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242 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
C. Disorganized sucking
D. All of the above
2. What features of a breast pump are key to
supporting lactation?
A. Strong suction and rhythm that empties the
breast in less than 20 minutes
B. Alternating electric and battery-operated
systems
C. Pumping each breast separately
D. Rapid cycling to drain the breast quickly
3. Why might a parent complain of chronic
nipple pain and persistent lacerations when
the baby latches?
A. Shallow attachment
B. It is normal for nipples to hurt for 2 months
after delivery
C. Tongue tie
D. a or c
4. If a baby was choking because a mother was
producing high volumes of milk that caused
the flow to be fast, what would you advise her
to do?
A. Recline so gravity slows the flow
B. Unlatch the baby periodically during
letdown
C. Downregulate lactation by block feeding
D. All of the above
5. How would you advise a mother to maintain
lactation whose 3-week-old healthy term
infant is only able to drink about 30 mL
during nursing sessions?
A. Triple feed
B. Provide 2 ounces of formula after each
breastfeed
C. Feed the baby more often to increase intake
D. No changes, this is a normal feeding
regimen
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bfm.2022.29207.kbm
Pediatric Dysphagia:
Assessment of Disorders of
Swallowing and Feeding
CHAPTER OUTLINE
Introduction
Etiologies
Epidemiology
Feeding Versus Swallowing
Anatomy of Feeding and Swallowing
Physiology of Feeding and Swallowing
Respiratory Coordination for Pediatric
Swallowing
Prematurity
Milk to Solids
Taking a Case History
Clinical Evaluation
Instrumental Evaluations
Intellectual Development
Family Support
Summary
Discussion Questions
Study Questions
References
Chapter
11
245
246 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
A Look at the Chapter
This chapter illuminates comprehensive
approaches for assessing feeding and
swallowing integrity. Emphasis is placed on
a detailed medical review for consideration
of developmental, structural, inflammatory,
behavioral, neurogenic, and other coexisting
conditions. A sampling of these categorical
diagnoses is illustrated. Pediatric dysphagia
management is typically delivered in a multidisciplinary setting. This includes ancillary teams
and physician specialty care, such as otolaryngology, neurology, cardiology, pulmonology, and
gastroenterology. Caregivers are a cornerstone
of treatment as they will ultimately be overseeing
therapeutic interventions. Gauging involvement
of parents and other caretakers will impact
recommendations that emerge from feeding
and swallowing evaluations. Promoting a
child’s autonomy throughout their treatment
course is essential. The complexity of diet
recommendations as influenced by comorbidity,
family support, and anticipated disease course
is provided. Case vignettes illustrate functional
application of the organized approach to helping
families and children with dysphagia.
INTRODUCTION
purposeful because pathological reentry of material
from the stomach to the esophagus can be uncomfortable. Other disorders are better defined among a
syndrome such as trisomy 21, also known as Down
syndrome. Known muscular weakness can impact
all aspects of feeding and swallowing. Dysmorphic
conditions such as cleft lip and palate complicate
oral intake and involve a wide variety of disciplines
to manage. Autism spectrum disorder (ASD) affects
behavior, sensitivity, and sometimes intellect. Children with ASD may be exquisitely preferential to
textures and flavors in a manner that poses risk
of malnutrition. Medical complexity could start at
the time of a preterm or traumatic delivery where
oral intake has never been deemed safe and the
child is reliant on a feeding tube. In all of these
scenarios, there is opportunity to thoughtfully
evaluate each stage involved in feeding and swallowing. While there is tremendous value in instrumental exams — videofluoroscopic swallowing study
(VFSS) and flexible endoscopic swallowing studies
(FEES) — they should be performed sparingly and
with a therapeutic lens that will translate into diet
upgrades and treatment targets. Consider the child
with neurogenic dysphagia due to brain injury who
will require protracted dysphagia intervention.
These children may undergo numerous studies that
expose them to radiation
2,3
or hypersensitivity and
fear associated with repeated endoscopies. As children mature and have the intellectual capacity to
interact therapeutically, their motivation will play
a strong role in restoring safe oral consumption of
food and liquids.
Working with families as they support safe oral
intake of their child’s developmental or acquired
aerodigestive disorder is an inherently collaborative
endeavor. Age of the child and cognitive status will
influence engagement in the therapeutic process.
The distinction between feeding and swallowing
relates to the means of ingestion versus swallowing
stages for successful transport to the stomach. Clinical history may highlight the area of dysfunction.
