7  Admissions and Common Presentations

Some background on admitting a child to hospital

Not everyone will be as versed in the hospital system as you are. Particularly families who have never had a child admitted to hospital will often be very anxious about the process. You will likely have seen many children with pneumonia. In your mind you can already picture the little 3 year old before you a few days down the track, running around the ward, being chased by a parent. The parent’s vision of the imminent future for their child might not be quite as rosy.

Fear plays a central part in the mindset of most people seeing a doctor for an acute health issue. This is magnified for parents of a sick child, even more so if this child requires admission to hospital. Be mindful of the fact that emotions are often high in these situations. Use a level of language appropriate for the family you are seeing. Remember that much of what you explain is likely to fall by the wayside as families grapple with their anxieties.

If you admit a patient from the ED outline what is going to happen next, such as when the family can expect to be transferred to the ward, any further tests that might be required, or other team members that will be reviewing the child. If you have already discussed a treatment plan with your ATR or consultant make sure the family understand what is going to happen.

Give the family space to ask questions. If you can not answer a question or feel you are not in the best place to answer (for instance because you do not feel it appropriate to talk about possible deterioration and the need for invasive ventilation) let the family know that you will arrange for a senior doctor to discuss these questions with the family.

Try not to fall into the trap to promise good outcomes if you can’t be sure. On the other hand, don’t be too guarded if the child is likely to be fine in a few days. Talking to families is a skill and an essential part of you growing into a more senior role. We have all started off with little experience and all been in a situation where we wished we could have addressed a certain issue in a different way. Listen to the way other team members talk to patients and families and see which techniques you would like to incorporate into your bedside manner.[^12]

General principals for admissions

Like all other tasks that you add to your to-do list on a continuing basis, there will be competing interests. Time management is the magic word whispered on every corridor - no matter the field of work you’re in. Prioritise the requests you receive. Patients who have already been sorted out in ED, are stable and simply waiting to go to the ward are likely in less urgent need of your input than a 7 months old boy with respiratory distress being commenced on high-flow cannula oxygen support without a clear diagnosis.

Of course, your list will also include numerous requests for charting drugs, scripts, fluid orders, inpatient reviews and many more. You might be carrying an additional pager because you’re cross-covering for a colleague’s afternoon off. It’s because you will be busy that you need to take the time to sort out what to concentrate on.

In the end, it will always come down to basic principles:

  1. Communicate frequently with others in your team. Make sure they’re doing ok.

  2. Review tasks

  3. Prioritise

  4. Allocate tasks

  5. Attend to your tasks

  6. Go back to 1, rinse, repeat.

There’s nothing wrong with needing help. Speak to the ATR or contact the on-call consultant.

Like any other sub-specialty, we have our “bread and butter” presentations that we see very frequently. That said: be wary of the “typical” child with whatever frequent presentation you have been seeing over the last week. Not every baby with crackles has bronchiolitis, not every tachypnoeic child with hypoxaemia has pneumonia. Ask yourself: “what else could this be?” with every patient you see.

You will find a selection of frequent presentations to our service over the following pages with some guidance on how to best initiate these patients’s workup and treatment.

Respiratory conditions are the most common illnesses responsible for children’s hospital admissions over all age groups. If your rotation with us falls into the summer, you might only see the occasional child with bronchiolitis. Conversely, if you are with us during a winter rotation you might come to think Respiratory Medicine was mostly about bronchiolitis and severe, complicated pneumonia.

Bronchiolitis is an interesting disease. Infants make up about 1% of the population but 10% of all hospital admissions. A proportion of these admissions occurs for conditions such as prematurity and jaundice but the majority of the rest is for respiratory illnesses. It is estimated that 2-3% of all infants will be hospitalised for bronchiolitis at some point. As bronchiolitis affects mostly young infants up to 6 months of age, it is frequently the cause for a child’s first hospital admission.

