Most infants sent home from a bronchiolitis assessment come back not because the assessment was wrong but because the family was not told what the next three days would look like. Bronchiolitis peaks on days three to five, which means an infant discharged on day two will predictably get worse before improving, and a parent who has not been told that will read deterioration as a missed diagnosis.
Say the trajectory out loud: this will get worse before it gets better, the worst is usually day three to five, and the cough can last three weeks after everything else has settled. That single sentence prevents more re-attendances than any leaflet.
Then give specific return criteria rather than 'come back if you are worried'. Working of the breathing — nasal flaring, ribs drawing in, grunting. Feeding at less than about half the usual amount over several feeds, or fewer wet nappies. Pauses in breathing. Colour change around the lips. A baby who is difficult to rouse.
And say what will not be given and why, because an expectation that goes unaddressed becomes a second consultation elsewhere. There is no antibiotic, no bronchodilator and no steroid that helps ordinary bronchiolitis. Saying so, briefly and without defensiveness, is more effective than declining a request later.
One addition where maternal RSV vaccination or infant monoclonal antibody is available: record what the infant received or did not, because that history will matter at the next presentation and nobody will be able to reconstruct it.
- Tell families bronchiolitis peaks on days three to five, so worsening after discharge is expected, not a missed diagnosis
- Give specific return criteria: work of breathing, reduced feeding or wet nappies, apnoea, colour change, difficulty rousing
- Warn that cough can persist for about three weeks after recovery
- State plainly that antibiotics, bronchodilators and steroids do not help, before the family asks elsewhere
- Record maternal RSV vaccination and any infant monoclonal antibody in the notes
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