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Dysphagia in Children
Kimberly L. Duffy, MA, CCC-SLP

Speech-Language Pathologists (SLP) play an integral role in
evaluating and treating pediatric patients with dysphagia
related to aerodigestive disorders. Non-supportive anatomy,
cardio-respiratory and medical status, state control, neurologic
functioning, postural stability and control, gastrointestinal
functioning, hunger and satiation, developmental abilities,
oral-motor skills, oral/pharyngeal reflexes, airway protection
and secretion management can create barriers to successful
oral feeding. Swallowing is broken down into four phases and
difficulties can occur during any phase or in combination with
another phase of swallowing. Dysphagia is diagnosed by both
clinical and instrumental evaluation. Objective evaluations of
swallowing include the Video Fluoroscopic Swallow Study
(VFSS) and Fiberoptic Endoscopic Evaluation of Swallowing
(FEES). A Video Fluoroscopic Swallow Study (VFSS) is a
radiographic study assessing oropharyngeal swallow function.
The Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
is conducted by passing a laryngoscope through the nose to
just below the soft palate for a “bird’s eye view” of laryngeal
anatomy and swallow function. Following a diagnosis of
dysphagia from either a clinical or instrumental assessment,
there are a variety of avenues that can be pursued including
diet modifications, compensatory strategies, and use of speci-
alized equipment to ensure a safe feeding plan and reduce the
risk of aspiration. In conclusion, through numerous evaluation
and intervention approaches, the contributions of SLPs helps
provide input for well-rounded, multi-disciplinary plans sup-
porting successful oral feeding.
Curr Probl Pediatr Adolesc Health Care 2018;48:71-73

structural boundaries to oral

S peech-Language Pathologists
(SLP) are an integral part SLPs determine the most appro- feeding. Other factors con-
of the multi-disciplinary tributing to successful oral
priate feeding strategies and feeding include stable car-
evaluation and treatment of pedia-
tric patients with aerodigestive dis- equipment to support long term dio-respiratory and medical
orders. SLPs assess non-nutritive feeding development with a safe status, state control, neuro-
logic functioning, postural
and nutritive oral-motor skills, and efficient feeding plan.
state control/feeding readiness, and stability and control, GI
swallowing safety in infants and functioning, hunger and
children. SLPs determine the most appropriate feeding satiation, developmental abilities, oral-motor skills,
strategies and equipment to support long-term feeding oral/pharyngeal reflexes, and airway protection/secre-
development. When appropriate, SLPs perform instru- tion management.
mental swallowing assessments to provide objective Swallowing is described in four phases. The oral
evaluation of swallow function. preparatory and oral phases are where the bolus
Feeding and swallowing problems can arise from a preparation and oral transit occur. Next, during the
variety of structural and functional issues in both pharyngeal phase, the velum elevates and retracts with
developmentally delayed and normal children.1 Non- elevation and anterior movement of the larynx support-
supportive anatomy in the oral cavity, pharynx, or ing closure by means of the vocal cords, the arytenoids
esophagus can create barriers to successful oral tilting forward and the epiglottis inverting. The bolus
feeding. For example, a cleft lip, laryngeal cleft, then is delivered into the pharynx and the pharyngeal
tracheoesophageal atresia, or fistula could create muscles contract to pass the bolus through the pharynx.
From The Center for Childhood Communication, The Children’s Hospital
As the upper esophageal sphincter relaxes to open and
of Philadelphia, Philadelphia, PA. E-mail address: DuffyK@email.chop.edu allow the bolus to pass into the esophagus, the
Curr Probl Pediatr Adolesc Health Care 2018;48:71-73 esophageal phase of swallowing begins. Once the
1538-5442/$ - see front matter
& 2018 Elsevier Inc. All rights reserved. bolus is in the esophagus, peristalsis occurs trans-
https://doi.org/10.1016/j.cppeds.2018.01.003 porting the bolus through the esophagus until the lower