It may seem to you that being admitted to hospital was a common thing for a child but it is actually not. The lifetime risk for hospitalisation for a child up to the age of 17 is somewhere around 1:15. What is an everyday event for you – such as admitting a child with bronchiolitis – is very likely an extraordinary (and highly stressful) event for the family in front of you.

The majority of admissions of babies with bronchiolitis will come in under the General Paediatric team. Babies with bronchiolitis admitted under our bed card are usually the ones who are very sick and require admission straight to ICU or patients who are already known to our unit.

What to look out for

Even in our selected group of very sick babies with bronchiolitis the vast majority will have an excellent outcome.

Be aware of underlying conditions that pose an increased risk of morbidity and mortality:

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Also, very young infants (< 6 weeks) are at high risk of becoming very sick with bronchiolitis and frequently require intensive care admission.

General principles

Though bronchiolitis has an enormous impact on health care systems all over the world in terms of cost and health care utilisation, no illness modifying treatments have emerged in the last 50 years. You will likely have read a bit about the use of steroids, inhaled adrenaline / β-agonists or hypertonic saline for bronchiolitis. Unfortunately, none of these interventions make a discernible difference to length of stay or illness severity. The hallmarks of hospital treatment remain unchanged:

You will assess children along these lines accordingly. Does the child need supplemental oxygen? What is their respiratory rate and work of breathing? Is their breathing compatible with feeding orally? Remember that feeding is hard work for small infants and increases in their work of breathing and respiratory rate are not only going to make them more tired but also more prone to aspiration.

If supplemental oxygen is needed on the ward we use dry or humidified oxygen (to saturation vapour pressure) up to a flow of 2 l/min, heated to body temperature (370C). High flow oxygen (>2 l/min) via nasal cannula will always be humidified.

If the child can feed orally, consider whether decreasing the volume per feed and increasing the feed frequency might be beneficial. If you want to avoid oral feeds consider nasogastric feeds before you decide on intravenous fluids. The sickest infants with marked tachydyspnoea will usually not be candidates for enteral feeding and require intravenous fluids.

In general we aim for a reduced amount of daily fluids during the acute phase of moderate or severe bronchiolitis. Aim for 2/3 of the baby’s calculated fluid maintenance to keep the likelihood of dilutional hyponatraemia low (2nd to inappropriate ADH secretion, SIADH). This intervention might also reduce the likelihood of pulmonary oedema.

Respiratory support

If work of breathing becomes too much the baby will require help. The mode of respiratory support for a wide range of conditions has seen a significant shift over the past few years. Almost overnight humidified high flow nasal cannula oxygen (HFNCO2) has become first-line treatment for many infants and children requiring respiratory support.

Getting ready for discharge

Assess how well the child it is going throughout the day. Are there still problems following a prolonged ICU stay? How is the baby sleeping, how much rest is the mother (still mostly the primary care giver) getting? Is the child back to its pre-admission feeding regime and oxygen requirements? Make sure you check oxygen requirements over night as oxygen saturations tend to dip during deep sleep. How are the parents coping?

Not everything has to be back to normal for a child to return home. Often infants will continue to cough for quite a few weeks following a severe LRTI. Feeding might still not be fully at pre-illness levels – but it should be close. The odd child might even go home on a defined period of supplemental oxygen if there are no other concerns keeping the child in hospital.

Children who had a severe episode of bronchiolitis might benefit from follow up visits by the Monash Children’s @ Home team as a post-acute care follow-up. This way you can make sure the family copes with the anxieties of returning home, the baby is feeding well and gaining weight and is indeed continuing to improve.

Pneumonia occurs frequently in children. In affluent countries almost all children with pneumonia – be they of viral or of bacterial cause – will have complete recovery. In fact, most children with pneumonia in Australia don’t even require admission to hospital.[^13]

Of those children with pneumonia admitted to Monash Children’s only see a small proportion are admitted under our bedcard. Children with uncomplicated lobar pneumonia requiring hospital care are usually admitted under the General Paediatric bed card, unless special circumstances warrant admission under our team’s care (for instance, if the child is known to our team).

