Pediatric Dysphagia

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Key points

  • Feeding and swallowing disorders in the pediatric population are becoming more common, particularly in infants born prematurely and in children with chronic medical conditions.

  • The normal swallowing mechanism is divided into 4 stages: the preparatory, the oral, the pharyngeal, and the esophageal phases.

  • Feeding disorders have multiple causes; medical, nutritional, behavioral, psychological, and environmental factors can all contribute.

  • Pathologic conditions involving any of the anatomic sites

Epidemiology

The overall incidence of dysphagia in children is increasing. A major contributor to this increase is the improved ability to care for infants born prematurely (<37 weeks’ gestation). Survival rates for preterm infants have improved and the percentage of infants born prematurely has increased 20% since 1990.3, 4 Early gestational age, low birth weight, and especially very low birth weight (<500 g or 1 lb, 2 oz) are strong predictors of infant mortality, morbidity, and cerebral palsy (CP).5, 6

Causes of dysphagia

Feeding disorders have multiple causes; medical, nutritional, behavioral, psychological, and environmental factors can all contribute.7, 8 The medical causes of dysphagia can be organized into diagnostic categories that include neuromuscular disorders, aerodigestive tract anatomic abnormalities, genetic abnormalities, mucosal and esophageal pathologic abnormality, and other conditions affecting suck/swallow/breathing coordination.9 Rommel and colleagues10 categorized feeding problems as either

Evaluation techniques

The evaluation of a child with a feeding disorder begins with a thorough history and physical examination by a physician, which is supplemented by a clinical swallow assessment performed by a qualified feeding specialist. Detailed information regarding the structure and function of the oral, pharyngeal, laryngeal, and upper esophageal swallow complex is collected. An assessment of the potential benefits of compensatory and treatment strategies is also determined. The most common examinations

Treatment options

Improvement of a feeding problem in a pediatric patient is most likely to occur when the underlying cause is determined and corrected. Outcomes data for the treatment of dysphagia are limited,9 in part because dysphagia is often secondary to multiple associated comorbidities or syndromes that in and of themselves have no definitive treatment. Premature infants and/or those infants with comorbidities may benefit from interventions that facilitate the development of oral motor skills, lessen the

Summary

The incidence of dysphagia in children continues to increase, largely because of the improved survival of premature infants and children with chronic medical conditions. The ability to obtain objective outcomes data remains difficult because the cause of feeding problems is often multifactorial. A multidisciplinary team armed with the knowledge of the complexity of the swallowing mechanism, an awareness of the pathologic conditions that can affect swallowing, and an understanding of the

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      Involvement of the central nervous system as in cerebral palsy, Arnold-Chiari malformations, and prior stroke contributes to the development of dysphagia in children.7 Cerebral palsy is the most common neuromuscular condition seen in children, and there is significant overlap between this and prematurity, such that cerebral palsy is present in 20% of infants born before 26 weeks.3 Several other neuromuscular conditions can contribute to dysphagia including microcephaly, hydrocephalus, congenital viral infection, seizure disorders, and traumatic brain injury.

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      As an adjunct to this clinical assessment, a video fluoroscopic swallow study (VFSS) can provide objective evidence of the presence or absence of laryngeal penetration and/or tracheal aspiration. VFSS can also provide important information about the risk of penetration or aspiration using certain feeding positions, nipple or other delivery systems, and consistencies of liquid or food.15,16,17 This information can be used to develop a safe feeding plan that may allow a child to continue oral feeding for nutrition or for pleasure, with or without tube feeding supplementation.

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