Feeding and swallowing disorders during childhood are on the increase and typically occur in conjunction with multiple and complex medical, health, and developmental conditions. A multidisciplinary approach is essential for the evaluation of these disorders and the prompt initiation of appropriate treatment. Following a brief description of the terms feeding and swallowing, this article provides an overview of the available epidemiologic data on dysphagia and its common diagnostic conditions, impact, evaluation, and management in the pediatric population.
Feeding and swallowing disorders during childhood are on the increase and typically occur in conjunction with multiple and complex medical, health, and developmental conditions. A multidisciplinary approach is essential for the evaluation of these disorders and the prompt initiation of appropriate treatment. Following a brief description of the terms “feeding” and “swallowing,” this article provides an overview of the available epidemiologic data on dysphagia and its common diagnostic conditions, impact, evaluation, and management in the pediatric population.
Feeding and swallowing processes are linked inextricably during infancy and early childhood. Feeding provides children and their caregivers with communication and social experiences that form the basis for many future interactions. “Swallowing” refers to process of deglutition that occurs after liquids or foods enter the mouth. Mealtime disruptions that occur early in life may result in long-term feeding problems or exacerbate pre-existing dysphagia. Consequently, unless distinguishing between feeding and swallowing is relevant to the discussion, the generic term “feeding/swallowing” is used henceforth in this article.
Epidemiologic data
The prevalence of feeding disorders in the pediatric population is estimated to range from 25% to 45% in typically developing children and from 33% to 80% in children who have developmental disorders . The incidence of pediatric dysphagia is increasing . A partial explanation for this increase is the improved survival rates of children who have histories of prematurity (<37 weeks’ gestation), low birth weights, and complex medical conditions . The percentage of infants delivered preterm has increased 20% since 1990 , and the proportion of infants born with low birth weight (<2500 g or 5 lb, 8 oz) is at the highest level reported in the past 50 years . Early gestational age, low birth weight, and especially very low birth weight (<500 g or 1 lb, 2 oz) are strong predictors of infant mortality, morbidity, and cerebral palsy (CP) .
Approximately 37% to 40% of infants and children assessed for feeding/swallowing problems were born prematurely and are at increased risk for respiratory, neurologic, and developmental problems. Immaturity of organ systems and the presence of concurrent disease processes contribute to morbidities associated with prematurity . For example, preterm infants are at risk for poorly coordinated feeding, and those who have bronchopulmonary dysplasia (BPD, chronic lung disease associated with prematurity) have poorer feeding endurance and performance than those who do not have bronchopulmonary dysplasia .
Another potential reason for the rising incidence of pediatric feeding/swallowing disorders during the last 20 years is the increased life expectancy of children who have CP and developmental disabilities . CP has been reported in 20% of infants born between 24 and 26 weeks’ gestation and in 4% of infants born at 32 weeks’ gestation . In one survey, approximately 30% of children who had CP and were referred to a feeding program had histories of preterm births . Additionally more children with other developmental disorders are surviving . Finally, swallowing dysfunction is being identified in children who previously had not been recognized as having impairments in deglutition .
Despite the presentation of this information, data on the prevalence and incidence feeding problems in the pediatric population are limited. Possible reasons for this paucity are that disabling or disease conditions are more likely to be counted than are symptoms of diseases (eg, dysphagia) , terminology for the coding of feeding-related behaviors may be reflected by multiple underlying diagnostic conditions , standardized diagnostic protocols are lacking, and differences exist in methods of ascertainment . Additionally, it may be challenging to distinguish between feeding patterns associated with variability during normal development and those associated with impairment. For example, identifying children who have delays in the acquisition of specific feeding behaviors (eg, drinking from an open cup or with a straw) requires an appreciation of the wide age range in which typically developing children first acquire the same behaviors .
Diagnostic conditions associated with pediatric dysphagia
Causes of dysphagia may evolve from five broad diagnostic categories: neurologic disorders (eg, immaturity, delays, or defects), anatomic abnormalities involving the aerodigestive tract, genetic conditions, conditions affecting suck/swallow/breathing coordination, and other comorbidities influencing deglutition ( Table 1 ). Regardless of age, similar diagnostic conditions and comorbidities probably would present with comparable impairments in deglutition. Nonetheless, specific diagnostic conditions are likely to differ across the age spectrum. Neurologic conditions are the etiologies most frequently associated with dysphagia. Although CP is the most common neurogenic condition associated with dysphagia in children, stroke is the most common neurologic condition in adults. Similarly, airway and craniofacial anomalies may be associated with dysphagia regardless of age; however, congenital conditions are more common in children, and acquired conditions occur more often in adults.
| Site or process | Examples of diagnostic conditions |
|---|---|
| Neurologic disorders (immaturity, delays, or defects) |
|
| Anatomic abnormalities of the aerodigestive tract |
|
| Genetic conditions |
|
| Conditions affecting suck-swallowing/breathing coordination |
|
| Other comorbidities |
|
a Laryngomalacia appears twice in this table because it is a common anatomic abnormality associated with pediatric dysphagia and it may compromise suck/swallow/breathing coordination.
