Feeding and Swallowing Issues

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Feeding and Swallowing Issues

Pediatric Otolaryngology
Author Credentials 

William O. Collins, MD
Associate Professor
Department of Otolaryngology
University of Florida College of Medicine
Gainesville, FL

Module Summary

Swallowing is a complex action which occurs in most individuals effortlessly. Any dysfunction in the process of swallowing can affect both the intake of nutrition as well as respiratory function. It is important to recognize the anatomical and physiological disturbance in swallowing so as to better tailor the treatment regimen to the specific dysfunction. Treatment options range across a broad spectrum from long term rehabilitative options such as swallowing therapy, to medical management of underlying sialorrhea and GERD, and finally surgical options.

Module Learning Objectives 
  1. Describe the common phases of swallowing.
  2. Recognize the potential complications of impaired swallowing in a pediatric patient. 
  3. Describe a comprehensive diagnostic approach to identify the etiology of swallowing dysfunction in pediatric patients.
  4. Develop a treatment plan for swallowing dysfunction in pediatric patients. 

Anatomy

Learning Objectives 

To understand the role of anatomic structures within the upper aerodigestive tract and how they affect swallowing. 

References 
  1. Strahan RC, Meyers AD. Aspiration in Pediatric Otolaryngology, Fourth Edition. Ed. Bluestone CD, Stool SE, Alper CM, et al. Saunders, Philadelphia, PA; 2003:1405-1412.

Pathogenesis

Learning Objectives 

To describe abnormalities of the 4 phases of swallowing:

  • Preparatory phase
  • Oral phase
  • Pharyngeal phase
  • Esophageal phase

 

References 
  1. Derkay CS, Plant RL. Dysphagia in Pediatric Otolaryngology, Fourth Edition. Ed. Bluestone CD, Stool SE, Alper CM, et al. Saunders, Philadelphia, PA; 2003:1128-1137.
  2. Newman LA, Keckley C, Peterson MC, Hamner A. Swallowing Function and Medical Diagnoses in Infants Suspected of Dysphagia. Pediatrics. 2001 Dec;108(6):E106.

Incidence

Learning Objectives 

To identify the incidence of  swallowing dysfunction in pediatric patients.  

References 

 

  1. Derkay CS, Plant RL. Dysphagia in Pediatric Otolaryngology, Fourth Edition. Ed. Bluestone CD, Stool SE, Alper CM, et al. Saunders, Philadelphia, PA; 2003:1128-1137.

Patient Evaluation

Learning Objectives 

To perform a comprehensive history and physical examination on a pediatric patient suspected of having swallowing dysfunction.  

References 
  1. Newman LA, Keckley C, Peterson MC, Hamner A. Swallowing Function and Medical Diagnoses in Infants Suspected of Dysphagia. Pediatrics. 2001 Dec;108(6):E106.

Measurement of Functional Status

Learning Objectives 

To describe the effects that swallowing dysfunction can have on development and growth in pediatric patients.

References 
  1. Heckathorn DE, Speyer R, Taylor J, Cordier R. Systematic Review: Non-Instrumental Swallowing and Feeding Assessments in Pediatrics. Dysphagia. 2016 Feb;31(1):1-23.

Imaging

Learning Objectives 

To describe the role of imaging in the diagnosis of swallowing dysfunction in pediatric patients:

  • Swallow studies
  • CT and MRI
  • Radionuclide scintigraphy

 

References 
  1. Strahan RC, Meyers AD. Aspiration in Pediatric Otolaryngology, Fourth Edition. Ed. Bluestone CD, Stool SE, Alper CM, et al. Saunders, Philadelphia, PA; 2003:1405-1412.

Treatment

Learning Objectives 

To describe a treatment strategy for management of a patient with swallowing dysfunction:

  1. Non-surgical options
    1. Medical therapies
    2. Rehabilitative options
  2. Surgical options

 

References 
  1. Derkay CS, Plant RL. Dysphagia in Pediatric Otolaryngology, Fourth Edition. Ed. Bluestone CD, Stool SE, Alper CM, et al. Saunders, Philadelphia, PA; 2003:1128-1137.

Medical Therapies

Learning Objectives 

Describe medical therapies which may help alleviate swallowing dysfunction and aspiration in pediatric patients:

  • Anti-sialogogues for sialorrhea
  • GERD therapy

 

References 
  1. Thompson DM, Arora AS, Romero Y, Dauer EH. Eosinophilic esophagitis: Its Role in Aerodigestive Tract Disorders. Otolaryngol Clin N Am. 2006;39: 205-221.

Surgical Therapies

Learning Objectives 

To develop a surgical treatment plan for pediatric patients with swallowing dysfunction and aspiration:

  • Procedures on the GI tract:
    • Feeding tubes
    • Nissen fundoplication
    • Cricopharyngeal myotomy
  • Sialorrhea procedures:
    • Botox injections of the salivary glands
    • Submandibular gland excision
    • Parotid duct ligation
  • Laryngeal procedures:
    • Tracheotomy
    • Vocal fold medialization
    • Laryngotracheal separation

 

References 
  1. Strahan RC, Meyers AD. Aspiration in Pediatric Otolaryngology, Fourth Edition. Ed. Bluestone CD, Stool SE, Alper CM, et al. Saunders, Philadelphia, PA; 2003:1405-1412.
  2. Derkay CS, Plant RL. Dysphagia in Pediatric Otolaryngology, Fourth Edition. Ed. Bluestone CD, Stool SE, Alper CM, et al. Saunders, Philadelphia, PA; 2003:1128-1137.

Rehabilitation

Learning Objectives 

To understand the role of rehabilitative therapies in pediatric patients with swallowing dysfunction and/or aspiration, including long term swallowing therapy. 

Case Studies

  1. A 12 month old male presents with recurrent pneumonias. What anatomic abnormalities of his upper aerodigestive tract could predispose him to recurrent pneumonias?
  2. A 6 month old female is brought to her pediatrician with poor feeding patterns, and poor weight gain. What is the differential diagnosis? What aspects of the history are important from an otolaryngologist’s perspective to help discern the underlying cause of her difficulties?

Complications

Learning Objectives 

To recognize long term consequences of untreated aspiration.  

References 
  1. Kelchner LN, Miller CK. Current research in voice and swallowing outcomes following pediatric airway reconstruction. Curr Opin Otol Head Neck Surg. 2008;16(3):221-225.
  2. Osborn AJ, de Alarcon A, Tabangin ME, et al. Swallowing function after laryngeal cleft repair: more than just fixing the cleft. Laryngoscope. 2014;124(8):1965-1969.

Review

Review Questions 
  1. What are the phases of swallowing?
  2. Describe some common dysfunctions at each phase of swallowing.
  3. What are sequelae in pediatric patients of impaired feeding and swallowing?
  4. What are common diagnostic tests used to workup a pediatric patient with impaired swallowing?
  5. What surgical therapies can be used to treat pediatric patients with abnormal swallowing and aspiration?
Resources 

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  1. Annual Meeting Webcast (AMW):