The Decision Maker's Guide to Bronchiolitis Assessment

 This bronchiolitis season is going to be different.  While SARS-CoV2 virus does not seem to be a significant cause of wheeze in children (1), all the other usual viruses are still out there and will be causing wheeze soon in a child near you.  What might have changed is how we make decisions about that child.

For the purposes of exploring our decision making, it is important to define bronchiolitis as a condition that is a virally induced inflammation of the small airways of the lungs in a child, typically under the age of 1.  It is clinically distinctive from viral induced wheeze which is virally induced bronchospasm of the large airways, typically in a child over the age of 1.  For a separate article on differentiating these two conditions, click this link.

The necessary decisions regarding bronchiolitis haven't changed.  What might change during a global pandemic is the outcome of those decisions.  Hospitals have always been dangerous places, with a significant risk of hospital acquired infection.  That risk has escalated due to the prevalence of the highly infective SARS-CoV2 virus.  Though very unlikely to cause COVID-19 infection in children, there is that risk, the risk of PIMS-TS and the risk of COVID-19 to the accompanying adults.

The aim in bronchiolitis decision making has always been to keep as many children out of hospital as is safe to do so.  In order to do that expertly, we just need to make three decisions.

1. Does this child have bronchiolitis?
2. Should this child be managed at home or in hospital?
3. What treatment should the child be given?

Question 1: Does this child have bronchiolitis?

Most children under the age of 1 year presenting with a tight cough, wheeze, respiratory signs and poor feeding have bronchiolitis.  There are other possible explanations for that presentation however and it is important to know about these other possibilities.

Viral induced wheeze, which involves bronchospasm is separate from bronchiolitis.  Clues that it may be viral induced wheeze include the age of the child (most commonly over 1 year) and previous episodes of viral induced wheeze.  The other clue is the onset of the respiratory changes.  Bronchiolitis is a slow accumulation of wetness in the airways and the history is typically of a gradual and progressive worsening of symptoms over days.  Viral induced wheeze, due to the bronchospasm involved, presents with a more sudden onset of wheeze and distress, often going from normal to significantly abnormal over a few hours.

Pneumonia is almost never associated with wheeze in children (2).  Focal crepitations are often heard in a viral lung infection of any kind.  The presence of wheeze strongly suggests that the signs and symptoms are virally induced in some way.  Infants with pneumonia will tend to be significantly unwell.  The simple rule of thumb is this:  If the infant has a wheeze and is well enough to be managed in a pre-hospital setting, they do not have bacterial pneumonia.

Congestive cardiac failure (CCF) due to haemodynamically significant yet undetected congenital cardiac abnormalities is a rare mimic of bronchiolitis but one that is important to be aware of.  The typical cause is a large ventricular septal defect (VSD) causing a significant left to right shunt.  This increased pressure through the lung circulation causes pulmonary odema which manifests as poor feeding, fine crepitations and wheeze.  Thankfully, most significant heart defects are detected before a baby is discharged from postnatal care, but occasionally one slips through and the signs and symptoms are easily mistaken for bronchiolitis.

There are usually clues however.  A murmur is the most obvious clue but this can be difficult to hear at >160bpm.  An excessive tachycardia is a possible sign of CCF.  A significant hepatomegaly (normal babies often have up to a centimetre of palpable liver) is highly suspicious of CCF.  Finally, the progression of symptoms does not fit for bronchiolitis as they continue to get worse after the 3-4 days in which bronchiolitis reaches its peak.

Putting these things together, it is usually possible to be confident in diagnosing bronchiolitis as long as the history and findings are consistent with bronchiolitis and not one of the other pretenders.

If the diagnosis is bronchiolitis, we can move onto our next question:

Question 2: Should this child be managed at home or in hospital?

Most children with bronchiolitis can be managed in the community.  Keeping people away from hospital where it safe to do so has never been more important.  In the UK, the NICE guidelines for bronchiolitis (3) give recommendations for when to refer and when to consider referral.

Referral is always recommended for red flags.  In the NICE guidelines, these are a combination of signs of potential respiratory failure.  Notably, apnoeas are included as a stand-alone red flag.  That means that a child without any chest signs of severe respiratory distress should still be referred if they have had episodes where they appear to stop breathing.  The reason for this is that in such cases, immature respiratory drive may be a factor.  Following an apnoea, a baby can temporarily seem much improved but may go on to have further events and deteriorate suddenly.

