On the Methodological and Justice Considerations in the Australasian Bronchiolitis Guidelines 2025

Abstract

Clinical variation in the management of bronchiolitis is a significant and well-documented feature of paediatric respiratory care worldwide [1]. The first attempt to promote evidence-based approaches for care of infants with bronchiolitis in Australia and Aotearoa New Zealand (AoNZ) was in the form of a landmark piece by Fitzgerald and Kilham [2]. It was expert-driven, reflecting contemporaneous norms. More than a decade later, in 2016, came the first guideline to harmonise treatment for bronchiolitis in emergency departments of Australia and AoNZ, under the auspices of the Paediatric Research in Emergency Departments International Collaborative (PREDICT). A multi-component targeted intervention [3] to improve guideline uptake in primary care found a 14.1% improvement in compliance with guideline recommendations. However, this also means significant variability in practice remains. The 2025 update of the Australasian Bronchiolitis Guidelines is timely and welcome, given its significantly expanded scope [4]. It covers 41 recommendations (11 new and 7 key updates) on 25 topics on management of bronchiolitis in patients presenting to hospital or hospitalised with bronchiolitis (including with SARS-CoV-2 coinfection) and for RSV prevention, thus enhancing its utility.

While reducing unwarranted variation in clinical practice is the central goal of any guideline, it is equally important to recognise that not all variation is inappropriate. Some degree of variation is necessary to ensure that care remains responsive to local needs and preferences. The raison d'être for a clinical practice guideline is not to eliminate all variation, but to distinguish between what variation is warranted (based on context, equity, and patient need) and what variation is not. Striking this balance within a clinical practice guideline is inherently challenging—medicine after all is both a science and an art. Methodologists seek to achieve this balance through a range of strategies: a structured, transparent process, rigorous evaluation of scientific evidence, and engagement of diverse interest-holders ¹ . A meta-research study [5] found that half of the diagnostic guidelines for children in primary care failed to involve parent representatives, lacked adequate conflict of interest management, and real-world applicability.

The 2025 Bronchiolitis guideline has made significant progress both on its scope and rigour, demonstrating the commitment to improving care within the PREDICT network [4, 6]. The guideline rates high on evidence evaluation, governance and transparency. The policy for determining, reporting, and managing conflicts of interest was robust and implemented well. The guideline has robust measures of collecting conflict of interests (over various time points), assessing for both presence and severity of conflicts, and instituted measures to mitigate it (abstain or exclude, as relevant). Standard methods for identifying, appraising, and synthesising evidence and formulating guideline recommendations were also used. The guideline's approach to interest-holder engagement also stands out. Engaging with families through a formal qualitative study, which used purposive sampling to ensure Indigenous and non-Indigenous representation, reveals the desire of the guideline developers to better understand diverse values and preferences for bronchiolitis care. This demonstrates a meaningful commitment to understand and address equity issues in clinical care and improve the relevance and applicability of guideline recommendations. Consultation with colleges, societies, hospitals and local governance groups was also explicitly sought. Overall, it offers a robust model for inclusive guideline development. But the qualitative study and the consultations fall short of addressing structural issues which influence the lives of those with bronchiolitis and their families, and the dilemmas of health care workers. How can access to care be improved? Are medications the right treatment approach for a family living in a house infested with ‘moulds’? Should guidelines on bronchiolitis be blind to social, commercial, and political determinants of health?

As medical doctors, sworn by an Oath [7], justice is at the heart and soul of our vocation. This obligation to fairness, however, extends to all health professionals, guiding how we care, prioritise, and shape the systems and guidelines that support equitable health for all. Hower, we may not always recognise or pursue it explicitly. The inclusion of justice as a guiding principle in clinical guideline development is both timely and necessary. The pursuit of justice in clinical practice guidelines challenges us to go beyond the question of “what works”. We also need to ask: what is fair, what is just, and what is responsive to the needs of diverse people and contexts in which these guidelines will be implemented. Through these additional “what” questions, we essentially reframe the conversation to ask what works, how, and for whom. The pursuit for justice in clinical practice guidelines will also prompt us to ask, “why are we not developing recommendations for some aspects (e.g., prevention, in relation to housing, inequalities) of care?”.

