Dysphagia is a term that means "difficulty swallowing." It is the inability of food or liquid to pass easily from the mouth, into the throat, through the esophagus and into the stomach.
To understand dysphagia, it helps to first understand how swallowing occurs.
Swallowing involves four stages. These stage are controlled by nerves that connect the digestive tract to the brain:
Oral preparation stage. Food is chewed and moistened by saliva.
Oral stage. The tongue pushes food and liquids to the back of the mouth toward the throat. (This phase is voluntary: people have control over chewing and beginning to swallow.)
Pharyngeal stage. Food enters the pharynx (throat). Parts of the larynx (voice box) close so that the food does not enter the trachea and go to the lungs. Next, the muscles in the throat relax, and food and liquid are quickly passed down the pharynx (throat) into the esophagus. The larynx opens to allow for breathing. (This phase starts under voluntary control, but then becomes an involuntary phase that can't be consciously controlled.)
Esophageal stage. Liquids fall through the esophagus into the stomach partially by gravity. Muscles in the esophagus push food and liquid 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)
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
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
Dysphagia can result in aspiration, which occurs when food or liquids go into the trachea (windpipe) and lungs. Aspiration of food and liquids may cause pneumonia and/or other serious lung conditions.
Children with dysphagia usually have trouble eating an adequate amount, leading to poor nutrition and failure to gain weight or grow properly. Evaluation and treatment are important because they reduce the risk for adverse outcomes, including oral aversion of foods and liquids as well as behavioral resistance to feeding. Additionally, identification of swallowing dysfunction and management reduce the risk for aspiration (the passage of food or liquids into the airway).
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 person may experience symptoms differently. Symptoms may include:
Trying to swallow a single mouthful of food several times
Difficulty coordinating sucking and swallowing
Gagging during feeding
A feeling that food or liquids are sticking in the throat or esophagus, or that there is a lump in these areas
Arching or stiffening of the body during feedings
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
Frequent respiratory infections
Spitting up or vomiting frequently
Food or liquids coming out of the nose during or after a feeding
Irritability or lack of alertness during feedings
Symptoms of dysphagia may look like other conditions or medical problems. Please consult your child's health care provider for a diagnosis.
A doctor or other health care provider will examine your child and get a medical history. You will be asked questions about how your child eats and any problems you notice during feeding.
Imaging studies and endoscopy may also be performed to evaluate the mouth, throat, and esophagus. These tests can include:
Oral-pharyngeal video swallow study. Also known as the Video-Fluoroscopic swallow study (VFSS) or Modified Barium Swallow Study (MBSS): 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. This is performed in the presence of a speech language pathologist (SLP) or occupational therapist (OT), who are specially trained in the evaluation of swallowing disorders.
Barium swallow/upper GI series. Your child is given a liquid containing barium to drink. This is a metallic, chemical, chalky, liquid used to coat the inside of organs so that they will show up on an X-ray. A series of X-rays are then taken. The doctor 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.
Fiberoptic Endoscopic Evaluation of Swallowing (FEES): Like the Oral-Pharyngeal swallow study, FEES is performed in the presence of a speech pathologist or occupational therapist. This swallowing evaluation involves an Otolaryngologist, who places a small camera through the nose while your child is completely awake. With the camera in place, your child remains comfortable while they are allowed to eat and drink different types of solids and liquids. This study allows for the function of the vocal cords, and the larynx to be directly observed during swallowing. This study is safe in children of all ages.
Gastroesophageal Endoscopy. This is 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. An endoscopy is done under anesthesia. 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.
Testing for reflux disease. Esophageal and stomach acidity probes (also known as “pH Probes”), and impedance probes, are used to test for reflux disease. The probe is a very thin acid measuring device that is placed by your GI specialist, commonly under sedation in the operating room. They are generally not uncomfortable when in place, and are often removed the following day. Please contact us or your gastroenterology (GI) specialist for more information.
Other tests that may be done 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 how well food moves through the esophagus.
Laryngoscopy. Under anesthesia, a doctor places a tube into your child's throat and looks through it for narrowed areas and other problems.
Specific treatment for dysphagia will be determined by your child's health care provider 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 language pathologists and occupational therapists are instrumental in the diagnosis and treatment of children with dysphagia. 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 or 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 until they are at least 4 months old, since they do not have the proper coordination to swallow foods 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 and complete evening meal at least 3 hours before bedtime.
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.
Many children learn to eat and drink successfully. 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 cerebral palsy, muscular dystrophy and brain injury, may not be able to experience much improvement with their swallowing difficulties.