77  Feeding and
Swallowing Disorders
CLAIRE KANE MILLER, PhD, MHA, JENNIFER MAYBEE, OTR/L, MA, CCC-SLP,
JEREMY PRAGER, MD, MBA, and SCOTT PENTIUK, MD, MEd
Introduction
The maturation of feeding and swallowing skills evolves in
a natural and seemingly effortless progression in typically
developing infants and children. Given that the pharynx
is a shared pathway for breathing and swallowing, precise
coordination of respiration and swallowing ensures mainte-
nance of airway protection during feeding. Intact anatomy
and function of the aerodigestive tract and normal develop-
ment of neural control mechanisms are essential. Feeding
and swallowing dysfunction (pediatric dysphagia) occurs in
infants and children because of a multitude of factors, includ-
ing structural anomalies in the aerodigestive tract, static
or degenerative neurologic conditions affecting the range
and strength of the necessary musculature, and cardiopul-
monary conditions that result in respiratory compromise
with oral feeding attempts. Etiologies of dysphagia are not
mutually exclusive, and often multiple interacting factors are
present.
The multifactorial nature of feeding and swallowing dis-
orders necessitates the involvement of multiple disciplines
in the evaluation and management process. Therefore a
team approach is efficacious in the consideration of issues
that involve disciplines including, but not limited to, oto-
laryngology, gastroenterology, pulmonary medicine, radi-
ology, occupational therapy, nutrition therapy, and speech
pathology. This chapter will review the clinical and procedural
evaluation and management of infants and children present-
ing with feeding and swallowing from a multidisciplinary
perspective.
Epidemiology
There is no universal, standardized clinical assessment instru-
ment available that covers the range of ages and conditions
that have accompanying pediatric dysphagia. Therefore
standardized data collection and reporting are not possible,
and the true epidemiology of pediatric dysphagia is largely
unknown in infants and children. Available assessment pro-
tocols are targeted toward specific age ranges and condition
types, for example, for characterizing preterm infant feeding
behaviors, assessing oral motor skill development, and docu-
menting signs and symptoms of dysphagia in specific diag-
noses or conditions.
It has been widely reported that at least 25% of typically
developing children experience some type of feeding difficulty,
such as chewing difficulty, choking, or texture refusal.1–3 The
likelihood of feeding and swallowing dysfunction increases
sharply in developmentally delayed or medically fragile
1106
children, who present with structural, neurologic, or meta-
bolic issues affecting feeding and swallowing, with reported
estimates ranging between 40% and 70%.3–5 Dysphagia has
been frequently reported in the context of cerebral palsy,
with estimates citing a 75%–80% or higher probability of
feeding and swallowing difficulty, and in patients with Down
syndrome, with estimates of 50%–60%.6–8 Comprehensive
evaluation and management of feeding and swallowing issues
is essential to defining the anatomic and physiologic factors
affecting feeding and swallowing efficiency and safety.
Anatomy, Physiology,
and Development
The larynx serves three functions: connection of the upper
and lower respiratory airway, closure for protection of the
lower airway during swallowing, and generation of sound
for voice. Identification of the maturational changes that
occur in the anatomy of the aerodigestive tract and in the
ontogeny of feeding and swallowing development is funda-
mental in delineating physiologic abnormalities and in defin-
ing the effect of compensatory strategies for improvement
of laryngeal function.
In terms of anatomy, there are differences in the size and
location of the structures associated with the key laryngeal
functions in the infant as compared with the child or adult.
At birth, the larynx is positioned relatively high in the neck,
located adjacent to cervical vertebrae C1 to C3, and later
descending to levels C6 to C7. The overall size of the infant
larynx is approximately one-third that of the adult, with the
membranous portion of the true vocal folds (TVFs) measur-
ing approximately 2–3 mm and the bulkier cartilaginous
portion measuring 3–4 mm. The thyroid cartilage of the
pediatric larynx is rounded, the epiglottis may have an omega
shape, and the cricoarytenoid joints and vocal processes are
proportionately larger than in the adult larynx.9 The delicate
respiratory epithelium that lines the infant airway is par-
ticularly prone to injury from prolonged or traumatic intu-
bation, and the subglottic region is often the site for reactive
stenosis.10
The small size and shape of the oral cavity relative to the
tongue facilitates early sucking as the buccal fat pads provide
lateral stability for efficient tongue motion. As the infant
grows, the prominent buccal pads decrease, the oral cavity
increases in size, and the relative size of the tongue decreases.
More space is available for differentiated tongue movements
during both feeding and speaking. Elongation of the pharynx
occurs as does the maturational descent of the larynx from
C3 to C6 by approximately 3 years of age. As the larynx
descends, increased neuromuscular control of the structural
 77  •  Feeding and Swallowing Disorders 1106.e1

ABSTRACT KEYWORDS
Feeding and swallowing dysfunction (dysphagia) occurs in feeding
infants and children in the context of structural, neurological, swallowing
respiratory, and metabolic conditions that span the scope of pediatric
multiple disciplines. Knowledge of the specific mechanisms of aerodigestive
dysphagia associated with congenital and acquired medical
conditions is essential. Adverse consequences of dysphagia
include inadequate nutritional intake and the aspiration of
secretions, food, and liquid leading to potential pulmonary
contamination, infection, and morbidity. Diagnostic evalu-
ation of dysphagia includes clinical assessment of oral sen-
sorimotor skills and instrumental assessment of swallowing
function via the videofluoroscopic swallowing study (VFSS)
and/or fiberoptic endoscopic evaluation of swallowing (FEES).