Complexity and interaction of swallowing phases
often influence feeding behavior. Imagine a young
nonverbal child with gastroesophageal reflux, eosinophilic esophagitis,
1
or gastroparesis. The child may
present with a feeding disorder. Refusal to eat is
ETIOLOGIES
n Neurological conditions impacting swallowing
may be apparent from birth, evolve during
development, or surface from an acquired
condition such as traumatic brain injury or
cancer. Congenital conditions commonly accompanied by dysphagia include cerebral palsy,
trisomy 21, muscular dystrophy, and idiopathic
developmental delays that may eventually be
defined within a syndrome. Neuromuscular
impairment is typically seen in numerous
11. PEDIATRIC DYSPHAGIA: ASSESSMENT OF DISORDERS OF SWALLOWING AND FEEDING 247
body systems.4 This can implicate treatment
techniques during dysphagia management, such
as trunk and neck support while eating.
5
Their
ability to reactively cough for airway protection
is also of consideration when assessing safety
of oral intake.
6
Vocal quality and motor speech
coordination will affect dietary recommendations and may lead to detection of a unifying
neuromuscular condition. If lung health is
compromised and there is intellectual impairment, aspiration safeguards are limited. These
circumstances can lead to significantly more
restriction of oral intake, whether by texture,
volume, or oral gratification in the setting of
chronic tube feeding. Family support is paramount as they will ultimately monitor signs of
their child tolerating oral intake. Depending
on a child’s medical complexity, therapeutic
diet transitions may require approval from the
physician team.
n Morphological deviations of the aerodigestive
tract can inhibit suckling vacuum. Cleft lip and
palate are congenital malformations that are
typically repaired in later infancy.
7
Infants with
clefts work closely with a feeding therapist
to determine the most efficient means of
safely transmitting milk orally. Clinical work
in the area of cleft palate is often performed
among a multidisciplinary team of surgeons,
speech-language pathologists (SLPs), dieticians,
dentists, geneticists, and psychologists.
8
Pierre
Robin sequence is another congenital condition
characterized by micrognathia, glossoptosis,
and airway obstruction.
9
These children often
have a cleft palate and may require tracheostomy. Beckwith-Wiedemann syndrome
10
is the
most common congenital overgrowth syndrome;
it can create early feeding complications due
to macroglossia. They are additionally at risk
for tumors in their first 7 years of life. These
may create structural and neurological changes
in the aerodigestive tract. Another condition
characterized by widespread benign tumor
growth is neurofibromatosis.
11
While this condition originates within the nerve sheath, tumors
can become quite large and create limitations
of feeding, swallowing, breathing, and phonation. A more comprehensive list of craniofacial
abnormalities commonly implicating aerodigestive dysfunction is provided in Figure 11–1.
n The aerodigestive tract can become inflamed
and present clinically in varying ways. Gastroesophageal reflux is the most common culprit.
As an infant, it is normal to spit up after nursing
and bottle-feeding. More than 90% of these
reflux episodes are nonacidic, presumably a
benefit of exclusively drinking high-pH milk,
and occur 1 to 2 hours after nursing or bottlefeeding.
13
The upper and lower esophageal
sphincter laxity gradually improves with age.
A baby’s behavior determines whether the
reflux is pathological and warrants intervention. Postprandial infant irritability can occur
independent of reflux, particularly in preterm
and neurological impairments
empiric acid suppression is not advised.
15
; therefore,
12,16
Neurological immaturity and hypersensitivity
usually account for fussiness during and after
feeds. Helping families distinguish pathological
reflux from normal newborn behavior steers
appropriate interventions. Some parents benefit
from attending peer-based newborn classes to
observe the wide variability of newborn behaviors, which can normalize their experience.
Reviewing neurological calming maneuvers
such as swaddle, suckling, movement, white
noise, and prone positioning could ease an
infant’s distress after meals. Additionally,
burping, upright posture, and avoiding cow’s
milk protein may be advised.
