Respiratory – DSMIG

Overview

Children with Down Syndrome (DS) have an increased susceptibility to respiratory problems e.g. nasal congestion, obstructive sleep apnoea (see separate Topic Page “Sleep Disordered Breathing”), respiratory infections, wheeze and pulmonary vascular disease. Congenital anomalies also occur e.g. tracheo-/laryngomalacia and oesophageal atresia (respiratory complications may persist after corrective surgery).

The increased frequency of respiratory conditions is partly explained by:

Anatomical differences in the airways – midface hypoplasia, relative macroglossia, shorter and often narrower airways, hypotonia
Coexisting medical conditions such as:
Congenital Heart Disease (CHD) e.g. increased association of AVSD with pulmonary vascular disease, airway compression from vascular anomalies, complications of cardiac surgery such as chylothorax, diaphragmatic paralysis.
Gastro-oesophageal Reflux (GOR) and dysphagia can lead to aspiration, wheezy episodes and lower respiratory tract infections.
Well documented immune defects and possible altered responses to routine vaccinations due to the influence of genes expressed on chromosome 21. Infections of the respiratory tract are the most common in children with DS with more frequent hospital visits, prolonged admissions and mortality due to severity of the illness – particularly Respiratory Syncytial Virus infection.
Other factors include obesity

Therefore, when assessing respiratory symptoms in a child with DS, a careful history is vital to consider a wide number of differential diagnoses. Management may include more prolonged antibiotic therapy or prophylaxis for infections; optimising treatment for GOR (and low threshold to suspect aspiration as this can be silent); investigate and treat obstructive sleep apnoea earlier; as well as ensuring that children with DS have completed their routine UK Immunisation Schedule. The additional Pneumococcal Polysaccharide Vaccine (PNEUMOVAX 23) should be offered after the 2^nd birthday. Since September 2024, expectant mothers in the UK have been offered the RSV vaccine from 28 weeks gestation, offering passive immunity to their babies. High risk babies should be offered one of the two licensed RSV monoclonal antibody immunisations – PALIVIZUMAB or, where available, NIRSEVIMAB, in line with current JCVI Recommendations.

Dr Vicky Ho, February 2025