Clinical pathways for multidisciplinary assessment, medical
management, and dysphagia treatment are discussed. Collabo-
ration and communication are essential between services to
ensure comprehensive assessment and optimal management.

elements of the pharynx is critical for maintenance of airway
protection during swallowing.11
In addition to the anatomic interrelation of the structures
involved in feeding and swallowing, there is common neural
control that is composed of cortical influences, peripheral
afferent signals, nerve networks, and efferent responses driven
by motor neurons. Branches of cranial nerves (CNs) primar-
ily innervate the oral, nasal, pharyngeal, and laryngeal
structures: V, VII, IX, X, XI (vagal branch), XII, and branches
of the upper cervical nerves. There are further structural
and regulatory interrelationships within the brainstem, spe-
cifically the medulla (e.g., central pattern generator). Afferent
input for swallowing is primarily located in the nucleus tractus
solitarius (NTS); efferent control is localized in the nucleus
ambiguus (NA) and the dorsal motor nucleus of CN X. Simi-
larly, afferent input is received by the NTS for respiration,
with efferent respiratory control via premotor neurons in
the NTS and NA that project to the spinal cord motor neurons
and innervate the respiratory skeletal musculature.
FEEDING SKILL DEVELOPMENT
Feeding gradually evolves from a reflexive behavior in infants
to a cortically regulated behavior during the first 2 years of
life (Table 77.1). Anatomic changes in oral and pharyngeal
structural relationships, as well as maturation of the central
nervous system during the first 2 years of life, are reflected
in the transition to mature oral motor/feeding and swal-
lowing skills. Sucking occurs early in utero and continues
as the primary means of obtaining nutrition for the first
3–4 months of life.12 As the motor and digestive systems
mature, smooth solids such as pureed foods are introduced at
approximately 4–6 months of age. Head control and stability
improve with differentiation of tongue movements at 7–9
months of age, at which time increased food textures are
typically presented. Continued emergence of active oral motor
movements such as tongue lateralization and rotary chewing
facilitate the transition to table foods at approximately 1 year
of age. By approximately 2 years of age, oral motor/feeding
Table 77.1  Oral Motor/Feeding Skill Development
Age Range Skill
Birth to 4 months Sucking predominates
4–6 months Anteroposterior tongue movements for efficient
transfer of smooth solids
7–9 months Efficient sucking, emergent skills for cup drinking
Emergence of tongue lateralization
Vertical chewing motion in response to solids
9–12 months Increasing lateral tongue movements for
mastication of foods
Vertical chewing pattern with emergence of
lateral tongue movements
Transition to cup drinking
Trend toward less formula intake as solid intake
increases
12–18 months Consistent tongue lateralization
Emergence of mature rotary chewing pattern
19–24 months Chewing efficiency increases
Cup drinking
24 months Oral motor/feeding skills have emerged, with
refinement in skills to continue
77  •  Feeding and Swallowing Disorders 1107
and swallowing skills are in place, with refinements in oral
motor movements as the child continues to mature.13
Phases of Swallowing
The swallowing process is composed of the oral preparatory,
oral, pharyngeal, and esophageal phases. For an efficient
oral phase of swallowing to occur, it is crucial to have normal
anatomy and intact gross discriminative and special sensory
input from olfaction via CN I and the oral cavity via CN V
(V2 and V3), VII, IX, and X. It is also essential to have intact
muscular strength and coordination of the buccal and oral
musculature. Adequate oral preparation of the bolus, fol-
lowed by posterior transfer of the bolus to the hypopharynx
via tongue base retraction and simultaneous closure of the
soft palate against the posterior pharynx occurs. After the
oral bolus is transferred to the hypopharynx, airway protec-
tion must occur during the pharyngeal swallowing phase
to prevent aspiration. Tactile receptors in the pharynx provide
sensory stimulation to the medullary swallow center, and
swallowing is initiated via the NA and the dorsomedial vagal
nucleus.14
Airway protection during the pharyngeal phase of the
swallow occurs as a sequence involving the cessation of
respiration (swallowing apnea), adduction of the TVFs in
association with the medial approximation of the arytenoid
cartilages, compression of the ventricular vocal folds, and
retroversion of the epiglottis.15 At the initiation of the swallow,
the larynx is elevated under the base of the tongue, facilitat-
ing the stretching and opening of the cricopharyngeus, as
the pharyngeal constrictors shorten the pharynx and propel
the bolus into the upper esophageal sphincter. After passage
of the bolus has occurred, the larynx returns to its resting
position, the airway reopens, and respiration resumes. Swal-
lowing apnea and glottic closure are linked events, although
swallowing apnea has been described to occur as a result of
a dedicated neural command.16 The exact neural control
mechanisms are unknown, although past and recent inves-
tigations suggest that a designated neural command from
the central pattern generator within the medullary brainstem
Food Types
Liquid (breast milk, formula)
