Pneumonia, a common cause for acute respiratory infection, is one of the most common causes of hospital admissions in children.
We know that children with neurological disorders (e.g. cerebral palsy, epilepsy, and neuromuscular disorders) are more likely to be admitted to hospital with pneumonia than children with other conditions but, until recently, little was known why.
We also know these children are older, have a longer length of stay and are more likely to be admitted to intensive care. When these children are tested, a respiratory pathogen is less likely to be found, because the cause of their pneumonia is from aspiration and not from infection.
I am leading a research project to better understand respiratory risk factors for children with cerebral palsy with the ultimate aim of reducing symptom severity and the need for hospital admissions.
We have identified three key risk factors for admission for acute respiratory infections in children with cerebral palsy (see Fig. 1). These include severe cerebral palsy (inability to control head posture against gravity), admission to hospital during the previous year, or two courses of oral antibiotics in the previous year.
We have also worked on identifying potentially modifiable risk factors including oropharyngeal dysphagia (mealtime modifications like tube feeding, thickened fluids), frequent respiratory symptoms (coughing, choking on saliva, wheezing, or gurgling), current seizures, gastro-oesophageal reflux, mealtime respiratory symptoms, nightly snoring and poor dental hygiene.
What does it mean for GPs?
- Children with severe neurological disorders are at increased risk of respiratory infections.
- Maximise general health including ensuring current vaccination protection, dental hygiene, nutritional status, and physical activity is optimised.
- Prevention by treating/managing modifiable risk factors is key.
- Earlier treatment of wet sounding cough with antibiotics is indicated in these children, even if the rest of their examination is stable. Children with neurological disorders and wet cough may need a prolonged course of antibiotics as they may be unable to effectively cough.
- If antibiotics are required for respiratory illness more than twice in 12 months, consider referral to a paediatrician.
- Children with oropharyngeal dysphagia may not cough but present with gurgling/wheezing during and post feeding.
- Aspiration is often silent. There does not need to be an episode of choking or vomiting. Check that parents have had their child’s mealtime management assessed by a speech pathologist including management plans for when the child is well and unwell.
- Gastroesophageal reflux is common in children with neurological disorders and managing this is important, particularly for treating silent aspiration. Referral to a paediatrician may be needed.
The modifiable risk factors all have multiple treatment options. By treating these, it may be possible to prevent or reduce the severity of acute respiratory infections in this group.
Our research team is currently collecting evidence as to whether this can be achieved through the RESP-ACT study (Can RESPiratory hospital Admissions in Children with cerebral palsy be reduced? A feasibility randomised controlled trial pilot study). We are following 20 children with cerebral palsy over 12 months – 10 in the usual care group and 10 in the additional care group.
Children in the usual care group continue to be overseen by their current health care professionals. Children in the additional care group are seen by a respiratory doctor, a physiotherapist and a speech pathologist and offered a videofluoscopy swallow study and complex care coordination through a specialised nurse.
A treatment plan depending on the child’s specific risk factors is developed and implemented. Each family is asked to complete a fortnightly survey on their child’s health, recording the medical treatments received and tracking the impact on their child’s health. Families and clinicians will be interviewed at the conclusion of the trial on whether the interventions were acceptable and achievable.
We will also be considering wider application of the outcomes. Specifically, we will consider whether interventions found to be useful in children with cerebral palsy may also be effective in children with other neurological conditions.
This research is in collaboration with Dr Noula Gibson PhD, Research Coordinator Physiotherapist, Physiotherapy Department, PCH, Dr Marie Blackmore, Telethon Kids Institute, Dr Katherine Langdon, Paediatric Rehabilitation Consultant, PCH, and Clinical A/Prof Andrew Wilson, Head of Respiratory and Sleep Medicine PCH. It is supported by the Research Foundation of Cerebral Palsy Alliance.
Key messages
- Children with neurological disorders are more likely to need hospitalisation with pneumonia
- Prevention and treating modifiable risk factors are key
- New research seeks to identify ways to reduce symptoms and hospitalisations.
Author competing interests – the author leads the study