Children with complex disabilities may be vulnerable to respiratory complications such as aspiration, infections and pneumonia that impact quality of life, health and wellbeing.

Why are children with complex disability more vulnerable to respiratory complications?

Some disabilities such as Cerebral Palsy can directly impact a child’s breathing because the muscles needed for breathing don’t work as they should. In an Australian Cerebral Palsy registry, breathing problems were very common, with daily cough or wheeze, sleep apnea, cough with drinking and chest x-rays demonstrating grumbling chest infections common for these children (Proesmans; 2016; p98). 

Other children have swallowing difficulties and struggle to prevent saliva, food or fluids entering their lungs. However, respiratory complications can arise for a number of reasons.

Causes of respiratory complications

• Weak breathing muscles – Weakness or spasticity in the muscles involved in breathing and swallowing can cause aspiration. Aspiration means when something other than the air that we breath is taken into the trachea (windpipe) or the lungs such as saliva, food or drink.
• Weak digestive muscles – Weakness in the muscles of the digestive tract can also cause breathing problems, as this can contribute to aspiration. 
• Unable to cough – Children who are unable to cough due to weak muscles or other complications will struggle to clear secretions from their chest leaving them vulnerable to infections.
• Spinal curvature – Scoliosis (also known as spinal curvature) - where the spine is more curved than usual – can affect the ability of the lungs to expand and cause breathing difficulties.
• Obstructive sleep apnea – A sleep disorder in which breathing repeatedly stops and starts during sleep due to an obstruction in the airway. The obstruction can happen during waking hours but is more dangerous during sleep.
• Hypoventilation - is caused when a person breathes too shallowly or slowly to breath in the amount of oxygen that their body needs. Children with complex disability may be vulnerable to hypoventilation because they are less active and their breathing may be shallow and slow.
• Asthma – is quite common in children but for children with complex disabilities and other related health conditions, it can create further complications.

Risks factors associated with respiratory complications

The following can put children at risk of respiratory complications and for these children the monitoring and management of respiratory health is so important.

• Children who have difficulty effectively taking deep breaths or coughing.
• Children with musculoskeletal irregularities and muscle wasting/weakness and find it hard to move or take deep breaths to clear their lungs.
• Where a child has a mealtime plan requiring only enteral feeding or modified foods and fluids. If these plans aren’t followed, and the child is provided the wrong type of food or fluid the risk of breathing in food or fluids is greater.
• Children who are immobile and struggle to take deep breaths, cough effectively or change their position on their own as movement helps to effectively clear secretions from the chest infections. 
• Some children may also have a poor swallowing reflex which increases their chance of food/fluid going into their lungs (aspirating) and this can increase the child’s chance of chest infection.
• Inappropriate suctioning of secretions can cause scarring and damage to the nasal passages and lungs.
• When children have reflux combined with poor swallowing or cough reflexes, they are at risk of stomach acids getting into their windpipe and lungs which can cause irritation.
• Underlying lung disorders such asthma or hyperplastic lungs (tight lungs which can make it more difficult for the lungs to expand).
• Trachea tubes or ventilation machines.
• Compromised immune system, making it harder to fight off infections if they occur.

Managing respiratory health

For children with complex disability who are at risk of complications, respiratory health must be closely monitored and managed. There are a number of approaches that can be used to help to prevent, improve and treat respiratory complications in children with disability.  Your child’s health team should work with you on the best strategies for your child. Below are some examples of respiratory interventions and treatments.

Strategies to reduce the likelihood of chest infections

• Understand the signs of choking and swallowing difficulties.
• Understand which medications your child is on that can increase swallowing and choking risks.
• Promote teeth and oral hygiene as this helps feeding, chewing and having a moist tongue to manipulate food.
• Change your child’s position regularly and ensure their head and chest is as straight as possible. If this isn’t easily possible, changing their position from side to side will also assist lung drainage and expansion.
• Ensure mealtime plans developed by speech pathologists and/or dietitians are strictly followed to prevent aspiration (inhalation) of fluid/foods into lungs. Position your child appropriately when feeding and use related feeding techniques:
  • Your child should be at 60-degree angle at minimum when feeding orally including enteral feeding
  • Don’t feed your child while they lie flat or are positioned with an arched or hyper-extended neck, as this creates an open airway, making it easier to choke
  • Position your child’s head so that it is upright or flexed very slightly forward.
• Make sure your child stays upright for 30 minutes after feeding, even if enteral feeding.
• Provide a comfortable and relaxed mealtime environment, checking your child is as alert as they can be during mealtimes with reduced distractions.
• At the end of each meal, ensure that your child’s mouth is empty and there is no food left in their mouth (e.g. in the cheeks or under the tongue).
• If required, manage reflux with prescribed medication, sitting up also helps reflux.
• You may be advised by a physiotherapist or nursing staff to assist with techniques to help clear your child’s airways – such as gentle percussion with your hands.  Don’t undertake this unless you have been taught how to do this by a health professional.
• Your child may need suctioning to remove secretions but overzealous suctioning can scar lungs and nasal passages so this needs to be done with care.
• Follow infection control precautions.
• Encourage Flu and related vaccinations.
• If you notice your child’s breathing, temperature or wellness changing, escalate this early with the aim to prevent the need for hospitalisation.

Find out more

Our health care team are here to support you to care for your child’s health and wellness  risks. An unwell child can’t participate in their community or school and we aim to work with you to keep your child as well as possible and enjoying activities.  If you’d like to find out more about how we can help, visit our nursing page, call 1800 XAVIER or email intake@xavier.org.au