Bronchiolitis is common with almost every child under the age of two having one episode of bronchiolitis. It is typically a mild, self-limiting illness that can safely be managed at home. As we’ve seen, there is an oncoming surge of children with bronchiolitis presenting to hospitals and we need to be on top of our game.
Most children with bronchiolitis are relatively well. They are well enough to stay at home or be discharged from the ED. But, there is also a powerful message that comes with sending home a child with bronchiolitis. “You’re not sick enough to come to hospital (yet)”.
Neighbour (2018) discussed the core components of safety-netting as:-
- If I am right, what do I expect to happen?
- How will I know if I am wrong?
- What would I do then?
So, let’s talk about safety netting for children with bronchiolitis. We need to ensure that the right layers are in place to enable us, as responsible clinicians, to hold that balance between admitting everyone and sending home a child who is too unwell. We will establish the foundation for a safe discharge plan and the conditions for which a child should come back to the hospital for further assessment.
Diagnosis
This safety net guide is for mild bronchiolitis. This primer relies on a reasonable level of diagnostic certainty – not absolute certainty – but enough clarity to be confident in assigning the diagnosis. The suggestion of an alternative diagnosis should put the brakes on discharge, allowing time for the relevant differential diagnoses to be considered and investigated. You need to consolidate your history and examination findings, and actively consider the possibility of pneumonia and sepsis (and importantly the once-a-season masquerading congenital heart disease)
Make the diagnosis of bronchiolitis in a child aged between three months to (for post COVID) two years with a coryzal prodrome followed by a persistent cough, increased work of breathing and wheeze or migratory crackles on auscultation. A fever (usually <39°C) and poor feeding are common.
Having challenged, and satisfied, a diagnosis of bronchiolitis, you’ll be able to grade the severity and trajectory of the illness. Why might the child in front of you need admission?
Severity
The severity of the episode depends on the twin pillars of feeding and breathing. In short, if the child is feeding at more than 50% of their usual intake, and they’re maintaining their oxygen saturations at, or above, 90%, they’re likely appropriate for outpatient management. This is mild bronchiolitis.
Conversely, any patient with bronchiolitis requiring feeding or respiratory support, OR at risk of rapid deterioration OR having episodes of apnoea needs admission. Additional factors that contribute to the likelihood of the need for admission are age less than three months, babies born prematurely (especially <32/40), patients with chronic lung disease, haemodynamically significant congenital heart disease, immunodeficiency or neuromuscular disorders.
Feeding
If the child is taking in “more than 50%” of their usual intake, they are probably safe for discharge. This is an art as well as a science as ascertaining 50% isn’t always easy so the feeding history requires some nuanced assessment. This is a key factor in deciding whether to admit or discharge the patient. One way to approach this is by quantifying the child’s maintenance fluid requirements and diving into the detail of intake, both the tempo and trajectory of the pattern. For example, if the child has been unwell for three days, their respiratory distress has settled and they are “getting hungry” today, you’ll be more reassured than a child who has been feeding well at home but has not fed since they arrived in the department.
Ask about the mode of feeding (breast or bottle) as well as the duration and frequency of feeds. For breastfeeding parents ask if the breast feels empty post feed, and if is there a frequent loss of latch or fussing. It’s okay if there’s limited interest in solids, so long as the child is taking more than half of their usual intake. Nobody likes to eat when they feel unwell.
Respiratory Failure
As part of the child’s review in your Emergency Department, they must have had their oxygen saturations measured; check your local thresholds as they do vary. A SpO2 of 90% or more is safe. Provided that the child does not have worsening saturations or worsening work of breathing, they should be safe for discharge.
The presence of tachypnoea poses an interesting challenge. It is an objective measure, but likely overvalued as a measure of severity. That is, a child who is pathologically tachypnoeic due to type 1 respiratory failure will have either measurable desaturations to less than 92% or will have their feeding deteriorate as a consequence.
Outpatient care
If you’ve decided that this child is well enough for discharge; it’s critical that their carer is equally safe to look after them. Caring for a sick child can be challenging., It can be even more so if it’s a busy household with lots of children, or there is limited health literacy or adverse social circumstances. Sending the child a long way from care or with limited transport may be risky. Establishing the social history early in the consultation beyond the address stated on the chart is invaluable. A concern about carer skill or confidence is always worth discussing with a senior colleague.
Red Flags
You’ve predicted this child’s trajectory to be improving. What should the carer look out for? It’s important to note here that a red flag to health care workers has a different meaning to parents and carers. We are providing a safety net not trying to scare people; be sensitive and considered with your language.
- Working harder – Identify the signs of increased work of breathing. Show parents what chest recessions, nasal flaring and grunting look and sound like.
- Dropping fluid intake – While the child may have been feeding well enough at the point of discharge, things may deteriorate. Set clear parameters about the frequency, and volume, of feeds you expect;. A concrete number makes it easier for a parent to return in a timely manner.
- No wet nappies – Go beyond the arbitrary count of “3 nappies in 24 hours”. Most parents are in the habit of changing their child after every feed, or multiple times each day. The nappy might feel “too light”, and should be a something for the carer to look out for.
- Fatigue / exhaustion – If the child is too tired to interact, or wakes only after a significant stimulation, they should re-present. This is a major red flag. The parents should be encouraged to call emergency services. Similarly, cyanosis or apnoea also requires emergency activation.
Other information
Provide information
It’s simply good practice to include written information for families leaving the ED, in the appropriate language and that actually makes sense.
Smoking cessation
Smoke in the home is associated with more severe symptoms. This is the moment for a brief intervention with smoking parents. You can talk about abstinence, smoking outside or anything that reduces the child’s exposure to smoke.
Next Look
If all is going well, when will this child next be reviewed?
The Bottom line
Most children get mild bronchiolitis and can be managed at home, provided the child has reasonable oxygen saturations, is feeding adequately and has a responsible carer. Providing a robust safety net requires you to be both kind and available. Ensure parents or carers are empowered to return for review in the event of any concerns.
I always aim to close my consultation with the affirmation that “If you need us, we are always here”.