Children with pneumonia requiring admission under Paediatric Respiratory

Children with the following diagnosis at presentation require admission under the Paediatric Respiratory bed card:

Which tests to order for a child with suspected pneumonia

Which tests to order for a child with suspected pneumonia

In any infectious disease we would like positive confirmation of the pathogen causing the disease. In children with pneumonia we are rarely in the lucky situation to achieve this. This has a variety of reasons.

Most children are unable to provide a sputum sample to send for culture, which usually has the highest yield of positive confirmation. Urinary antigen tests (mostly for S pneumoniae) are in wide use in adult medicine. Unfortunately they are of little use in paediatrics because of their high rate of false-positives and false-negatives in this age-group, making it impossible to reliably interpret the result.

Blood cultures in childhood pneumonia are also a notoriously frustrating enterprise. Occasionally (≈5%), your efforts will be rewarded with a true-positive blood culture in a child with bacterial pneumonia (most often invasive S pneumoniae). More often though your efforts to improve your management by taking a blood culture will be complicated by Staphylococcus contamination from a poorly obtained blood-culture specimen. Try to avoid taking blood cultures for these patients - they rarely help with management for above reasons. To top it all off, it’s a costly practice that rarely changes management.[^14]

If you do decide to obtain a blood-culture make sure you adhere to a strict aseptic technique. Touching the skin of the insertion site just before inserting the needle to confirm position of the vein is likely to contaminate your blood-culture sample.

The child with empyema

Pleural empyema in children most often occurs as a complication of bacterial pneumonia. Often the child will initially be sick enough to warrant a chest X-ray. In the early stages of the illness there might not yet be much evidence of pleural effusion. In hindsight, subtle changes such as dulling of the costophrenal angle can often be seen even on early X-rays. Keep a close eye on a child with these early findings.

Frequently the suspicion of empyema is raised when a child fails to show clinical improvement despite adequate treatment with empirically appropriate antibiotics.

Indicators of treatment failure

Children with bacterial pneumonia usually improve within 24 hours after initiating appropriate antibiotic therapy. Failure of clinical improvement within 48 hours or clinical deterioration at any point requires re-evaluation of diagnosis and management.

Indicators of treatment failure:

You will primarily be guided by clinical features. Observing trends of laboratory parameters (acute phase proteins, WCC) has its role when in doubt about the clinical course of the patient. Avoid second guessing yourself by routinely ordering inflammatory labs on a patient that is clearly improving.

Workup / management of suspected pleural empyema

Routine investigations to investigate potential pleural empyema include:

On chest xray look for signs of pleural effusion, i.e.:

Ultrasound of the chest is highly sensitive in detecting the presence and amount of fluid. The report will also comment on the presence of fibrinous strands and the formation of loculations within the pleural space.

Discuss the ultrasound findings with the Respiratory ATR or on-call consultant to decide on further management of the patient. In some cases ongoing conservative management of the condition may be appropriate even in the presence of a small to midsized pleural effusion. Larger effusions, particularly those with formation of loculations within the pleural space, are unlikely to improve with conservative therapy alone and will frequently require surgical intervention.

Referring the patient to Paediatric surgery

If the decision has been made to refer the patient to Paediatric Surgery you may be asked to contact the Paediatric Surgical Resident or Registrar asking the team whether VATS (Video-assisted thorascopic surgery) would be appropriate for this patient. VATS is not the only way to address this condition. Many units will use intrapleural proteinases as first line treatment with excellent outcomes. Monash Children’s has traditionally used a more surgery forward approach but this may well change over time.

Make sure the family is aware of the referral to surgery and that their child might need an operation.

The referral should include brief history, positive and negative findings relevant to the current presentation, management so far and relevant past medical history. The surgeons at Monash Children’s are well versed with thorascopic techniques. Should the surgical team suggest a different approach or require further information these discussions will take place between the surgical team and the ATR or on-call consultant.

Monash Children's @ Home

Monash Children’s @ Home looks after patients in their home environment in a variety of constellations: