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Bronchiolitis in children

About

What is covered

This interactive flowchart covers the diagnosis and management of bronchiolitis in children, and includes recommendations on when to refer and admit a child to hospital.
Bronchiolitis can be caused by many respiratory viruses. It is most commonly caused by the respiratory syncytial virus (RSV) and is seasonal, peaking in the winter months over a 6–8 week period. RSV accounts for 80% of bronchiolitis cases. Bronchiolitis is the most common disease of the lower respiratory tract during the first year of life. It usually presents with a cough with increased work of breathing, and it often affects a child's ability to feed. The condition may be confused with a common cold, though the presence of lower respiratory tract signs (wheeze and/or crackles on auscultation) in an infant in mid winter would be consistent with this clinical diagnosis. The symptoms are usually mild and may only last for a few days, but in some cases the disease can cause severe illness.

Updates

Updates to this interactive flowchart

21 June 2016 Bronchiolitis in children (NICE quality standard 122) added.
8 December 2015 Link to intravenous fluid therapy in hospital pathway added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on diagnosing and managing bronchiolitis in children in an interactive flowchart

What is covered

This interactive flowchart covers the diagnosis and management of bronchiolitis in children, and includes recommendations on when to refer and admit a child to hospital.
Bronchiolitis can be caused by many respiratory viruses. It is most commonly caused by the respiratory syncytial virus (RSV) and is seasonal, peaking in the winter months over a 6–8 week period. RSV accounts for 80% of bronchiolitis cases. Bronchiolitis is the most common disease of the lower respiratory tract during the first year of life. It usually presents with a cough with increased work of breathing, and it often affects a child's ability to feed. The condition may be confused with a common cold, though the presence of lower respiratory tract signs (wheeze and/or crackles on auscultation) in an infant in mid winter would be consistent with this clinical diagnosis. The symptoms are usually mild and may only last for a few days, but in some cases the disease can cause severe illness.

Updates

Updates to this interactive flowchart

21 June 2016 Bronchiolitis in children (NICE quality standard 122) added.
8 December 2015 Link to intravenous fluid therapy in hospital pathway added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Extracorporeal membrane oxygenation (ECMO) in postneonatal children (2004) NICE interventional procedures guidance 38
Bronchiolitis in children (2016) NICE quality standard 122

Quality standards

Bronchiolitis in children

These quality statements are taken from the bronchiolitis in children quality standard. The quality standard defines clinical best practice in assessing, diagnosing and managing bronchiolitis in children and should be read in full.

Quality statements

Antibiotic use

This quality statement is taken from the bronchiolitis in children quality standard. The quality standard defines clinical best practice in assessing, diagnosing and managing bronchiolitis in children and should be read in full.

Quality statement

Children with bronchiolitis are not prescribed antibiotics to treat the infection.

Rationale

Bronchiolitis is caused by a viral infection so antibiotics should not be used as treatment. The number of children who have bronchiolitis and who then develop a bacterial infection is extremely low. Antibiotics can lead to common adverse reactions. Reducing unnecessary antibiotics will help prevent the development of bacterial resistance and will also reduce costs.

Quality measures

Structure
Evidence of local prescribing protocols to direct antibiotic prescribing in children with bronchiolitis.
Data source: Local data collection.
Process
a) Proportion of diagnoses of bronchiolitis with a prescription for antibiotics in primary care.
Numerator – the number in the denominator with a prescription for antibiotics.
Denominator – the number of diagnoses of acute bronchiolitis in primary care.
Data source: Local data collection.
b) Proportion of diagnoses of bronchiolitis with a prescription for antibiotics in secondary care.
Numerator – the number in the denominator with a prescription for antibiotics.
Denominator – the number of diagnoses of bronchiolitis in secondary care.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as primary and secondary care and emergency departments) ensure that protocols are in place to ensure that healthcare professionals do not prescribe antibiotics to treat bronchiolitis in children. Services also ensure that procedures are in place to monitor antibiotic prescriptions for bronchiolitis in children.
Healthcare professionals (GPs and secondary care clinicians) do not prescribe antibiotics to treat bronchiolitis in children.
Commissioners (NHS England and clinical commissioning groups) ensure that primary and secondary care services do not prescribe antibiotics to treat bronchiolitis in children.