Feeding and hydration is probably the least well defined element of the decision making element.  The guidelines ask the clinician to consider a variety of factors, however being able to assess whether the amount of feeding is adequate is next to impossible apart from overt signs of dehydration.  We never know how much a breast fed baby is getting unless the answer is "nothing."  If the baby is bottle fed, applying a percentage to that as being adequate doesn't take into account the fact that many bottle fed babies take much larger volumes as a baseline.  As a result, the most objective measure of adequate feeding has to be signs of hydration or dehydration.  For that reason, I have included clinical dehydration in the list of red flags and beyond that, feeding difficulties remain a matter of clinical judgement when it comes to referral.

Possibly the most controversial element of the decision making is the presence of risk factors.  In the guidance, it is stated "When deciding whether to refer a child with bronchiolitis to secondary care, take account of any known risk factors for more severe bronchiolitis such as... (e.g.) premature birth, particularly under 32 weeks."  The guideline evidence statement lists the basis for each risk factor listed and with the exception of neuromuscular disease, the committee acknowledged that there is no credible published evidence for the other risk factors.  Apart from neuromuscular disease, they are all consensus opinion recommendations.

So what are you supposed to do when you see an 8 month old baby with mild bronchiolitis, no red flags and adequate feeding when you know that they were born at 31 weeks gestation?  Do you send them to secondary care in case because they have a risk factor for severe bronchiolitis or do you keep them well away from hospital because they don't have severe bronchiolitis and you don't want to add a hospital acquired infection to their list of problems?

Balancing risk vs benefit is what it is all about here.  There is a known risk of hospital acquired infection vs an unknown risk of severe bronchiolitis.  There is also no evidence that admitting high risk children with bronchiolitis is any safer than good safety-netting advice.

If the decision is made to manage a child with bronchiolitis at home, the third and final question is:

Question 3: What treatment should the child be given?

There has been a load of research done to try to find an effective treatment for bronchiolitis.  Supportive interventions (oxygen, CPAP etc) in the cases where respiratory support are needed have been shown to be effective.  Each and every other therapy have in turn shown to have no benefit for mild to moderate uncomplicated bronchiolitis.  Therapies proven to be ineffective include β-agonists, ipratopium, hypertonic saline, antibiotics and corticosteroids.  The bottom line is that for a child being managed in the community, no pharmacological treatment should be given.  This recommendation is consistent  across guidelines from the UK, USA and Australia (3,4,5).

That makes this flowchart nice and simple:

Finally, you might be asking yourself if you are an expert decision maker when it comes to a small person who has a cough and wheeze.  Hopefully this post helps you to feel that you are.  Decision making in such children is all about recognition, knowing the red flags and above all, learning that if in doubt, looking at the child will almost always give you your answer.

Edward Snelson
@sailordoctor

References

1. Roland D, Teo KW, Bandi S, et al COVID-19 is not a driver of clinically significant viral wheeze and asthma Archives of Disease in Childhood Published Online First: 16 October 2020. doi: 10.1136/archdischild-2020-320776
2. Hirsch A, Monuteaux M, Neuman M, Bachur R, Estimating Risk of Pneumonia in a Prospective Emergency Department Cohort, Paediatrics, Vol 204, p172-176.E1, Jan 01, 2019 doi:10.1016/j.jpeds.2018.08.077
3. Bronchiolitis in children: diagnosis and management, NICE guideline [NG9] Published date: 01 June 2015
4. American Academy of Pediatrics Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis, Pediatrics November 2014, 134 (5) e1474-e1502; doi: 10.1542/peds.2014-2742
5. The Royal Children's Hospital Melbourne Clinical Practice Guidelines: Bronchiolitis

What am I missing? The child with fever but no obvious cause

The fear that a significant illness wil go unreconised in a child is one that is always present for the clinician who sees acutely unwell children.  The stories that we hear of infections and other illnesses being "missed" fuels that anxiety.  The common sense side of us tells us that significant illness should manifest itself in an obvious way, but that doesn't stop us from asking the question, "What am I missing?" when we see a child with a febrile illness and no apparent cause?

Scenario

You have just seen Billy, a 1 year old child with a fever that started today.  They have no cough or runny nose.  They appear well and have a heart rate of 120.  Chest is clear, heart sounds are normal and abdomen is soft.  Tympanic membranes are not inflamed.  You may or may not have looked at their throat but if you did, there is nothing obvious to see.

What do you do?

The answer to this is to understand what the possible causes of fever are, know how to exclude them and have an idea of how likely they are.  The latter brings us onto an important question:

How likely is significant or dangerous infection in a child?

That depends on the child.

The most common risk factor that we encounter is the infant.  The likelihood of an unwell newborn having a significant infection is high.  This is further compounded by their non-specific symptoms and lack of physiological response in the first few weeks of life.  The risk of serious infection multiplied by the risk of underestimating the illness makes a baby under the age of 60 days a high risk patient.

After those first few weeks, the infant becomes less reliant on maternal antibodies and begins to produce a more vigorous response to infection, most of which are now viral.  As a result, the risk diminishes inversely.

