Interventions for management of respiratory disease in young people with cerebral palsy: A systematic review

Caregivers' Experiences of Sleep Systems for Children with Complex Neurodisability: A Qualitative Study

AIM

To understand caregivers' experiences of implementing sleep systems for children with complex neurodisability. This knowledge would help develop and refine the evidence base to inform clinical practice to improve care and support increased engagement and adherence to this approach.

METHODS

Semi-structured interviews were conducted with nine caregivers (7 mothers, 2 fathers) of eight children aged 4-17 years (mean age 7.7 years) with complex neurodisability. Interviews were audio-recorded and transcribed. Interpretive Description methodology and inductive analysis based on Morse's four-step framework were employed to analyze the data.

RESULTS

Three themes were developed: (1) It's a complex night; (2) This is what I know, incorporating subthemes "What I know about my child" and "What I know about sleep systems"; and (3) Support me to support my child. Sleep system interventions that account for nighttime health complexity and address caregivers' priorities of sleep and comfort for their child were perceived as more sustainable and successful by caregivers.

CONCLUSION

Embedding principles of family-centered care in sleep system assessment, prioritizing caregivers' goals of sleep and comfort, and fostering hope and trust through the co-production of postural care solutions are critical components of care. A shift in focus from "future prevention" of deformity to "protection and comfort" may advance the quality of care and uptake of sleep systems.

Hospitalizations Following Complex Hip Surgery in Children with Intellectual Disability: A Self-Controlled Case Series Analysis

OBJECTIVE

To evaluate the associations between complex hip surgery and subsequent hospitalizations in children with intellectual disability, including a subset of children with cerebral palsy.

STUDY DESIGN

We conducted a retrospective cohort study using linked administrative, health, and disability data from Western Australia. Children born between 1983 and 2009 who underwent complex hip surgery by end 2014 were included (intellectual disability, n = 154; subset with cerebral palsy, n = 91). A self-controlled case series analysis using Poisson regression was used to estimate the age-adjusted associations of complex hip surgery on all-cause hospitalizations and when the principal diagnosis was lower respiratory tract infection or epilepsy, for periods following the individual's first major hip surgery, compared with the year before surgery.

RESULTS

Age adjusted incidence of all-cause hospitalizations decreased after surgery (year 1: incidence rate ratio [IRR] 0.87 [95% CI, 0.74-1.02]; year 6: IRR 0.57 [95% CI, 0.46-0.72]). The incidence of hospitalizations for lower respiratory tract infection increased (year 1: IRR, 1.03 [95% CI, 0.72-1.51]; year 6: IRR 2.08 [95% CI, 1.18-3.68]). The incidence of hospitalizations for epilepsy decreased (year 1: IRR 0.93 [95% CI, 0.57, 1.54]; year>6: IRR 0.72 [95% CI, 0.34-1.55]) after surgery. A similar pattern was observed for the subset of children with or without cerebral palsy.

CONCLUSION

Complex hip surgeries are associated with fewer hospitalizations overall but not respiratory hospitalizations for children with intellectual disability. Fewer hospitalizations suggest benefits for better musculoskeletal alignment.

The management of Pseudomonas aeruginosa respiratory infection in children with cerebral palsy: A narrative review

Children with cerebral palsy have increased respiratory morbidity and mortality. Infection with Pseudomonas aeruginosa (PA) is associated with poorer outcomes, yet there are no formal guidelines to inform treatment of respiratory infection in children with cerebral palsy. This review explores the existing literature regarding management of PA-infection in children with cerebral palsy, with the aim of synthesising clinical recommendations and identifying gaps in current understanding. Medline (Ovid), PubMed and Embase were searched using keywords. Full-text articles involving the paediatric population and antimicrobial therapy were included. There was no limit on date of publication. Four retrospective case series were identified. Respiratory microbiology, in samples collected from a range of sites along the respiratory tract, was reported in three studies. Patients who received PA-specific antibiotics clinically improved. Two studies suggest that the use of suppressive inhaled anti-pseudomonal therapy may improve respiratory morbidity in the chronic setting. There is minimal evidence to guide management of PA respiratory infection in children with cerebral palsy. Children with cerebral palsy are at risk of developing bronchiectasis, so in the absence of high-quality evidence, management should be informed by extrapolating from the non-cystic fibrosis bronchiectasis guidelines. Further research examining surveillance and management of PA-infection in this population is required given that early intervention may prevent irreversible lung damage.