What the quality statement means for parents and carers

Children with bronchiolitis are not given antibiotics to treat the condition because it is caused by a viral infection.

Source guidance

Bronchiolitis in children: diagnosis and management (2015) NICE guideline NG9, recommendation 1.4.3 (key priority for implementation)

Bronchiolitis management

This quality statement is taken from the bronchiolitis in children quality standard. The quality standard defines clinical best practice in assessing, diagnosing and managing bronchiolitis in children and should be read in full.

Quality statement

Parents and carers of children with bronchiolitis are informed that medication is not being used because the condition is usually self-limiting.

Rationale

In most cases, medication is not needed to manage bronchiolitis because it is usually self-limiting (that is, it settles without the need for treatment). Helping parents and carers to understand this can increase their confidence in caring for their child at home if hospital admission is not needed. It may also help parents and carers understand why medication is not being given even if the child is admitted to hospital.

Quality measures

Structure
Evidence of local arrangements to help parents and carers of children with bronchiolitis understand that medication is not being used because the condition is usually self-limiting.
Data source: Local data collection.
Process
a) Proportion of diagnoses of bronchiolitis in primary care where the parents and carers are informed that medication is not being used because the condition is usually self-limiting.
Numerator – the number in the denominator where the parents and carers are informed that medication is not being used because the condition is usually self-limiting.
Denominator – the number of diagnoses of bronchiolitis in primary care.
Data source: Local data collection.
b) Proportion of diagnoses of bronchiolitis in secondary care where the parents and carers are informed that medication is not being used because the condition is usually self-limiting.
Numerator – the number in the denominator where the parents and carers are informed that medication is not being used because the condition is usually self-limiting.
Denominator – the number of diagnoses of bronchiolitis in secondary care.
Data source: Local data collection.
Outcome
a) Parent- and carer-reported confidence in caring for children with bronchiolitis at home.
Data source: Local data collection.
b) Antibiotic prescribing rates for bronchiolitis.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as primary and secondary care and emergency departments) ensure that resources are available to help parents and carers of children with bronchiolitis understand that medication is not being used because the condition is usually self-limiting.
Healthcare professionals (such as GPs and secondary care clinicians) inform parents and carers of children with bronchiolitis that medication is not being used because the condition is usually self-limiting.
Commissioners (NHS England area teams and clinical commissioning groups) ensure that primary and secondary care providers have procedures in place to inform parents and carers of children with bronchiolitis that medication is not being used because the condition is usually self-limiting.

What the quality statement means for parents and carers

Parents and carers of children with bronchiolitis are informed that bronchiolitis usually settles without the need for treatment, which is why medication is not being used.

Source guidance

Bronchiolitis in children: diagnosis and management (2015) NICE guideline NG9, recommendation 1.4.3 (key priority for implementation)

Key safety information

This quality statement is taken from the bronchiolitis in children quality standard. The quality standard defines clinical best practice in assessing, diagnosing and managing bronchiolitis in children and should be read in full.

Quality statement

Parents and carers of children with bronchiolitis are given key safety information about what to expect and when to be concerned if caring for the child at home.

Rationale

Providing key safety information will reassure parents and carers about the natural progression of bronchiolitis, and provide information about when help from healthcare professionals is needed. Children may deteriorate rapidly, so it is vital that parents and carers can identify the signs and symptoms that mean they need to seek appropriate help from a healthcare professional.