Other risky patients are those with ongoing reasons to either have more significant infections or less obvious signs of serious illness.  These include children with neurodisability, immunodeficiency or chronic illness.

For the usually healthy child beyond early infancy, the very great probability is that an illness will be benign and that those infections that are dangerous will manifest themselves in some significant way.  This itself brings a challenge: complacency.  We become so used to good outcomes and fruitless investigations that we start to think that everything is an uncomplicated viral infection.
It usually is, but what if it isn't?  That brings us on to the next question:

What are the less common causes of fever in a child?

One way to think about the causes is within categories:

When there are so many possibilities, it is often best to consider the least common first.  Let's start with the non-infective.  These illnesses cause inflammation without active infection.  They are all very uncommon compared to other things on the list but that makes them easy to forget and therefore miss.

Kawasaki Disease - This is a vasculitis which can look like a prolonged viral illness.  The cause has not yet been identified but it is presumed to be a post-infective phenomenon.  If a child has had a fever for five or more days without a clear cause, we should check if the child fulfils the criteria for Kawasaki disease.  You can check the criteria in a book or use an online tool such as this one linked here.

Leukaemia - Haematological malignancy in children occasionally presents as an unexplained and prolonged pyrexia.  More often there are other symptoms and signs such as increasing lethargy, weight loss, pallor, bruising, bleeding and unexplained pains.

Systemic Onset Juvenile Idiopathic Arthritis (JIA) - this subtype of JIA is rare but is one possible cause of unexplained fever.  Often the fever is accompanied by a typical salmon pink rash and joint pains, even if there is no clinically obvious joint swelling yet.

These non-infective causes of fever should not be over-thought.  The presenting symptoms of childhood illness are often so non-specific that it can be all to easy to imagine zebras instead of horses.  The key to not missing these is to be aware of them as entities and to look for features of these in the child with unexplained fever, especially when that fever is prolonged.

Next, the sepsis question.  Every febrile child should be assessed for sepsis, whether a focus the fever is found or not.  That decision can be made easy for you in one of two ways.  Either the child is very well to the extent that sepsis can be ruled out, or the child is so unwell that sepsis is presumed.  Everything in between is a case of careful assessment, including risk factors and the trajectory of the illness.

So, if we have considered the very rare and the sepsis question, what we should be left with is a child who we think does not have sepsis and yet has a fever without an immediately obvious focus.  At this point we return to the list of possibilities.

The task in a child with fever and no clear focus is to rule these possibilities out, which is usually based on clinical assessment.  Start with the complications of upper respiratory tract infection (URTI) as these are the most common significant infections in children.

Mastoiditis - infection of the mastoid is usually a complication of otitis media infection there should be evidence of that.  Mastoiditis is excluded clinically if there is no erythema, swelling or significant tenderness of the mastoid process.

Peritonsillar abscess - A collection of pus in the peritonsillar tissues is manifested by swelling which displaces the tonsil.  At the time of writing this, throat examination is not routinely performed due to the COVID-19 pandemic.  However, peritonsillar abscess is highly unlikely in a child who is willing to drink or eat.  If the child is refusing all oral intake, it may be necessary to use droplet PPE, including eye protection, to visually exclude peritonsillar abscess.

Lymph node abscess - Inflamed or enlarged lymph nodes are a common finding in children with URTI. Occasionally, the lymph node becomes bacterially infected.  When this happens, the lymph node is more enlarged and painful.  The overlying skin is often erythematous.  Another common feature is that the child becomes reluctant to turn their neck due to the pain from inflammation of the surrounding tissues.  These infected lymph nodes may respond to high dose oral antibiotics, however they may require incision and drainage.  Discussion with or referral to ENT is therefore advisable.

Osteomyelitis and septic arthritis - This is a good example of something that is rare but also often missed when it is a cause of unexplained fever.  Infection in a bone or joint can be visible or hidden.  If a parent has noticed a swollen, red or hot area or that the child has localising signs in a limb, that can lead to early diagnosis.  It is also the case that in a significant number of cases, the infection is not identified early on.  It is no surprise when a febrile child is miserable and moves less.  It is not common practice for clinicians to examine every bone and joint in a febrile child.  However, this is something that needs to be done if a child has an unexplained fever.  If limbs have not been examined for swelling, hot spots or erythema at first presentation, I would suggest that this should be done at the second assessment should fever persist and remains unexplained.

Urinary tract infection (UTI) - UTI is probably the most common cause of fever without a clinically obvious focus in children.  The younger the child, the less likely they are to present with specific symptoms.  Fever without obvious cause is an indication to screen the child for UTI.  Blind treatment with antibiotics is not recommended.  Urine should ideally be sent for culture so that treatment is based on the most robust result - a significant bacterial growth.

