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BACKGROUND

Feeding difficulties are frequent comorbid conditions in infants and children with both acute and chronic illnesses and can alert the clinician to an underlying condition. In fact, feeding problems can precede the diagnosis of cerebral palsy in 60% of children with both cerebral palsy and oromotor dysfunction.1 Decreased oral intake can lead to nutritional deficiencies, failure to thrive, and dehydration. The ability of infants and children to feed and grow relies on safe oromotor coordination, endurance while feeding, adequate caloric intake, an appropriate food source, and positive feedback with respect to the feeding experience. Although poor feeding may be associated with many other pediatric illnesses, by far the most common feeding-related issues are gastroesophageal reflux (GER) and gastroesophageal reflux disease (GERD). Dysphagia and feeding aversion are two other distinct feeding-related diagnoses that will be addressed. Complications related to feeding aversion and to aspiration are also often concomitant diagnoses in medically complex children.

DYSPHAGIA

Dysphagia, or difficulty swallowing, is the term often used to refer to a swallowing abnormality, which frequently leads to an effect on eating. Swallowing can be divided into three phases: oral, pharyngeal, and esophageal. Problems at any stage of swallowing can affect eating to some degree. During the oral phase, an infant forms a bolus of fluid after creating suction with the lips, tongue, and palate. The bolus is then moved to the posterior pharynx. Infants older than 3 to 4 months and children are able to complete the oral phase of swallowing with more mature tongue movements and are able to move boluses of food of different consistencies by chewing and tongue movements. The oral phase depends on normal oral anatomy, normal sensation and sensory feedback, strong sucking (in infants), and normal oral muscular function (in children).

The pharyngeal phase of swallowing is an involuntary action that is initiated when the bolus touches the posterior pharyngeal wall. During this phase, respiration ceases as the vocal cords close, the larynx elevates, and the upper esophageal sphincter relaxes to allow the bolus to enter the esophagus. In children with poor oral muscular coordination, early entry of the bolus into the pharynx before vocal cord closure may allow aspiration into the trachea. Similarly, delay in relaxation of the upper esophageal sphincter allows food to pool above or penetrate the larynx and increases the risk for aspiration when the vocal cords open again.

The involuntary esophageal phase of swallowing requires normal esophageal mucosa, caliber, and motility to allow the bolus to enter the stomach. Esophageal inflammation, stricture, dysmotility, and obstruction can all contribute to dysphagia.

Abnormalities in swallowing are most common in premature infants and children with neurologic abnormalities or airway anomalies, such as laryngeal clefts, vocal cord palsy, and tracheoesophageal fistula. Disorders of swallowing in children differ from those in adults because of the anatomic relationships of airway structures in children and variations in neurologic ...

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