Effects of pulmonary function improvement devices in the pediatric population with cerebral palsy: Systematic review and meta-analysis of randomized clinical trials

INTRODUCTION

Enhancing lung function can significantly improve daily life functionality for children with cerebral palsy, leading to increased interest in respiratory physiotherapy training devices in clinical practice. This study aims to evaluate the efficacy of devices (inspiratory muscle training and feedback devices) for improving pulmonary function through various respiratory parameters.

METHODS

A systematic review with meta-analysis of randomized clinical trials was conducted in seven databases up until May 2023. The included studies focused on training inspiratory muscle function using specific devices (inspiratory muscle training and feedback devices) in children with cerebral palsy. The main outcomes were maximum expiratory pressure and maximum inspiratory pressure. Secondary outcomes included forced vital capacity, forced expiratory volume in 1 s, peak expiratory flow, and the Tiffenau index. The effects of respiratory treatment were calculated through the estimation of the effect size and its 95% confidence intervals. The risk of bias in the included studies was assessed using the Cochrane Collaboration's tool for assessing the risk of bias (RoB2).

RESULTS

Nine studies were included in the systematic review with meta-analysis, involving a total of 321 children aged between 6 and 18 years after secondary analyses were conducted. Feedback devices were found to be more effective in improving maximum expiratory pressure (effect size -0.604; confidence interval -1.368 to 0.161), peak expiratory flow, forced expiratory volume in 1 s, and forced vital capacity. Inspiratory muscle training devices yielded better effectiveness in improving maximum inspiratory pressure (effect size -0.500; confidence interval -1.259 to 0.259), the Tiffeneau index, and quality of life.

CONCLUSION

Both devices showed potential in improving pulmonary function in children with cerebral palsy. Further high-quality clinical trials are needed to determine the optimal dosage and the most beneficial device type for each pulmonary function parameter.

Respiratory Comorbidities and Complications of Cerebral Palsy

Respiratory complications are the most frequent cause of morbidity, mortality, and poor quality of life in children with cerebral palsy (CP) and represent the leading cause of hospitalizations. Several factors negatively influence the respiratory status of these children: lung parenchymal alterations and factors modifying the pulmonary pump function of chest and respiratory muscles, as well as concomitant pathologies that indirectly affect the respiratory function, such as sleep disorder, malnutrition, epilepsy, and pharmacological treatments. Early management of respiratory complications can improve the global health of children with CP and enhance quality of life for them and their caregivers.

Community-based respiratory health measures in children and young people with cerebral palsy: A scoping review

AIM

To identify, map, and describe outcome measurement domains and instruments used within a community setting to assess respiratory health in children and young people aged 1 to 18 years, diagnosed with cerebral palsy (CP).

METHOD

A scoping review methodology informed structured searches in nine databases, grey literature, and registries, conducted in August 2021 (updated in February 2023). Articles were screened for eligibility by two independent researchers. Any outcome measurement instruments used to assess respiratory health or associated impact were extracted, categorized, and mapped to health and health-related domains of the International Classification of Functioning, Disability, and Health.

RESULTS

Seventy-six outcome measurement instruments were identified across 78 articles worldwide between 1970 and 2023. These were categorized into 'Body functions and structures' (n = 20), 'Activity and performance' (n = 22), and 'Participation and quality of life' (n = 19), with a further 15 mapped to 'Health care resources use'.

INTERPRETATION

No consensus of 'what' to measure and 'how' to measure respiratory health in children and young people with CP was found. Moreover, many measures were not replicable in individuals with more severe forms of CP, excluding those at increased risk of respiratory-related morbidity and mortality. Further research is required to agree important outcome domains and associated measures in research and clinical practice.

WHAT THIS PAPER ADDS

A limited number and size of experimental designs were found. Seventy-six measures were identified to assess respiratory health in cerebral palsy. No consensus was found in 'what' or 'how' to measure respiratory health. Many measures were not replicable in children and young people at risk of poorer respiratory health outcomes. Children and young people with comorbidities and learning disability were frequently excluded from studies.

Can RESPiratory hospital Admissions in children with cerebral palsy be reduced? A feasibility randomised Controlled Trial pilot study protocol (RESP-ACT)

INTRODUCTION

The most common cause of morbidity and mortality in children with severe cerebral palsy (CP) is respiratory disease. BREATHE-CP (Better REspiratory and Airway Treatment and HEalth in Cerebral Palsy) is a multidisciplinary research team who have conducted research on the risk factors associated with CP respiratory disease, a systematic review on management and a Delphi study on the development of a consensus for the prevention and management of respiratory disease in CP. These strategies have not been investigated; therefore, it is not known if implementation is feasible, if they improve patient outcomes or if they are acceptable for families.