Quality measures

Structure
Evidence of local arrangements to ensure key safety information is provided to parents and carers of children with bronchiolitis being cared for at home.
Data source: Local data collection.
Process
a) Proportion of diagnoses of bronchiolitis in primary care where the parents and carers are given key safety information if the child is to be cared for at home.
Numerator – the number in the denominator where the parents and carers are given key safety information.
Denominator – the number of diagnoses of bronchiolitis in primary care where the child is to be cared for at home.
Data source: Local data collection.
b) Proportion of discharges from hospital or emergency care of children with bronchiolitis where the parents and carers are given key safety information.
Numerator – the number in the denominator where the parents and carers are given key safety information.
Denominator – the number of discharges from hospital or emergency care of children with bronchiolitis.
Data source: Local data collection.
Outcome
Parent- and carer-reported confidence in caring for children with bronchiolitis at home.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as primary and secondary care and emergency departments) ensure that key safety information is available for parents and carers of children with bronchiolitis when the child is to be cared for at home.
Healthcare professionals (GPs and secondary care clinicians) give key safety information to parents and carers who are caring for children with bronchiolitis at home.
Commissioners (NHS England area teams and clinical commissioning groups) specify that key safety information is given to parents and carers who are caring for children with bronchiolitis at home.

What the quality statement means for parents and carers

Parents and carers of children with bronchiolitis are given key safety information if they are caring for the child at home. This information should explain how to reduce the risks to the child, and how to tell when the child needs to see a healthcare professional.

Source guidance

Bronchiolitis in children: diagnosis and management (2015) NICE guideline NG9, recommendation 1.6.1 (key priority for implementation)

Definitions of terms used in this quality statement

Key safety information
What to expect
In most children, bronchiolitis is mild and their breathing and feeding will get better within 5 days, though their cough may take longer to go (usually around 3 weeks, but sometimes it can be longer). There are no medicines that can cure bronchiolitis, but the normal medicines you would give for a cold (like paracetamol or ibuprofen) can help make the symptoms better.
When to be concerned
When caring for your child at home, you need to know these important signs and if they may be getting worse so you can get help as quickly as you can:
  • breathing becoming harder work – this may mean they are making an ‘effort noise’ every time they breathe out (often called grunting), flaring their nostrils, their chest might ‘suck in’ between the ribs, or they may use their stomach to breathe
  • not taking in enough feeds (half to three quarters of normal, or no wet nappy for 12 hours) – these are signs they might be dehydrated
  • pauses in their breathing for more than 10 seconds (apnoea)
  • skin inside the lips or under the tongue turning blue (cyanosis)
  • exhaustion (not responding as they usually would, sleepy, irritable, floppy, hard to wake up).
If you notice any of these signs, you must get help from a healthcare professional immediately.
Smoking can make their bronchiolitis symptoms worse, so do not smoke in your house.
[Bronchiolitis in children: diagnosis and management (NICE guideline NG9) information for the public, ‘caring for your child at home’ and recommendation 1.6.1]

Admission avoidance and early supported discharge: placeholder statement

This quality statement is taken from the bronchiolitis in children quality standard. The quality standard defines clinical best practice in assessing, diagnosing and managing bronchiolitis in children and should be read in full.

What is a placeholder statement?

A placeholder statement is an area of care that has been prioritised by the Quality Standards Advisory Committee but for which no source guidance is currently available. A placeholder statement indicates the need for evidence-based guidance to be developed in this area.

Rationale

Further guidance is needed on admission avoidance and early supported discharge of children with bronchiolitis. Bronchiolitis is most common in the winter months. Approximately 1 in 3 children will develop bronchiolitis in the first year of life and 2–3% of them will require hospitalisation. Involving teams such as children’s community nursing when a child has been diagnosed with bronchiolitis may help to reduce hospital admissions. Early supported discharge may also reduce hospital readmissions.
Caring for a child at home will also enable a flexible and personalised approach to care, meeting the needs of children with bronchiolitis and their families.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Glossary

Paths in this pathway

Pathway created: June 2015 Last updated: July 2017

© NICE 2017. All rights reserved. Subject to Notice of rights.

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