Thursday, 10 December 2015

Is your wheezer happy or are they waving a red flag?

Once you have decided that a child has bronchiolitis, there is only one real decision to be made*: home or hospital?  In some cases this decision will be made clear but for others the clues may be more in need of detective work.

*Decisions re antibiotics, inhalers and steroids are easy: don't give them!

If possible, babies with bronchiolitis should be kept well away from hospital.  Nothing quite makes bronchiolitis worse than catching rotavirus gastroenteritis from the nice family in the waiting room, while you are waiting for your mother to see the paediatrician who will send you home.  But, if you need to go you need to go.  There are three main categories of things that necessitate admission:
  • Inadequate feeding
  • Ineffective breathing or excessive work of breathing
  • A red flag symptom
Although they do not necessarily mandate referral, a risk factor that makes a sudden collapse more likely is the fourth factor in the referral risk assessment.

Inadequate feeding was covered in the last post.  Feel free to do the maths, work out what the baby is getting, look at the baby or all of the above.  For me, how alert and hydrated the child is will always be a better measure of adequacy.

Ineffective breathing or excessive work of breathing is based on many factors.  It is important to assess respiratory rate, intercostal recession and how loud the breath sounds are on auscultation.  I would say that it is even more important to look at the baby and get a gut feel for how they are coping.

The term "happy wheezer" has been around for as long as I can remember.  A happy wheezer is a baby with bronchiolitis who, often despite an impressively audible wheeze, looks ridiculously happy.  It's funny that none of the official guidelines legislate for the happy wheezer who is above the 91st centile for weight (catchy eh?).  I think that they deserve a pathway of their own.  They seem to cope well and manage far better than equivalent skinny babies with bronchiolitis.

There are two other considerations which affect the level of clinical concern.  These are risk factors and red flags.

Risk factors are important to ask about and will often not be volunteered unless the right questions are asked.  Risk factors in children with bronchiolitis include:
  • Ex-prematurity
  • Underlying respiratory problems e.g. chronic lung disease
  • Age under three months old
  • Underlying cardiac problem
  • Underweight
  • Known immunodeficiency
  • Neurological problems
The presence of risk factors presents an interesting conundrum.  Take the baby with mild bronchiolitis who is two months old.  They do not currently need nasogastric feeding nor do they need supplemental oxygen.  So why refer?  The argument for is that they are more difficult to assess and they will decompensate more rapidly.  The argument against is that being at risk and in hospital can actually be a bad thing.

The presence of a risk factor does not change the clinical assessment of the child (they still have mild bronchiolitis after all) but it sometimes changes the decision to refer or get advice from an experienced paediatrician.  If in doubt, discuss.

The well baby with mild bronchiolitis and a risk factor is better not sent to the emergency department for all the reasons above.  If they need to come in they should be referred directly to paediatrics.

Finally, there are red flags.  These are great because they make the decision easy.  If a child with bronchiolitis has a red flag, they must be referred for observation as a minimum.  Most will need intervention.  Red flags include:
  • Increasing pauses in breathing
  • Grunting
  • Refusing feeds
  • Head bobbing
  • Not waking for feeds
  • Floppy
  • Pale or cyanotic episodes
  • Episodes which alarm parents
Some red flags tell you what you already know - bad things are happening for this baby.  Some red flags tell you that bad things are happening even when it is not obvious from looking at the baby.

So the decision to bounce a bronchiolitic in the direction of a paediatrician is usually straightforward.  If they're need help feeding or support with breathing then the paediatricians need to have them.  Also refer if there are red flag signs or symptoms.  If they are mild but have a risk factor, then either refer or discuss them with an experienced paediatrician.

If the episode is mild and there are no risk factors or red flags, keep them well away from hospital.  They are not good places to be.

Edward Snelson

Disclaimer:  If the baby is waving an actual red flag, they are probably fine.

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