Pureed, smooth, semisolid foods
Semisolids with increased textures (e.g., cottage cheese, regular
applesauce, fruited yogurt)
Solid items (e.g., very easily dissolvable cereal pieces, soft cookies,
shredded cheese)
Fork-mashed or slightly blended table foods
Transitioning toward easy-to-manage solid foods (e.g., scrambled eggs,
toast strips, pasta pieces, crunchy but dissolvable cookies, and
crackers)
Easy-to-manage solid foods (e.g., crackers, breads, casseroles, soft fruit
pieces, and tender meat such as flaked fish or chicken)
Table foods requiring greater mastication (e.g., tender meats, steamed
vegetables, and fruits)
Wide range of textures
1108 SECTION 8  •  The Aerodigestive Model
occurs.14,16,17 The specific respiratory phase patterns and
duration of apneic pause in relation to normal and abnormal
swallowing parameters in the pediatric population is pres-
ently unknown; however, there are emerging data regarding
respiration and nutritive swallowing parameters in the infant
population.18
The neurologic arch that allows for airway protection is
described as the laryngeal adductor reflex (LAR).19 The supra-
glottic area contains chemoreceptors, mechanoreceptors,
thermal receptors, and baroreceptors (i.e., stretch/pressure
receptors) that are highly sensitive to specific kinds of sensory
input. The LAR is activated by mechanical or chemical stimu-
lation of the supraglottic mucosa in the region of the ary-
epiglottic fold.19 The internal branch of the superior laryngeal
nerve transmits sensory information via the special visceral
afferent fibers to the inferior nodose ganglion. The informa-
tion passes to the nucleus solitarius, which is responsible for
the regulation of swallowing and respiration. The efferent
response initiated at the NA and dorsal motor nucleus of
CN X results in glottic closure and inhibition of respiration
with or without a swallow.20–23
The actions of the intrinsic laryngeal musculature are of
major importance to airway closure during swallowing. The
intrinsic muscles (i.e., cricothyroid, posterior cricoarytenoid,
lateral cricoarytenoid, thyroarytenoid [vocalis], and the trans-
verse and oblique arytenoids) serve to adduct, abduct, and
tense the vocal folds, as well as open and close the laryngeal
valve. The cricothyroid stretches and tenses the vocal fold and
is innervated by the external branch of the superior laryngeal
nerve. The posterior cricoarytenoid is the sole abductor of
the vocal folds and is innervated by the recurrent laryngeal
nerve. The lateral cricoarytenoid adducts the interligamen-
tous portion of the vocal fold and is supplied by the recurrent
laryngeal nerve. The thyroarytenoid and the transverse and
oblique arytenoids are likewise innervated by the recurrent
laryngeal nerve. The thyroarytenoid works to relax the vocal
folds. Its medial portion, the vocalis, relaxes the posterior
vocal ligament while maintaining and increasing tension of
the anterior portion. The transverse and oblique arytenoids
close the intercartilaginous portion of the glottis.
During the pharyngeal phase of the swallow, the upper
esophageal sphincter relaxes and allows the bolus to enter
the esophagus, initiating the esophageal phase of the swallow.
Peristaltic contractions propel the bolus through the esopha-
gus, and the lower esophageal sphincter subsequently relaxes
to allow the bolus to pass into the stomach. Propagation of
the peristaltic wave is reliant upon the intrinsic myenteric
plexus and on vagal afferents. The transit time of the esopha-
geal phase is much longer than the pharyngeal phase, between
3 and 9 seconds.14
Etiology/Pathogenesis
The upper aerodigestive tract is the confluence of the respira-
tory, digestive, and phonation systems. Precise integration of
functions is required for protection of the lower airway from
aspiration during swallowing. There is a variety of anatomic
and neurologic etiologies that may affect the structural integ-
rity and interrelated physiology of feeding and swallowing.
Many children with complex airway conditions also have
concomitant neurodevelopmental delays that place them
at even higher risk for feeding and swallowing disorders.24
The implications for untreated dysphagia are significant
and include failure to maintain proper nutrition/hydration
status, aspiration pneumonia, and long-term pulmonary
complications such as chronic lung disease from ongoing
aspiration. Outcome data related to the persistence or resolu-
tion of pediatric dysphagia are limited. Empirical research
is limited by the inconsistencies in the classification of dys-
phagia and in the terminology used to describe the physiologic
aspects of dysphagia. The use of standardized clinical path-
ways and data reporting systems during the workup of dys-
phagia, for both clinical and instrumental assessment, will
facilitate the accumulation of standardized data needed to
track the course of the dysphagia in association with specific
conditions and diagnoses to predict outcomes.
Conditions Associated With
Feeding, Swallowing, and
Airway Protection Problems
Difficulty with the oral, pharyngeal, or esophageal phases
of swallowing may occur because of structural, neurologic,
cardiorespiratory, metabolic, or inflammatory disorders (Table
77.2). The etiologies may be congenital or acquired, and the
interactions of the developing respiratory, neurologic, and
gastrointestinal (GI) systems create numerous variables to
consider.
