children’s conditions specific care pathways · (adapted from apls+) respiratory rate at rest:...

• Condition specific care pathways and family information leaflets- developed by the multi- agency pathways group

• Pathways and leaflets developed – Asthma and wheeze pathway

– Asthma and wheeze for under 2s pathway

– Asthma and wheeze leaflet

– Diarrhoea and vomiting pathway and leaflet

– Bronchiolitis pathway and leaflet

– Fever pathway and leaflet

– Acute lower respiratory tract infection pathway

• Pathways and leaflets being developed – Constipation pathway and leaflet

– Head injury pathway and leaflet

– Abdominal pain pathway and leaflet

Children’s Conditions Specific Care Pathways

Wheeze in Primary Care – Clinical Assessment / Management Tool UNDER 2 yearsManagement – Out of Hospital Setting acute Asthma/Wheeze

· <3/12· Extreme low birth weight· Prolonged NICU/SCBU· CHD, pre-existing lung

condition· Reduced feeding <50%· Previous severe epidosed

Alarming Signs· SpO₂<92%, Cyanosis· Bradycardia < 100 beats /min· RR < 20 / Apnoea· Marked Sternal recessions· Worsening SOB· Poor air entry· Previous severe episodes· Too breathless to feed

Refer to hospital urgently (999)

Oxygen via face mask

Oxygen driven salbutamol nebuliser

· Alert· Still feeding· SpO₂ > 92%· Bilateral wheeze on· Auscultation· Good air entry

First Line Treatment:Up to 10 puffs of beta 2 agonist via MDI with spacer and face mask (preferred route)

or nebulised salbutamol. O₂ driven is the recommended method of nebulisation (compressor driven nebuliser treatment is acceptable if oxygen is not available)

Re-assess after 15 – 30 minutes

Poor response

· Antibiotics should not be routinely given· Oral beta 2 agonist not recommended· Personalised written action plan· Check inhaler technique· Safety net and review by 48 – 72 hrs· Provide parent information leaflet· Consider oral Prednisolone 10mg once a day for 3 days· Plain 5mg tablets is the first line option· 5mg/5ml unit dose oral solution is the second line option

· Bleep on call paediatrician urgently 01908 660033· Oxygen if SpO₂ < 94%

This guidance has been produced by the MK Caring for Children Closer to Home Pathway Design Group and is written in the following contextThis assessment tool was arrived at after careful consideration of the evidence available but not exclusively NICE, SIGN, Bristol guidelines, EBM data and NHS evidence. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. The guidance does not, however, 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. Issue date June 2015.

High Risk Children Prompt recognition of respiratory failure

Mild - Moderate

Good Response

Management of Acute Asthma/Wheeze in Primary CareClinical Assessment / Management Tool for 2 – 16 yearsManagement – Out of Hospital Setting acute Asthma/Wheeze

Immediate resuscitation if required. Dial 999

· Attack in late afternoon, at night or early in the morning · Recent hospital admission· Previous severe attack · Young age · Previous cardio-respiratory illness· Significant co-morbidity · Already taking oral steroids· Concern over social circumstances or ability to cope at home· Food allergy

Table 1: High Risk Factors – Healthcare professionals should be aware of the increased need for hospital admission in infants with the following:

· Fever (pneumonia) >38.5 C· Dysphagia (epiglottitis)· Productive cough (pneumonia)· Inspiratory stridor (croup)· Breathlessness with light headedness and peripheral tingling

(hyperventilation)· Asymmetry on auscultation (pneumonia or a foreign body etc)· Excessive vomiting (GORD)· Possibility of anaphylaxis

Table 2: Consider other diagnoses if any of the following are present:

Child presenting with acute wheeze

Table 3: Traffic Light system for identifying severity of acute wheeze/asthma

· Send home with personalised written action plan

· 3 days of oral prednisolone (See Table 4: Drug Doses)

· Antibiotics should not be routinely given· Check inhaler technique · Safety Net · Advise parents to contact their GP surgery the

next day to arrange a follow up within 48 – 72 hours

· Remember to check they have enough inhaler and appropriate spacer

· Consider stand-by steroids for future exacerbations

· Consider hospital admission/999· Oxygen if Sp02 <94%· Continue with further doses of

salbutamol while awaiting transfer· Add ipratropium dose mixed with

salbutamol nebuliser

· Refer to hospital A&E resus urgently via ambulance (999)· High flow oxygen via face mask if available· Give 10 puffs of salbutamol via spacer or nebuliser, oxygen driven if

available (See Table 4: Drug Doses)· If poor response add ipratropium bromide dose mixed with the

nebulised salbutamol (See Table 4: Drug Doses)· Continue with further doses of bronchodilator while awaiting transfer · Give 3 day course of prednisolone (See Table 4: Drug Doses)

· Give 2-10 puffs of salbutamol via spacer +/- facemask (given 1 puff at a time, inhaled separately using tidal breathing). If nebulising this should be oxygen driven but if necessary compressor driven is acceptable.

· Reassess 15-30 minutes post intervention· Consider a 3 day course of prednisolone – 1st dose now. (See

Table 4: Drug Doses)

Poor ResponseGood Response

Green – Moderate Amber – Severe Red – Life Threatening

Talking In sentences (active/alert) Not able to complete a sentence in one breathToo breathless to talk or feed

Not able to talk / Not respondingConfusion / Agitation

Auscultation of chest Good air entry, mild – moderate wheeze Decreased air entry with marked wheeze Silent chest

Respiratory Rate Within normal range • < 40 breaths / min (2-5 yrs)• < 30 breaths / min (> 5 yrs)

> 40 breaths p/min (2–5 yrs)> 30 breaths p/min (> 5 yrs)

CyanosisPoor respiratory effort Exhaustion

Heart Rate < 140 beats p/min (2–5 yrs)< 125 beats p/min (> 5 yrs)

> 140 beats p/min (2–5 yrs)> 125 beats p/min (> 5 yrs)

Tachycardic or Bradycardic Hypotension

Oxygen Saturation in air Greater than or equal to 92% in air < 92% in air < 92% in air

PEFR (if possible) > 50% of predicted 33 – 50% of predicted < 33% predicted

Feeding Still feeding / eating Struggling Unable to feed / eat

Table 4: Drug Doses:

This guidance has been produced by the MK Caring for Children Closer to Home Pathway Design Group and is written in the following context:

This assessment tool was arrived at after careful consideration of the evidence available including but not exclusively NICE. SIGN, Bristol guideline, EBM data and NHS evidence. Healthcare professionals are expected to take it fully into account when exercising clinical judgement. The guidance does not, however, 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. Issue date: June 2015.

