Written by Kimiko Dunbar
Spoon Feed
Management of pneumonia in patients with neurologic impairment should include minimization of broad-spectrum antibiotics, increased airway clearance, and engagement of caregivers in discharge planning.
When in doubt, cough it out
Pneumonia is common in children with neurologic impairment, likely as a result of associated medical complexity such as respiratory muscle weakness, impaired cough, and aspiration risk. Despite this, they are often excluded from clinical practice guidelines, and management is highly variable. In this study, a national expert panel utilized the RAND/UCLA Appropriateness Method and endorsed 72 recommendations, with emphasis on minimizing broad-spectrum antibiotics, incorporating respiratory therapists for airway clearance, and engaging families and outpatient providers for discharge planning. Specifically, appropriateness of respiratory gram stain and culture for children with tracheostomies was considered uncertain, and routine viral testing was not recommended. Experts agreed that initial antibiotic therapy should be parenteral, for 7 days (unless extenuating circumstances), and that a macrolide should be added for children over 5 without clinical improvement. Experts also agreed that increased airway clearance and respiratory support above baseline should be used alongside antibiotics. Further, patients could be discharged home on increased respiratory support from baseline, provided clinical improvement and caregiver comfort. Limited high-quality evidence led to reliance on expert consensus.
How does this change my practice?
This article highlights the need to put as much thought into secretion management as antibiotic therapy in this patient population. I’m not sure I’ll empirically be extending antibiotic courses beyond the typical 5 days, although I’ll feel better about doing so without fearing poor antibiotic stewardship in the case of slowed improvement or severe disease.
Source
Recommendations for Pneumonia in Hospitalized Children With Neurologic Impairment. Pediatrics. 2025 Apr 1;155(4):e2024067216. doi: 10.1542/peds.2024-067216. PMID: 40031989
