantly affected the authors’ conclusions. Still, the research highlights important issues: “Why are clinicians not following the guidelines for all our U.S. infants and toddlers?” And, “Why do clinicians not use evidence-based medicine?” If clinicians are treating young children from ethnic groups differently, why is that happening?

The AAP guidelines were developed with the support of the American Academy of Family Physicians, the American College of Chest Physicians (CHEST), the American Thoracic Society, and the European Respiratory Society. The guidelines outline that clinicians should diagnose bronchiolitis and assess severity based on a standard history and physical. Chest radiographs should not be routinely ordered. The guidelines also recommend that a carefully monitored trial of alpha-adrenergic or beta-adrenergic medication is an option. However, inhaled bronchodilators should be continued only if there is a documented positive response. Among many other recommendations, corticosteroids are definitively not recommended for routine bronchiolitis treatment.

The Journal of Pediatrics recently published an article by Dr. Todd A. Florin of the Cincinnati Children’s Hospital and his colleagues on variation in the management of hospitalized infants with bronchiolitis(2014;pii: S0022-3476[14]00507-1 [doi:10.1016/j.jpeds.2014.05.057]). More than 60,000 hospitalizations were analyzed for infants aged 12 months and younger. After adjustment for patient characteristics, obtaining a chest radiograph was the one factor that had a great variation between hospitals. There was an 8.6% decrease in obtaining chest x-rays during the study period of 2007-2012. There also was wide variation among hospitals in regard to bronchodilator use, and there was no decrease in its use observed over the study period, despite the guidelines. Finally, a decrease of only 3.3% in corticosteroid use occurred during 2007-2012 – after the guidelines came out!

There is a theme: Family physicians, pediatricians, and other health care providers are not assessing and managing bronchiolitis using evidence-based medicine.

Mr. Santiago’s multicenter trial looked at 2,130 subjects and 24% were non-Hispanic blacks and 38% were Hispanic. Their median age was 4 months, while the mean age of the children in Dr. Florin’s study was 3.7 months. Many points of these studies can be teased out. For example, in Mr. Santiago’s study, non-Hispanic black children were more likely to receive albuterol before admission with an odds ratio of 1.58, and in the larger study by Dr. Florin, use of albuterol, in general, increased the patients’ length of stay. If Mr. Santiago’s study were expanded with stricter entry criteria and more hospitals, would a similar increased length of stay be found among non-Hispanic black children?

The guidelines are now 8 years old, and new guidelines are coming. But this important information, thoroughly analyzed by respected thought leaders, should be well disseminated among our peers. Our common goal should be to make sure that children at risk are not subjected to unnecessary x-rays, breathing treatments, and medications for bronchiolitis. The Hippocratic Oath, loosely translated, states: “I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.”