Table 5: Normal Paediatric value(Adapted from APLS+) Respiratory Rate at rest: Heart Rate Systolic BP mmHg

Pre-school 2 – 5 years 25 – 30 95 – 140 85 – 100

School 5 – 11 years 20 – 25 80 – 120 90 – 110

Adolescent 12 – 16 years 15 – 20 60 – 100 100 – 120

Dose of Prednisolone (orally)First line option: plain 5mg tabletsSecond line option: 5mg/5ml unit dose oral solution

<2yrs 10mg; 2-5yrs 20mg; 5-7yrs 30mg; >7yrs 40mg

Dose of salbutamol nebulisers <5yrs 2.5 mg; >5yrs 5mg

Dose of Ipratropium Bromide 250 mcg all ages (or up to 500mcg via nebuliser for over 12 years)

Name: ...................................................................

Date: ...................................

How to Treat yourAsthma/Wheeze

Useful Websites:

Asthma UK: www.asthma.org.uk

Teenage Health Freak:www.teenagehealthfreak.com

Asthma is a condition that affects your airways (the tubes that take oxygen to and from your nose and mouth to your lungs),

and can begin at any age. With asthma, the airways are usually inflamed and are very sensitive to allergens and ‘triggers’.

During an asthma attack the airways become narrower making it harder for air to get in and out of the lungs. As air whistles

through the airways you can sometimes hear a wheeze.

Everyone’s triggers can be different but the most common include: colds and flu; smoke inhalation; exercise or playing; and

allergens, like dust mite, pollen or animal fur. It is important to recognise your triggers so that you can avoid them.

What is asthma?

Warning signs that your asthma is not well controlled include:● Waking up regularly to cough, feeling tight / wheezy during the night ● Early morning tightness wheeze or cough● Frequently needing your blue inhaler or using it more than 3 times a week

● Frequent exercise induced cough or wheeze

Reassess and monitor your child regularly (symptoms may start or get worse in the evening ) - please follow traffic light advice above.

REMEMBER ALWAYS HAVE YOUR BLUE INHALER AND SPACER WITH YOUIMPORTANT: ASTHMA/WHEEZE CAN BE LIFE THREATENING

LIFE THREAT

If your child:● becomes unresponsive● becomes blue● is having severe difficulty breathing - using tummy muscles - ribs are sinking in● unable to complete sentences● is unable to take fluids and is

getting tired ● is pale, drowsy, weak or quiet

MODERATE

If your child is:● having some difficulty in breathing /

noisy breathing● Mild wheeze and has breathless -

ness that is not responding to the usual reliever (blue inhaler) treatment

● Using their blue reliever inhaler – more than 2 puffs every 4 hours

● Breathing more quickly than normal

You need to contact a nurse or doctor today – within 4 hours

Please ring your GP surgery during the

day or when your GP surgery is closed,

please call NHS 111 by dialling 111

.

MILD

If your child is:Needs doctor / nurse review over the next few days, unless deteriorating. Continue to use blue inhaler as required. Read this leaflet about how to help with your wheeze / Asthma symptom control.

What do I do if my child is Wheezy / has Asthma? (traffic light advice)

You need EMERGENCY helpRing 999 - you need help immediately

If you have a blue inhaler use it now - 1 puff per minute via Spacer

UNTIL AMBULANCE ARRIVES

Nearest hospital: Milton Keynes Hospital (open 24 hours 7 days a week)

This guidance has been produced by the MK Caring for Children Closer to Home Pathway Design Group and is written in the following contextThis assessment tool was arrived at after careful consideration of the evidence available including but not exclusively ‘NICE, SIGN, Bristol guideline, EBM data and NHS evidence. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. The guidance does not, however, 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. Issue date: June 2015.

Increase blue inhaler 10 puffs over 20 minutes and repeat every 4 hours via spacer (1 puff every 5 breaths – tidal breathing)

Using their reliever more than usual or more than 3 times a week but is not breathing quickly and is able to continue doing day to day activities and is able to talk in full sentences

Spacers

One puff every five breaths using the spacer (Tidal Breathing)

Aero ChamberVolumatic

Treatment Plan once you are homeOral Prednisolone (Dose) .............................................................................................

Length of treatment (in days) ..............................................................................................

Start date: ..................................................... End date: ......................................................

Salbutamol (Blue Reliever Inhaler)

Dose.................................................. Start Date ................................................................

................................................................

Other Medication ................................................................................................................

................................................................................................................

This should be reduced using the Six Steps to reducing your inhaler usage guide below

Steroids (Preventer Inhaler) ......................................................................................

Dose.................................................. Start Date

Other Medication

Rinse gargle and spit after using steroid inhalersA follow up review should be undertaken by your GP/nurse within the next

................ days.

Always take your inhalers via a spacer as this is a much more effective way of getting medicines into the lungs● Smaller children (generally under 3 years)

to use spacer with face mask● Older children (generally over 3 years) to

use spacer with mouth piece

Reliever (Blue Inhaler)

Preventer Inhalers (many different colours but not blue)

My Preventer Inhaler is ................... (colour)

This inhaler prevents my lungs becoming irritated and inflamed.

I must use this every day even when I am well to keep my asthma under control.

Spacer prescribed? YES NO

Health Care Professional has checked technique?