Meningitis and encephalitis - Central nervous system (CNS) infection is the most feared of the causes of fever without focus.  In the younger child, symptoms are less specific.  Infants may be irritable, jittery and not feeding well.  Vomiting and excessive sleeping are also common features but again, non-specific.  In an infant with an open fontanelle, this should be examined.  A bulging fontanelle (when not crying) is a red flag sign.  Older children may exhibit classical signs of neck stiffness, headache and photophobia.  Younger children are more likely to stand out because they just won't settle or have an abnormal tone or conscious level.  CNS infection is usually ruled out by the child demonstrating normal interaction or behaviour, often after adequate analgesia has been provided.

Appendicitis - In an older child, recognising appendicitis is done in a similar way to adult practice.  Appendicitis is rare in younger children but when it does occur, it can easily be missed.  Guarding tends to be a later sign in the pre-school child because their abdominal wall muscles are not very strong.  Children often cry or otherwise appear distress when their abdomen is examined, leaving the clinician uncertain.  Analgesia and reassessment is a good way of clinically ruling out appendicitis if the initial assessment is ambiguous.

Pneumonia and empyema - Lower respiratory tract infection (LRTI) is common in children.  Cough and fever are non-specific symptoms and are not grounds for diagnosing LRTI on their own.  Hearing crepitations on auscultation is also a common finding that should not be given too much weight.  Many LRTIs in children are viral and self-limiting.  Important discriminators are how unwell the child is, their work of breathing and more specific focal signs such as localised reduced air entry or a dull percussion note.

Tropical diseases - If a child has an unexplained fever and has recently returned from an area with e.g. malaria, they need to be referred to secondary care for investigation.

And finally...

So if Billy looks well and behaves in a way that effectively rules out sepsis and meningitis, his fever without clear focus means that we should look just a bit harder.  A urine sample should be taken to exclude UTI; blind treatment with antibiotics is not recommended without good evidence of UTI.

If there are reasons to suspect one of the less common (than uncomplicated viral infection) causes of fever, referral to secondary is likely to be the way forward.  If there is no evidence of a significant cause and what you are left with is a reasonably well child with an unexplained fever, the final question is, "should I refer this child or send them home with safety-netting advice?"

Both options are valid and the choice should be made in the best interest of the child.  In secondary care, the assessment of the child should be clinical in the majority of cases.  As such, referral may simply add a further clinical history and examination.  If a second opinion or physical period of observation is felt to in the child's interest, that is fine.  If not, it may be best to keep the child away from hospital and the risks associated with a secondary healthcare setting/

Before a final decision is made, risk should be considered.  For the majority of healthy children presenting to Primary Care (including the Emergency Department) with no specific risk factors, the likelihood of any febrile illness being a serious bacterial illness is very low.  That makes it perfectly reasonable for a child who has had a careful clinical assessment to be managed conservatively and with good safety-netting advice.

There are children who have a significantly higher risk.  As mentioned above, the most commonly encountered risk factor is the baby.  If your patient is a baby, especially if not yet started on their primary vaccinations, fever without focus warrants a referral to paediatrics.

Fever in a child who does not have an immediately obvious focus is a clinical conundrum for all of us.  Many children can be managed with a thorough history and examination.  If there are significant risk factors or specific findings then appropriate referral is likely to be the next step.

Edward Snelson
99% Type 1 decision maker
@sailordoctor

Disclaimer: If it's the clinician who has no focus, there's nothing I can do for you.

Chest X-rays in children - The Wimbledon Rules

We've come a long way in terms of reducing unnecessary tests in paediatrics.  It is within my career that it was standard to obtain a chest X-ray (CXR) for any child presenting with their first episode of wheeze.  Now, such an approach is seen as outdated.  This is a good thing.  In fact the vast majority of acute and sub-acute respiratory presentations in children can be managed without needing a CXR.

In some ways it was a lot easier to know when to do a CXR 20 years ago.  The answer was pretty often.  Every lower respiratory tract infection (LRTI), every first episode of wheeze and every persistent cough tended to result in a CXR.  Now, we should rarely do CXR in those circumstances.  Rarely doesn't mean never though, so how do you know if you're doing too many?  Enter the Wimbledon Rules for CXR in children…  I’ll come to that later.  First, I’ll explore a little bit about the complexities of doing CXRs in paediatrics.

The problem with CXR in children is that it can be misleading.  The most common scenario in which this is true is for the wheezy child.  Wheeze is a strong negative predictor of pneumonia(1).  This makes sense clinically when you think about it.  If an infant or child has restricted lower airways, that is reason enough to have respiratory distress.  If you then take a section of lung out of action, you won't be wondering if they might have a problem.  It is likely to be very obvious from how unwell they are and how abnormal their breathing is.  As a rule, children with tight airways and pneumonia together are in a very bad way.

