Pediatric Small Talk – Asthma and Bronchiolitis and Febrile Neonates…OH MY! A reflection on recent pediatric volumes and how we can provide care

Welcome back to Small Talk.  Every first Wednesday of the month we will release high yield PEM content written by PEM talent from around the country.  We hope you enjoy these reviews. Comments, questions, accolades or concerns: feel free to reach out to Joe Ravera, MD (pemgemspod@gmail.com).

Author: Joe Ravera MD (@pemuvm1, Director of Pediatric Emergency Medicine, Assistant Professor of Surgery, Division of Emergency Medicine, University of Vermont Medical Center) // Reviewed by: Alex Koyfman, MD (@EMHighAK); Brit Long, MD (@long_brit)

Overview

Respiratory viruses are currently channeling Arnold Schwarzenegger and his most prophetic line, “I’ll be back”.  The data are clear that pediatric ED visits, and in particular visits for respiratory disease, took a sharp dive in April 2020 and remained lower than average for several years.  The purported reasons for this range from the obvious “day care was closed” to the more nuanced “parents were afraid to bring their children to the hospital or had no access to primary care”.^1,2  However, with current safe and effective vaccines, coupled with a shift in policy on mitigation strategies, the number of cases of children with sick respiratory complaints is at or surpassing pre-pandemic numbers. This also has to be taken in the context of healthcare worker burnout, staffing shortages, and limited availability of pediatric inpatient beds, all of which have led to increase demand on the ED to triage, resuscitate, and in some cases provide ongoing care to ill children.  While I am certainly not a policy expert, and I don’t have the answers to boarding, I can provide some resources education to help with taking care of kids with these complaints on your next shift.

Bronchiolitis 

While RSV gets most of the publicity, there are dozens of viruses that cause the clinical syndrome of bronchiolitis.  If you can name it, we have tried it for treatment, and despite years of data and decades (if not centuries) of the disease, our best offer is still nasal suction and antipyretics.  I have affectionately called this the disease that only time will heal.

For more information about bronchiolitis and its care, we have a previous piece on emDocs.net or for the listening crowd a podcast.

The main cognitive decision for caring for children with bronchiolitis is whom needs to be admitted. This decision is also under increased pressure and scrutiny as there are fewer and fewer pediatric beds available.

The Five Indications for Admission

Hypoxemia: This seems straightforward: if the child needs oxygen, they need admission to the hospital.  While most people in the PEM community will initiate supplemental 02 at 92%, the most recent AAP guidelines suggest 90% (while awake) as a cut off for the initiation of therapy.³ In children who are otherwise well and only require a small amount of oxygen there are even a few pilot protocols looking at discharging hypoxemic babies with supplemental oxygen. Currently, these protocols have not yet been standardized and often it is difficult to titrate but may be something on the horizon.⁴

Increased Work of Breathing: Even without hypoxemia, children who have signs of moderate to severe respiratory distress such as abdominal retractions or grunting should be admitted for monitoring. HFNC can be helpful in these children even in the absence of hypoxemia, as it may provide some airway stenting with positive pressure. While there are scoring systems to quantify the degree of respiratory distress, some of the most difficult babies are the “happy retractors.”  This is the child who is at baseline, tolerating PO, but still has residual intercostal retractions.  Oftentimes, it is best to have a discussion with the family, with specific focus on their ability to recognize clinical deterioration, return to the ED, and access outpatient care.

Inability to Tolerate PO: This is another standard of PEM and EM in general. If the kid is unable to keep up with their baseline PO intake, combined with increased insensible losses from the illness, then they require admission for IV fluids.

Complex Medical Disease: Bronchiolitis disproportionately affects children with chronic medical problems.⁵ Even well appearing children can become critically ill as the disease progresses. While there are no hard and fast rules, these authors recommend admission (or consultation with specialists) for all children with complex cardiac, pulmonary, or neuromuscular disease who present with even mild bronchiolitis. 

Apnea: While apnea with bronchiolitis has been reported in older babies, the vast majority and highest risk are in the first month of life with occurrence estimates ranging from 1-5%.  History of prematurity, younger age (<2 weeks), or babies with a witnessed apneic episode by the parents are at even higher risk. It is important to note that apnea in these young babies can occur in the absence of severe respiratory disease. While this is an ongoing debate with inpatient pediatrics, it is our recommendation that all children under a month (in particular under 2 weeks and/or a history of prematurity), with RSV or clinical bronchiolitis be discussed with inpatient pediatrics for admission.⁶

Asthma 

Part and parcel with an increase in respiratory viruses in an increase in virally mediated asthma. Anecdotally, I have seen several severe exacerbations caused by rhinovirus but have yet to see data published on the most recent surge.  Regardless of the trigger, treating the underlying asthma is treated the same way with bronchodilators, steroids, and adjuncts such magnesium or parenteral (or IM) beta agonists.  Asthma is also a spectrum of disease from the mild to the moribund, and the expediency and breadth of treatment varies widely depending on the presentation.  A review of this spectrum and therapies can be found here.

Febrile Infants

Another passenger of the train of respiratory virus resurgence is the well appearing neonates (under 60 days) with a fever.  The vast majority of these are viral in etiology (approximately 90%), with older siblings back in school and bringing home the “usual crud” and passing it along the newborn.  As luck would have it, AAP published new guidelines for the diagnosis and management of the febrile neonate, and a review can be found here and for the podcast inclined here.

Recap and Acknowledgement 

Hopefully, this short review will provide some resources and tips for dealing with the current surge of pediatric patients with respiratory complaints as well as the downstream effects. Beyond, the nuts and bolts of the medicine I want to acknowledge all of the hard work EM docs do, from critical access to quaternary center.

References

1. Finkelstein, Yaron MD∗; Maguire, Bryan MSc†; Zemek, Roger MD‡; et al. on behalf of Pediatric Emergency Research Canada (PERC). Effect of the COVID-19 Pandemic on Patient Volumes, Acuity, and Outcomes in Pediatric Emergency Departments: A Nationwide Study. Pediatric Emergency Care: August 2021 – Volume 37 – Issue 8 – p 427-434
2. Radhakrishnan L, Leeb RT, Bitsko RH et al. Pediatric Emergency Department Visits Associated with Mental Health Conditions Before and During the COVID-19 Pandemic – United States, January 2019-January 2022. MMWR Morb Mortal Wkly Rep. 2022 Feb 25;71(8):319-324. doi: 10.15585/mmwr.mm7108e2. PMID: 35202358.
3. Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics. 2014;134(5):e1474–e1502
4. Watkins T, Keller S. Home oxygen therapy criteria, guidelines and protocols for hypoxia management in pediatric patients with acute bronchiolitis: a scoping review protocol. JBI Database System Rev Implement Rep. 2018 Aug;16(8):1606-1612.
5. Fujiogi M, Goto T, Yasunaga H, et al. Trends in Bronchiolitis Hospitalizations in the United States: 2000-2016. Pediatrics. 2019 Dec;144(6):e20192614.
6. Schroeder AR, Mansbach JM, et al. Apnea in children hospitalized with bronchiolitis. Pediatrics. 2013 Nov;132(5):e1194-201. doi: 10.1542/peds.2013-1501. Epub 2013 Oct 7. PMID: 24101759; PMCID: PMC3813402.