YES NO

● Organise a review with your GP or Asthma Nurse at least once a year

● Keep your blue inhaler with you at all times

● Get a new inhaler when you start your last full one

● Ask your Health Care Professional how to use your inhaler and spacer properly and check your technique at every appointment

● If you run out, in an emergency a pharmacist may be able to supply a reliever inhaler (there may be a charge for this)

● Avoid trigger factors for your asthma/wheeze eg. pollen/dust

● Remember to rinse your mouth out after using your preventer● Wash your spacer monthly with warm soapy water, leaving it to drip dry.

Replace every 12 months● Smoking even outdoors will make asthma worse

When my asthma is back under control this is what I should do

If your child gets more wheezy or breathless, go back up a step and contact your GP as soon as possible

(If your child is sleeping and breathing comfortably you do not need to wake them to give them their inhalers overnight).

6 Inhale 10 puffs every 4 hours for 24 hours

5 Then inhale 8 puffs every 4 hours for 24 hours



2 Then inhale 2 puffs every 6-8 hours for 24 hours

1 Then inhale 2 puffs as and when required

GIVING YOUR INHALER Steps 1 -3 needs to be followed for each puff e.g. if asked to give 2 puffs; repeat the whole process twice. You may be given different coloured inhalers or chambers. The process is the same for all colours. Below are some examples of different coloured inhalers and chambers.

Top TipsSix Steps to reducing your salbutamol (Blue Reliever Inhaler) usage

This is my BlueReliever Inhaler.

This is used to relieve the wheeze/cough and can be used before exercise if necessary - it is best used with a spacer.

This helps me when I am coughing or wheezing by opening up and relaxing my lungs.

If I am using this more frequently than normal or more than 3 times a week, I should see my doctor or nurse to have my asthma checked.

When my asthma is well controlled I should not need to use my blue inhaler regularly.

Green - low risk Amber - intermediate risk Red - high risk

Activity - Responds normally to social cues - Altered response to social cues - Not responding normally to or no - Content/smiles - Decreased activity response to social cues - Stays awake / awakes quickly - No smile - Appears ill to a healthcare professional - Strong normal cry / not crying - Unable to rouse or if roused does not stay awake - Weak, high-pitched or continuous cry

Skin - Normal colour skin - Normal skin colour - Pale/Mottled/Ashen blue - Normal turgour - Warm extremities - Cold extremities - Reduced skin turgour

Respiratory - Normal breathing - Tachypnoea (ref to norm values box 3) - Tachypnoea (ref to normal values box 3)

Hydration - CRT < 2 secs - CRT 2 - 3 secs - CRT > 3 secs - Moist mucous membranes - Dry mucous membranes (except after a drink) (except for mouth breather) - Normal urine - Reduced urine output

Pulses / - Heart rate normal - Heart rate normal - Tachycardic (ref to norm values box 3) Heart rate - Peripheral pulse normal - Peripheral pulses normal - Peripheral pulses weak

Blood Pressure - Normal (ref to normal values box 3) - Normal (ref to normal values box 3) - Hypotensive (ref to normal values box 3)

Eyes - Normal eyes - Sunken eyes

Clinical Assessment tool for the Child with suspected gastroenteritis 0-5 yearsManagement Out of Hospital Setting

Child presenting with diarrhoea and/or vomiting:Assess for signs of dehydration, see table 1. (Consider Boxes 1 & 2 overleaf)

If there is blood or mucus in the stool or a suspicion of septicaemia or if the child is immunocompromised, bleep on call paediatrician 01908 660033.

• Home with advice to give 50ml/kg of an oral rehydration solution over 4 hours

without delay, often and in small amounts in addition give on-going ORS fluid

maintenance.

• Continue breastfeeding.

• Consider supplementing with usual fluids (including milk feeds/water, but not fruit

juices or carbonated drinks.

• If after 4 hours child is not tolerating ORS / vomiting / there is no improvement

/ cause for concern parents should be instructed to consider a face to face

re-assessment from a healthcare professional.

• Refer to Box 4 for stool microbiology advice.

• Give advice sheet.

• Consider admission according to clinical and social circumstance.

• Seek further advice – bleep on call paediatrician 01908 660033

• En-route parents should be encouraged to give child fluids often and in small amounts (including milk

feeds/water, but not fruit juices or carbonated drinks).

Send child for urgent assessment in hospital setting.

Commence relevant treatment to stabilise baby/child for transfer if

appropriate. Consider appropriate transport means (999).

Provide parents/carers with advice. Follow up by arranging an appointment with the appropriate health care professional. Direct to

local numbers overleaf.

If all green features and no amber or red

No clinical dehydration

Preventing dehydration:• Continue breastfeeding and

other milk feeds.

• Encourage fluid intake.

• Discourage fruit juices and carbonated drinks (especially

those children in Box 2).

• Offer oral rehydration solution (ORS) as supplemental fluid to those at increased risk

of dehydration (Box 2).

• Refer to Box 4 for stool microbiology advice.

Depending on severity of child and social circumstances in this category action should be based on clinical

judgement (consider Box 2).

If any amber features and no red

Clinical dehydration

If any red features

Clinical shock suspected or confirmed

Table 1 - Traffic light system for identifying signs and symptoms of clinical dehydration and shock

CRT: capillary refill time RR: respiration rate

Clinical Assessment tool for the Child with suspected gastroenteritis 0-5 yearsManagement Out of Hospital Setting

Box 1 Consider the following that may indicate diagnoses other than gastroenteritis:

Box 2 These children are at increased risk of dehydration:

Box 4 Stool microbiology advice:

- Temperature of 38oC or higher (younger than 3 months)- Temperature of 39oC or higher (3 months or older)- Shortness of breath or tachypneoa- Altered conscious state- Neck-stiffness- Abdominal distension or rebound tenderness- History/Suspicion of poisoning

- Children younger than 1 year, especially those younger than 6 months- Infants who were of a low birth weight- Children who have passed six or more diarrhoeal stools in the past 24 hours- Children who have vomited three times or more in the last 24 hours- Children who have failed to tolerate ORS- Infants who have stopped breastfeeding during the illness- Children with signs of malnutrition

Consider performing stool microbiological investigations if:

- the child has recently been abroad- the diarrhoea has not improved by day 7- suspected septicaemia- immunocompromised child- blood in stool

- Bulging fontanelle (in infants)- Non-blanching rash- Blood and/or mucus in stool- Bilious (green) vomit- Severe or localised abdominal pain- History of head injury

This guidance has been produced by the MK Caring for Children Closer to Home Pathway Design Group and is written in the following contextThis assessment tool was arrived at after careful consideration of the evidence available including but not exclusively ‘NICE, SIGN, Bristol guideline, EBM data and NHS evidence. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. The guidance does not, however, 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. Issue date: June 2015.