Anatomic abnormality in any of the structures from the
nasal cavity to the GI tract has the potential to disrupt the
processes of feeding, swallowing, and ability to achieve and
maintain airway closure and protection. Anatomic defects
in the oral cavity or oropharynx create difficulty in the oral
phase of swallowing and include craniofacial syndromes,
cleft lip and cleft palate, and macroglossia.25,26 Congenital
defects of the larynx, trachea, or esophagus (e.g., laryngo-
malacia, laryngeal cleft, or tracheoesophageal fistula) are
associated with airway compromise, as well as esophageal
phase abnormalities.27 In particular, congenital or acquired
conditions involving the supraglottic, glottis, or subglot-
tic airway require airway surgical interventions that may
have an effect on laryngeal function for airway protection,
swallowing, and voicing.26–29 Any necessary reconstruc-
tion procedures involve anatomic alteration of the laryn-
geal anatomy; therefore careful preoperative assessment of
laryngeal anatomy and function pertinent to swallowing
and phonation is required. Surgical reconstruction may alle-
viate the obstructive structural defects, although problems
Table 77.2  Conditions Associated With Dysfunction in
the Oral, Pharyngeal, and Esophageal Phases of
Swallowing
Oral/Preparatory Pharyngeal Esophageal
Cleft lip/cleft palate Cricopharyngeal Tracheoesophageal
Choanal atresia achalasia fistula
Macroglossia Arytenoid prolapse Eosinophilic esophagitis
Micrognathia Laryngeal cleft Vascular ring
Oral hypotonia Vocal cord paralysis Gastroesophageal reflux
Oral sensory-motor Laryngo-pharyngitis disease
dysfunction Esophageal dysmotility
Cranial nerve Achalasia
paralysis Esophageal stricture

may persist with phonation and laryngeal function during
swallowing.30,31 Tracheoesophageal fistula repair can alter
nerve function and esophageal motility leading to prolonged
bolus clearance and increased risk for gastroesophageal reflux
(GER) and esophageal mucosal injury.32 There is also the risk
of stricture formation at the repair site, as well as possible
recurrence of the fistula, leading to aspiration.
Neurologic conditions are by far the most common etiol-
ogy of potential feeding, swallowing, and airway protection
problems. Neuromotor impairment as a result of cortical
dysfunction, abnormality in the brainstem, or cervical cord
injury may affect laryngeal functions that are critical for
adequate feeding/swallowing, phonation, and airway protec-
tion. Such problems include cerebral palsy, vocal fold paralysis,
Arnold-Chiari malformation, cricopharyngeal achalasia, and
CN abnormalities associated with syndromes such as the
CHARGE association (Coloboma, Heart defect, Atresia
choanae, Retarded growth and development, Genital hypo-
plasia, Ear anomalies), and Moebius syndrome.
Cardiorespiratory compromise secondary to airway abnor-
malities (e.g., subglottic stenosis, airway edema, and other
structural issues) may be reflected in an infant’s inability to
coordinate respiration and swallowing, and it is often appar-
ent during initial attempts at oral feeding. Feeding-related
apnea or episodes of bradycardia may occur. In older infants
and children, problems with respiratory compromise are
reflected in poor respiratory support during phonation and
poor coordination or inappropriate timing of airway protec-
tion during swallowing, resulting in coughing, choking, noisy
breathing, or recurrent episodes of pneumonia, bronchitis,
or atelectasis.33
Inflammatory processes such as esophagitis from chronic
GER or chronic inflammation/irritation secondary to eosino-
philic esophagitis may result in airway manifestations that
can interfere with the development of oral motor and feeding
skills and with swallowing.34–36 These diseases are increas-
ingly being recognized in children with complex airway
disease. Chronic reflux or irritation to the laryngeal area
has been associated with airway reconstruction failure.28
Hyposensitivity in the pharyngeal and laryngeal area from
chronic reflux irritation may result in poor sensory aware-
ness and a higher risk for aspiration.22
SPECIFIC AIRWAY CONDITIONS AND THE
EFFECT ON FEEDING AND SWALLOWING
Pathologic airway conditions in pediatric patients include
congenital or acquired subglottic stenosis, glottic stenosis,
laryngotracheal stenosis, laryngeal webs or atresia, and tra-
cheal lesions. Congenital subglottic stenosis is relatively rare
and typically occurs in conjunction with genetic syndromes or
laryngeal malformations. Acquired laryngotracheal stenosis is
more common, occurring after manipulation or insult to the
airway. Such conditions comprise subglottic stenosis because
of prolonged or traumatic intubation, hypopharyngeal steno-
sis secondary to trauma or caustic agent inhalation or inges-
tion, vocal fold paralysis as a result of surgical intervention,
and tracheal stenosis following intubation. Tracheotomy with
later surgical intervention for reconstruction and expansion
of the airway is often necessary. The surgical reconstruction
techniques are selected based upon the extent and location
of the airway lesion and are designed to expand or resect
the airway. Avoidance of damage to the recurrent laryngeal
77  •  Feeding and Swallowing Disorders 1109
nerve, as well as to intact laryngeal structures, is a primary
goal. As discussed previously, an important consideration is
the effect that the necessary surgical interventions may have
upon the laryngeal functions of phonation and airway pro-
tection during swallowing. As children with complex airway
conditions often have persistent aspiration or severe reflux,
they may be candidates for fundoplication prior to airway
reconstruction. It should be noted that these procedures
can worsen unrecognized esophageal dysmotility, leading
to symptoms of gagging and retching.37
Airway expansion procedures may involve the placement
of anterior and/or posterior grafts that are stabilized via an
indwelling airway stent during the postoperative period.
