Chapter 16: Care of the Medically Complex Child

GENERAL PRINICPLES

The term medically complex encompasses a diagnostically heterogeneous group of chronic conditions affecting multiple organ systems. Children with medical complexity often have greater dependence on technology and are at higher risk of infection, malnutrition, and medical errors. They require multispecialty care that is coordinated among providers and families.

RESPIRATORY CONCERNS

Clinical Manifestations

• Signs and symptoms of respiratory distress include tachypnea, wheezing, hypoxia, and increased work of breathing.

• Fever may also be present with respiratory concerns.

• Poor tolerance of feeds.

Differential Diagnosis

• Broad differential includes infection (both viral and bacterial), difficulty with oral secretions, pain, obstruction from the upper or lower airway, asthma, neuromuscular weakness, and aspiration.

ASPIRATION

Epidemiology

• Common among the medically complex population, and especially prevalent in those with neurologic impairment.

Pathophysiology

• Commonly due to inhalation of infectious or noninfectious oral secretions or gastric contents.

ASPIRATION PNEUMONITIS

Pathophysiology

• Occurs after the acute inhalation of gastric contents into the lungs, resulting in an intense inflammatory reaction; bacteria are not often involved.

Management

• Many patients require ICU level of care for increased respiratory clearance and respiratory support including noninvasive ventilation and intubation.

• Can be difficult to distinguish pneumonitis from aspiration pneumonia and often antibiotics are given empirically.

ASPIRATION PNEUMONIA

Etiology

• Occurs after inhalation of nasopharyngeal and oropharyngeal contents containing normal upper respiratory tract bacteria into the lower airways.

• Organisms are usually oral anaerobes

Management

• Empiric treatment with amoxicillin–clavulanic acid (or ampicillin–clavulanic acid if IV required) or clindamycin

ASPIRATION FROM ABOVE

Epidemiology

• Increased drooling, or sialorrhea, is common in the medically complex population.

Etiology

• Increased secretion of saliva is rarely the underlying cause.

• Often oromotor dysfunction, lack of laryngeal sensation, and dysphagia leading to pooling of secretions.

• Oromotor dysfunction can also lead to aspiration of orally ingested foods and liquids.

• Aspiration of thin liquids is most common; this can lead to both aspiration pneumonitis and aspiration pneumonia.

• Aspiration of oral feeds can worsen over time, as oromotor dysfunction often declines, especially in neuromuscular diseases.

• Leads to ongoing pulmonary issues as well as malnutrition requiring enteral tube feeding.

Diagnostics

• Speech therapists may evaluate a child’s swallowing safety at the bedside by performing a clinical assessment.

• More formal studies include videofluoroscopy or fiberoptic endoscopic evaluation of swallowing.

• A salivagram can be helpful in identifying aspiration of saliva only.