Information to give to parent/carer: • Ensure parent/carer has name and contact number of GP/practice nurse/relevant healthcare professional• MK Urgent Care Service – open 24/7, based at MK Hospital Campus, Standing Way, Eaglestone, Milton Keynes MK6 5NG• NHS 111• D&V patient information leaflet

Box 3: Normal Paediatric Values (also refer to PEWS chart)

Age Respiratory rate/min Heart rate/min Systolic Blood pressure mmHg

0-3 months 30-60 110-160 > 60

3-12 months 25-50 100-150 80

1-4 years 20-40 90-120 90 + (2 x age in years)


12 + 12-16 60-100 120

1oz = 30ml

Oral fluid challenge

Name

Date

Weight of child

Age of child 24 Hour fluid replacement

DOB

Time Fluid Amount Taken (ml/oz) Vomit/Diarrhoea (tick please)

Urine (tick please)

For the first four hours, please give your child ……………..mls of …………………. every ……..minutes

After 4 hours please give you child ……………..mls of …………………. every ……..minutes

(plus NICE 50ml/kg over 4 hours if dehydrated)

Please complete the chart below to show when you have given fluid, how much has been taken and whether your child has had any vomiting and/or diarrhoea and/or has urinated. Please keep this chart to give to a healthcare professional when/if your child is seen.

Clinical Assessment Tool for Babies/Children with Suspected BronchiolitisManagement in Primary Care

· Assess clinical signs and symptoms

· Assess Risk factors· Look for life threatening

signs and symptoms

See table 1 and Boxes 1 and 2

Box 2 Risk Factors:

· Pre existing lung disease, congenital heart disease, neuromuscular weakness, immune-incompetence

· Age <6weeks (corrected)· Prematurity (less than 35 weeks)· Family anxiety · Re-attendance · Duration of illness is less than 3 days and

Amber – may need to admit · Exposure to parental smoke

C

Consider referral to hospital according to clinical and social circumstance and risk factors. If further advice is required by a paediatric professional bleep the Paediatrician on call on 01908 660033.Provide a safety net for the parents/carers by using one or more of the following:

· Written or verbal information on warning symptoms and accessing further healthcare· Arrange appropriate follow up – refer to local services · Liaise with other professionals to ensure parent/carer has direct access to further assessment · Consider the need to follow up this child within 4 hours and see Hydration advice in box 2

If all green features and no amber or red If there are amber features and no red

Provide parents/carers with discharge advice. Follow up by arranging an appointment with an appropriate healthcare professional. Provide

information overleaf.

Oxygen support required? Send child for urgent assessment in hospital

setting.

Commence relevant treatment to stabilise baby/child for transfer if appropriate.

Consider commencing high flow oxygen support.

Consider calling 999

If any red features

No Yes

Is feeding sufficient to maintain hydration?

Box 1 Signs and Symptoms can include:

· Rhinorrhoeas (Runny nose)· Cough· Poor Feeding· Vomiting· Pyrexia· Respiratory distress· Apnoea· Inspiratory crackles +/- wheeze· Cyanosis

Yes No

Green – low risk Amber – intermediate risk Red – high risk

Colour (of skin, lips or tongue) Normal colour Pallor reported by parent/carer Pale/mottled/ashen/blue

Activity Responds normally to social cuesContent/smilesStays awake or awakens quicklyStrong normal cry/not crying

Not responding normally to social cuesNo smileWakes only with prolonged stimulationDecreased activity

No response to social cuesAppears ill to a healthcare professionalDoes not wake or if roused does not stay awake

Respiratory Nasal flaringTachypnoea:- RR >50 breaths/minute, aged 6-12 months- RR >40 breaths/minute, age > 12 monthsOxygen saturation ≤95% in airCrackles in the chest

GruntingTachypnoea: RR >60 breaths/minuteModerate or severe chest indrawing

Circulation and hydration Normal skin and eyesMoist mucous membranes

Tachycardia:- > 160 beats/minute, age <12 months- >150 beats/minute, age 12-24 months- >140 beats beats/minute, age 2-5 yearsCRT ≥3 secondsDry mucous membranesPoor feeding in infantsReduced urine output

Reduced skin turgor

Other None of the amber or red symptoms or signs

Age 3-6 months, temperature ≥39°CFever for ≥5 daysRigoursSwelling of a limb or jointNon-weight bearing limb/not using an extremity

Age <3 months, temperature ≥38°CNon-blanching rashBulging fontanelleNeck stiffnessStatus epilipticusFocal neurological signsFocal seizures

CRT: Capillary Refill Time, RR: Respiratory Rate. * This traffic light table should be used in conjunction with the recommendations in the guidelines on investigations and initial management in children with fever. See http://guidance.nice.org.uk/CG160 (update of NICE clinical guidance 47).


This assessment tool was arrived at after careful consideration of the evidence available including but not exclusively NICE. SIGN, Bristol guideline, EBM data and NHS evidence. Healthcare professionals are expected to take it fully into account when exercising clinical judgement. The guidance does not, however, 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. Issue date: TBA.

Information to give to parent/carer:

Ensure patient/carer has name and contact number of GP/Practice Nurse/relevant healthcare professional

MK Urgent Care Service – Open 24/7, based at MK Hospital Campus, Standing Way, Eaglestone, Milton Keynes, MK6 5NG

NHS 111

Bronchiolitis patient information leaflet

· Children younger than 1 year, especially those younger than 6 months· Infants who were of a low birth weight· Children who have passed six or more diarrhoeal stools in the past 24 hours· Children who have vomited three times or more in the last 24 hours· Children who have failed to tolerate ORS· Infants who have stopped breastfeeding during the illness· Children with signs of malnutrition

Box 4: These children are at increased risk of dehydration:

Table 3

Normal paediatric values:

Age Respiratory rate Hear rate/min Systolic Blood pressure mmHg

0-3 months 30-60 110-160 >60

3-12 months 25-50 100-150 80



12+ years 12-16 60-100 120

· Your child may have a runny nose and sometimes have a temperature and a cough.