Swallowing is possible during the period that the stent is in
place; however, difficulties may arise, depending upon the
necessary location of the stent. If placement of the stent is
necessary at the glottic level, swallowing dynamics are
affected. If the stent location extends to the level of the ary-
tenoids or to the base of the epiglottis, swallowing dynamics
may be significantly compromised. Patients who undergo
placement of posterior grafts may be at risk for destabiliza-
tion of the cricoarytenoid joint and lateral cricoarytenoid
muscles and are therefore at risk for difficulty with airway
protection during swallowing and significant degrees of
dysphagia.31
Safe and efficient feeding and swallowing skills are depen-
dent upon postural stability, appropriate strength and range
of jaw, cheek, lip, and tongue movements, the capacity to
process sensory information, and upon the ability to establish
and maintain airway protection during oral intake. The
coordination and strength of lip, tongue, and jaw patterns
during feeding may be limited by underlying muscle tone
abnormalities and/or sensory processing dysfunction. Neu-
rologic conditions may interfere with appropriate coordina-
tion of oral motor movements during feeding and have a
negative impact on the timing of swallowing and airway
closure. Underlying structural issues may preclude closure
of the airway during swallowing. As such, clinical signs and
symptoms of feeding and swallowing dysfunction observed
during the clinical assessment may signal feeding inefficien-
cies or threats to airway protection. Changes in physiologic
status during feeding are of concern, such as decreased
oxygen saturation or increases in respiratory or heart rate.
Increased stridor with the respiratory effort of feeding, cough-
ing, choking or gagging, color changes, or an increased wet,
vocal quality should be noted. Of note, “silent” aspiration
(no overt sign of airway protection threat) has been shown
to be prominent in infants and in children with neurologic
impairment and feeding difficulties.38–40 Therefore the pos-
sibility of silent aspiration should be considered and can be
ruled out during an instrumental swallowing assessment.
Imaging, Instrumental
Assessment of Swallowing
Function, and Airway Protection
As discussed in Chapter 76, plain chest radiographs and
high-resolution computed topography (CT) of the chest
(dynamic and static) are not diagnostic tests for aspiration
but provide information regarding lung disease and the pro-
gression or resolution over time.
1110 SECTION 8  •  The Aerodigestive Model

If clinical signs or symptoms of possible difficulty with is clearly visualized. Abnormalities in the swallowing process,
airway protection during swallowing are noted during the such as premature or inefficient oral bolus transfer, delayed
clinical feeding evaluation, or if the child presents with initiation of swallowing response (Video 77.1), inadequate
chronic pulmonary problems suspicious for aspiration, objec- pharyngeal clearance following swallowing (Video 77.2),
tive studies to assess airway protection during swallowing penetration of the bolus into the larynx (see Video 77.2),
are indicated. The most common instrumental examinations and aspiration of the bolus into the airway below the vocal
include the videofluoroscopic swallow study (VSS) and fiber- folds (Video 77.3), are readily identified. Patient reaction
optic endoscopic evaluation of swallowing (FEES). Indications or response to abnormalities in the swallowing process can
for the pediatric FEES study and the videofluoroscopic swal- be assessed. For example, protective reaction or adequacy
lowing study are listed in Table 77.3. The relative advantages of clearing response to episodes of aspiration can be ascer-
and disadvantages of each examination are summarized in tained. Compensatory strategies can be implemented to assist
Table 77.4. with maintenance of airway protection during swallowing
or to improve swallowing efficiency. Positioning adjustments,
increasing liquid viscosity/texture alteration, altering the
VIDEOFLUOROSCOPIC SWALLOW STUDY
bolus delivery system (e.g., nipple or cup flow rate) or pos-
The pediatric VSS provides visualization of all phases of tural strategies (e.g., chin flexion or head tilting) may be
the swallow under fluoroscopy.40,41 Delineation of tongue implemented to assess effect on swallowing dynamics and
motion during bolus preparation and adequacy of tongue improving airway protection during swallowing.
base retraction for swallowing initiation are analyzed. Bolus Disadvantages to the pediatric VSS include radiation expo-
transfer through the pharynx and upper esophageal sphincter sure to the patient and to the feeder. The necessary addi-
tion of barium to the food and liquid potentially decreases
the child’s willingness to eat or drink during the exami-
Table 77.3  Indications for Videofluoroscopy and/or
nation. Implementing compensatory strategies adds to
Fiberoptic Endoscopic Evaluation of Swallowing
the overall radiation exposure time, limiting the extent to
Videofluoroscopic Fiberoptic Endoscopic which options can be tested. Infants or children who have
Swallowing Study Evaluation of Swallowing only negligible amounts of oral intake are not appropriate
Baseline assessment of Known or suspected structural candidates for a VSS because an enough contrast must be
swallowing function: Need abnormality with implications ingested to obtain adequate imaging. See Fig. 77.1 for a
overall view of oral, for airway protection during sagittal view of swallowing structures as seen during the
pharyngeal, and esophageal swallowing
phases of swallowing
VSS exam.
