Paediatric Dietitians – referral criteria
This advice is for infants with suspected bronchiolitis seen in Primary Care. Bronchiolitis is usually seen in babies < 1 year of age. There is separate guidance on ‘Acute Wheeze’.
Bronchiolitis is usually characterized by:Coryzal prodrome 1-3 days, followed by:a) Chesty coughb) Tachypnoeac) Chest recessionsd) Bilateral crackles with or without wheeze on chest auscultatione) 30% will have a fever (usually < 39 degrees Celsius).f) Poor feeding and/or vomitingg) Apnoeas may be seen as a complication of bronchiolitis, especially in young babies < 6 weeks of age. This is a ‘red flag’ and needs ‘999’ paramedic ambulance.Bronchiolitis occurs in children < 2 years of age, most commonly in the first year of life. Symptoms peak between 3-5 days of illness. The cough resolves in 90% of infants within 3 weeks. Most children will not require any treatment.Please use the table under ‘Management’ to assess severity of illness.Measuring Oxygen saturationsIf pulse oximetry is available, measure oxygen saturations in every infant presenting with suspected bronchiolitis. Ensure an age appropriate oximeter is used – using an adult probe can give inaccurate readings.
The following are ‘Red Flags’ for more serious illness and should be referred urgently for hospital assessment.• Fever in baby less than 3 months old (fever in the 48 hours post immunization may be expected)• Worsening work of breathing: grunting, nasal flaring, chest recessions• Respiratory rate > 70• Fluid intake <50% of normal• No wet nappies for 12 hours• Apnoeas• Cyanosis• ExhaustionRisk factors for more severe bronchiolitis:a) Premature birth (particularly < 32 weeks)b) Chronic lung diseasec) Congenital heart disease (hemodynamically unstable)d) Younger age group especially if < 3 months.e) Neuromuscular disordersf) Immunodeficiencyg) Children with a chromosomal anomaly like Down syndrome
|
High Risk |
Intermediate Risk |
Low Risk |
|
|
Behaviour |
Sleepy Weak or continuous cry No response social cues |
Decreased activity Unsettled / unhappy |
Alert Normal |
| Skin |
Pale / Blue / Mottled CRT > 3 seconds |
Cool peripheries Pale CRT 2-3 seconds |
CRT < 2 seconds Normal colour |
| RR |
>70 breaths/ minute |
>60 breaths / minute |
< 50 breaths / minute |
|
Sats in room air |
< 92% |
92-94% |
95% or above |
|
Work of breathing |
Severe |
Moderate |
Mild |
|
Feeding / Hydration |
<50% fluid intake over 2-3 feeds* Significantly reduced wet nappies |
50-75% fluid intake over 2-3 feeds Mild reduction in wet nappies |
Tolerating at least 75% of normal feed volumes Occasional vomit |
|
Apnoeas |
Present | None | None |
|
Recommended Actions |
1. High-Flow oxygen2. Stay with child3. Immediate referral to emergency care by 9994. Call Paediatric referral phone to alert of impending arrival.*if only concerns regarding hydration, use clinical judgement as to method of transport to hospital. | 1. Review additional risk factors for severe disease (see below)2. Consider discussing with local paediatrician via Paediatric referral phone3. Provide parents with red flags information4. Arrange follow up for review | 1. Review additional risk factors for severe disease (see below)2. Provide parents with information leaflet |
Consider an alternative diagnosis such as: (Please seek Paediatric Review if unsure)1. Sepsis if fever in < 3 months old (unless clearly related to immunisation).2. Pneumonia – if high fever > 39 and/or persistently focal crackles.3. Viral induced wheeze / early-onset asthma if > 1 year of age and:a) Persistent wheeze without crackles.b) Recurrent episodic wheeze.c) Personal or family history of atopy.4. Cardiac condition – if sweaty and/or pale and/or cardiac murmur.Children falling in the low risk category can be discharged home with advice. Take into account:1. Social circumstances.2. Skills and confidence of carer to care for the child and to spot red flag symptoms.3. Distance to healthcare facility in case of deterioration.Treatments that have no evidence base in bronchiolitis and should therefore, not be used include:• Antibiotics• Hypertonic saline• Nebulised adrenaline• Salbutamol• Montelukast• Ipratropium bromide• Systemic or inhaled corticosteroidsSymptom management with paracetamol, saline nose drops and adequate oral feeds is recommended. Bronchiolitis advice sheet should be given to all parents/carers. There is a link under ‘Supporting Information’ to the NHS parent information leaflet.
Encouraging smoking cessation in parents is important. Smoking in the home can cause more severe symptoms.There is an NHS parent leaflet about bronchiolitis that can be downloaded here:https://