· After a few days your child’s cough may become worse.· Your child’s breathing may be faster than normal and it

may become noisy. He or she may need to make more effort to breathe.

· Sometimes, in very young children, bronchiolitis may cause them to have brief pauses in their breathing.

· Sometimes their breathing can become more difficult, and our child may not be able to take their usual amount of milk by breast or bottle or may want to feed more frequently but take a smaller amount.

· You may notice fewer wet nappies than usual. · Your child may vomit after feeding and become irritable.

What are the symptoms?

If they have or were:· A premature baby· Are less than 6 weeks old· A lung problem · A heart problem · A problem with their immune system· Or any other pre-existing medical conditions that may

affect your child’s ability to cope with this illness

Please contact your Practice Nurse or Doctor

Below are some other conditions that could affect your child’s ability to cope:

· Most children with bronchiolitis will seem to worsen during the first 1-3 days of the illness before beginning to improve over the next two weeks. The cough may go on for a few more weeks.

· As a parent / carer, you may find this useful to know as it lasts longer than the normal coughs / colds that children get.

· Your child can go back to nursery or day care as soon as he or she is well enough (feeding normally and with no difficulty in breathing).

· There is usually no need to see your doctor if your child is recovering well. If you are worried about your child’s progress, discuss this with your Health Visitor, Practice Nurse or Doctor.

How long does bronchiolitis last?

If you need advice please try:

Your local pharmacy can be found at www.nhs.uk

Health Visitor: ……………………………………………………..

Your GP Surgery: ………………………………………………….

Please contact your GP when the surgery is open or call NHS 111 when the GP surgery is closed. NHS 111 provides advice for urgent care needs.NHS 111 is available 24 hours a day, 365 days a year. Calls from landlines and mobile phones are free.NHS Choices: www.nhs.uk

Some useful telephone numbers:

If you are worried about your child, trust your instincts.

Contact your GP or dial NHS 111


This assessment tool was arrived at after careful consideration of the evidence available including but not exclusively NICE. SIGN, Bristol guideline, EBM data and NHS evidence. Healthcare professionals are expected to take it fully into account when exercising clinical judgement. The guidance does not, however, 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. Issue date: TBA.

Bronchiolitis Advice Sheet

Advice for parents and carers of children aged 2 years old and under

What is bronchiolitis?

Bronchiolitis is when the smallest air passages in a child’s lungs become swollen. This can make it more difficult for your child to breathe. Usually, bronchiolitis is cause by a virus called respiratory syncytial virus (known as RSV). Almost all children will have had an infection caused by RSV by the time they are two years told. It is most common in the winter months and usually only causes mild “cold-like” symptoms.

Most children get better on their own. Some children, especially very young ones, can have difficulty with breathing or feeding and may need to go to hospital.

Most children with bronchiolitis get better within about two weeks. The cough may go on for a few more weeks.

· If your child is not feeding as normal, offer smaller feeds more frequently.

· If your child is distressed or you feel they are in discomfort you may use medicines (Paracetamol or Ibuprofen) to help them feel more comfortable. However, you may not need to use these medicines.

· At home, we do not recommend giving both Paracetamol and Ibuprofen at the same time together. If you child has not improved after 2-3 hours you may want to give them the other medicine. Never exceed the dose on the bottle.

· Please read and follow the instructions on the medicine container. Over the counter (OTC) medicines may not be available to purchase for all age groups. Ask your pharmacist.

· If your child is already taking medicines or inhalers, you should carry on using these. If you find it difficult to get your child to take them, ask your Pharmacist, Health Visitor or Doctor for advice.

· Bronchiolitis is caused by a virus so antibiotics will not help.

How can I help my baby?

Make sure your child is never exposed to tobacco smoke. Passive smoking can seriously damage your child’s health. It can make breathing problems like bronchiolitis worse. Remember smoke remains on your clothes when you smoke anywhere including outside.

Passive smoking affects your baby – if you would like help to stop smoking: www.nhs.uk/smokefree

What do I do if my child has bronchiolitis? (traffic light advice)

Most children with bronchiolitis get better over time, but some children can get worse.You need to regularly check your child and follow the advice below.

RED

AMBER

GREEN

If your child has any one of these below:· Has blue lips· Or is unresponsive or very irritable· Or is struggling to breathe· Or has unusually long pauses in breathing· Or has an irregular breathing pattern

If your child has any one of these below:· If your child’s health gets worse or you are

worried· Or has decreased feeding by 50% (half)· Or you are needing to change the nappy less

frequently than normal· Or has vomited on more than one occasion· Or temperature is above 38 degrees centigrade· Or is finding it difficult to breathe· Please see box “conditions that could affect

your child’s ability to cope” overleaf

If none of the features in the red or amber boxes above are present.

You need EMERGENCY helpCall 999 or go straight to the nearest Hospital

Emergency (A&E) Department

Nearest Hospitals (open 24 hours 7 days a week):

· Milton Keynes Hospital · John Radcliffe, Oxford· Luton and Dunstable Hospital · Bedford Hospital · Northampton Hospital· Stoke Mandeville Hospital, Aylesbury

Bring your child’s Red Book with you.

You need to contact a nurse or doctor today

Please ring your GP Surgery during the day or when your GP Surgery is closed,

please call NHS 111


Self CareUsing the advice on this leaflet you can

care for you child at home.If you feel you need advice please contact your Health

Visitor or GP Surgery or your local pharmacy(follow the links at www.nhs.uk)

You can also call NHS 111

Fever Advice Sheet for Children 0-5 yearsMost children with a fever do get better very quickly but some children can

get worse. You need to regularly check your child and follow the advice below.

