Dysphagia

What is dysphagia?

Simply put, it’s having trouble getting food or liquid from the lips down to the stomach. Dysphagia basically means trouble swallowing. It’s different than feeding difficulties, which occur when a child has difficulty eating with a spoon, chewing, or sucking during breastfeeding.

What are the symptoms of dysphagia?

Symptoms are varied, but they can include gagging, spitting up, arching or stiffening while feeding, or having trouble coordinating the suck, swallow, and breath cycle. You might notice your child eating or swallowing slowly, needing repeated breaks during the feed, or having liquids come out of the nose after feeding. Suspect dysphagia when your child experiences chest congestion, coughing, choking, or drooling after eating or drinking. Sometimes symptoms are less obvious, such as when your child has unexplained frequent colds, weight loss, or prolonged feedings.

Is there a cure for dysphagia?

The treatment for dysphagia depends on the reason for your child’s swallowing difficulty. In many cases, it can be cured or greatly improved with feeding and swallowing therapy. This is often performed to ensure that your child is swallowing safely as his or her swallow function matures with time. If there is an anatomic abnormality (physical defect) contributing to your child’s swallowing difficulty, surgery may be necessary to correct the defect. Under some circumstances, a combination of surgery and swallowing therapy may be needed.

Which children are at risk for dysphagia?

We frequently see dysphagia in premature infants who have difficulty coordinating their muscle function during swallowing. However, it can occur in children of any age.

What causes dysphagia?

Dysphagia can occur for a number of reasons, and multiple causes may be present. For example, dysphagia might be caused by a neuromuscular issue (when the nerves and muscles do not work correctly together, which can make it hard to squeeze the muscles in the tongue, esophagus [feeding tube], or throat) or an anatomical issue (a physical defect) such as a laryngeal cleft, vocal cord immobility, or an esophageal fistula that disrupts the normal swallowing pathway. In other children, dysphagia occurs when there is a narrowing of the esophagus or disrupted movement of the esophagus. An example of this can be seen in children with eosinophilic esophagitis (EoE), a chronic disease of the esophagus that often occurs in response to an allergy. Head or neck injuries can also cause dysphagia, as can ingesting something that burns the esophagus or swallowing an object that gets stuck in the esophagus.

How do you diagnose dysphagia?

Dysphagia is not always obvious and easy to diagnose. That’s why we offer a full gamut of testing to identify the cause of dysphagia. Because we see a large volume of children with dysphagia, and we work with a multidisciplinary team of experts, we are able to identify subtle signs of dysphagia. To gain insight into your child’s dysphagia, we start with a physical exam, a clinical feeding and swallowing evaluation, and potentially a swallow study. Which swallow study your child receives depends on his or her symptoms and our discovery during the exam. Often, a VFSS and/or FEES is used to diagnose dysphagia. Our swallow studies include the following:

• Videofluoroscopic swallow study (VFSS), also called a modified barium swallow (MBS) study. In this study, a moving x-ray shows the workings of your child’s mouth and throat muscles while he or she swallows a liquid dye called barium. We observe the path that the dye takes as it travels from the mouth into the esophagus. This study is performed by a speech-language pathologist and a radiologist.
• Fiberoptic endoscopic evaluation of swallowing (FEES). In this study, which is a modified form of laryngoscopy, we place a flexible laryngoscope (a thin flexible camera) through the nose to visualize the throat, tongue, and airway as your child eats or drinks. We are able to view the larynx (voice box) to see if there are any visible anatomic defects, determine if it is functioning normally, and test for sensation. While your child eats and drinks, we watch to see if the liquid or food being swallowed follows the usual path to the esophagus. We can see if it deviates from the normal pathway and instead enters the airway above the vocal cords (penetration) or through the vocal cords (aspiration) into the trachea (windpipe) and lungs. It’s performed in our Center for Pediatric Voice and Swallowing Disorders with a pediatric otolaryngologist and speech-language pathologist. Radiation is not required.
• Triple endoscopy. This combined, investigative endoscopic procedure offered by our multidisciplinary Aerodigestive and Airway Reconstruction Center gives us a view of your child’s entire aerodigestive tract, from the nose and mouth to the windpipe and esophagus. The triple endoscopy includes rigid laryngoscopy and bronchoscopy with a pediatric otolaryngologist, pulmonary bronchoscopy with a pediatric pulmonologist, and an evaluation of the esophagus, stomach, and small intestine (esophagogastroduodenoscopy, or EGD) with a pediatric gastroenterologist. It is performed in the operating room under general anesthesia. Doing a triple scope means less stress for your child, since one procedure with an experienced team is all that is needed—a part of our family-centered care.
• Advanced swallowing diagnostics. If further evaluation is needed, your child can be seen in our advanced Motility Program, where specialized gastroenterologists use esophageal manometry and specialized radiographic studies to test the function of the esophagus.

How do you treat dysphagia?

When the reason for your child’s dysphagia is anatomical (physical), we may need to perform a surgery—usually minimally invasive—to repair the physical abnormality. A key component to improving dysphagia, especially when the source is neuromotor (a misfiring of nerves or muscles), is swallowing therapy. At our multidisciplinary Center for Pediatric Voice and Swallowing Disorders, one of the most advanced multidisciplinary clinics in California, otolaryngologists, speech-language pathologists, occupational therapists, and nutritionists provide care for simple to complex voice and swallowing disorders, including dysphagia.

In addition to working with a feeding or swallowing therapist, other nonsurgical interventions might include thickening liquids to slow their movement, so that your child’s body has time to undergo all of the complex mechanisms necessary to swallow safely. If your child has reflux or eosinophilic esophagitis, he or she might need medicines or other treatments to improve the inflammation in the esophagus, which can thereby greatly improve or cure dysphagia.

When does a child need surgery for dysphagia?

When we determine that the reason for dysphagia may be anatomical, we investigate in the operating room via a diagnostic procedure such as a rigid laryngoscopy and bronchoscopy. When surgery is required, the majority of our surgeries are minimally invasive, and we are able to do them through the mouth without making any incisions in the skin.

When should I see a specialist for my child’s dysphagia?

Whenever there is a question that dysphagia exists, or when your child’s pediatrician suspects that dysphagia might be contributing to other symptoms, you should see a specialist. For example, seek out help from a pediatric otolaryngologist (ENT) when your child has reoccurring or long-lasting upper respiratory infections, unresolved asthma, abnormal breathing, or concerning behaviors surrounding meals. Also, if your child has a history of a neuromuscular disorder, you should seek care if he or she starts showing symptoms of dysphagia.

What type of specialist treats dysphagia?

A pediatric otolaryngologist who is ideally part of a multidisciplinary team, such as our Aerodigestive and Airway Reconstruction Center or our Center for Pediatric Voice and Swallowing Disorders here at Stanford Medicine Children’s Health. Our speech-language pathologists are all members of the American Speech-Language-Hearing Association (ASHA) and dedicated to the management of dysphagia. In addition, our pediatric otolaryngologists, pulmonologists, and gastroenterologists all have subspecialty training in the diagnosis and management of swallowing disorders.

For more information, please contact our Aerodigestive and Airway Reconstruction Center or our Center for Pediatric Voice and Swallowing Disorders.