See also

• Cerebral Palsy - Common Emergency Presentations:
  
  • Increased seizures
    
  • Pain/Irritability
    
• Pneumonia

Background

• Chest infections are the commonest reason for children with cerebral palsy to require hospital admission
• Predisposing factors include:
  • Pseudobulbar palsy - aspiration of saliva or food/fluid
  • Gastro-oesophageal reflux
  • Poor cough
  • Increased secretions (eg secondary to benzodiazepines)
  • Immobility
  • Severe scoliosis
• Causative organisms:
  • The same as for other children (eg viral, Strep pneumoniae, mycoplasma), though may be at risk for anaerobes if aspiration is a contributing factor

Assessment

• Severity of respiratory distress (tachypnoea, intercostal/subcostal recession, accessory muscle use, grunting)
• Oxygen requirement
• Respiratory failure (conscious state, venous blood gas (pH, CO2))
• Presence of bronchospasm (wheeze, response to salbutamol?)
• Risk factors for severe respiratory illness
  • Previous ICU admissions
  • Pre-existing respiratory failure (previous blood gases?)
  • Severe scoliosis

Children with cerebral palsy may develop hypothermia (rather than fever) in the presence of severe infection
NB Chest X-rays may be difficult to interpret in children with scoliosis

Management

• See Pneumonia guideline
• Antibiotics: as for other children
  • Have a lower threshold for starting antibiotics in children with severe cerebral palsy
  • Penicillin is thought to provide adequate anaerobic cover for aspiration pneumonia in children
  • If very unwell consider adding gram negative cover (especially if hospital-acquired), or metronidazole (especially if on maintenance ranitidine or omeprazole)
• Discuss with senior doctor +/- ICU if:
  • Evidence of acute respiratory failure
  • Severe respiratory distress
  • Oxygen requirement >50%
  • Risk factors for severe respiratory illness (see above)
• Salbutamol - use if there is evidence of bronchospasm (hyperinflation, wheeze, response to trial of salbutamol)
• Secretions: 
  • nebulised saline may help to mobilise secretions (give 5mls normal saline via nebuliser)
  • oro-pharyngeal suctioning 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
• Feeding:
  • For moderate or severe respiratory distress withhold feeds and give IV fluids at 75% maintenance.
• Oxygen:
  • Give oxygen if the child's oxygen saturations are <90% in room air
  • Be careful with oxygen in children with chronic respiratory failure (known hypoventilation with elevated CO₂ even when well) - in this case aim for saturations 90-95%

Prevention

• Children with severe cerebral palsy should receive annual influenza vaccine in addition to the usual vaccines on the schedule.
• Consider pneumococcal vaccine (all children <4 years are eligible to receive on the schedule from January 2005)