METHODS AND ANALYSIS

Mixed-method feasibility pilot randomised controlled trial with economic analysis. Twenty children with CP aged 0-12 years who are at risk of respiratory disease will be followed up for 1 year. All children will receive baseline assessments for comparison. The control group will receive usual care from their treating teams. The intervention group will receive comprehensive assessments from physiotherapy, speech pathology and respiratory medicine. An individualised investigation and treatment plan will then be made. Participants in both groups will complete fortnightly patient-reported outcome surveys to assess symptoms and health service use. Analysis will include assessments of acceptability through qualitative interviews, implementation by ability to recruit, randomise and retain, practicality including costs of intervention and hospitalisation, and explore efficacy through quality-of-life surveys and decreased health service use for respiratory-related symptoms.

ETHICS AND DISSEMINATION

Ethics and governance approvals have been obtained through Child and Adolescent Health Service Human Research Ethics Committee. At completion, this study will lead to the design of the definitive protocol to test intervention efficacy that maximises recruitment, retention and adherence to interventions.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12620000114943).

Understanding and managing respiratory infections in children and young adults with neurological impairment

INTRODUCTION

Patients with neurocognitive impairment (NI) have multiple medical needs, with respiratory problems leading to an important reduction in quality of life and life expectancy. We aimed to explain that the origin of chronic respiratory symptoms in patients with NI is multifactorial.

AREAS COVERED

In people with NI there is a high prevalence of swallowing dysfunction and hypersalivation inducing aspiration; cough efficacy is decreased resulting in chronic lung infection; sleep-disordered breathing is frequent and muscle mass is abnormal due to malnutrition. Technical investigations are not always specific and sensitive enough to better diagnose the causes of the respiratory symptoms; moreover, they can sometimes be difficult to perform in this vulnerable patient population. We provide a clinical pathway to adopt to identify, prevent, and treat respiratory complications in children and young adults with NI. A holistic approach in discussion with all care providers and the parents is highly recommended.

EXPERT OPINION

The care for people with NI and chronic respiratory problems is challenging. The interplay between several causative factors may be difficult to entangle. Well-performed clinical research in this field is largely missing and should be encouraged. Only then, evidence-based clinical care will become possible for this vulnerable patient group.

Antibiotics for chronic pulmonary infection in children with a neurodisability (neurodevelopmental disorder)

BACKGROUND

'Neurodisability' refers to a group of conditions that result primarily from a neurological problem (e.g. cerebral palsy), neuromuscular problem (e.g. a muscular dystrophy) or developmental problems (e.g. developmental impairment, Down syndrome). Children and young people with these conditions may have similar problems with mobility, feeding and airway clearance. Chest and breathing problems (including pulmonary infections) are commonly experienced by children and young people with neurodisabilities and are often a cause for them requiring hospital care. For those who are unable to completely clear their airway of secretions, or have frequent infections, pulmonary infections may not be able to be completely eradicated and therefore become chronic. It is unclear what treatment is best for children and young people in this position.

OBJECTIVES

To assess the effectiveness and adverse effects of antibiotic treatment for chronic pulmonary infection in children and young people living with a neurodisability, including quality-of-life measures, effects on hospitalisation and healthcare contacts.

SEARCH METHODS

We searched the Cochrane Airways Trials Register, Cochrane Acute Respiratory Infections Group Register of Trials (CARIGRT), Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), Cumulative Index to Nursing and Allied Health Literature (CINAHL), OpenGrey (www.opengrey.eu) and three trials registries up to 8 February 2022. Additionally, we identified related systematic reviews through Epistemonikos.org (8 February 2022) and searched reference lists of these.

SELECTION CRITERIA

All randomised controlled trials of antibiotic therapy for chronic pulmonary infection in children and young people up to the age of 18 living with a neurodisability were eligible.

DATA COLLECTION AND ANALYSIS

Two independent review authors screened results of the searches against predetermined inclusion criteria, resolving any discrepancies by discussion.

MAIN RESULTS

We identified a total of 1968 independent records through our searches, of which we assessed six full-text articles for eligibility. We identified one ongoing study as well as one related substudy but did not identify any completed studies eligible for inclusion in this systematic review.