Approximately 50% of children who have feeding disorders have multiple causes contributing to their feeding difficulties , and 90% have at last one medical diagnosis . Swallowing problems are prevalent in infants and young children who have histories of preterm births, BPD, congenital heart disease, anatomic abnormalities, and various syndromes and neurologic abnormalities . Gastroesophageal reflux disease (GERD) has been identified as a common underlying medical condition associated with feeding problems .
For some children, dysphagic symptoms may be the first sign of other underlying conditions. Feeding problems during infancy have been predictive of severe illness . Despite the increased risk of dysphagia associated with varying medical or developmental conditions, isolated swallowing dysfunction has been documented in otherwise neurologically normal children without identifiable causes at the time of presentation . Dysphagia also may occur after the acute states of respiratory infections in previously healthy children .
Diagnostic conditions associated with pediatric dysphagia
Causes of dysphagia may evolve from five broad diagnostic categories: neurologic disorders (eg, immaturity, delays, or defects), anatomic abnormalities involving the aerodigestive tract, genetic conditions, conditions affecting suck/swallow/breathing coordination, and other comorbidities influencing deglutition ( Table 1 ). Regardless of age, similar diagnostic conditions and comorbidities probably would present with comparable impairments in deglutition. Nonetheless, specific diagnostic conditions are likely to differ across the age spectrum. Neurologic conditions are the etiologies most frequently associated with dysphagia. Although CP is the most common neurogenic condition associated with dysphagia in children, stroke is the most common neurologic condition in adults. Similarly, airway and craniofacial anomalies may be associated with dysphagia regardless of age; however, congenital conditions are more common in children, and acquired conditions occur more often in adults.
| Site or process | Examples of diagnostic conditions |
|---|---|
| Neurologic disorders (immaturity, delays, or defects) |
|
| Anatomic abnormalities of the aerodigestive tract |
|
| Genetic conditions |
|
| Conditions affecting suck-swallowing/breathing coordination |
|
| Other comorbidities |
|
a Laryngomalacia appears twice in this table because it is a common anatomic abnormality associated with pediatric dysphagia and it may compromise suck/swallow/breathing coordination.
Approximately 50% of children who have feeding disorders have multiple causes contributing to their feeding difficulties , and 90% have at last one medical diagnosis . Swallowing problems are prevalent in infants and young children who have histories of preterm births, BPD, congenital heart disease, anatomic abnormalities, and various syndromes and neurologic abnormalities . Gastroesophageal reflux disease (GERD) has been identified as a common underlying medical condition associated with feeding problems .
For some children, dysphagic symptoms may be the first sign of other underlying conditions. Feeding problems during infancy have been predictive of severe illness . Despite the increased risk of dysphagia associated with varying medical or developmental conditions, isolated swallowing dysfunction has been documented in otherwise neurologically normal children without identifiable causes at the time of presentation . Dysphagia also may occur after the acute states of respiratory infections in previously healthy children .
Manifestations of feeding/swallowing disorders in infants and young children
Presentations of pediatric feeding/swallowing disorders are variable and may include poor sucking coordination , pharyngeal phase dysfunction , respiratory distress , GERD , nutrition compromise , oral motor delays , food refusal or selectivity , delayed transition or refusal to consume developmentally appropriate textures or foods , or some combination of these presentations. Differing patterns of clinical presentation may be associated with specific underlying diagnostic conditions. Oral motor dysfunction or delays are common in children who have developmental delays and occur in up to 90% of children diagnosed as having CP and in 80% of children who have Down syndrome . In contrast, children diagnosed as having specific developmental delays (eg, the autistic spectrum) are more likely to exhibit selectivity of type and texture of food than oropharyngeal dysphagia .
Infants who have unexplained causes of dysphagia at the time of presentation are likely to represent a heterogeneous cohort of patients with varying degrees of dysphagia . Presentations of “unexplained” dysphagia have ranged from profound problems characterized by “very weak or absent pharyngeal contraction” or “incomplete pharyngeal palsy” , to moderate pharyngeal dyscoordination , to suck/swallow/breathing incoordination . Investigations are needed to provide careful details regarding the types of presentation of dysphagia and their relationship to feeding/swallowing development and general well being.
