Respiratory Infections In Children With Cerebral Palsy

Respiratory infections in children are common particularly in the first three years of life. They have a considerable impact on childhood health, account for most hospital admissions, affect quality of life, and are a sizeable economic burden to society because of health care use, parental work absenteeism, and secondary infections of parents and siblings. ¹  

Children with Cerebral Palsy (CP) suffer from some degree of abnormal development of the brain or damage to the developing brain that affects a child’s ability to control his or her muscles. The degree of control varies among children. Obvious muscles affected are those large muscles of the arms and legs but muscles that control breathing, and swallowing, can also be affected. 

Children with CP are vulnerable to respiratory infections because they tend to move less, breathe shallow and have weakened oral motor skills. It is not uncommon for any child with neuromuscular abnormalities to have underlying respiratory illnesses. 77% of the deaths of children with severe disabilities were caused by pneumonia, an infection of the lungs. ²   

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What Are The Risk Factors That May Contribute To Development Of A Respiratory Infection? 

  • Difficulty controlling head and body posture in most positions 
  • At least one hospital admission for respiratory illness per year 
  • Oral dysphagia (Swallowing difficulties) 
  • Seizures 
  • Frequent symptoms of cough, wheezing, phlegm or a gurgly chest 
  • Reflux disease 
  • At least two courses of antibiotics for chest infections in the last year 
  • Mealtime respiratory symptoms (gurgly voice, wheezing coughing, sneezing, choking) 
  • Snoring every night and/or gasping with sleep. 
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What Is The Most Common Cause Of Respiratory Infections In Children With Cp?

The most common cause of respiratory illness and pneumonia in children with CP is aspiration. Aspiration is when food, drink or saliva make their way into the lungs. Aspiration may be noticed when a child coughs or chokes, often during mealtimes but most of the time there are no outward signs of aspiration (silent aspiration). Bacteria in the aspirate that enters the lungs can cause respiratory illness or chronic inflammatory responses. This can lead to the development of frequent lung infections, wheezing, cough and pneumonia. 

There are four major risk factors for aspiration:

(1) Dysphagia-difficulty swallowing It is the inability of food or liquids to pass easily from a child’s mouth, into the throat, and through the esophagus to the stomach during the process of swallowing. This can also be drooling saliva (which is a marker of swallowing difficulties). Dysphagia may result in inadequate airway protection during swallowing. The child may not be able to manage food or liquid well or accept an age-appropriate diet.

(2) Uncontrolled seizures- Epilepsy is common in CP. During a seizure, a child may vomit, drool, or stop breathing. The vomit or excess saliva can be aspirated into the lungs. Seizure medications can sometimes cause sedation which leads to increased drooling and further aspiration.

(3) Gastro‐esophageal reflux (when material from the stomach rises to the esophagus) from weakness or spasticity in the muscles of the digestive tract. Reflux may trigger cough and choking which may also cause breathing problems that can contribute to aspiration which in turn may lead to respiratory illnesses. 

(4) Scoliosis– spinal curvature. Scoliosis is a deformity of the backbone (spine) identified as a side-to-side curve. Depending upon the severity of the curvature, this deformity an affect the ability of the lungs to expand and make breathing more difficult. As the child grows, the degree of curve can become greater and over time create more breathing problems. Children also tend to be less active as the curve increases.

A child with CP may experience one or all of the above conditions leading to a significant risk for frequent respiratory illnesses. 

What Can Be Done To Prevent Aspiration?

  • Consider a comprehensive assessment by a multidisciplinary team including speech pathology.
  • Introduce foods and drinks with thickened textures.
  • Postural support and proper positioning for head control to prevent aspiration of saliva.
  • Observe for aspiration of saliva, food, and/or fluids. Note that aspiration may involve gagging, choking, or coughing, or it may be silent aspiration.
  • Consider implementing strategies for developing oral motor skills.
  • Monitor for ongoing seizures and seek the advice of a neurologist.
  • Optimize airway clearance- some children with CP have an ineffective cough and are unable to clear their airways effectively. Physiotherapists/Respiratory therapists can prescribe techniques to maintain clear airways and show caregivers how to use them. 
  • Optimize positioning for lung expansion. 
  • Consider an assessment by an Ear, Nose and Throat specialist if the child has a history of apnea (stop breathing), snoring, gasping or if they have large tonsils or swollen turbinates (nasal passages). 

What Else Can Be Done To Prevent Respiratory Illness?

  • Optimize nutrition to support growth and development as well as immune system. Seek counsel from a nutritionist/dietician to determine appropriate caloric intake and nutrients.  
  • Optimize physical activity and fitness- physical exercise causes deep breathing and deep breathing helps shift secretions from the airways. Exercise particularly helps to clear smaller airways that cannot be cleared with coughing. 
  • Maintain good oral care and dental hygiene. The mouth can be a reservoir for the bacteria that cause respiratory illnesses.
  • Vaccinate against influenza.
  • Reduce exposure to tobacco smoke. 

What Type Of Treatments Are Prescribed For Children With Respiratory Illness?

Treatment of respiratory illness, like prevention, involves a partnership between health professionals and children/families with CP. Management must be proactive and timely. ³

  • Medications may include antibiotics, bronchodilators and anti-inflammatory agents. These can be prescribed as breathing treatments that may help open the airways and thin secretions as well as fight infection. 
  • Airway clearance therapy may include chest physiotherapy and proper suction technique along with positioning and postural drainage to help mobilize secretions.
  • Mealtime management may consist of pureed foods, thickened liquids and consideration of enteral feeding tube if aspiration is a problem. Proper positioning during mealtime is important to aid in proper body mechanics and digestion.
  • Regular review with the medical provider team is an ongoing process to assess for risk factors as the child grows and develops. Early intervention aims to identify and document concerns, risk factors, care and comfort needs as well as changes in gross motor function or eating and swallowing function.

Assessment of respiratory health in children with CP is an ongoing process that continues for every child until the risk is mitigated. Medical follow up will assist in identification of both risk and presence of respiratory illness, inform planning for ongoing management of respiratory risk factors, support education and assist clear communication. ³  

¹ Vissing, N. et al. (2018) Epidemiology and Risk Factors of Infection in Early Childhood. Pediatrics,141(6),1-13

² Seddon, P., Khan, Y. (2003) Respiratory Problems in Children with Neurological Impairment. Archives of Diseases in Children. 88(1). 

³ Gibson, N et al. (2021) Prevention and Management of Respiratory Disease in Young People with Cerebral Palsy: Consensus Statement. Developmental Medicine & Child Neurology, 63, 172-182.

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