17
It is
not considered safe to raise the head of the
bed for a baby, as they lack neck strength to
prevent accidental asphyxiation. If a child has
pulmonary consequences potentially associated
with reflux events, there is heightened attention
to intervention with feeding volume and
texture modifications. In some cases, reflux
medications may also be prescribed. For the
infant, toddler, and young child unable to
verbalize their dysphagia, close observation
of mealtime behavior is helpful. While frank
regurgitation in all age groups is more easily
identified, other signs of reflux can be insidious. Some children will simply refuse to eat
because it is uncomfortable. One such example
is eosinophilic esophagitis, an allergic condition
12
14
248 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
Neuromuscular
Structural
Inflammatory
Chiari malformation, muscular dystrophy, congenital myopathy,
spinal muscular atrophy, viral infection, traumatic brain injury,
seizure
Choanal stenosis/atresia, pyriform aperture stenosis, congenital
intranasal masses, midface hypoplasia, turbinate/adenoid hypertrophy,
ankyloglossia, micrognathia/retrognathia, cleft lip/palate,
macroglossia, high palate, laryngomalacia, vocal fold immobility,
laryngotracheoesophageal cleft, glottic stenosis, subglottic stenosis,
esophageal atresia, tracheoesophageal fistula, cricopharyngeal
achlasia, tracheobronchomalacia, tracheal stenosis
Gastroesophageal reflux, viral infections of oropharynx and
hypopharynx; iatrogenic
Behavioral
Oral aversion, hypersensitivity, intellectual disability, psychiatric
conditions, anorexia, bulimia, conversion disorder
Cardiopulmonary
Congenital cardiac disease, bronchopulmonary dysplasia, intubation,
tracheotomy, mechanical ventilation
FIGURE 11–1. Types of dysphagia and associated etiologies.
that impairs esophageal motility and patency.18
As children become verbal, engage them in the
process of problem-solving why eating is not
enjoyable.
n Behavioral origins of dysphagia involve hyper-
sensitivity syndromes, such as ASD, intellectual
impairment, mental illness, and avoidant restrictive food intake disorder. Acommon disorder
seen within speech-language pathology purview
is ASD. There are feeding teams solely dedicated to intensive mealtime training so children
develop healthful eating and drinking patterns.
Their sensory system may process normal
physiology as threatening. They may also have
heightened awareness of specific textures and
taste. The range of severity results in a variety
of functional impairments from “picky eater” to
nonoral nutrition.
dysphagia relates to intellectual impairment,
they may require meal assistance so impulsivity
does not pose choking hazards. Depending on
their functional presentation, they may require
total assistance with feeding and swallowing.
Mental illness can pose unfortunate complications of avoidance and binging. Treatment is
typically collaborative with an eating disorders
19
If the origin of behavioral
11. PEDIATRIC DYSPHAGIA: ASSESSMENT OF DISORDERS OF SWALLOWING AND FEEDING 249
also benefit from consulting with an eating
Term Infant With Hypoxic Ischemic
Encephalopathy (HIE). This hours-old infant
was delivered at 39 weeks because of low
amniotic fluid. She sustained complications
during delivery resulting in HIE. For 1 week,
she underwent therapeutic hypothermia in the
neonatal intensive care unit. The mother used a
breast pump and provided her milk through the
feeding tube that is seen orally. Once the child’s
body was warmed, and the tubes were removed,
the mom worked on latching. The child went on
to breastfeed without complication. She is now
18 months old and thriving. Depending on the
extent of the brain injury, some infants with HIE
will experience oral-pharyngeal dysphagia and
aspiration as they are weaned from oxygen and
the feeding tube.
23
disorders team while addressing texture integration with an SLP.
n Cardiopulmonary conditions, while they may
not directly implicate muscular dysfunction of
the aerodigestive tract, can affect energy and
airway protection. Children with cardiac disease
may require partial or total enteral feeding to
preserve energy expenditures. Perioperative
cardiac protocols often involve periods of
nonoral nutrition and hydration until cleared
by an SLP with a clinical or instrumental swallowing study.
20
Due to the proximity of the
recurrent laryngeal nerve, there is risk of left
vocal fold paralysis as this branch wraps around
the aorta and can be damaged during surgery.
The ability of a child to protect their airway
with vocal fold immobility diminishes, often
21
leading to more conservative recommendations.
Pulmonary conditions may be developmental,
structural, or chronic. Varying levels of respiratory support from mechanical ventilation
delivered via tracheostomy, ambulatory oxygen,
to frequent respiratory treatments will impact
a child’s ability to remain hydrated and nourished. Respiratory procedures also pose the
risk of laryngeal scarring and vocal fold
immobility.
22
In both cardiac and pulmonary
cases, assessment of voice quality, cough, and
throat clearing are recommended. For infants,
this is assessed by the quality and projection
of their cry.
clinic. Cases of “picky eating” without organic
oral, pharyngeal, or esophageal disorders and
in the absence of autism spectrum signs may
The National Foundation of Swallowing Disorders
online Pediatric Dysphagia Support Group can be
found by scanning the accompanying QR code.