Impact of pediatric dysphagia
Influential factors
Infants and young children who have dysphagia are at increased risk for the development of aspiration-induced chronic lung disease, malnutrition, neurodevelopmental problems, and stressful interactions with their caregivers . Unfortunately, little is known about the impact of pediatric dysphagia and the efficacy of interventions on the long-term health and quality-of-life outcomes for affected children . With sparse evidence to guide clinical decision making, clinicians have made decisions by using information extrapolated from studies of adults who have dysphagia or from anecdotal reports or by adhering to institutional routines. Given the current state of knowledge, Lefton-Greif and McGrath proposed adapting a pediatric asthma model as a framework to view the impact of pediatric dysphagia as an interaction among host characteristics, environmental/social factors, and age or timing of dysphagic exposure ( Fig. 1 ).
Although comparable factors modify the impact of dysphagia across the lifespan, the impact of specific factors is likely to differ with age. For example, when considering host characteristics, infants and young children may be especially sensitive to the effects of dysphagia at certain ages or developmental periods. The respiratory and nutritional sequelae associated with dysphagia may exert a profound influence on overall growth and on the growth and development of specific organs . Likewise, environmental/social factors (eg, access to appropriate health and rehabilitation services and adherence to management recommendations) influence the impact of dysphagia in all affected persons, but the patient’s age and neurodevelopmental status alter the specific features of these factors. Age or timing of exposure to the swallowing dysfunction probably is the most critical factor that distinguishes between impact of the dysphagia in pediatric and adult populations. Interruptions at critical stages may interfere with the development of optimal function or may compromise the functioning of current systems.
Critical or sensitive periods
Critical or sensitive periods seem to emerge soon after the relevant sensory information first becomes available to the specific organism . When swallowing dysfunction is present, it may interrupt normal development at critical or sensitive periods of time, delay or interfere with typical development or established patterns of feeding/swallowing, and facilitate the development of feeding aversions. Case studies suggest that children who are not given the opportunity to eat solid foods shortly after they learn to chew may have difficulty taking solids or may refuse to chew . Recently, the introduction of tastes during the first 5 months of life has been shown to influence later food preferences .
Successful feeding requires sufficient experience in addition to neurologic maturity . Further research is needed to define the critical stages of development in children who have dysphagia and identify necessary stimuli and appropriate dose–response relationships when oral feedings are interrupted or modified. Additionally, investigations are needed to determine whether swallowing disruptions that occur in early childhood have consequences later in life, particularly in the setting of adult-onset dysphagia.
Long-term outcomes
Unfortunately, outcome data for the resolution of dysphagia are limited. The prognosis for the recovery from dysphagia is dictated by the underlying diagnostic condition, by whether the condition is an acute or chronic condition, and, if the condition is chronic, by whether it is static or progressive (see for a detailed description of the progression of disease conditions).
For some children, dysphagic symptoms may be one of the first indications of an underlying condition . That said, children may present with severe feeding problems even if they were without difficulty with early sucking behaviors. One study reported feeding problems in 55% of adults who had CP .
Another way to view outcomes is to consider the long-term sequelae associated with the respiratory and nutritional consequences associated with pediatric dysphagia. Although the influence of recurrent aspiration on the developing airways is not well understood, many lung diseases in adults are thought to begin during childhood . Recurrent aspiration during the first decade of life may interfere with normal or compensatory lung growth .
Malnutrition is another complication associated with pediatric dysphagia and is linked with adverse cognitive and developmental outcomes . Additionally, specific micronutrient deficiencies during the childhood periods critical to brain development may interfere with brain development, behavior, and cognition .
Evaluation of infants and young children suspected of having dysphagia
Clinical or bedside evaluation
Input from multiple medical, health, and developmental disciplines is essential for establishing a diagnosis and developing an appropriate treatment plan for pediatric patients who have feeding/swallowing problems. Moreover, early evaluation of the swallowing dysfunction and prompt initiation of appropriate therapies are critical to lessen the impact of the morbidities associated with dysphagia.
Evaluation of all children who have feeding/swallowing difficulties begins with taking a thorough history and completing a physical examination. Foci of the clinical examination are organ and symptom specific and are directed toward identifying the appropriate diagnostic tests to determine the nature and extent of the swallowing impairment. The clinical examination process is complicated by the variability in the presentations of feeding/swallowing disorders.
Regardless of patient age, dysphagia may present as respiratory distress, nutritional compromise, and stressful mealtimes. Critical issues to consider when evaluating all children for feeding/swallowing concerns include the presence of episodic or chronic signs of respiratory distress and patterns of weight gain. Respiratory presentations differ with age and neurodevelopmental status ( Table 2 ) . Unlike adults, children are expected to gain weight. Consequently, either weight loss or failure to gain weight is concerning , particularly during the first 2 years of life when appropriate nutrition is critical for brain and lung development. The duration of meals and reports of stressful meals may provide some clues about the extent of the feeding/swallowing problems. Mealtimes in excess of 30 minutes on a regular basis are too long and may compromise the balance between the nutritional value and the energy expended with the feeding.
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