When we see infants with bronchiolitis, identifying the sick ones is pretty easy. But what we actually want to do is identify which patients are going to deteriorate, which patients we need to admit, and which patients we need to observe for a bit longer in the Emergency Department.
Here are my top five tips on how to manage bronchiolitis.
Tip 1. Assess the feeding.
The ability to feed is a key important factor in predicting how well your patient will do, and whether or not you need to keep them in hospital.
Often, infants with bronchiolitis feed more frequently, but with smaller volumes per feed. Sometimes the feed may take longer than normal because they feed more slowly. Or they might have shorter, more frequent feeds. All of these are acceptable, as long as they are taking at least half of their normal feeds.
If the baby is bottle feeding, then you can literally make a calculation on the volume of feeds they’ve had in the last 24 hours. The infant should be taking somewhere between 100 and 150 ml/kg/day. You can divide that into the number of feeds they have in a 24 hour period, and get an idea of what they SHOULD be having for each feed.
If the infant is breastfeeding, we can’t make an exact assessment. However, there are many other things we can assess.
We can evaluate how effectively the infant is breastfeeding. The parent will be able to tell you whether the infant is feeding for the same length of time as they normally do.
Are feeds taking longer? Are they more frequent? Do their breasts feel full at the end of a feed?
Another good way to measure this is by asking how many wet nappies they are having. Parents know how often babies normally have wet nappies, and also they often pick up a nappy and feel its weight.
Do the nappies feel lighter than normal? Are they changing them less often?
If the parents are happy that the infant is still having a decent number of wet nappies, then that’s a reassuring sign that they’re getting enough in the way of feeds.
So, you can work out if they’re taking at least 50%, but you can also make a reasonable estimate based on parental reporting of a combination of their feeding and the number and volume of wet nappies.
Tip 2. Identify the high risk babies.
There are some babies and infants who are at higher risk of having severe bronchiolitis that needs admission and intervention.
With these infants, we should have a lower threshold for admission. This might mean that even if they look reasonably well, and you might send a similar baby with no risk factors home, you should be more cautious in this group.
Risk factors include:
- Prematurity (<32/40)
- Babies <3 months
- Chronic lung disease
- Neuromuscular disorders
- Congenital heart disease
With this group of infants, you should be more cautious. It doesn’t mean you HAVE to admit them, but it does mean you should have a lower threshold for admission compared to an infant without these risk factors.
Tip 3. The drugs don’t work (except oxygen).
No matter how tempted you are to try different treatments with bronchiolitis, please don’t. There’s been plenty of studies and evidence that make it clear that none of them works. Don’t give ‘a trial of salbutamol’. No amount of nebulisers drops, antibiotics, steroids, or adrenaline is worth trying. They don’t make any difference.
What saline drops can do is help clear the baby’s nose so that during the next feed they might be able to breathe a bit more easily through their nose, and therefore may find feeding a bit easier. But this doesn’t affect the overall pattern of their bronchiolitis. It is not going to have any impact on their progress. It is simply temporary relief.
Having said that, there are two things that can be useful: oxygen and high flow.
Use oxygen to supplement where the sats are low. The exact cut-off for sats will depend on your local guide, but it’s likely to be somewhere between 90% and 92%. The recent NICE guidelines said that in under six-week-old babies, we should maintain sats >92%, but in over six week old babies we could tolerate >89%. Certainly, if you have sats in the 80s, you should use supplemental oxygen. In the low 90s, it’ll depend on the age of the child and your local guidance.
High flow is the other treatment that is potentially useful. Check out our DFTB resource on high flow here. If you have an infant who is working hard and who might need some extra support, high flow can be a really useful intervention. Whether you start it in ED may depend on availability.
The other intervention that might be needed is help with feeding. When infants are breathing quickly, they don’t always have the ability to feed and breathe at the same time, and the feeding can drop off. You may need to supplement their feeds with NG feeds or IV fluids.
Tip 4. Know your discharge criteria.
When discharging an infant with bronchiolitis, you want to be reassured that you’re doing it safely.
Firstly, make sure that they’re not having apnoeas. These are a red flag and will need admission. Then you want to ensure that the baby is feeding well – observing a feed in the department can help evaluate this. And finally, they need to have adequate oxygen saturation over a period of time. The NICE guidelines suggest this should include a period of sleep. I’m not sure how practical that is in an Emergency Department, but if you can then it’s worth checking. If the sats are maintained even during sleep, that’s very reassuring.
So if the child looks well, feeds well, and has normal sats over a period of time in ED, you can be reassured. Remember, we only see a snapshot during our brief consultation, and it’s often helpful to observe them in ED for a few hours. This gives us a better idea of how feeding is going, and how the baby is behaving, and it can inform our decision about discharge or admission. Work of breathing is a great indicator too as these are the patients who will likely have feeding problems.
Tip 5. Safety net well.
Make sure that you are comfortable with discharging the patient, but also that the family feel confident to look after their baby at home. They should know how to recognise the signs and they should be clear on when to return.
Bronchiolitis is usually at its worst around day 3 or 4 of the illness. If they are early on in the illness, then advise the family that it may get worse before it gets better, and they may need to represent.
They should be looking out for:
- Worsening work of breathing
- Reduced wet nappies
This is also a good time to provide smoking cessation advice. Ask them who smokes at home – smoking will adversely impact their child’s respiratory problems. We have an important role as ED physicians in encouraging parents to stop smoking, and also to explain the impact of smoking on their child’s health.
Finally, it needs to be practical for them to return. If they live hours away from the nearest hospital, it may actually not be appropriate to discharge them. If you don’t feel confident that the family will be able to seek help appropriately, then you may change your plan based on this.
When they do go home, make sure that you give them some written discharge advice so they can refer back to it when they need to.
Haskell L, Tavender EJ, Wilson CL, et al. Effectiveness of Targeted Interventions on Treatment of Infants With Bronchiolitis: A Randomized Clinical Trial. JAMA Pediatr. Published online April 12, 2021. doi:10.1001/jamapediatrics.2021.0295