SWALLOWING DISORDERS IN CHILDREN
Swallowing is one of the most complex neuromuscular functions of the body. An
average of 10 million Americans are evaluated for swallowing disorders every
year. A swallowing disorder is the inability to move food from the mouth to the
stomach. Swallowing disorders in children may cause weight loss, aspiration
pneumonia, dehydration, or airway obstruction.
Swallowing has three phases:
oral, pharyngeal, and esophageal.
The oral phase of swallowing:
The oral phase is voluntary, and is controlled by the cerebral
cortex and corticobulbar tracts of the brain. It is divided into the
oral preparatory and oral propulsive phases.
The oral preparatory phase prepares the bolus of food, so that it is “swallowable.”
The oral propulsive phase propels the food from the oral cavity into the oropharynx.
The paryngeal phase of swallowing:
This is the shortest, but most complex phase. This phase is involuntary and
is triggered by contact of the bolus with the tonsillar
pillars and pharyngeal wall. It takes place in less than one second.
The swallow reflex involves high cortical centers, brain stem centers, and cranial
nerves V (trigeminal), VII (facial), IX (glossopharyngeal), X (vagus)
and XII (hypoglossal).
There are 29 muscle pairs which are involved in this phase of swallowing.
First, the soft palate moves upward to seal the nasal cavity. Then the
larynx and hyoid bone move forward and upward. The epiglottis fold back to
protect the airwary. The tongue pushes the bolus of food downward into the
The esophageal phase of swallowing:
This final phase of swallowing is controlled by the brainstem and myenteric
The bolus of food is moved down by a peristaltic wave that begins in the
pharynx and ends at the lower esophageal sphincter. The lower esophageal
sphincter (LES) allows the bolus to enter the stomach.
WHAT TYPES OF SWALLOWING DISORDERS CAN CHILDREN HAVE?
Children can have swallowing disorders in the oral phase, pharyngeal
phase, or esophageal phase. They can also experience aspiration
of food into the airway.
Oral phase swallowing disorders:
These disorders are usually caused by impaired control of the tongue during
There may be: difficulty keeping liquid in the mouth, difficulty chewing
food, pocketing of food in the vestibule of the mouth, or aspiration of food
Pharyngeal phase swallowing disorders:
Food is retained in the pharynx, and may not reach the esophagus. As a
result, some of the food may be aspirated into the airway.
Esophageal phase swallowing disorders:
This can be caused by a motility disorder, mechanical obstruction, or
impaired opening of the lower esophageal sphincter.
This results in retention of food and liquid in the esophagus.
Zenker diverticulum may cause difficulty swallowing , with possible
aspiration during sleep.
Achalasia can cause faulty gastroesophageal junction relaxation, or faulty
This is the passage of food or liquid through the vocal cords and into the
trachea. It can be caused by the overflow of food or liquids which are
retained in the pharynx. Aspiration may result in aspiration pneumonia,
which is very serious.
WHAT CAUSES SWALLOWING DISORDERS IN CHILDREN?
Structural lesions, neurologic disorders, connective tissue diseases,
psychiatric disorders, and iatrogenic problems can cause swallowing
Iatrogenic causes (medical treatment) causing dysphagia:
Medications such as: nitrates, calcium tablets, aspirin, Vitamin C,
anticholinergic agents, iron tablets, calcium channel blockers, and
WHAT ARE THE SIGNS AND SYMPTOMS OF IMPAIRED SWALLOWING IN CHILDREN?
Choking during swallowing.
Food sticking in the throat.
Pocketing of food in the mouth.
Impaired gag reflex.
Unexplained weight loss.
HOW ARE SWALLOWING DISORDERS EVALUATED?
The most important step in treating a swallowing disorder is establishing
an accurate diagnosis.
A multidisciplinary team provides the best method of establishing a
diagnosis and providing treatment. The team often includes members from:
speech pathology, nutrition, otolaryngology, gastroenterology, psychology,
and occupational therapy.
The evaluation of swallowing disorders begins with the child’s feeding
history. Weight, caloric intake, and vital signs are assessed to determine
if they are appropriate for the child.
Medical comorbidities such as recurrent pneumonia, stridor, choking,
stroke, or traumatic brain injury are noted.
During the physical examination, abnormal voice or abnormal speech are
noted – as they are signs of motor dysfunction. Lungs should be checked
for wheezing, rales/crepitations, or ronchi.
A full head and neck examination is done, including inspection of cranial
nerve function. During the examination phase, the thyroid cartillage is
gently moved to either side. The anterior part of the neck is palpated for
masses. Laryngeal movement is evaluated by placing two fingers on the larynx
during swallowing. Any facial symmetry is noted, as it may indicate cranial
The oral cavity, soft palate, and pharynx are examined for abnormalities.
Ankyloglossia, cleft lip or palate, and macroglossia need to be excluded.
A water swallow test may be used to check for abnormal drooling or
Examination of: pace of feeding, ability to handle oral secretions, tongue
and jaw movements, emesis, coughing, the number of swallows required to
clear a bolus of food, and noisy airway during swallowing.
The presence of a normal gag reflex may be verified by touching the
pharynx with a cotton-tipped applicator. Some patients with dysphagia may
have a normal gag reflex, however. During the gag reflex test, the palate
should pull evenly and symmetrically. Lateral movement of the mucosa of the
posterior pharynx suggests weakness on the opposite side.
Nasal obstructions such as choanal atresia or choanal stenosis may cause
feeding difficulties in children.
The videofluorographic swallowing study (VFSS) is the gold standard for
evaluating swallowing disorders. During this diagnostic procedure, the
patient eats and drinks foods which are mixed with barium to make them
radiopaque. The VFSS shows the motions of the anatomic structures of the
oral cavity, pharynx, and esophagus.
Any patient who experiences aspiration during feeding, in addition to
showing cranial nerve IX or X involvement, should have MR imaging done to
diagnose a possible brain stem lesion or a Chiari malformation.
WHAT IS THE TREATMENT FOR IMPAIRED SWALLOWING IN CHILDREN?
The goals of treatment are to maintain adequate nutrition, and to maximize
Swallowing disorders are usually managed by dietary modification, training
in swallowing techniques, and exercises. Swallowing is usually the best
therapy for swallowing disorders.
The decision to allow oral feeding depends on balancing the convenience of
oral feeding versus the potential risks for aspiration.
For children with gastroesophageal reflux disease (GERD), a dietary
modification such as pureed food may be useful. For children who have stroke
or multiple sclerosis, dietary modification and swallow therapy may be
For some patients, holding the breath or tucking the chin may decrease
aspiration of food during swallowing. Other compensatory techniques are:
head rotation, head tilt, supraglottic swallow, and the Mendelsohn maneuver.
Exercises can increase muscle tone of the lips, jaws, tongue, cheek, vocal
cords, and soft palate.
In children with severe disorders, it may be necessary to provide enteral
or parenteral nutrition. The percutaneous endoscopic gastrostomy tube (PEG)
is a safe way to provide nourishment in these severe cases. With PEG, the
child is being fed directly into the stomach.
Surgical treatment, such as esophageal dilation, or esophageal resection
may be needed.
Periodic reevaluation of a child’s pulmonary status and ability to feed
An article in American Family Physician reviews normal and
abnormal swallowing, methods of evaluating dysphagia, and treatment options
for the problem. The article describes the physiology of swallowing,
including the oral, pharyngeal, and esophageal phases of swallowing.