Need to view sequential swallow Questionable secretion
sequences management ability FIBEROPTIC ENDOSCOPIC EVALUATION
Need to exclude structural Patient accepts minimal
problem in the esophagus, amounts of food/liquid orally OF SWALLOWING
stomach, or duodenum as a
source of dysphagia A FEES study to assess adequacy of airway protection during
swallowing is indicated for patients who have never fed orally
or who have minimal oral intake. The FEES is a useful tool
for patients with brainstem or CN involvement (allows visu-
Table 77.4  Advantages and Disadvantages of alization of asymmetrical pharyngeal contraction) and as
Pediatric Fees an interval exam that does not involve radiation exposure
Advantages Disadvantages for patients requiring serial swallow studies. In addition,
patients with congenital, traumatic, or surgical upper airway
Specific focus on airway Possible discomfort with scope
protection during swallowing passage anomalies (either preoperative or postoperative) are excellent
Provides assessment of patient Presence of scope may induce candidates given that the otolaryngologist gains information
ability to manage secretions gagging and vomiting in
patients with hypersensitive
responses
Does not require alteration of View is obscured during
food or liquid with contrast swallowing contraction; can
only view events before and
after “white-out”
No radiation exposure Focus of exam is limited to
primarily the pharyngeal phase sphincter
Can determine readiness to Lack of view during rapid
transition to oral feeding in sequential swallowing (bottle
regard to airway protection feeding)
ability
Effect of compensatory Contraindicated for patients with
strategies on improvement of choanal atresia, nasal stenosis,
swallowing function/safety nasal obstruction, pharyngeal Epiglottis
can be determined during stenosis
exam
Visual picture of swallowing may Requires special training Vocal folds
provide beneficial feedback to
Fig. 77.1  Sagittal view of swallowing structures as seen via videofluo-
family
roscopic swallow study.

from the flexible laryngoscopy exam. FEES is also a good
alternative method for patients who are too medically fragile
to be transported to the radiology department for a VSS, or
who cannot be positioned adequately for a VSS. Assessment
of swallowing dynamics during breast feeding (Video 77.4)
is possible, a distinct advantage of the FEES examination in
comparison to videofluoroscopy.42
FEES is accomplished by transnasal passage of a pediatric
flexible endoscope, allowing direct visualization of pharyngeal
and laryngeal structures, function, management of secre-
tions, intactness of sensation, and spontaneous swallows.43
The device may be passed by an otolaryngologist or a speech
language pathologist, depending upon practice pattern and
licensing. The swallowing assessment is performed using the
patient’s normal foods and liquids (which may be mixed with
a small amount (<1 mL overall) of food dye to aid in visual-
ization of the bolus.43–45 Information regarding secretion
management and ability to generate spontaneous swallows
can be achieved without requiring the patient to ingest food
or liquid. See Video 77.5 for an example of poor laryngeal
clearance of secretions during the FEES exam. The focus of
the pediatric FEES study is on airway protection ability and
sensation, as well as anatomic abnormalities and their poten-
tial role in dysphagia. Compensatory strategies to assist with
achieving airway protection during swallowing (e.g., those
used during the VSS) can be implemented without concern
for prolonged radiation exposure. As noted previously, patients
who are being evaluated for possible airway reconstruction
procedures are particularly appropriate candidates for FEES
because information regarding integrity of structures and
function is made available.46 Assessment of current swal-
lowing ability and laryngeal function provides the information
necessary to proceed with surgical intervention designed to
rebuild and preserve total laryngeal function. A clinical swal-
lowing assessment in conjunction with the pediatric FEES
examination has been shown to identify patients with dif-
ficulty achieving airway protection preoperatively and to
identify patients likely to require short-term swallowing
treatment postoperatively.46
One distinct advantage of the pediatric FEES exam is the
ability to obtain information regarding the patient’s laryn-
gopharyngeal sensory threshold, fundamental to airway
protection integrity. The adequacy of the LAR for protection
from aspiration can be assessed by gently tapping the endo-
scope in the region of the aryepiglottic fold, for observation
of reflex glottic closure. Disadvantages to the pediatric FEES
examination include potential discomfort with endoscope
passage, although topical anesthesia (1 : 1 mixture of oxy-
metazoline and 2% pontocaine) can be administered nasally
prior to the exam to increase patient comfort. In addition,
use of lidocaine gel on the scope facilitates numbing of the
nasal passageway and may also increase patient comfort
with the procedure. In dysphagic adults a standard dose of
atomized lidocaine (0.2 mL of 4% lidocaine) administered
in combination with 0.2 mL nasal decongestant (oxymetazo-
line HCL) was shown to improve exam tolerability and did
not impact pharyngeal swallowing function.47 Studies of
topical anesthesia have not been performed in the pediatric
population on a large scale. Administration of topical anes-
thetic during FEES is not indicated in infants younger than
12 months or in patients with significant neurologic involve-
ment due to concern that the anesthetic could impact
77  •  Feeding and Swallowing Disorders 1111
pharyngeal sensation and swallowing function; however,
viscous lidocaine on the scope may be used to increase comfort
during the examination.43 In addition, swaddling, having
the patient be held by a familiar caregiver, and introducing
a pacifier or bottle during the exam are effective calming
measures. In some institutions, other team members are
present during the FEES exam, including occupational thera-
pists to assist with positioning, compliance with state regula-
tions, and observation of oral feeding during the exam and
child life/therapeutic recreation specialists to provide distrac-
tion and calming measures. Patients with oral hypersensitivity
or oral aversion may have a gagging reaction in response to
the tactile stimulation of the instrument and may therefore
have difficulty participating in a functional exam. FEES may
be contraindicated in patients who present with choanal
atresia, nasal stenosis, nasal obstruction, or pharyngeal ste-
nosis, because passage of the endoscope can be impeded.
