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Every second baby that comes to ED in winter seems to be a viral baby. 
The trick is to pick out the ones that require treatment and further workup 
- with a majority of babies not requiring any specific treatment prior to discharge home. 

Let’s start by clarifying some definitions:
Coryza: The colloquial ‘head cold’. Needs to be evidenced by clinical findings. Runny nose, dry cough, injected throat/TM, urticaria, sick contacts, positive swab. Adults and babies get this alike.
Croup: Laryngotracheobronchitis. A viral infection that has gone further down the respiratory tract. Laryngitis, tracheitis, and bronchitis. Older babies 2yo to 6yo tend to get this. The come in with a typical barking cough and can sound like a dying seal. The larynx is affected, so voice is hoarse.
Bronchiolitis: A viral illness that has gone even further down into the lungs. This is a viral infection of the smallest airways. Nonspecific crackles everywhere. Occasional wheeze. Younger babies, usually 2 months to 2 years tend to get this.
Lower Respiratory Tract Infection (LRTI): A lung infection, with a clinical diagnosis (eg unilateral coarse creps) but no radiological diagnosis.
Pneumonia: A lung infection with radiological evidence (CXR, US Lung, CT).
Viral Induced Wheeze (VIW): Commonly seen in babies with any kind of viral illness. It would be premature to diagnose these kids with asthma. Most babies with bronchiolitis, for example, will have wheeze due to lower airway inflammation (just like how patients with pulmonary oedema can get a bit wheezy without a history of asthma). That said, a trial of ventolin is safe and is sometimes beneficial.

Coryza / The Common Cold

HMO Edu Spiel: “This is a diagnosis of exclusion in the ED setting. As a rule of thumb, ensure the following prior to discharge”

Step 1: Confirm dx / evidence of coryza

Viral illness evidenced by (examples): nasal discharge, dry cough, blanching itchy rash, injected TM / throat.

Step 2: Ensure no red flags warranting further investigation.

All of the following are true:
– Vital signs completely WNL.
– Immunizations up to date (consider adm for obs. Screen for Pertussis / HiB)
– Corrected age > 44 weeks.
– No hx of severe prematurity
– No hx of Chronic lung disease / Congenital heart disease / Down’s syndrome / Immunodeficiency / ATSI or Indigenous / Chronic Neurological conditions
– No Suspicion of
— Pneumonia (Unilateral Coarse Creps / reduced AE)
— NAI
— Kawasaki’s / vasculitis (prolonged fever + Lymphadenopathy / Desquamation / Conjunctivitis / strawberry tongue / swollen hands or feet)
– No potentially sinister rash (eg nonblanching small petechiae < 3mm, or purpura, measles migratory pattern of exanthem w cough/conjunctivitis/coryza)

Step 3: Ensure the following prior to discharge

Vital signs completely within normal limits
While babies with viral illnesses can appear irritable, there are ‘periods of happiness’ whereby the baby appears normal to carers and observers.
Tolerating oral intake:
— TFI 150(0-3mo)/140(4-6)/130(7-9)/100(10-12)ml per kg per day.
— Divided by no of feeds per day.
— At least two thirds of that amount tolerated in ED.
— without starvation ketosis or hypoglycaemia on fingerprick.
Weight clearly documented on discharge paperwork.
If previous weight available, ensure not dropping centiles. If unavailable, ensure GP followup in 2-3 days to re check weight (especially if prev weight not available). Also instruct to review swab results if sent.
Safety net / Advice to return provided

Croup / Laryngotracheobronchitis

HMO Edu Spiel: “6mo to 6yo with a barking cough that’s worse at night, with no red flags.” Croup Red Flags: Daytime / multiple adrenaline / clinical (hypoxia / agitation / tiring / bradypnoea) / laryngomalacia (lose airway quickly) / epiglottitis (HiB unimmunised) / bacterial tracheitis (look very toxic/febrile/septic) / retropharyngeal abscess (slow progressing / pain on neck movement / muffled hot potato voice).

Step 1: Confirm dx Croup and exclude red flag

Right age for croup: > 6mo, < 6yo
Barking cough
End-of-the-bed-o-gram: Does not look unwell. (Fever is acceptable)
No suspicion of inhaled foreign body
No pre-existing narrowing of airways (laryngomalacia, birth defects, etc)
No signs of anaphylaxis (rash, oedema, abdo pain, nausea/vomiting)
No suspicion of sinister infective cause of stridor (see above)

Step 2: Risk Stratify

[Mild] stridor only when upset, normal RR, no WOB.
[Moderate] intermittent stridor at rest, mild tachypnoea, some WOB, agitation
[Severe] persistent stridor at rest, agitated++ or drowsy, marked WOB
[At Death’s Door] *Hypoxia* 🡪 Life Threatening 🡪 ICU/Anaesthethics, airway code, may require gas induction / theatre w ENT backup.

Step 3: Stepwise treatment

1mg/kg Prednisolone (mild/mod).
0.6mg/kg (12mg) IM dexamethasone (severe)
    OR 0.3mg/kg +/- 0.3mg/kg PO (in case kid vomits)
5ml 1:1000 5mg adrenaline in nebuliser undiluted. 15L O2 via non-rebreather.

Step 4: Disposition Planning

Discharge Criteria: Stridor free at rest. > 4 hours since last had adrenaline nebuliser. Given Handout. Safety net advice. Day time.
Provide education: “antitussives / antibiotics / humidifier doesn’t work”.
Admit if required more than one dose of adrenaline nebs.

Bronchiolitis

HMO Edu Spiel: “Viral LRTI 2mo to 2yo. Clinical diagnosis. Worse on day 3. Better in a week. An exercise in restraint and doing nothing.”

Step 1: Confirm this is actually bronchiolitis and exclude red flags

Right age… 2mo to 2yo. Peaks at 3-4mo, with:
– Coryzal illness prodrome (cough, runny nose)
– One or more of: cough, tachypnoea, rib retractions, widespread crackles/wheeze, fever.
With no red flags:
– Under 10 weeks old
– Chronic lung disease
– Congenital heart disease
– Down’s syndrome
– Immunodeficiency
– Indigenous
– Chronic Neurological conditions
– Suspicion of Pneumonia (Unilateral Coarse Creps / reduced AE)
– Suspicion of Pneumothorax (hx trauma / NAI / unequal chest rise / note absent breath sounds hard to illicit in babies)

Step 2: Severity Assessment for Bronchiolitis (sats apnoea feeding wob)

*All bronchiolitis babies will have transient desaturations. SpO2 telem not usually indicated.

MILD
>92% RA. No apnoeic episodes. Normal behaviour. Feeding well.
Discharge if meets all criteria below:
>> maintaining oxygenation; maintaining oral intake; daylight hours
>> safety net. Edu about expected course. Return if necessary / safety net.

MOD
90-92% RA. Brief apnoea. Some difficulty feeding. Intermittent irritability. Moderate WOB*

SEVERE
<90% RA. Frequent/long apnoeas. Reluctant feeding. Marked WOB (chest retractions, suprasternal retraction, nasal flaring). Fatigued, irritable.

Step 3: Management / Supportive Care (O2 and Feeding)

1) NP O2, target SpO2 > 90%. HFNP if still hypoxic on NP O2. Nasal CPAP and ICU referral if still not improving.
2) NG hydration if <50% normal feeds over 12 hours.
*No antibiotics. No antivirals.