DESCRIPTION

• Eating and drinking are dynamic processes that require complex interactions of several systems (central and peripheral nervous systems, oropharyngeal mechanism, cardiopulmonary system, and gastrointestinal tract) with support from the craniofacial structures and musculoskeletal system.
• Dysphagia is any difficulty coordinating the cascade of swallowing events (oral preparatory, oral, pharyngeal, esophageal) that negatively impacts the safety, efficiency, and ability to consume a variety of solids and liquids for optimal nutrition and growth.
  • Symptoms of dysphagia can vary depending on age, pathologic cause, and associated risk factors (medical, nutritional, feeding skill, and/or oral sensory functioning).
  • Children with dysphagia can present with multiple swallowing difficulties that can negatively impact any or all the phases of swallowing and associated sensory-motor components.
• A feeding disorder is considered a broad term that refers to infants and children who presents with feeding difficulties that may or may not include oropharyngeal dysphagia. Children may show motor, sensory, behavioral, and/or aversive responses to food or liquid that may be a consequence to previous experiences versus a true oropharyngeal swallowing deficit.

RISK FACTORS

Potential risk factors are included but not limited to the following:

• Prematurity
  • Low gestational age at birth
  • Low birth weight
  • Comorbidities associated with prematurity
    • Apnea of the newborn
    • Transient tachypnea of the newborn
    • Pulmonary dysplasia
    • Respiratory distress syndrome
    • Laryngomalacia/tracheomalacia/bronchomalacia
• Gastrointestinal disorders
  • Tracheoesophageal fistula and esophageal atresia
  • Congenital diaphragmatic hernia
  • Gastroesophageal reflux disease (GERD)
  • Eosinophilic esophagitis
• Food allergies and intolerances
• Neurologic disorders
  • Microcephaly
  • Hydrocephalus
  • Intraventricular hemorrhage
  • Periventricular leukomalacia
  • Lissencephaly
  • Birth asphyxia
  • Cerebral palsy
  • Autism
  • Acquired brain injuries
  • Seizures
• Neuromuscular diseases
  • Duchenne muscular dystrophy
  • Muscular dystrophy
• Congenital abnormalities
  • Ankyloglossia
  • Cleft lip/palate
  • Moebius syndrome
  • Trisomy 21
  • DiGeorge syndrome
• Maternal and perinatal issues
  • Jaundice
  • Maternal diabetes and neonatal hypoglycemia
  • Fetal alcohol syndrome
  • Neonatal abstinence syndrome
• Iatrogenic complications
  • Enteral feedings
  • Tracheostomy
  • Respiratory support
  • Certain medications
• Ingestional (caustic injuries)
  • Cleaning agents
  • Battery

COMMONLY ASSOCIATED CONDITIONS

• Pediatric feeding disorder (PFD) is defined as impaired oral intake that is not age appropriate and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction. PFD can be classified as acute (<3-month duration) and chronic (>3-month duration).
• Avoidant/restrictive food intake disorder (ARFID) presents as disruptions to eating and drinking that leads to nutritional deficiency, inability to meet nutritional and energy needs, and related psychosocial imbalances. ARFID commonly is initially seen in childhood; however, it may occur across the lifespan.

HISTORY

• Screening
  • Pediatric Eating Assessment Tool (PediEAT) is a parent-report instrument developed to assess symptoms of feeding problems in children aged 6 months to 7 years who are consuming at least one solid.
  • PediEAT screeners: a 10-question screener for parents or physicians who are not concerned with the child’s feeding. If the child does not pass, the full version assessment is recommended.
  • Neonatal Eating Assessment Tool (NeoEat) is a parent-report instrument developed to assess symptoms of feeding problems in an infant aged <7 months. Separate full assessment tools were developed for exclusively breastfed, exclusive bottle-fed, and mixed breastfed and bottle-fed infants.
  • Infant and Child Feeding Questionnaire (ICFQ): a six-question screening tool designed to identify feeding concerns and facilitate discussion with the child’s healthcare team; accessible at https://www.feedingmatters.org/; developed for ages 0 to 4 years
  • Pediatric Eating Assessment Tool-10 (pEAT-10): a caregiver-administered 10-item questionnaire to evaluate dysphagia symptoms in children and to detect children at high risk for aspiration. Higher pEAT-10 scores indicate further assessment and intervention; developed for ages 3 to 18 years
• Comprehensive understanding of factors, including birth, medical, and surgical history should be considered when determining the need for further investigation for swallowing/feeding disorder. Include the following questions:
  • Are you worried about your child’s eating or drinking habits?
  • Is feeding stressful for you or for the patient?
  • Does your child cough when drinking liquids or eating solids?
  • Does your child gag and/or vomit with solid foods?
  • Does your child complain of feeling solid food sticking in their throat?
  • Has your child experienced explained/unexplained weight loss?
  • Does your child limit the types of foods they eat?
  • Does your child refuse liquids or prefer thicker liquids?

PHYSICAL EXAM

• Cranial nerve (CN) exam: specifically CN abnormalities associated with feeding and swallowing: CNs V, VII, IX, X, and XII
  • Trigeminal (CN V)
    • Motor: difficulties moving jaw
    • Sensory: hyporesponse/hyperresponse from the hard and soft palates and altered general sensation from the anterior 2/3 of the tongue
  • Facial (CN VII)
    • Motor: difficulties moving lips and cheeks
    • Sensory: altered sense of taste to the anterior 2/3 of the tongue
  • Glossopharyngeal (CN IX)
    • Motor: swallowing difficulties (elevating larynx and pharynx during swallowing)
    • Sensory: altered sensory information within the nasopharynx; altered sense of taste and general sensation from the posterior 1/3 of the tongue
  • Vagus (CN X)
    • Motor: difficulties with posterior tongue movement; difficulties with swallowing (all motor innervation to intrinsic laryngeal muscles and esophagus)
    • Sensory: cough response (all sensory innervation from the larynx and esophagus)
  • Hypoglossal (CN XII): primarily motor
    • Motor: difficulties with tongue movements

DIFFERENTIAL DIAGNOSIS

Dysphagia is a skill-based disorder and is considered a secondary diagnosis. The following are some primary factors that predispose potential oropharyngeal deficits.