If your child has any one of these below:· Has blue lips· or is unresponsive or very irritable· or is struggling to breathe· or has unusually long pauses in breathing· or has an irregular breathing pattern· or has a non-blanching rash· or has had a fit (having never had one in the

past)· or has a bulging fontanel· or is unresponsive· or has neck stiffness

You need EMERGENCY helpCall 999 or go straight to the nearest Hospital Emergency (A&E)

DepartmentNearest Hospitals (open 24 hours 7 days a week):

· Milton Keynes Hospital· John Radcliffe, Oxford· Luton and Dunstable Hospital· Bedford Hospital· Northampton Hospital· Stoke Mandeville Hospital


If your child has any one of these below:· If your child’s health gets worse or you are

worried· or has decreased feed by 50% (half)· or you are needing to change the nappy less

frequently than normal· or has vomited on more than one occasion· or temperature is above 38° C· or is finding it difficult to breathe· or has had a fever for more than 5 days· or has had a rash that has not been seen by a

clinician· or has had a severe pain that doesn’t go away

with painkillersPlease see box “conditions that could affect your child’s ability to cope” overleaf

If none of the features in the red or amber boxes above are present.

Self careUsing the advice on this leaflet you can care for your child at

home.If you feel you need advice please contact your local Health Visitor

or GP surgery or your local pharmacy (follow the links at www.nhs.uk)

You can also call NHS 111

You need to contact a nurse or doctor today

Please ring your GP surgery during the day or when your GP surgery is closed please call NHS 111


Keep a record of how your child is doing to help you remember when you gave the medicines and how your child has been feeling.

Time and date Temperature Medicines given What is your child doing?

If you have been given this leaflet by a doctor or nurse they will advise you about what to look out for.

Name of child________________________________________________________________________________

Age______________________ Date/Time advice given__________________________________

Name of professional (print)____________________________________________________________________

Signature of professional______________________________________________________________________

Further advice/Follow Up______________________________________________________________________Some useful telephone numbersGP/Practice Nurse____________________________________________________________________________(Parent to complete)Health Visitor________________________________________________________________________________(Parent to complete)If out of hours please call 111

· Check your child during the night to see if they are getting better· If a rash appears do the tumbler test (see guidance below)· If you are concerned that your child is not improving follow the advice on the

front of this sheet· Children with fever should not be under cover or over dressed· If your child is hot to touch remove some of their clothes· If your child is distressed or very unwell you may use medicines (paracetamol or

ibuprofen) to help them feel more comfortable however it is not always necessary

· Please read the instructions on the medicine bottle first· Don’t give both medicines (paracetamol and ibuprofen) at the same time· Use one and if your child has not improved 2-3 hours later you may want to try

giving the other medicine· Please ask your local pharmacist for more advice about medicines· Never give aspirin to a child· Offer your child regular drinks (where a baby is breastfed the most appropriate

fluid is breast milk)· If your child is due to have immunisations please consult your GP, practice nurse

or Health Visitor for advice as there may be no need to delay their appointment· If you need to keep your child away from nursery or school while they are unwell

and have a fever please notify the nursery or school – your health visitor, community nurse of GP will be able to advise you if you are unsure

Looking After Your Feverish Child

The Tumbler Test

Do the ‘tumbler test’ if your child has a rash. Press a glass tumbler firmly against the rash. If you can see the spots through the glass and they do not fade this is called a ‘non-blanching rash’. If this rash is present seek medical advice immediately. The rash is harder to see on dark skin so check paler areas, such as palms of the hands, soles of the feet, tummy and inside the inside the eyelids.

(Photo courtesy of the Meningitis Research Foundation)

If they have or were:· A premature baby· Are less than 6 weeks

old· A lung problem · A heart problem · A problem with their

immune system· Or any other pre-

existing medical conditions that may affect your child’s ability to cope with this illness


If they have or were:· A premature baby· Are less than 6 weeks

old· A lung problem · A heart problem · A problem with their

immune system· Or any other pre-

existing medical conditions that may affect your child’s ability to cope with this illness


Below are some other conditions that could affect your child’s ability to cope:

Management of Feverish Illness Out of HospitalClinical Assessment and Management Tool for Children over 3 months

Child presents with a feverish illness

Remote assessment Face to Face Assessment

Using the traffic light system; If evidence of any amber features, undertake a face

to face assessment within 2 hours

First, healthcare professionals should identify any immediately life-threatening features, including compromise of the airway, breathing or circulation, and decreased level of consciousness

Immediate resuscitation if required.

Dial 999

Identifying risk of serious illness Identifying life threatening features

Use the traffic light system to assess the risk of serious illness

Children with ‘green’ features and none of the ‘amber’ or ‘red’ features can be cared for at

home with appropriate advice for parents and carers, including advice on when to seek

further attention from the healthcare services

See advice box 3 for home care

If any ‘amber’ features are present and no diagnosis has been reached, provide parents or carers with a ‘safety net’ or refer to specialist

paediatric care for further assessment. The safety net should be 1 or more of the following:

· providing the parent or carer with verbal and/or written information on warning symptoms and how further healthcare can be assessed

· arranging further follow-up at a specialist time and place· liaising with other healthcare professionals, including out-of-hours

providers, to ensure· direct access for the child if further assessment is required.

