wisely to our paediatric patients, treating each child as an individual, selecting our management options carefully and adjusting them where there is no evidence of individual benefit. Key points Respiratory symptoms at the end of life are common, distressing and have a lasting impact on parents, yet research into their management is lacking Current management is based predominately on adult studies, often in specific disease groups that bear little resemblance to the paediatric population Even within adult studies, strong research evidence for the management of common paediatric symptoms (dyspnoea, cough and retained secretions) is lacking and it is difficult to extrapolate this data into recommendations for paediatric practice There is an urgent need for well-designed multi-centre paediatric studies to demonstrate the efficacy of commonly used interventions and the impact on the child and family’s quality of life. In the absence of a paediatric evidence base, each child must be treated individually, based on best practice derived predominately from adult studies, with treatment tailored according to observed individual benefit. References 1. Rapoport A, Shaheed J, Newman C, Rugg M, Steele R. Parental Perceptions of Forgoing Artificial Nutrition and Hydration During End-of-Life Care. Pediatrics. 2013;131(5):861-9. 2. Blume ED, Balkin EM, Aiyagari R, Ziniel S, Beke DM, Thiagarajan R, et al. Parental Perspectives on Suffering and Quality of Life at End-of-Life in Children With Advanced Heart Disease: An Exploratory Study*. Pediatric Critical Care Medicine. 2014;15(4):336-42.
Table 1: Causes of respiratory symptoms in paediatric palliative patients Cause Dyspnoea Cough Haemoptysis Retained secretions Infection    Anaemia  Pain  Anxiety  Respiratory muscle weakness    Cardiac failure Pulmonary oedema    Pleural or pericardial effusion   Pneumothorax  Tumour mass     Superior vena cava obstruction   Aspiration   Reflux  Impaired ability to swallow   Abnormalities of clotting, eg haematological malignancy  Table 2: Symptomatic management of dyspnoea fan at No in (8). be to all with Not
Oxygen No Oral, intravenous and subcutaneous opioids No Intranasal fentanyl or diamorphine One small neonatal case note review Transmucosal fentanyl No Nebulised opioids No Anxiolytics No
Over the cough medications Effect of honey preparations studied in children aged 1-5 years with nocturnal cough and sleep disturbance secondary to upper respiratory tract infection No benefit of antitussives, antihistamines, and combinations in children with acute cough (58). Guaifenesin may be an effective protussant (56, 60). Evidence for benefit of honey preparations over placebo, although not studied in palliative care patients (59). Honey preparations should be tried on an individual patient basis, prior to opioids. Consider guaifenesin preparations if a protussive is required. Sodium cromoglycate A single-arm open trial in children with chronic cough (62) In adults with advanced cancer this was more effective than placebo (61) and has been recommended for adults prior to commencing opioids (55). Based on recommendations for adults, could be tried in children prior to commencing opioids. Inhaled local anaesthetics No Evidence of benefit in adult patients (63) Not recommended due to insufficient evidence in children and risk of bronchoconstriction and aspiration secondary to local anaesthesia Nebulised saline solutions and DNase Children with cystic fibrosis, but not specifically looking at effect on cough Saline effective but in adult studies less so than hypertonic saline (64). Mucolytics such as Dnase are more effective than saline (65) Nebulised saline or DNAse can be tried on an individual patient basis for children with thick secretions and/or insufficient cough strength to remove secretions from airway. Mechanical Children with weakness Mechanical insufflation/exsufflation can increase peak cough flow and improve secretion clearance Mechanical should be considered as an adjunct to chest physiotherapy in children with insufficient cough strength to remove secretions from airway. Table 4: Symptomatic management of haemoptysis
Anticholinergics No No studies comparing anticholinergic to placebo. Weak evidence that glycopyrronium may be superior to hyoscine hydrobromide (76) No difference between atropine, hyoscine hydrobromide or hyoscine butylbromide (78) Although evidence of benefit over placebo is lacking, anticholinergics can be tried on an individual patient basis. Glycopyrronium may be more effective than other anti-cholinergics. Octreotide No No evidence that octreotide is better than placebo or anticholinergics (79) Although there is no evidence that octreotide is better than any other medcation for management of secretions, it could be tried if anti-cholinergics fail.