While wheeze is a strong negative predictor of pneumonia, a CXR in wheezy children is rarely clear.  In many cases there is a patchy white area on the CXR.  This is often at the right heart border, or as it is sometimes called, "the area of radiological romance."  If you do a CXR too often in wheezy children, this will happen fairly frequently and it may be difficult to ignore.

Even if a child does have a LRTI, CXR is not necessary in many cases.  The British Thoracic Society (BTS) guidelines for community acquired pneumonia (CAP) recommend the following:

• Chest radiography should not be considered a routine investigation in children thought to have community acquired pneumonia. 
• Children with signs and symptoms of pneumonia who are not admitted to hospital should not have a chest x-ray.

These recommendations are based on two important facts.

• Children with clear clinical signs of CAP may have a normal CXR
• Children with abnormal findings on a CXR often do not have clinically significant CAP (2)

So when should we do CXR in children?

Let’s start with the times when CXR is not recommended routinely:

• Bronchiolitis not requiring admission to a critical care unit (PCCU)
• Episodes of asthma and viral wheeze (no matter how severe or whether it is the first episode of wheeze for that child) which are responding to treatment
• Community acquired pneumonia without atypical features and which responds to treatment within the first two days
• Most cases of cough without other features
• Chest pain in children

CXR is usually most helpful in children in these circumstances

• Severe exacerbations of asthma or viral wheeze which are getting worse despite appropriate treatment 
• Community acquired pneumonia which has atypical features or fails to respond to appropriate treatment
• Daily cough with any of the following features
• Lasting more than 8 weeks
• Progressively worsening over several weeks, esp. if moist cough
• Red flag features (daily fever, night sweats, weight loss)
• Known exposure to TB
• History consistent with inhaled foreign body

The other side of the problem is that there is no gold standard test for many of those clinical scenarios where CXR is not routinely recommended.  There is often poor correlation between clinical and radiological findings, but which is more valid?  For example if you take pneumonia in children and treat based on radiological findings versus clinical findings you will end up treating different children.  Clinical findings will be falsely positive and falsely negative just as radiological findings are.

Therefore we need to get a balance between clinical common sense and judicious use of CXR in children.  A simplistic approach which could be applied looks like this:

Whether a CXR is necessary or not is highly subjective.  Ask ten clinicians and you'll get ten different answers, due to the human factors.  It's a little like an umpire in a tennis game.  They're not right all of the time.

For this reason, in a major tournament tennis game, players are allowed to appeal.  However the players appeals are limited.  If they appeal against a decision and that appeal is upheld, they retain the number of appeals that they had before the appeal.  So wrong once, they can appeal again.  Wrong twice and they're out of appeals.

I suggest that clinicians should apply the same rules to the use of CXR in children.  Before doing a CXR, we should ask ourselves the question, "What would I do based on a purely clinical assessment?"  After doing a CXR, we should then ask, "Has the CXR added genuinely useful information to my clinical decision?"

Having a CXR result in a child which doesn't alter our clinical decision, or which dysfunctionally suggests a pathology in the absence of a congruous clinical picture should make us rethink our approach to our use of CXR.  If we're going to apply the Wimbledon CXR rule, when we get one completely normal CXR (or one with a non-descript small white fluffy patch which makes us want to give antibiotics when we wouldn't have done so before the CXR) we should think about more cautious use of CXR. If we get two, we should stop and re-read the rules.

Just as tournament tennis players don't have an unlimited number of appeals, we shouldn't think of CXRs as an unlimited diagnostic resource.  We should use them when they are most likely to change our game.

Edward Snelson
Unappealing Paediatrician
@sailordoctor

Disclaimer: If you turn the umpire off and back on, the number of appeals resets.

References

1. Hirsch, A. et al., Estimating Risk of Pneumonia in a Prospective Emergency Department Cohort, The Journal of Pediatrics, Volume 204, 172 - 176.e1
2. Virkki R, et al. Radiographic follow-up of pneumonia in children. Pediatr Pulm 2005;40:223e7.

Making the Right Judgement - a comprehensive 3D model for deciding what to do with each child with a respiratory presentation

In the previous post, I covered how best to make a diagnosis of lower respiratory tract infection (LRTI).  Anyone who has the pleasure of working with acutely ill children knows, the diagnosis is only a small part of what we do.  A big part of what we do is making that all important decision - home or hospital?

