By Mark Mannenbach, MD, Assistant Professor of Pediatric and Adolescent Medicine at the Mayo Clinic College of Medicine, Division Head of Pediatric Emergency Medicine, and Vice Chair of Education in the Department of Emergency Medicine
As a child, I remember playing games of hide-and-go-seek with family and friends. In the fall, we had great fun playing in the leaves and the cooler temperatures with a relief from the hot and humid days of summer. I can still hear the words, “Ready or not, here I come!” echoing in our local apple orchard as we played together.
Unfortunately, ready or not, the days of fall will also bring the challenges to care for infants and young children with bronchiolitis. In the January 19, 2018 issue of MMWR, Rose EB, et al reported nationally, across three RSV seasons, lasting from the week ending July 5, 2014 through July 1, 2017, the median RSV onset occurred at week 41 (mid-October), and lasted 31 weeks until week 18 (early May). The median national peak occurred at week 5 (early February).
In my experience, I have found the care of these patients to often be very frustrating given the limited successful treatment options available. I can already envision my need to spend extra time with families to explain the natural course of this disease process which is nearly always longer than anyone would like to see. I will worry and be unsure about the children I send home from our emergency department. I will wonder how they will be doing and hope that the illness will not be too much for families to handle.
What can we do to best prepare to care for these children? A tool I will be using to remind me of best practices is the 2014 American Academy of Pediatrics Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. The most important aspect of this guideline is the emphasis on diagnosis based upon history and physical exam. I will be paying close attention to infants with respiratory symptoms to determine the severity of their illness as well as the potential for other diagnoses. Through careful attention to the child’s respiratory rate, work of breathing, oxygen saturation, and hydration status, I hope to provide reassurance to most of the families challenged to care for these sick infants.
I will be very tempted to obtain chest x-rays and blood work that will most often have little positive impact for the care of these children. These diagnostic studies should be reserved for children with concerns for other diagnoses such as myocarditis. I will need to be diligent to look for organomegaly in all of the infants with poor feeding, tachypnea, or retractions. Many false positive results like the “patchy infiltrate” found on the chest x-ray will lead to my inappropriate use of antibiotics and inappropriate expectations of their value for these families.
I will be tempted to offer other treatments such as bronchodilators or steroids despite the lack of evidence supporting their efficacy. If the child does not respond to a bronchodilator treatment in our department, I will not recommend continued use of this therapy at home. The AAP policy statement provides its strongest recommendation in its emphasis NOT to administer corticosteroids to infants with bronchiolitis. I will have honest discussions with families regarding the lack of treatment options and emphasize the value of nasal suctioning as well as smaller and more frequent feedings. I will emphasize my willingness to re-evaluate these patients knowing the difficulty in assessing them over the typical two to four week duration of the illness.
For those children with increased work of breathing and the need for hospitalization, I will be utilizing the high flow nasal cannula technology we found so successful last season. Just as Schibler A, et al found a change in their ventilatory practice, including a reduced need for intubation in their 2011 study in Intensive Care Medicine, we also saw improvements in our care of hospitalized children when using this helpful tool.
I will be relying upon these studies to guide me through the busy and hectic days ahead in my practice. I hope they help identify those children who require more aggressive care as you seek to deliver consistent and quality care for the children.
