See also       

Cerebral palsy

Cerebral palsy: increased seizures

Cerebral palsy: pain and irritability

Community acquired pneumonia

Key Points

1. Children with cerebral palsy can deteriorate quickly and may require higher levels of supportive care
2. Have a low threshold for starting antimicrobial treatment in children with severe cerebral palsy
3. Review and consider management of secretions and feeds if there is moderate to severe increased work of breathing

Background

Chest infections are the most common reason for children with cerebral palsy to require hospital admission

Predisposing factors for pneumonia for children with cerebral palsy include:

• pseudobulbar palsy leading to aspiration of saliva, food or fluid
• increased secretions
• poor cough
• gastro-oesophageal reflux
• decreased mobility
• severe scoliosis
• malnutrition
• chronic airway carriage of pathogenic bacteria
• impaired airway protection secondary to fluctuations in level of consciousness, which may be due to medications eg benzodiazepines

Causative organisms are the same as for other children

• Consider anaerobic organisms if aspiration is a contributing factor

Assessment

The clinical features and assessment for chest infections in children with cerebral palsy does not differ from that of other children

Children with cerebral palsy can deteriorate quickly and may require higher levels of supportive care

History

In children with cerebral palsy, careful attention should be paid to:

• Fever or hypothermia
• Apnoea
• Vomiting/unable to tolerate usual feeding regimen
• Risk of aspiration
• Change in baseline level of consciousness
• Increased oxygen or suction requirements

Risk factors for severe respiratory illness

• Previous ICU admission for pneumonia
• Pre-existing respiratory failure
• Home respiratory non-invasive support
• Scoliosis
• Increased seizure activity if known seizure disorder

Examination

• Lethargic or unwell
• Signs of upper airway obstruction
• Increased work of breathing, can be exacerbated by dystonia

Assessment of severity

Severe pneumonia should be considered if there is a rapid deterioration and/or any of the following are present:

• severe respiratory distress
• marked tachycardia
• severe hypoxaemia or cyanosis
• decreased level of consciousness/deterioration in baseline level of consciousness
• increased respiratory supports required

Management

Investigations and treatment of pneumonia in children with cerebral palsy should follow the pneumonia guideline, though clinicians should be aware that these children may deteriorate quickly and require higher levels of supportive care

• Have a lower threshold for starting antibiotics in children with severe cerebral palsy
• Have a lower threshold for admission

Chest X-rays may be difficult to interpret in children with scoliosis. It can be helpful to compare with previous X-rays

Key considerations

Inform senior clinician and/or ICU early if:

• Acute respiratory failure
• Severe respiratory distress
• Oxygen requirement FiO2 >50% (>6L/min) or requiring increase in baseline non-invasive support
• Unwell and has risk factors for severe illness (as above)

Antibiotics

• Penicillin provides adequate anaerobic cover for aspiration in children
• Consider Oseltamivir to cover influenza virus

Positioning

• If significant scoliosis, position the child sitting up, with the ‘better inflated lung’ up
• Consider nasopharyngeal airways in severe cerebral palsy and upper airway obstruction (especially if drowsy/decreased consciousness and hypoxic)

Oxygen 

• Give oxygen if oxygen saturations are <90% in room air
• If possible, administer humidified oxygen

Salbutamol

• Consider trial of Salbutamol if evidence of bronchospasm (wheeze, hyperinflation) and reassess for improvement

Secretions

• Nebulised saline (5mls of sodium chloride 0.9%) may help mobilise secretions
• Oro-pharyngeal suction may be useful if the child is unable to clear oral secretions
• Chest physiotherapy is helpful if children have large airway secretions and a poor cough, or focal consolidation
• Be aware of anticholinergics eg glycopyrrolate which thicken secretions.  These may need to be reduced during acute illness. Discuss with a senior clinician

Feeding 

• Withhold feeds if moderate or severe work of breathing and give enteral/IV fluids at two-thirds maintenance rate unless dehydrated. See intravenous fluids

Consider consultation with local paediatric team when

Child requiring hospital admission

Consider transfer when

• Severe or complicated pneumonia
• FiO2 requirement >50% (>6L/min)
• Requiring care above the level of comfort of the local hospital

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Consider discharge when

Child is maintaining adequate oxygenation and oral intake/feeds and tolerating enteral antibiotics if required

Additional notes

• Children with severe cerebral palsy should receive the annual influenza vaccine in addition to the usual vaccines on the schedule
• Consider indications and eligibility for further pneumococcal vaccination. See Australian Immunisation Handbook

Last updated July 2023