• Body structures and functions:
  • Structures: oral, pharyngeal, laryngeal, and upper esophageal structures; pulmonary system; and gastrointestinal tract
  • Functions: sensorimotor integrity of CNs function for those structures crucial for feeding and swallowing, positioning, cognitive-communication factors influencing eating and drinking
• Activity and participation:
  • Preparation (e.g., use of utensils, opening bottles/cans, pouring liquids, mixing foods)
  • Bolus administration (e.g., feeding from breast, bottle, drinking from bottle/cup/straw, syringe)
  • Use of adaptions/modifications (e.g., head/body positioning alterations, special utensils, modified textures)
• Environmental, personal, and cultural factors:
  • Environmental factors: caregiver understanding of feeding and swallowing disorder, access to and willingness to prepare appropriate foods and liquids, access to and willingness to use adaptive equipment
  • Personal factors: age, race, other comorbidities present
  • Cultural factors: connections to culture with food and food patterns

DIAGNOSTIC TESTS & INTERPRETATION

An instrumental swallowing assessment is used to comprehensively assess the functional and structural aspects of the oral, pharyngeal, and esophageal swallow that cannot be visualized during physical examination. It can answer questions pertaining to level of swallow dysfunction, safety for feeding, concern for anatomical anomalies, and effectiveness of therapeutic strategies. Instrumental examinations are not considered as only a pass/fail examinations to rule out aspiration but rather to further assess oropharyngeal physiology. One or more of the following assessments may be required to fully understand the degree of swallow dysfunction.

• Video fluoroscopic swallow study (VFSS) or modified barium swallow study (MBSS):
  • A radiographic procedure that provides a dynamic view of the oral, pharyngeal, and upper esophageal anatomy, allowing for direct assessment of swallow timing, amount of penetration, and/or aspiration and pathophysiology of the swallow
  • Age is limited to term infant and beyond.
  • Conducted with speech language pathologist and radiologist
  • Test includes modifications to positioning, texture, and viscosity to determine appropriate recommendations for efficient and safe feeding.
  • Limitations: not portable, requires transport to radiology and limited positioning options, contraindicated for exclusively breastfed infants, time limitations due to radiation exposure, requires radiopaque contrast mixed with food and liquids
• Flexible endoscopic evaluation of swallowing (FEES)
  • A portable procedure that can be conducted in office or bedside in which a nasopharyngoscope is passed transnasally, allowing for thorough assessment of anatomical structures of the upper aerodigestive tract and pharyngeal swallow physiology.
  • Allows for assessment for of pharyngeal swallow before and after ingestion of liquids and/or solids
  • Most successful with <9 months and >4 years of age
  • Conducted with speech-language pathologist alone and/or otolaryngologist to additionally rule out possible nasal, pharyngeal, and laryngeal disease impacting swallow function
  • No radiation exposure or time limitations and can observe swallow over the course of a meal or bottle feeding
  • Beneficial for exclusively breastfed babies
  • An alternative instrumental assessment for patients who cannot be safely transported to radiology
  • Higher sensitivity for laryngeal penetration, depth and consistency of aspiration, and residue patterns
  • Can assess for secretion management alone
  • Beneficial for therapeutic context and diagnostic therapy
  • Limitations: not indicated for patients with significant medical fragility, severe agitation, movement disorders, severe bleeding disorders, pharyngeal stenosis, trauma to nasal cavity or bilateral obstruction of the nasal cavity; does not allow for assessment of oral and esophageal phase of the swallow
• High-resolution pharyngeal manometry:
  • A diagnostic procedure which provides quantifiable biomechanical measures of the pressures generated by the pharyngeal muscles during the swallow; additionally, measures timing and bolus transit
  • Indicated for patients with a diagnosis of pharyngeal dysphagia as an adjunct to FEES or VFSS
• Esophageal manometry:
  • A diagnostic procedure which provides quantifiable biomechanical measures of the pressures generated in the esophagus from upper esophageal sphincter (UES) to lower esophageal sphincter (LES)
• Esophagram
  • Dynamic radiographic study viewing the movement of ingested barium liquid contrast through the esophagus to assess for structural abnormalities
• Dual pH-multichannel intraluminal impedance (pH-MII)
  • A diagnostic assessment use to measure the presence of GERD
  • A probe is inserted through the child’s nasal cavity into the pharynx and passed into the esophagus, and remains for 24 hours.

Medications

• H₂ blockers
• Proton pump inhibitors (PPIs)
• Promotility agents
• Appetite stimulants
• Secretion management
  • Botulinum toxin (Botox^®)
  • Anticholinergic agents

PROGNOSIS

Children with feeding/swallowing difficulties are susceptible to the interruption of the normal trajectory of development with subsequent long-term consequences.

ICD 10

• R13.10 Dysphagia, unspecified
• R13.12 Dysphagia, oropharyngeal phase
• R13.14 Dysphagia, pharyngoesophageal phase
• Q39.3 Congenital stenosis and stricture of esophagus
• R13.19 Other dysphagia
• R13.13 Dysphagia, pharyngeal phase
• R13.11 Dysphagia, oral phase