Dysphagia

What is dysphagia?

Dysphagia is a term that means "difficulty swallowing." It is the inability of food or liquids to pass easily from the mouth, into the throat, and down into the esophagus to the stomach during the process of swallowing.

What causes dysphagia?

To understand dysphagia, we must first understand how we swallow.

Swallowing involves three stages. These three stages are controlled by nerves that connect the digestive tract to the brain.

• Oral preparation stage. Food is chewed and moistened by saliva. The tongue pushes food and liquids to the back of the mouth toward the throat. (This phase is voluntary: we have control over chewing and beginning to swallow.)

• Pharyngeal stage. Food enters the pharynx (throat). A flap called the epiglottis closes off the passage to the windpipe so food cannot get into the lungs. The muscles in the throat relax. Food and liquid are quickly passed down the pharynx (throat) into the esophagus. The epiglottis opens again so we can breathe. (This phase starts under voluntary control, but then becomes an involuntary phase that we cannot consciously control.)

• Esophageal stage. Liquids fall through the esophagus into the stomach by gravity. Muscles in the esophagus push food toward the stomach in wave-like movements known as peristalsis. A muscular band between the end of the esophagus and the upper portion of the stomach (known as the lower esophageal sphincter) relaxes in response to swallowing, allowing food and liquids to enter the stomach. (The events in this phase are involuntary.)

Swallowing disorders occur when one or more of these stages fails to take place properly.

Children's health problems that can affect swallowing include:

• Cleft lip or cleft palate

• Dental problems (teeth that do not meet properly, such as with an overbite)

• Large tongue

• Diseases that affect the nerves and muscles, such as a stroke, tumor, nerve injury, brain injury, or muscular dystrophy, and can cause paralysis or poor function of the tongue or the muscles in the throat and esophagus

• Large tonsils

• Tumors or masses in the throat

• Problems with the prenatal development of the bones of the skull and the structures in the mouth and throat (known as craniofacial anomalies)

• Prenatal malformations of the digestive tract, such as esophageal atresia or tracheoesophageal fistula

• Oral sensitivity that can occur in very ill children who have been on a ventilator for a prolonged period of time

• Irritation of the vocal cords after being on a ventilator for long periods of time (as may occur with premature babies or very ill children)

• Paralysis of the vocal cords

• Having a tracheostomy (artificial opening in the throat for breathing)

• Irritation or scarring of the esophagus or vocal cords by acid in gastroesophageal reflux disease (GERD)

• Compression of the esophagus by other body parts, such as enlargements of the heart, thyroid gland, blood vessels, or lymph nodes

• Foreign bodies in the esophagus, such as a swallowed coin

• Developmental delays

• Prematurity

Why is dysphagia a concern?

Dysphagia can result in aspiration which occurs when food or liquids go into the windpipe and lungs. Aspiration of food and liquids may cause pneumonia and/or other serious lung conditions.

Children with dysphagia usually have trouble eating enough, leading to inadequate nutrition and failure to gain weight or grow properly.

What are the symptoms of dysphagia?

The symptoms that children with dysphagia have may be obvious, or they can be difficult to associate with swallowing trouble. The following are the most common symptoms of dysphagia. However, each individual may experience symptoms differently. Symptoms may include:

• Eating slowly

• Trying to swallow a single mouthful of food several times

• Difficulty coordinating sucking and swallowing

• Gagging during feeding

• Drooling

• A feeling that food or liquids are sticking in the throat or esophagus, or that there is a lump in these areas

• Discomfort in the throat or chest

• Congestion in the chest after eating or drinking

• Coughing or choking when eating or drinking (or very soon afterward)

• Wet or raspy sounding voice during or after eating

• Tiredness or shortness of breath while eating or drinking

• Frequent respiratory infections

• Color change during feeding, such as becoming blue or pale

• Spitting up or vomiting frequently

• Food or liquids coming out of the nose during or after a feeding

• Frequent sneezing after eating

• Weight loss

Symptoms of dysphagia may resemble other conditions or medical problems. Please consult your child's physician for a diagnosis.

How is dysphagia diagnosed?

A physician or health care provider will examine your child and obtain a medical history. You will be asked questions about how your child eats and any problems you notice during feeding.