Selection of this modality would be at the discretion of the
otolaryngologist and speech language pathologist involved
in the patient’s care.
Differences in anatomy across infants and children to ado-
lescents and young adults necessitate the use of varied endo-
scope sizes during pediatric FEES. Standard-sized endoscopes
(3.5–4.0 mm) are appropriate for most infants and children,
although the use of a smaller endoscope (2.0–2.4 mm) is
more commonly used for comfort and may be necessary if
structural abnormalities of the nasal passageway or midface
are present. Transnasal passage of the endoscope may be
carried out by either the otolaryngologist or the speech
pathologist, depending upon the laws governing the scope
of practice for the latter in a particular state. The nasal
exam may demonstrate etiologies of nasal obstruction
(e.g., turbinate hypertrophy), as well as providing evalua-
tion of the nasal surface of the soft palate during speech or
feeding. This may be particularly useful in patients at risk
for submucosal cleft of the soft palate and nasopharyngeal
regurgitation.
As the scope is advanced into the hypopharynx during
the anatomical assessment, consideration is given to any
pooled secretions that may be present, because difficulty with
secretion management has been associated with significant
swallowing abnormality. Spontaneous swallow efforts to clear
secretions should be noted. Laryngeal penetration and aspi-
ration of secretions and the patient’s protection reaction (or
lack thereof) can be clearly visualized.
Interpretation of swallowing parameters during FEES
includes assessment of the timeliness of swallowing onset,
laryngeal penetration prior to swallowing onset, aspiration
before or after the swallow, and the adequacy of hypopha-
ryngeal clearance following the swallow (Fig. 77.2). In addi-
tion, patients with poor esophageal motility and severe reflux
may be seen to regurgitate during the exam (Video 77.6).
Patients with cricopharyngeal achalasia may demonstrate
failure to relax the upper esophageal sphincter, resulting in
stacking of material in the pyriform sinuses.
The depth of laryngeal penetration prior to swallowing
onset can be clearly visualized. Aspiration is often visualized
only prior to the swallow or detected after the swallow. The
upward motion of the larynx, retroversion of the epiglottis,
and contraction of the pharynx during the swallow result
in subsequent deflection of light, and “white-out” at the
actual moment of the swallow. The loss of view during
1112 SECTION 8  •  The Aerodigestive Model
Upper esophageal
sphincter
Vocal folds
Epiglottis
Base of tongue
Fig. 77.2  Endoscopic view of swallowing structures as seen during
fiberoptic endoscopic evaluation of swallowing.
sequential swallowing such as during bottle feeding is not
advantageous; the VSS is superior for visualization of swal-
lowing dynamics during consecutive chain swallowing cycles.
See Fig. 77.2 for endoscopic view of swallowing structures
as seen during the FEES exam.
Additional testing may be performed as indicated by the
patient’s history and exam. Further imaging studies include
an upper GI or esophagram to define the upper GI anatomy,
as well as get a broad view of motility. Endoscopy remains
important for detecting mucosal abnormalities such as lar-
yngitis or esophagitis, as well as structural abnormalities.
This can include assessment with microlaryngoscopy, bron-
choscopy, and upper endoscopy. In multidisciplinary aerodi-
gestive programs, these procedures are often coordinated
and performed sequentially to limit exposure to anesthesia,
as well as to maximize shared communication and planning
between subspecialties and families.
Impedance probe monitoring is another useful test for GER
and provides information regarding esophageal clearance,
acidity of the refluxate, and symptom correlation. Although
impedance is gaining popularity in the evaluation of children,
esophageal manometry remains the gold standard for motil-
ity.48,49 Children with frequent vomiting or evidence of severe
GER may also benefit from a gastric emptying scan. An MRI
of the brain may be needed to evaluate for possible neurologic
causes of dysphagia and aspiration, such as Arnold-Chiari
malformation.
Diagnosis, Management,
and Treatment
The clinical oral motor feeding assessment is often the initial
step in the overall diagnostic evaluation of feeding and swal-
lowing problems. The presentation of feeding and swallowing
dysfunction can be variable and often requires the input from
multiple providers. The insidious nature of silent aspiration
may be a complicating factor and should be considered during
the clinical assessment process. Clinical assessment provides
the initial framework for consideration of medical and devel-
opmental history, direct assessment of oral sensorimotor
skills, and documentation of clinical signs and symptoms
of possible swallowing dysfunction. Direct observation of
clinical signs and symptoms of compromised airway protec-
tion during feeding, as well as suspicion based on history
and diagnoses associated with dysphagia, prompt referral
for further procedures and instrumental assessment of swal-
lowing function.