Children with any ‘red’ features but who are not considered to have an immediately life threatening illness

should be referred urgently to the care of a paediatric specialist

Management by a paediatric specialistSee pathway

Assess for Symptoms and signs of a specific illness

If any red featuresIf any amber features and no redIf all green features and no amber or red

Table 1: Symptoms and signs of specific illness

Diagnosis to be considered

Meningococcal disease

Bacterial meningitis

Herpes simplex encephalitis

Pneumonia Urinary tract infection

Septic arthritis

Kawasaki disease

Symptoms and signs in conjunction with fever

Non-blanching rash, particularly with one or more of the following:- An ill-looking child- Lesions larger

than 2mm in diameter (purpura)

- Capillary refill time of ≥3 seconds

- Neck stiffness- Bacterial

meningitis- Bulging fontanelle

Bulging fontanelleDecreasing level of consciousnessConvulsive status epilepticusNeck stiffness

Focal neurological signsFocal seizuresDecreased level of consciousness

Tachypnoea: respiratory rate:>60 breaths/minute,

age 0-5 months>50 breaths/minute, age 6-12 months>40 breaths/minute, age >12monthsCrackles in the chestNasal flaringChest indrawingCyanosisOxygen saturation ≤95%

VomitingPoor feedingLethargyIrritabilityAbdominal pain or tendernessUrinary frequency or dysuria

Swelling of a limb or jointNot using an extremityNon-weightbearing

Fever for more than 5 days and at least 4 of the following:- bilateral

conjunctivalinjection

- Change in mucus membranes

- Change in the extremities

- Polymorphous rash

- Cervical lymphadenectomy

Bacterial meningitis and meningococcal

septicaemia NHS Guidelines

Urinary tract infection in

children NICE Guidelines










Reduced skin turgor





Management of Feverish Illness Out of HospitalClinical Assessment and Management ToolTable 2

Normal paediatric values:

Age Respiratory rate Hear rate/min Systolic Blood pressure mmHg

0-3 months 30-60 110-160 >60

3-12 months 25-50 100-150 80



12+ years 12-16 60-100 120

Advice for home careManage the child’s temperature as described in antipyretic interventions.Advise patients or carers looking after a feverish child at home:· To offer the child regular fluids (where a baby or child is breastfed the most appropriate fluid is breast milk)· How to detect signs of dehydration by looking for the following features:

· sunken fontanelle· dry mouth· sunken eyes· absence of tears· poor overall appearance

· To encourage their child to drink more fluids and consider seeking further advice if they detect signs of dehydration· How to identify a non-blanching rash· To check their child during the night· To keep their child away from the nursery or school while the child’s fever persists but to notify the school or nursery of the illness.When to seek further helpFollowing contact with a healthcare professional, parents and carers who are looking after their feverish child at home should seek further advice if:· The child has a fit· The child develops a non-blanching rash· The parent or carer feels that the child is less well that when they previously sought advice· The parent or carer is more worried than when they previously sought advice· The fever last longer than 5 days· The parent or carer is distressed, or concerned that they are unable to look after their child· Difficulty breathing

Antipyretic interventionsEffects of body temperature reductionAntipyretic agents do not prevent febrile convulsions and should not be used specifically for this purpose.Physical interventions to reduce body temperatureTepid sponging is not recommended for the treatment of fever.Children with fever should not be underdressed or over-wrapped.Drug interventions to reduce the body temperatureConsider using either paracetamol or ibuprofen in children with fever who appear distressed.Do not use antipyretic agents with the sole aim of reducing body temperature in children with fever.When using paracetamol or ibuprofen in children with fever:· Continue as long as the child appears distressed· Consider changing to the other agent if the child’s distress is not alleviated· Do not give both agents simultaneously· Only consider alternating these agents if the distress persists or recurs

before the next dose is due.

Thermometers and the detection of feverOral and rectal temperature measurementsDo not routinely use the oral or rectal routes to measure the body temperature of children aged 0-5 years.Measurement of body temperature at other sitesIn infants under the age of 4 weeks, measure body temperature with an electronic thermometer in the axilla.In children aged 4 weeks to 5 years, measure body temperature by one of the following methods:· Electronic thermometer in the axilla· Chemical dot thermometer in the axilla· Infra-red tympanic thermometerHealthcare professionals who routinely use disposable chemical dot thermometers should consider using an alternative type of thermometer when multiple temperature measurements are required.Forehead chemical thermometers are unreliable and should not be used by healthcare professionals.

This guidance has been produced by the MK Caring for Children Closer to Home Pathway Design Group and is written in the following contextThis assessment tool was arrived at after careful consideration o the evidence available including but not exclusively NICE Guidelines. Healthcare professionals are expected to take it fully into account when excising their clinical judgement. The guidance does not, however, 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.

Advice box 1

Advice box 2 Advice box 3

Acute Lower Respiratory Tract Infection in Children(> 1 Year Old) Out of HospitalClinical Assessment & Management

Increased need for hospital admission if children have any of the following:· Recent hospital admission· Younger age children· Pre-existing cardio-respiratory condition· Compromised immune system

Acute illness with fever (>38.5°C) and breathlessness that is not thought to be asthma or bronchiolitis.

Cough, tachypnoea, signs of respiratory distress, crepitations, purrulent sputum, pleurritic chest pain or upper abdominal pain may or may not be present.

High risk factors Clinical Diagnosis of Pneumonia

Assess Severity (treat according to category of most severe signs and symptoms)

If all green features and no amber or red If any amber features and no red If any red features

Mild Disease· Can be managed in the community· Chest radiograph not required· Consider oral antibiotics

Consider 1st Line Oral AntibioticsFirst choice – Amoxicillin (7 days)Penicillin allergic – Clarithromycin (7 days)Amoxicillin plus clarithromycin may be required in certain situations

Safety NettingAdvice about:· Signs of deterioration· Fever management· Prevention of hydration· When to seek helpDischarge home – ask parents to return of:· Not tolerating fluids or oral antibiotics· High swinging or persistent fever

(particularly after 48hrs of treatment)· Increasing effort of breathing,

agitation or distressAdvise parents to seek review if cough persists 8 weeks after the initial illness

Moderate Disease· Discuss with Paediatric team

Severe Disease· Arrange urgent transfer to hospital· If Sp02 <92% oxygen given by nasal

cannula, high flow density delivery device or face mask to maintain oxygen saturation >92%

Moderate DiseaseIf both primary care physician and paediatric team agree child can be managed in the community. Follow advice for mild disease.

