Earlier this summer I found myself on the other side of the fence: the worried parent of a child admitted to hospital with bronchiolitis.
For context, my daughter is 2, has no significant PMH and has had no previous admissions. She started nursery in the spring that the pandemic began. Since then she has had plenty of minor coughs and colds. There was a notable pause in infections over the winter lockdown. At the time it was a nice break from the seemingly perpetual covid swabs that the parents of young children have come to expect!
A few weeks ago she came home grumpy and off colour. Then came the predictable fever, snotty nose and cough. Time for another covid swab. When it came back negative I was relieved- back to nursery soon!
However this time she just didn’t improve, things worsened. Over the next few days, all she wanted to do was sit on the sofa, sleep, cuddle and watch TV. Her work of breathing went up and she remained feverish. My husband took her to the GP. At this stage, they diagnosed a possible bacterial chest infection and prescribed antibiotics. By the time I finished work later that day she was lethargic, her respiratory rate was climbing, she had intercostal recessions and scattered wheeze on her chest. She was the most unwell I’ve seen her.
She needed review. As a doctor, I knew this. As a parent, I wobbled. She had been seen by a brilliant health care professional earlier that day and had only just begun a course of treatment. Was I overreacting?
The news was full of A+E being ‘overwhelmed by children with mild winter viruses’ that could be treated at home. During the pandemic, the normal levels of viral illness in children have been suppressed to the point where parents have not been experienced in dealing with them to the usual extent. Putting it simply I did not want to be another anxious parent straining the services- especially not as a GP!
However common sense prevailed and I took her in. By the time we reached paediatric assessment unit her oxygen saturations were 87% and she was admitted. She had a trial of treatment with salbutamol, to which she didn’t respond, was put on oxygen and was diagnosed with bronchiolitis. Thankfully my daughter rallied quickly and our stay was short. At the point that she started rampaging around the ward trying to break into the room that had minions on the wall, I knew it was time to go home!
Whilst I was in the department I witnessed many children with minor illness come and go. I could see the truth behind the headlines as the vast majority did not need A+E attention. However, this does not mean that the parental anxiety was not real and that advice is not needed. The RCPCH has produced a helpful parent facing resource to support parents in self-care/ accessing care from the most appropriate source to the situation.
Anecdotally the consultant reported that they were seeing an unseasonal increase in RSV bronchiolitis related admissions, including in children above the usual age range (0-2) without underlying medical conditions. This tallies with data from the southern hemisphere showing a marked peak in RSV in their summer when levels are usually low. The UK government is predicting a rapid rise in RSV this autumn as it circulates around naïve children. It looks like primary and secondary care alike need to brace for the wave of RSV coming our way as covid restrictions are relaxed. In preparation, the RCPCH have produced useful pathways for use in community settings, including remote assessment and we are covering this topic to update GPs on our current Hot Topics course.
Following this experience, I have reflected on the doubts I sometimes experience as a GP if a patient I have seen gets admitted down the line. I worry that my management was wrong, or that I should have been able to predict the decline. However, this was a key example of a clinical picture that evolved with time and the importance of appropriate safety netting. Children have the physiological reserve to be able to compensate with significant illness; they can be really quite unwell but maintain relatively normal observations and O2 sats and then suddenly 'fall off a cliff' when they decompensate. It was only with an extended period of monitoring and repeated review that things became clear. I felt supported by every professional along the way. The GP was a key part of that journey.
Finally, thank you to all those who looked after us (especially the supplier of the 2am tea and toast). You all deserve a big round of applause!