Evaluation and Management
Identification and management of feeding, swallowing, and
voice disorders is ideally done by a multidisciplinary team
comprising otolaryngologists, gastroenterologists, pulmonary
medicine specialists, speech pathologists, occupational thera-
pists, dietitians, behavioral psychologists, and social workers.50
Obtaining a detailed history of the child’s medical history,
development, diet, and feeding patterns is essential for feeding
and swallowing assessment. Clinical interview questions
include the types of foods and liquids typically ingested, tol-
erance of different textures and volume, and the child’s typical
behavior during meals. Specific inquiries should be made
regarding respiratory status, history of recurrent respiratory
infections or pneumonia, upper airway noise, stridor associ-
ated with feeding, and any interventions or operations involv-
ing the aerodigestive tract. A thorough clinical assessment
of nonnutritive and nutritive oral motor skills is conducted.
Clinical assessment of oral motor/feeding skills should include
assessment of parent-child interaction during feeding, because
disordered interactions may exacerbate feeding difficulties.
Clinical signs and symptoms of possible swallowing dysfunc-
tion have been noted, including gagging, coughing, choking,
color changes, increased noisiness during or after feedings,
periods of apnea or bradycardia associated with feeding,
increased difficulty with secretion management, frequent
suctioning needs, or evidence of food or liquid in the tra-
cheostomy tube.51
Treatment Strategies
The approach to intervention for feeding and swallowing
should be individualized for each patient and depends on
the constellation of issues present. Treatment approaches
include direct rehabilitative maneuvers/exercises and the use
of compensatory strategies such as sensory stimulation, diet
modifications, alterations in positioning for feeding, the use
of specialized feeding equipment, and the implementation
of specific behavioral approaches to facilitate positive and
productive feeder/child interactions. The specific approach
is determined by the medical issues present, the child’s devel-
opmental level, and the types of sensory and motor issues
that are contributing to the feeding and swallowing
dysfunction.
To ensure optimum nutrition, supplemental feeding via
nasogastric tube or gastrostomy may be helpful during the oral
feeding treatment period. The supplemental feeding allows the
child to receive calories needed for adequate growth as they
develop more functional swallowing skills and progress with

feeding therapy. Treatment techniques focus on improving
the child’s oral motor skills to assist with feeding efficiency
and ability to progress with food of increased texture. Treat-
ment may also include methods to assist with overcoming
sensory processing and oral sensory discrimination issues
that may be contributing to the overall oral feeding difficulty.
In cases of severe dysphagia, supplemental feeding methods
may provide total nutrition; however, allowing the child to
have some degree of oral stimulation, even if this consists
only of tastes without appreciable volume, promotes social
interaction at mealtime and may assist in preventing the
development of oral aversion or resistance to oral feeding. If
advancing the volume of oral feeding is appropriate during
treatment, collaboration with the managing physician and a
registered dietician is important during the transition period
to ensure that appropriate nutritional status is maintained.
It is important to recognize the behavioral issues that may
occur in this population. In general, oral aversion and resul-
tant poor oral intake may have a strong underlying behavioral
component.52 Parents or caretakers may be afraid to present
oral feedings because of their child’s medical complexity, or
they may view the child as “vulnerable” and therefore may
not provide mealtime structure or organization. Children
with complex airways and multiple medical issues who
undergo periods of time without oral intake can develop
aversions that persist even after their underlying condition
is corrected.
In a select group of children, innovative feeding practices
are needed. For example, giving pureed foods into the gas-
trostomy can decrease gagging and retching behaviors fol-
lowing fundoplication surgery. This method of feeding can
decrease symptoms and allow children to be more receptive
to taking food orally.53
77  •  Feeding and Swallowing Disorders 1113
Empiric data are limited regarding the efficacy of thera-
peutic strategies to assist with development of compensatory
swallowing techniques postoperatively in airway reconstruc-
tion patients. Introduction of a modified supraglottic swal-
lowing sequence to assist with achieving compensatory
airway closure during swallowing has been described as
effective in small patient samples.31 Indirect treatment strate-
gies include the alteration of textures and liquids (i.e., thick-
ening liquids) to slow liquid flow and provide an increased
time interval for use of supraglottic strategies to assist with
airway closure. Alternating solid intake with liquid intake
to assist with pharyngeal clearance has also been described
as an effective strategy in the postoperative airway recon-
struction period.
Summary
Analysis of specific laryngeal functions associated with swal-
lowing in the pediatric population is accomplished best
through clinical and instrumental examinations. Identifica-
tion of current laryngeal function and awareness of changes
that may occur in association with specific reconstruction
procedures assist clinicians in designing appropriate and
effective treatment plans. Based on the number of interact-
ing factors and possible comorbidities, a team approach to
airway and swallowing assessment and management is
essential to the child’s ultimate health outcome and quality
of life.
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Access the reference list online at ExpertConsult.com.

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