This decision is usually made up of several elements.  What is interesting is that the same principles can be applied to all of the major respiratory problems that we see, namely:

• Bronchiolitis
• Viral Wheeze
• Asthma
• Croup
• Pneumonia (LRTI)

Once one of these diagnoses has been made, the decision about whether to admit or manage at home is a huge one.  On the one hand, we don't want to admit children to hospital unnecessarily.  Apart from the inconvenience and stress to the family, there is a significant risk of adding insult to injury as so many children who attend hospital acquire additional infection.  On the other hand, we know that if a respiratory problem does deteriorate, it can do so quickly and catastrophically.  If there is a significant risk of a child going off, they should be somewhere that can respond appropriately.

In the majority of childhood respiratory illnesses, the treatment itself is not what requires the child to be in hospital.  It is no longer routine to have a chest X-ray and intravenous antibiotics for uncomplicated community acquired pneumonia. (1)  Many children who are admitted with pneumonia receive no investigations and are treated with oral amoxicillin and discharged when they show improvement.  Severe croup is often a waiting game.  Viral wheeze is usually treated with inhalers via spacer.  Babies with bronchiolitis are often observed while a team of expert paediatricians avoid the temptation to "try something" that research has proven to be pointless.  You get the picture.  These are the times that paediatrics is the art of masterful inactivity.  Believe me, that is harder than it sounds and is actually quite labour intensive when done properly.  The point is, they still need to be there, because these are the children who, if they got worse, would require escalation of treatment.

So if the need for hospital specific treatment isn't always the thing that determines the need for admission, what else is?  In illnesses that always need hospital treatment (e.g. Kawasaki Disease) the decision is made for you.  However in respiratory problems that can be treated in the community, the decision is mostly about risk assessment, which is never as simple as people make it sound.

Guidelines often imply that the assessment of a respiratory presentation is a simple matter of deciding severity or calculating a score.  I like an over-simplification as much as the next clinician, except when it doesn't work, which is fairly often.  Why isn't it that simple?  Because not a one dimensional assessment.  The good news is, it's not that complicated,  It's just 3D instead.

D1 - Severity

The first dimension of the assessment is to decide severity.  All acute respiratory problems, like chain coffees, come in small medium and large.  Deciding which presentation fits into mild moderate or severe is fairly intuitive and the same principles apply across the different diseases.

Severe makes the decision easy.  Severe needs to be treated in hospital for several reasons.  Severe is usually a set piece, and although severe can be terrifying, it's not usually a cause of decision fatigue.  That comes from deciding what to do with the rest of them.

In a previous post, I shared some thoughts on croup scores and severity.  You can read that via this link if it would be helpful.

Mild cases of croup, bronchiolitis, viral wheeze, asthma and LRTI are almost always best managed at home.  Almost.  Moderate cases can often go either way.

D2 - Risk factors

This means that other factors are involved in the decision.  Because we are assessing risk, we need to consider risk factors.  These, when applied to the severity of the illness literally multiply the risk of something bad happening.

As a rule, a risk factor alongside a moderate severity of respiratory problem is ore than enough to mandate admission to hospital.   That child with croup that you were thinking of sending home- I suspect that decision will be changed when you factor in the fact that they were born prematurely at 26 weeks.

What is slightly more complicated is how risk factors apply to the child with a mild presentation.  It's complicated because the presence of a risk factor does still ramp up the risk, but its a factor applied to a very small risk in the first place.  What's more, the same risk factors that apply to the presentation also apply to the risk of being in hospital.  An ex-premature baby with mild bronchiolitis could go off, but the risk is still small.  An ex-prem baby in hospital if they don't need to be is a risk all of its own.

The decision about what to do with a child who has a mild respiratory problem but also has risk factors is a difficult one.  It is a decision best made by an experienced clinician who understands the way that the particular risk factor interacts with the illness and knows the pitfalls associated with it.  If you're not sure, refer or discuss the case.  This may be a good opportunity for an experienced primary care clinician to share that decision with an experienced paediatician via a telephone consultation.

D3 - Red Flags

Finally, there are red flags.  Although independent of the apparent severity of the presentation, these features will usually mandate referral or admission.

A good example of a red flag feature would be a 4 month whose clinical examination is consistent with mild bronchiolitis.  If the accompanying adult says that the infant had an episode of suddenly becoming pale and floppy earlier that day, this should be treated as a warning sign.

Bringing those three dimensions together will give you the answer to the "home or hospital?" question.  It will also help the communication between primary and secondary care.  Referring a child with a respiratory problem, summarised as diagnosis, severity, risk factors and red flags is just showing off.  There's nothing wrong with that is there?

Edward Snelson
Dimensional Relativist
@sailordoctor

Disclaimer: I'm never sure which is worse: oversimplification or undersimplification.

References

1. Guidelines for the management of community acquired pneumonia in children: update 2011 British Thoracic Society Community Acquired Pneumonia in Children Guideline Group

Making a Diagnosis of Lower Respiratory Tract Infection in Children

This is one of the most common and difficult calls in General Practice, Emergency Medicine and acute Paediatrics: when to treat a child as a lower respiratory tract infection.  It's important because we don't want to miss a diagnosis of LRTI/ pneumonia, yet overtreating is bad medicine.  It's difficult because most children with an upper respiratory tract infection will have a cough and fever, and because the parents will be worried about the possibility of LRTI.  To make things worse, any child with uncomplicated URTI could later develop LRTI.  Not often, but often enough that it can influence our decision making.  So how do we get it right?

I think that it is a question of rule in/ rule out.  There are many elements to the assessment but there is one feature that determines whether the default is to assume that there is no LRTI and whether the default is to assume that there is a LRTI.  That feature is respiratory abnormality.

I think that when I was taught as a medical student, the auscultation findings in the chest were over-emphasised.  The reality is that these can be misleading.

First of all, the presence of focal findings in the chest are common even in the absence of LRTI.

• The infant or child with URTI will often have crepitations that can be hear in one or more places in the chest.  These may be transmitted sounds or due to secretions.  Breath sounds will be normal throughout.  In the absence of abnormal breathing, these crackles are not good evidence for LRTI.  Often, these noises go away or move around if re-examined, especially after a cough.
• The infant or child with a wheeze may have crepitations and variation in the loudness of breath sounds in different parts of their chest.  Bacterial LRTI does not usually cause wheeze but wheezy problems often lead to focal findings.  The clue that the problem is not a LRTI is that the child is systemically well.  The basic rule is this: if a child with a wheeze does not look ill enough to be admitted to hospital, they do not have a bacterial LRTI.  Bronchiolitis and viral induced wheeze are all the explanation needed for abnormal breathing.  If a child had one of these and a pneumonia, they would really be in difficulty. 
• The child with viral induced wheeze may have no wheeze to further complicate things.  Consider a trial of beta-agonist inhalers in well child with respiratory distress, especially if there is a past history of wheeze. 

Secondly, the absence of focal findings in the chest is a relatively common scenario in the child with LRTI.

• Auscultation and percussion in infants and small children is difficult.  Chests are small and there is always the possibility that the area of abnormality will be missed.  The child with cough, fever and abnormal breathing should be presumed to have a LRTI unless proved otherwise.
• Not all LRTIs even produce focal signs.  Sometimes a segment of a lobe is all that is infected (known radiologically as a round pneumonia) and it is quite common in such cases for the only clues to be the combination of unwellness and respiratory abnormality.

Nor should we rely on chest X-ray (CXR) to make the decision for us.  The sensitivity and specificity of CXR as a way to diagnose pneumonia in children is too poor to justify using radiation when the diagnosis should be made clinically.   The BTS guidelines for community acquired pneumonia in children and the Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America both recommend that CXR and blood tests are routinely avoided. (1,2)

There are no absolute rules.  This is paediatrics so there are special circumstances.

• Small infants and babies should be considered to have a higher probability of serious bacterial infection whenever they present.  However that should not mean a liberal use of oral antibiotics in a community setting.  If you are treating them differently because they have that higher risk of serious infections, they are also high risk for other reasons and should usually be referred if LRTI is suspected.
• Children with complex medical problems may not demonstrate abnormal breathing or unwellness in the way that normal children do.
• Children with chronic LRTI may be less unwell and have little in the way of respiratory abnormality.  Parents will often seem less anxious if the problem is developing more gradually.  Daily cough for several weeks should be taken seriously.  It is not unreasonable to try a course of broad spectrum oral antibiotics but be aware that this may not be the end of the problem.  Underlying causes including foreign objects, bronciectasis and simply unresolved LRTI may need to be ruled out in which case referral will be necessary.

Bringing all of these things together shows that there are two key features.  The first of these is abnormal breathing in the context of an unwell child with cough.  The presence of abnormal breathing almost immediately makes it overwhemingly likely that the problem is LRTI, bronchiolitis or viral wheeze.  The second feature is wheeze, which largely rules out LRTI.  It's almost that simple.  Almost...

For more on how to tell the difference between bronchiolitis and viral induced wheeze, read this post: "Why Do Different Children Wheeze Differently? - Simple, but first you have to understand all of paediatrics"

It is important to remember that LRTI is usually preceded by URTI.  Safety-netting advice is key.  Here's an example of the kind of thing that I tell parents: (3)

Ruling in and ruling out is a dynamic process.  Involving the parents is an important part of that.

Edward Snelson
Not a member of the ruling class
@sailordoctor

Disclaimer: Knowing whether you approach the problem from primarily a rule in or rule out approach is a bit like knowing whether you are coming or going, neither of which I am usually sure of.

References:

1. Guidelines for the management of community acquired pneumonia in children: update 2011 British Thoracic Society Community Acquired Pneumonia in Children Guideline Group
2. Bradley J et al, The Management of Community-Acquired Pneumonia in Infants and Children Older Than 3 Months of Age: Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America, Clinical Infectious Diseases, Volume 53, Issue 7, 1 October 2011, Pages e25–e76, https://doi.org/10.1093/cid/cir531
3. The Essential Clinical Handbook of Common Paediatric Cases, Edward Snelson

The Trouble with Training (Easter egg - when to do a Chest X-ray in children in the ED or General Practice)

I remember well how difficult it is to stay up to date across the thousands of clinical scenarios that face the General Practitioner.  When I was faced by something not in the top 100 weekly problems, I usually had to think back to my training.  That works well as long as what I recalled was accurate, and was best practice at the time and remained so.  What are the chances of all three being true even five years post-training?

Accurate recall (keep taking that thiamine) aside, the first issue is whether one's training involved the demonstration of standard care.  I was recently pulled into a twitter conversation about whether children with pneumonia required a chest X-ray (CXR).  The person facilitating the discussion was one of the local GP trainers who had himself been asked by one of the GP trainees here in Sheffield.  The trainee felt that they were getting mixed messages and wanted to know the right answer.  Of course a complete answer doesn't fit in a tweet.  Also, tweets are transient unless they are the kind that get you fired.  So a GPpaedsTips post seems to me to be the best place for a proper answer.  Since the question was about acute paediatrics, I can legitimately put a foot outside of the Primary Care remit of this site, but it seems the ideal opportunity to also address the question of when a CXR might be indicated for a child in a General Practice setting.

Continuing with the theme of see one do one, lets start with children with pneumonia in a secondary care setting in the UK.  The British Thoracic Society guidelines for community acquired pneumonia in children are, in my opinion, very good.  Their recommendation that "Chest radiography should not be considered a routine investigation in children thought to have community acquired pneumonia" is based on the old principle of 'if it doesn't change your management don't do it.'  Putting that into practice requires a little step back and for us to ask the question, 'what is a CXR for?'  I used to think it was needed to diagnose pneumonia.  That is a fallacy, since X-ray changes will have a time lag and a CXR can be a false negative.  So, is it to show the severity, or what kind of pneumonia it is?  No, the severity is a clinical assessment and the type of chest infection is determined by a combination of the clues in the assessment and the response to treatment.  According to the BTS guidelines, CXR in the ED or paediatric assessment unit should mainly be used for the cases which are a little bit different from the routine LRTI.  This might be repeated LRTI, a child who is severely unwell or a number of other reasons.  That doesn't mean find a reason.  It means find a good reason.  In particular, if you think the child is well enough to treat as an outpatient, BTS recommends never doing a CXR.  Never is a strong word but it's a good place to start and puts the GP CXR question in context.

Adults, with their risk of lung cancer, are different.  In children, signs and symptoms are usually all you need when making decisions about treatment or referral when it comes to children's respiratory problems.  In my opinion, doing a CXR for a child in primary care should be for a situation where the X-ray could give information that allows treatment to be given or a referral to be avoided.  I can't think of any situations where the CXR would do that but a history and examination would not.

I understand that one reason that CXRs are done for children in Primary Care is to reassure parents or clinicians.  I would be very wary of that plan.  CXRs often have findings on them, especially when a child has a viral illness.  A finding is not the same thing as a clinically significant abnormality, but it is not very reassuring either.

Then there is the possibility that a CXR might be done in the belief that one would be done for the same patient in a hospital setting.  That is also tricky since practices change.  The trouble is that they may change slowly and inconsistently.  I believe that the safest approach is to avoid second guessing what tests someone else will want.  I either ask them or leave them to request their own investigations.

So then there is the challenge of being up to date.  I would like to use this opportunity to tell all my secondary care colleagues how stupidly easy we have it in this regard.  The environment we work in continually provides us with updates and learning (if you are surrounded by the kind of clever yet pragmatic clinicians I work with).  I remember how General Practice is a relatively isolated learning environment and how difficult it is to keep abreast of changes in so very many areas.

That's the trouble with training and keeping up to date: these things have the tendency to look fun and manageable but actually have the tendency to expand exponentially and take over.  Meanwhile, we all have a ship to run. The solution: Cling on, outsource your troubles and let FOAMed give you the answers.

Snelson out


Disclaimer: I need reassurance too. I'm just not sure where to find it any more.

Reference:
BTS guideline for Community Acquired Pneumonia in Children