Curr Probl PediatrAdolesc Health Care, March 2018 71

esophageal sphincter relaxes passing the bolus into the
stomach.2
Problems can occur during any phase or in combi-
nation with another phase of swallowing. Oral dys-
phagia can include hyper/hyposensitivity to taste and
texture, oral loss, and poor manipulation/bolus for-
mation (developmental vs disorder). Pharyngeal dys-
phagia is characterized by poor contraction of
pharyngeal muscles, poor timing of the swallow, poor
laryngeal movement/airway closure, or decreased
sensation. This can result in naso-pharyngeal reflux,
pharyngeal residual, penetration, aspiration, or chok-
ing. Esophageal dysphagia can include problems such
as cricopharyngeal achalasia (failure of the upper
esophageal sphincter to relax for passage of the bolus
into the esophagus) and esophageal motility disorders.
Signs of dysphagia include difficulty keeping food in
the mouth, inability to control food or saliva in mouth
and, wet vocal quality, coughing, or throat clearing
before/during or after swallowing. Symptoms of
dysphagia include recurrent PNA, unexplained weight
loss or failure to thrive (FTT), increased secretions in
pharynx/chest after swallow and complaints of swal-
lowing difficulties including a bolus sensation in the
throat or pain.
Dysphagia is diagnosed by both clinical and instru-
mental evaluation. A clinical evaluation of feeding and
swallowing is likely to include review of history, a
physical examination of pre-feeding behaviors, an oral
mechanism exam, a feeding observation, and consid-
erations for all the other factors that are needed for
successful oral feeding.3The SLP may also trial strat-
egies and equipment/diet modifications. The goals of a
clinical feeding and swallowing evaluation include diet
recommendations, determining if an objective assess-
ment of swallowing function is warranted, possible
etiologies of the dysphagia and recommendations for
other consultations as appropriate. The goals of instru-
mental assessment are to assess oropharyngeal func-
tion, determine swallowing
safety, assess the effectiveness
of intervention strategies, estab-
lish a safe diet, and develop and
Instrumental
rehabilitation plan.4 Instrumen- not pass/fail and should be seen addition to the fact that it can be
tal assessments are not pass/fail as dynamic tools.
and should be seen as dynamic
tools providing valuable insight in the creation of
functional and safe feeding plans.
A Video Fluoroscopic Swallow Study (VFSS) is a
radiographic study assessing oropharyngeal swallow
72
function. VFSS evaluates the movement pattern of a
bolus from the oral cavity to the esophagus. This study
is extremely helpful in defining dysphagia, especially if
silent aspiration (lack of cough in response to aspira-
tion) is suspected.5 A VFSS is done under fluoroscopy
in conjunction with a radiologist. The patient is placed
in typical feeding position and presented with a barium
mixture via typical feeding equipment. Various con-
sistencies, positions, strategies, and equipment are
assessed. Information is obtained via running video
x-ray in low pulse rate so active deglutition can be
examined in both the lateral and anterior/posterior
views.
SLPs evaluate the function of the swallow and
determine a safe feeding plan. The Radiologist exam-
ines the anatomy of the swallowing mechanism.
Following completion of the examination, SLPs
counsel the patients and families and provide recom-
mendations for diet modifications, equipment, strat-
egies, or time limits that were found to be effective in
supporting safe feeding. SLPs also make referrals to
other professions in order to determine the etiology of
the dysphagia. Advantages of a VFSS include the test
being able to assess all phases of the swallow, viewing
anatomy as it is functioning, visualizing the moment of
swallow and providing real-time results. Some of the
limitations include radiation exposure, difficulty repli-
cating positioning, inability to assess breastfeeding and
the small amount of time captured in a study compared
to an actual meal.
The Fiberoptic Endoscopic Evaluation of Swallow-
ing (FEES) is another instrumental evaluation of
swallowing function. FEES are done with SLPs work-
ing in conjunction with an ENT. A laryngoscope is
passed through the nose to just below the soft palate for
a “bird’s eye view” of laryngeal anatomy. Green food
coloring is then added to a variety of textures and given
to the patient with the scope in place. The SLP and
ENT partner to evaluate structures and function of
the swallowing mechanism.
Advantages of this test include
the ability to assess secretion
assessments are management and sensation in
conducted with patients taking
minimal amounts orally.6 No
radiation is used and the lar-
yngeal structures are directly visualized. Limitations
are that it only assesses pharyngeal phase of the
swallow, there is “white out” during the swallow
Curr Probl Pediatr Adolesc Health Care, March 2018
which results in no direct visual- Therapeutic Interventions are
ization of the moment of swal- A Speech-Language Pathologist also possible following a dys-
low/aspiration, and there is helps provide input for well- phagia diagnosis. This may
limited tolerance by some include feeding strategies such
patients due to scope placement.
rounded, multi-disciplinary as use of a liquid wash, verbal
Following a diagnosis of dys- plans supporting successful oral or verbal cues or external pac-
phagia from either a clinical or feeding. ing (slowing the flow of the
instrumental assessment, there food ingested by incorporating
are a variety of avenues that planned breathing breaks), use
can be pursued. If a safe feeding plan is able to be of specialized equipment to change the flow rate or
established, diet modifications may be recommended. bolus size, position changes, or external support such as
If no consistencies are deemed safe, alternate nutrition bundling an infant or using a specialized feeding chair
is another possible recommendation. Diet levels run are also possible recommendations.
along a continuum of increasing texture ranging from In summary, SLPs play a vital role in the evaluation
thin liquids such as water or juice to a texture of a and management of patients with aerodigestive disor-
regular solid such as a chewable. According to the ders. Through numerous evaluation and intervention
National Dysphagia Diet there are four levels of solid approaches, the contributions of SLPs help provide
foods and four levels of liquids. Solids include pureed, input for well-rounded, multi-disciplinary plans sup-
mechanical altered, advanced (which includes items in porting successful oral feeding.
a regular diet with the exclusion of “very hard, sticky,
or crunchy foods”), and a regular diet. Liquid con- References
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Curr Probl PediatrAdolesc Health Care, March 2018 73