AUTHORS' CONCLUSIONS

The findings of this systematic review highlight a lack of evidence in the antibiotic treatment of chronic pulmonary infection in children and young people up to the age of 18 living with a neurodisability. Further research examining this topic is therefore required.

Health Conditions in Adults With Cerebral Palsy: The Association With CP Subtype and Severity of Impairments

Aim: To determine the prevalence of common health conditions in adults with cerebral palsy (CP) and to identify associations with the CP subtype or the severity of impairments.

Methods: A population-based, cross-sectional study of 153 adults with CP born from 1959 to 1978 (87 males, 66 females; median age 48 years 3 months, range 37–58 years; 41% with unilateral spastic, 36% bilateral spastic, 19% dyskinetic, and 4% with ataxic CP). Data was gathered through interviews, physical assessments, and medical record reviews.

Results: The most common health conditions in adults with CP were pain 65%, upper gastrointestinal disorders 33%, dysphagia 29%, epilepsy 29%, and depression 27%. Cerebral palsy subtype was significantly associated with the presence of pain (p = 0.029), gastrointestinal (p < 0.001), and respiratory disorders (p = 0.006). A more severe physical impairment was associated with a higher prevalence of gastrointestinal disorders (p < 0.001), respiratory disorders (p < 0.001), and pressure ulcers (p < 0.001). Intellectual disability was associated with a higher prevalence of gastrointestinal disorders (p < 0.001), pneumonia (p = 0.001) epilepsy (p = 0.001), and pressure ulcers (p < 0.001), but with a lower prevalence of pain (p < 0.004) and hypertension (p = 0.043).

Conclusion: The prevalence of several common health conditions is related to the CP subtype and severity of impairments, indicating that CP plays a role in the development of these health conditions. Follow-up of adults with CP needs to include not only impairments, but general health as well. Increased attention directed toward signs of gastrointestinal and respiratory disorders in individuals with either dyskinetic CP, gross motor function classification system (GMFCS) levels IV–V, or intellectual disability, is recommended.

Prevalence of long-term mechanical insufflation-exsufflation in children with neurological conditions: a population-based study

AIM

To determine the prevalence of long-term mechanical insufflation-exsufflation (MI-E) and concomitant mechanical ventilation in children with neurological conditions, with reported reasons behind the initiation of treatment.

METHOD

This was a population-based, cross-sectional study using Norwegian national registries and a questionnaire.

RESULTS

In total, 114 of 19 264 children with a neurological condition had an MI-E device. Seventy-three of 103 eligible children (31 females, 42 males), median (min-max) age of 10 years 1 month (1y 5mo-17y 10mo), reported their MI-E treatment initiation. Overall, 76% reported airway clearance as the main reason to start long-term MI-E. A prophylactic use was mainly reported by children with neuromuscular disorders (NMDs). Prevalence and age at initiation differed by diagnosis. In spinal muscular atrophy and muscular dystrophies, MI-E use was reported in 34% and 7% of children, of whom 83% and 57% respectively received ventilator support. One-third of the MI-E users were children with central nervous system (CNS) conditions, such as cerebral palsy and degenerative disorders, and ventilator support was provided in 31%. The overall use of concomitant ventilatory support among the long-term MI-E users was 56%.

INTERPRETATION

The prevalence of MI-E in a neuropaediatric population was 6 per 1000, with two-thirds having NMDs and one-third having conditions of the CNS. The decision to initiate MI-E in children with neurological conditions relies on clinical judgment.

WHAT THIS PAPER ADDS

The prevalence and age at initiation of mechanical insufflation/exsufflation (MI-E) differed between diagnoses. MI-E was most commonly used in spinal muscular atrophy, where it generally coincided with ventilatory support. One-third of MI-E devices were given to children with central nervous system conditions, and one-third also received ventilatory support.

Prevention and management of respiratory disease in young people with cerebral palsy: consensus statement

Respiratory illness is the leading cause of mortality in children with cerebral palsy (CP). Although risk factors for developing chronic respiratory illness have been identified, comprehensive clinical care recommendations for the prevention and management of respiratory illness do not currently exist. We invited over 200 clinicians and researchers from multiple disciplines with expertise in the management of respiratory illness in children with CP to develop care recommendations using a modified Delphi method on the basis of the RAND Corporation-University of California Los Angeles Appropriateness Method. These recommendations are intended for use by the wide range of practitioners who care for individuals living with CP. They provide a framework for recognizing multifactorial primary and secondary potentially modifiable risk factors and for providing coordinated multidisciplinary care. We describe the methods used to generate the consensus recommendations, and the overall perspective on assessment, prevention, and treatment of respiratory illness in children with CP. WHAT THIS PAPER ADDS: The first consensus statement for preventing and managing respiratory disease in cerebral palsy (CP). Risk factors for respiratory disease in CP should be identified early. Individuals with CP at risk of respiratory disease require regular assessment of risk factors. Effective partnerships between multidisciplinary teams, individuals with CP, and families are essential. Treatment of respiratory disease in individuals with CP must be proactive.