Justice is a concept is universally recognised across cultures and societies, though interpreted and expressed in diverse ways. At its core, justice can be understood through two broad lenses: epistemic justice and social justice. Epistemic justice relates to whose knowledge, experiences, and voices are recognised and valued in the guideline development process [8]. Social justice, on the other hand, relates to the fair distribution of resources, opportunities, and care, particularly for those who are disadvantaged by current or historical structures within society and health systems.

The pursuit of epistemic justice requires going beyond seeking the integration of experiences to inform applicability and consultation with diverse interest-holders. Guideline development groups should aspire to shift away from traditional norms by collaborating (or better still co-creating) with diverse consumers, healthcare workers, administrators, and systems managers to involve them as equal partners in the guideline development process. As equal partners, interest-holders will be part of the Guideline Development group, making decisions on every aspect of the process. This also implies involving interestholders from the very outset, beginning with the formulation of the key questions the guideline seeks to answer. In Australia and AoNZ, this entails the inclusion of a diverse set of interest-holders: Māori people, Aboriginal and Torres Strait Islander People, migrants, those from socio-economically disadvantaged backgrounds, and people living in rural, remote, and under-resourced settings. Their inclusion will bring nuance to guideline recommendations by enabling culturally safe and equitable care. While the 2025 guideline has made significant progress in inclusive engagement, comprehensive involvement of diverse interest-holders across all phases requires substantial resource investments. Provision for these resources should be considered a priority in future updates to sustain and deepen equity efforts. It is also essential to recognise that in Indigenous cultures, health is understood in a more holistic and multidimensional way, offering a perspective that can enrich the dominant biomedical paradigm. This broader view of health enhances both the relevance and legitimacy of guidelines, opening a pathway toward social justice in healthcare. In both Australia and AoNZ, factors such as housing, overcrowding, exposure to air pollution, and climate-related issues disproportionately affect Indigenous and low-income communities. In socio-economically disadvantaged populations in Australia, and Māori and Pasifika populations in New Zealand, hospitalisation for bronchiolitis is higher in those who live in cold, damp, and overcrowded housing conditions [9, 10]. Similarly, exposure to bushfire smoke in Australia is known to exacerbate acute respiratory conditions [11]. Clinical guidelines should prioritise consideration of these social justice issues, particularly in terms of prevention.

However, we recognise that such comprehensive engagement of diverse interest-holders requires significant investment of time, funding, and human resources. A phased or tiered approach to involvement may be more practicable in certain settings, without compromising the commitment to equity and justice.

To ensure justice principles are not only aspirational but actionable, future iterations of clinical guidelines could benefit from incorporating explicit frameworks to assess the equity implications of their recommendations. For instance, tools such as equity impact assessments or structured inclusion checklists for diverse communities can help operationalise justice throughout the guideline lifecycle—from deciding scope and question formulation to dissemination and implementation.

The 2025 Australasian Bronchiolitis Guideline sets a high bar for methodological rigour. As the clinical landscape evolves, future updates are anticipated. An explicit commitment to justice in guideline development elevates their purpose from delivering clinical excellence to contributing to a fairer healthcare system. A methodologically rigorous clinical practice guideline is a pro-justice one. The path is largely novel and uncharted, but it is a worthy path, and one we should take.

S.B. declares he has an ideological conflicts of interest as an advocate of equity and justice in the medicine and health knowledge ecosystem. A/Prof Bhurawala is a member of the Editorial Board of the Journal of Paediatrics and Child Health. The author declares no conflicts of interest. The views expressed in this commentary are solely those of the author and do not represent the views of the journal, its Editorial Board, or their employing institutions.