Considering the complexities of swallowing, it’s a wonder most babies are born knowing how to feed. Those who struggle with feeding may be diagnosed with dysphagia, which is the medical term for difficulty swallowing.

Babies generally receive hydration and nutrition from the breast or bottle. They need to coordinate sucking, swallowing and breathing throughout the feed, which typically takes 20 to 30 minutes. Safe feeding requires precise coordination of swallowing and breathing and as any parent whose baby develops a cold knows, any complication can make it more difficult.

For the vast majority of people, eating is a basic instinct. When a child is born prematurely or with medical complications, this may interrupt these instincts. It’s a red flag that something is wrong if a child doesn’t enjoy eating or isn’t growing as expected.

According to the March of Dimes, 10% of children in the United States are born prematurely. Many preterm babies experience early difficulties coordinating swallowing and breathing. Some full-term babies experience swallowing problems also, for a variety of reasons. Some babies overcome swallowing challenges as they mature, while others need clinical support for dysphagia to be able to swallow normally.

Dysphagia, PFD and ARFID

Many children with dysphagia are also diagnosed with pediatric feeding disorder (PFD). PFD is defined as impaired oral intake that is not age-appropriate and is associated with medical, nutritional, feeding skill and/or psychosocial dysfunction. Reliance on enteral feeds or oral supplements to sustain nutrition and/or hydration, need for modified feeding position or equipment, use of texture modification of liquid or food and/or need for modified feeding strategies are all indicative of PFD.

In some cases, a medical condition or mechanical issue, such as dysphagia, causes PFD. In other cases, the medical and mechanical issues are resolved, but the child continues to display PFD. Some children may also go on to display avoidant/restrictive food intake disorder (ARFID).

Treating dysphagia in children

Many newborns outgrow dysphagia within a few weeks of birth. In those cases, the goal is to help keep babies safe, hydrated, and nourished with modifications such as positioning changes during breastfeeds, varying bottle nipple flow or thickening liquids.

When dysphagia persists beyond the early weeks, children need additional evaluation to determine the cause and address any mechanical feeding issues.

Feeding therapy is based on an individualized treatment plan. This may include:

• Diet modifications: Modifying food and liquid textures to ensure they are safe and manageable. This may include pureeing foods or thickening liquids.
• Nutritional support: Ensuring the child receives adequate nutrition and considering alternative feeding methods if necessary, such as enteral feeding.
• Skill development: Teaching strategies to enhance oral motor skills, such as chewing and swallowing, through exercises and activities.
• Family mealtime interventions: Techniques to support mealtime routines, engagement and enjoyment with a focus on family education and support.

Frequently asked questions about pediatric dysphagia

Q: What is dysphagia and how is it different from other feeding issues?

Dysphagia describes difficulty swallowing, which can be due to anatomical, neurological or developmental issues. It refers to swallowing mechanics rather than a sensory or psychological food aversion.

Look for the following indicators of pediatric dysphagia:

• Breathing difficulties during feeding: Changes in breathing patterns, such as working hard to breathe or appearing out of breath, can signal dysphagia.
• Wet or congested sounds: If a child sounds wet or congested during feeds, it may indicate that food or liquid is entering the airway or staying in the throat and increasing the risk of entering the airway.
• Coughing, gagging or choking: Frequent coughing or gagging. The child shouldn’t hold their breath during a choke.

Growth concerns, prolonged feeding times and unusually stressful mealtimes can also be indicators of dysphagia.

Q: What causes dysphagia in children?

Dysphagia in children can occur due to prematurity or medical conditions. Sometimes, the exact cause may not be easily identifiable.

The following are some other causes of pediatric dysphagia:

• Neurological disorders, such as cerebral palsy and muscular dystrophy
• Structural abnormalities, such as cleft palate or esophageal atresia
• Genetic conditions, such as Down syndrome
• Developmental delays

Q: When is dysphagia diagnosed?

Swallowing difficulties can occur at any age. Some infants, such as those born prematurely and in the NICU have swallowing problems from birth. Others are diagnosed within a couple of weeks of going home.

 

Three months is another age when dysphagia can become apparent. By three months of age, reflexive sucking starts to diminish, and problems coordinating sucking, swallowing and breathing may become more apparent.

Dysphagia may appear in older children who are better able to communicate and signs of struggle may be easier to observe. or it can develop after an illness or incident that causes swallowing issues.

Q: How can parents differentiate between typical feeding challenges and something more concerning, like dysphagia?

Occasional feeding challenges are normal, but persistent issues that affect breathing, growth or overall enjoyment of mealtimes should prompt a professional evaluation.

Q: How is dysphagia diagnosed in children?

The comprehensive evaluation may involve a pediatrician, speech-language pathologist/ occupational therapist, and sometimes a gastroenterologist or otolaryngologist. 

Diagnostic tools may include:

• Physical exam
• Clinical swallowing assessments
• Videofluoroscopic swallow studies (VFSS),
• Fiberoptic endoscopic evaluation of swallowing (FEES)

Q: Once a child is diagnosed with dysphagia, what does the treatment process typically involve?

Treatment usually starts with determining strategies to ensure safe feeding, such as modifying the textures or consistencies of foods and liquids or adjusting feeding techniques. It may involve teaching older children specific skills to orally prepare and swallow food safely. The approach is tailored to the child’s specific needs and abilities.

Q: Can dysphagia in children improve over time?

Yes, with appropriate intervention and therapy, many children with dysphagia can see improvements in their swallowing function. The extent of improvement depends on the underlying cause and the child’s condition. Early intervention is key to better outcomes.

Q:  What are some of the most exciting developments in pediatric dysphagia research and management?

We continue to uncover evidence that early intervention and prevention strategies can significantly reduce the severity of the condition. Many families are better able to access care through the use of telehealth services as well. Ongoing research into precise diagnostic tools and effective therapies continues to advance the field.

Pamela Dodrill, PhD, CCC-SLP, is a clinical specialist on the neonatal intensive care unit feeding team at Brigham and Women’s Hospital in Boston and a member of the consensus group that developed the new pediatric feeding disorder codes. She is an affiliate of ASHA Special Interest Group 13, Swallowing and Swallowing Disorders (Dysphagia).