Imaging tests may also be done to evaluate the mouth, throat, and esophagus. These tests can include:

• Oral-pharyngeal video swallow. Your child is given small amounts of a liquid containing barium to drink with a bottle, spoon, or cup, or spoon fed a solid food containing barium. Barium shows up well on an X-ray. A series of X-rays are taken to evaluate what happens as your child swallows the liquid.

• Barium swallow/upper GI series. Your child is given a liquid containing barium (a metallic, chemical, chalky, liquid used to coat the inside of organs so that they will show up on an X-ray) to drink, and a series of X-rays are taken. The physician can watch what happens as your child swallows the fluid, and note any problems that may occur in the throat, the esophagus, or the stomach.

• Endoscopy. A test that uses a small, flexible tube with a light and a camera lens at the end (endoscope) to examine the inside of part of the digestive tract. Under anesthesia, an endoscopy is performed. Pictures are taken of the inside of the throat, the esophagus, and the stomach to look for abnormalities. Small tissue samples, called biopsies, can also be taken to look for problems.

Click Image to Enlarge

Other tests that may be performed to evaluate dysphagia include the following:

• Esophageal manometry. Under sedation, a small tube containing a pressure gauge is guided through your child's mouth and into the esophagus. The pressure inside the esophagus is then measured to evaluate the esophageal motility.

• Laryngoscopy. Under anesthesia, a physician places a tube into your child's throat and looks through it for narrowed areas and other problems.

What is the treatment for dysphagia?

Specific treatment for dysphagia will be determined by your child's physician based on the following:

• Your child's age, overall health, and medical history

• The extent of the disease

• The type of disease

• Your child's tolerance for specific medications, procedures, or therapies

• Expectations for the course of the disease

• Your opinion or preference

Speech or occupational therapy can be helpful for some children. These therapists can give your child exercises to help make swallowing more effective, or suggest techniques for feeding that may help improve swallowing problems.

Infants and children with dysphagia are often able to swallow thick fluids and soft foods (such as baby foods or pureed foods) better than thin liquids. Some infants who had trouble swallowing formula will do better when they are old enough to eat baby foods. The following suggestions should also be considered when caring for a child with dysphagia:

• Adding a small amount of rice cereal to infant formula or pumped breast milk may help dysphagia. Blending the formula/cereal mixture before adding it to a baby bottle can remove the lumps and make the mixture easier to suck through a nipple, as well as easier to swallow.

• Do not cut holes in nipples, since this can increase the risk for choking and aspiration, as well as interfere with the baby's oral development. Future feeding and speech skills may be affected.

• Baby foods should not be offered to infants from a spoon until they are at least 4 months old, since they do not have the proper coordination to swallow foods from a spoon until this age.

• Your child's speech or occupational therapist may be able to recommend other commercial products that help thicken liquids and make them easier to swallow.

Babies who have "oral aversion," which can occur after oral surgery or being on a ventilator for a prolonged period of time, may benefit from exercises and activities to desensitize them to having objects in their mouths. Exercises or activities may include:

• Provide safe toys and other objects for babies to chew on and mouth. Try things that have varying textures and temperatures.

• Vary the taste, texture, and temperature of soft foods for children older than 4 months.

• Allow your child to play with foods and get messy at mealtime.

When symptoms of GERD are also present with dysphagia, treating this condition may produce improvements in your child's ability to swallow. As the esophagus and throat are less irritated by acid reflux, their function may improve. Treatment of GERD may include:

• Remaining upright for at least an hour after eating

• Medications to decrease stomach acid production

• Medications to help food move through the digestive tract faster

• An operation to help keep food and acid in the stomach (fundoplication)

Children who have scarring or narrowing of the esophagus (esophageal stricture) may be able to be dilated, or widened, under anesthesia. This procedure may have to be repeated periodically.

What is the long-term outlook for a child with dysphagia?

Some children with dysphagia will have long-term problems. Children who have other health problems, especially those that affect the nerves and muscles (such as muscular dystrophy and brain injury), may not be able to experience much improvement with their swallowing difficulties. Other children may learn to eat and drink successfully. Many pediatric medical centers will have specialized feeding and/or swallowing teams.

Consult your child's physician regarding the prognosis for your child.