Deterioration or No Improvement at 48 hours· Re-evaluate· Consider possible complications (e.g. sepsis, pleural effusion, empyema, lung

abscess, metastatic infection, haemolytic uraemic syndrome, dehydration)· Consider whether child is having appropriate drug treatment at an adequate dosage· Consider adding macrolide· Discuss with paediatric team

Review at 48 – 72 hours or earlier if deterioration

Improving· Reinforce safety advice· Advise parents to seek review if

cough persists 8 weeks after the initial illness










Reduced skin turgor





Acute Lower Respiratory Tract Infection in Children(> 1 Year Old) in Primary CareClinical Assessment & Management

Chest X-RayShould not be routine in children not admitted to hospital as:· Poor correlation with clinical signs· CXR is too insensitive to distinguish viral from bacterial aetiology

However as per the NICE Guidelines “Feverish Illness in Children” there is a role for CXR in those aged less than three months with respiratory signs and in older children with fever and no focus.

Other InvestigationsGenerally investigations are not required in LRTI. Acute phase reactants (ESR/CRP) are not useful in distinguishing viral from bacterial pneumonia. Further microbiological diagnosis is useful only in children with severe pneumonia (i.e. PICU or complications).

Chest X-RayShould not be routine in children not admitted to hospital as:· Poor correlation with clinical signs· CXR is too insensitive to distinguish viral from bacterial aetiology

However as per the NICE Guidelines “Feverish Illness in Children” there is a role for CXR in those aged less than three months with respiratory signs and in older children with fever and no focus.

Other InvestigationsGenerally investigations are not required in LRTI. Acute phase reactants (ESR/CRP) are not useful in distinguishing viral from bacterial pneumonia. Further microbiological diagnosis is useful only in children with severe pneumonia (i.e. PICU or complications).

Antibiotics· Children under the age of 2 with mild symptoms do not usually have pneumonia and need not be treated with oral antibiotics. They should be

reviewed if symptoms persist.· All children > 2 years of age with a clear diagnosis of Community Acquired Pneumonia (CAP) should receive antibiotics as differentiating

between bacterial and viral pneumonia, clinically or radiologically, is unreliable.

Oral Antibiotics· Oral antibiotics are safe and effective for even severe CAP.· Amoxicillin is recommended as first choice oral antibiotic. A macrolide can be used in penicillin allergy.· Add Flucloxacillin for 14-21 days for suspected infection with staphylococci (in influenza or measles)Macrolide antibiotics can be added if:· There is no response to first line therapy after 48 hours· Mycoplasma or Chlamydia is suspected (symptoms worse than the signs would suggest, insidious onset, chest pain, non-respiratory

symptoms [e.g. arthralgia, headache, on-going malaise]. Mycoplasma pneumonia is responsible for up to 40% of community-acquired pneumonia in children over five years of age but should also be considered in younger children). Treatment should be for 10 days with both agents.

Antibiotics· Children under the age of 2 with mild symptoms do not usually have pneumonia and need not be treated with oral antibiotics. They should be

reviewed if symptoms persist.· All children > 2 years of age with a clear diagnosis of Community Acquired Pneumonia (CAP) should receive antibiotics as differentiating

between bacterial and viral pneumonia, clinically or radiologically, is unreliable.

Oral Antibiotics· Oral antibiotics are safe and effective for even severe CAP.· Amoxicillin is recommended as first choice oral antibiotic. A macrolide can be used in penicillin allergy.· Add Flucloxacillin for 14-21 days for suspected infection with staphylococci (in influenza or measles)Macrolide antibiotics can be added if:· There is no response to first line therapy after 48 hours· Mycoplasma or Chlamydia is suspected (symptoms worse than the signs would suggest, insidious onset, chest pain, non-respiratory

symptoms [e.g. arthralgia, headache, on-going malaise]. Mycoplasma pneumonia is responsible for up to 40% of community-acquired pneumonia in children over five years of age but should also be considered in younger children). Treatment should be for 10 days with both agents.

Follow UpIf a child was previously healthy and is recovering well from CAP then no follow up is needed. Parents should be instructed to see the GP after 3 weeks if the cough has not resolved. Hospital out-patient follow up and radiology should be arranged in cases of:· Severe pneumonia • Empyema • Lobar Collapse· Persisting symptoms • Lung abscess • Effusion

Follow UpIf a child was previously healthy and is recovering well from CAP then no follow up is needed. Parents should be instructed to see the GP after 3 weeks if the cough has not resolved. Hospital out-patient follow up and radiology should be arranged in cases of:· Severe pneumonia • Empyema • Lobar Collapse· Persisting symptoms • Lung abscess • Effusion

This guidance has been produced by the MK Caring for Children Closer to Home Pathway Design Group and is written in the following contextThis assessment tool was arrived at after careful consideration of the evidence available including but not exclusively NICE Guidelines. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. The guidance does not, however, 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.

Authors: Ralph Robertson, Craig McDonaldReferences:1. Harris et. Al. (2011), British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011. Thorax 2011; 66:ii1 – ii232. Richardson et. Al. (2007), Feverish illness in children: Assessment and initial management in children younger than 5 years. NICE Guidance.3. Wang et. Al. (2012), Clinical symptoms and signs for the diagnosis of Mycoplasma pneumonia in children and adolescents with community acquired pneumonia, Cochrane Database of Systematic Reviews4. BNFc (2014), Section 5.1.2.1, Cephalosporins

Age Respiratory rate/min Hear rate/min Systolic Blood pressure mmHg

0-3 months 30-60 110-160 >60

3-12 months 25-50 100-150 80

1-4 years4-12 years12+ years

20-4020-3012-16

90-12070-11060-100

90 + (2 x age in years)90 + (2 x age in years)120

Normal paediatric values

Table 2 – Oral Antibiotic DosesAmoxicillin

(7 day treatment duration)

Clarithromycin(7 day treatment duration)

Flucloxacilin(7 day treatment duration)

1-5 years: 250mg tds < 8kg: 7.5mg/kg bd 1 months – 2 years 62.5-125mg qds

5-16 years: 500mg tds 8-11kg: 62.5mg bd 2-10 years 125-250mg qds

12-19kg: 125mg bd 10-16 years 250-500mg qds

20-29kg: 187.5mg bd

>12y / >30kg: 250mg bd

children’s conditions specific care pathways · (adapted from apls+) respiratory rate at rest:...

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