Bronchiolitis is a common viral lung infection in young children. A diagnosis can be made based on history and a physical exam. However, chest x-rays are often unnecessarily ordered as a confirmatory test.

Despite Choosing Wisely recommendations and international guidance on avoiding this practice, evidence suggests that chest x-rays are overused in children with typical bronchiolitis, which can increase the rate of incorrect diagnosis of bacterial pneumonia and lead to unnecessary antibiotic use.

What drives unnecessary imaging?
Caring for infants with bronchiolitis spans many different practice settings from primary care to emergency medicine. These diverse settings often have different degrees of familiarity with clinical practice guidelines in managing children with respiratory illnesses. Many providers can feel discomfort “watching and waiting” with an unwell infant or feel pressured to manage the expectations of families and caregivers. These organizational and individual psychological barriers can often drive unnecessary testing and treatments.

How should practice change?
In this BMJ article, Dr. Friedman and an international group of clinician and patient coauthors suggest targeted quality improvement strategies—which include clinical champions, focused educational delivery, educational materials, and audit and feedback—are effective in reducing unnecessary chest x- rays in bronchiolitis.

Image from SickKids article Choosing Wisely at SickKids means holding off on x-raying infant bronchiolitis cases coming to the ED.