EPIDEMIOLOGY
Survival rates of extremely preterm and ill newborn
children have improved with medical advances and
are thought to contribute to the increased incidence
of pediatric feeding and swallowing disorders. In
the absence of well-defined diagnostic criteria, it is
challenging to quantify true dysphagia prevalence
though there are data that exist within diseases that
disrupt oral-pharyngeal physiology. A 2012 National
250 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
Health Interview Survey detected 1% prevalence of
pediatric dysphagia of which neurological conditions were the most common.
24
Cerebral palsy, a
complication in approximately 1 in every 500 live
25
births,
has about 50% prevalence of drooling, swallowing, and feeding difficulty that varies by disease
subtype. One of the most common birth defects that
occurs in isolation and among syndromes is oral
cleft. According to a 2022 meta-analysis, prevalence
per 1000 live births was 0.33 cleft palate, 0.34 cleft
lip, and 0.45 cleft palate and lip occurring simultaneously.
dren worldwide,
26
ASD, affecting an estimated 1 in 100 chil-
27
can disrupt digestive sensitivity
and create problematic mealtime behaviors in up
to 90% of children.
19,28–31
In some circumstances,
infantile feeding dysregulation could be an early
indicator of this increasingly common neurodevelopmental disorder.
Rates of silent aspiration are high in infants,
though this may not implicate problematic
sequelae.33 Pairing instrumental exams with
clinical observations is advised when making
dietary recommendations. Videofluoroscopic
findings have significant false-positive rates and
may unnecessarily lead to restrictive dietary
recommendations.34 Identifying aspiration in
an otherwise healthy infant without pulmonary
deterioration or feeding distress may resolve
spontaneously with development.
32
FEEDING VERSUS SWALLOWING
There are 3 phases of swallowing: oral, pharyngeal,
and esophageal. Taking material into the mouth
is the act of feeding; it involves sucking, hand to
mouth, or utensils. Once the food or liquid is in
the mouth, it is prepared for the pharyngeal phase
of swallowing. A breast- or bottle-fed infant suckles and almost immediately swallows. The same is
true for most liquids; the transition from oral to
pharyngeal stages should be rapid unless they are
implementing a technique to circumvent aspiration. Textured solid foods require rotary chewing,
moving the food to the posterior tongue, sequentially squeezing the pharyngeal muscles, safely
passing by the airway, and entering the esophagus.
Each step elicits precise sensory and motor integration of cranial nerves V (trigeminal), VII (facial),
IX (glossopharyngeal), X (vagus), and XII (hypoglossal). Acase history, oral-motor evaluation, and
meal observation will reveal the integrity of these
nerves.
Anatomy of Feeding and Swallowing
Pediatric oral and pharyngeal structures differ significantly from adults. They have innate morphological organization that protects their airway. An
infant’s tongue is proportionally larger than an
adult tongue, the palate and epiglottis approximate,
their hyoid rests high, and the larynx is nestled just
behind the mandible opposite the first and second
cervical vertebrae. As a child matures, teeth emerge
while the larynx descends for speech and ingestion
of solid food. Figure 11–2 superimposes the distinguishing traits of an infant’s and adult’s anatomical
features. The muscles essential for swallowing are
reflected in Figure 11–3 with their associated cranial
nerve innervations.
Physiology of Feeding and Swallowing
Swallowing begins in utero. It is one of the mechanisms of regulating amniotic fluid. Once infants enter
extrauterine life, they are equipped with reflexes that
enable effective feeding. These involve tonic neck,
rooting, lateral tongue, sucking, and swallowing.
A comprehensive list of newborn reflexes is provided
in Figure 11–4. The presence of reflexes reflects
central nervous system integrity. The rooting reflex identifies objects near their mouth and elicits tongue protrusion to locate the nipple. Infants
then create a vacuum, and suck and swallow reflexively. Their large tongue and palatal-epiglottic
proximity are barriers for airway invasion as they
drink milk. While breathing and swallowing are
anatomically separated, the timing of inhalation,
exhalation, and apnea is critical to safely transport
milk into the esophagus. Commonly, preemies and
11. PEDIATRIC DYSPHAGIA: ASSESSMENT OF DISORDERS OF SWALLOWING AND FEEDING 251
FIGURE 11–2. Adult and infant lateral view.