Evaluation and Management of Respiratory Illness in Children With Cerebral Palsy

Cerebral palsy (CP) is the most common cause of disability in childhood. Respiratory illness is the most common cause of mortality, morbidity, and poor quality of life in the most severely affected children. Respiratory illness is caused by multiple and combined factors. This review describes these factors and discusses assessments and treatments. Oropharyngeal dysphagia causes pulmonary aspiration of food, drink, and saliva. Speech pathology assessments evaluate safety and adequacy of nutritional intake. Management is holistic and may include dental care, and interventions to improve nutritional intake, and ease, and efficiency of feeding. Behavioral, medical, and surgical approaches to drooling aim to reduce salivary aspiration. Gastrointestinal dysfunction, leading to aspiration from reflux, should be assessed objectively, and may be managed by lifestyle changes, medications, or surgical interventions. The motor disorder that defines cerebral palsy may impair fitness, breathing mechanics, effective coughing, and cause scoliosis in individuals with severe impairments; therefore, interventions should maximize physical, musculoskeletal functions. Airway clearance techniques help to clear secretions. Upper airway obstruction may be treated with medications and/or surgery. Malnutrition leads to poor general health and susceptibility to infection, and improved nutritional intake may improve not only respiratory health but also constipation, gastroesophageal reflux, and participation in activities. There is some evidence that children with CP carry pathogenic bacteria. Prophylactic antibiotics may be considered for children with recurrent exacerbations. Uncontrolled seizures place children with CP at risk of respiratory illness by increasing their risk of salivary aspiration; therefore optimal control of epilepsy may reduce respiratory illness. Respiratory illnesses in children with CP are sometimes diagnosed as asthma; a short trial of asthma medications may be considered, but should be discontinued if ineffective. Overall, management of respiratory illness in children with CP is complex and needs well-coordinated multidisciplinary teams who communicate clearly with families. Regular immunizations, including annual influenza vaccination, should be encouraged, as well as good oral hygiene. Treatments should aim to improve quality of life for children and families and reduce burden of care for carers.

State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy

PURPOSE OF REVIEW

Cerebral palsy is the most common physical disability of childhood, but the rate is falling, and severity is lessening. We conducted a systematic overview of best available evidence (2012-2019), appraising evidence using GRADE and the Evidence Alert Traffic Light System and then aggregated the new findings with our previous 2013 findings. This article summarizes the best available evidence interventions for preventing and managing cerebral palsy in 2019.

RECENT FINDINGS

Effective prevention strategies include antenatal corticosteroids, magnesium sulfate, caffeine, and neonatal hypothermia. Effective allied health interventions include acceptance and commitment therapy, action observations, bimanual training, casting, constraint-induced movement therapy, environmental enrichment, fitness training, goal-directed training, hippotherapy, home programs, literacy interventions, mobility training, oral sensorimotor, oral sensorimotor plus electrical stimulation, pressure care, stepping stones triple P, strength training, task-specific training, treadmill training, partial body weight support treadmill training, and weight-bearing. Effective medical and surgical interventions include anti-convulsants, bisphosphonates, botulinum toxin, botulinum toxin plus occupational therapy, botulinum toxin plus casting, diazepam, dentistry, hip surveillance, intrathecal baclofen, scoliosis correction, selective dorsal rhizotomy, and umbilical cord blood cell therapy. We have provided guidance about what works and what does not to inform decision-making, and highlighted areas for more research.

Transition to adult care for young people with cerebral palsy

Cerebral palsy (CP) is associated with a high burden of comorbid respiratory disease subsequent to multiple risk factors associated with increasing levels of disability. Correspondingly, respiratory disease is the leading cause of death in CP, including amongst young people who are transitioning or who have just transitioned between paediatric and adult healthcare services. Therefore, consideration of both preventive and therapeutic respiratory management is integral to transition in patients with CP, as summarised in this review.