In response to the concerns raised by Walsh and Rothenberg that the guideline ignores the potential clinical benefit of bronchodilators in bronchiolitis, the committee respectfully disagrees and reiterates our logic. To recommend the use of a medication in any disease, the preponderance of benefit should outweigh the likelihood of harm across the entire population for whom the medication is prescribed. Although we clearly acknowledged in the guideline that a small proportion of children may appear to get a clinical benefit from bronchodilators (and there is significant disagreement as to whether the magnitude of said benefit is clinically meaningful), the majority of children with bronchiolitis do not stand to benefit. The pathology of early viral wheezing is hypothesized to result from the concomitant effects of virus-induced edema and debris in airways that are already small in diameter. A minority of patients with early viral wheezing will also exhibit airway obstruction due...

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