Symptoms of Dysphagiain Children
- Prolonged Feeds/Anorexia/Food Refusal Children who refuse feedings despite not having consumed adequate calories may be suffering from oropharyngoesophageal motor disorders. In these situations, the dysmotility causes refusal to eat owing to physical incapacity to eat, to discomfort, or to the threat of respiratory compromise. In 14 children younger than 6 years of age with chronic tube-feeding–dependent food refusal, manometry diagnosed two as having diffuse esophageal spasm and one as having nonspecific esophageal motility disorder. One must distinguish upper digestive dysmotility from other causes of feeding refusal, including pain from psychodynamic (e.g., anorexia nervosa) or esophageal inflammatory (e.g., reflux or eosinophilic esophagitis) sources.
- Poor Weight Gain/Malnutrition/Failure to Thrive Inadequate weight gain may accompany chronic obvious feeding refusal, or it may be the first sign of subtler instances of long-term esophageal dysmotility. In some instances, dysmotility causes inadequate energy intake simply due to extreme prolongation of feeding time rather than actual refusal of feeds. Malnutrition caused by dysmotility may negatively affect the immune system, which can worsen any associated aspiration pneumonias and cause vicious cycles of increasing debility.
- Drooling Drooling, sialorrhea, the unintentional loss of saliva and other oral contents from the mouth, is generally a sign of oral dysmotility involving striated musculature, and often occurs in the context of more general neurologic disability. Drooling does not itself impact nutrition or airway protection, but may be complicated clinically by maceration of the skin of face and neck, and wet and malodorous clothing. A study examining the source for drooling compared 14 drooling children with spastic cerebral palsy (7 to 18 years old) to 14 similar children without drooling and to 14 normal controls. Both cerebral palsy groups demonstrated nonsignificant tendencies to swallow less frequently and actually to produce less saliva. There was no correlation between the amount of saliva produced and the amount drooled. Drooling did correspond to greater dysarthria severity, greater intellectual disability, and lower nonverbal intelligence, but not to gross motor function, on validated scales. A summary of management of 78 neurologically impaired children with drooling described interventions ranging from oral-motor skills training through palatal training appliances through surgery (diversion of salivary flow); medication for drooling (generally anticholinergic) was used by only 8%.
- Tongue Thrust Tongue thrusting during swallowing is an abnormal oral motor pattern that may contribute to abnormalities of deglutition, speech, and orofacial development. Tongue thrust occurs in many children with obvious neurologic deficits, but may also occur in children who otherwise appear neurologically normal. A potential explanation for such tongue thrust has been described: watershed infarcts in brainstem vascular structures early during intrauterine development may be clinically expressed as various cranial neuropathies, which may embrace those affecting oral motor functions, including those of the tongue. Though clinically evident, such neuropathies are often beneath the resolution of current imaging modalities. Depending on their location and extent, such watershed infarcts have caused apnea, dysphagia, aspiration, or syndromes with orofacial abnormalities.
- Dysphagia Dysphagia (difficulty swallowing) may be a specific complaint in the older child, but in the less verbal child (either younger or developmentally delayed) it may be represented by refusal by a hungry child of offered nutrients, by regurgitation of undigested ingested food, or even by drooling in a child unable to handle oral secretions appropriately. In young or developmentally delayed nonverbal children, slow eating or repeated swallowing may be the only visible manifestation of dysphagia, whereas the teenager, like the adult, may describe the sensation, for example, of food getting stuck mid-chest. Whether dysphagia occurs with solids or liquids is important; solid dysphagia precedes liquid dysphagia in disorders that anatomically narrow the esophagus, whereas liquid dysphagia is an early manifestation of disorders of motility.
- Vomiting/Regurgitation When esophageal dysmotility prevents the appropriate caudal movement of ingested material, the material’s retrograde movement may result in regurgitation. Although this is often termed “vomiting,” the retrograde duodenogastric peristalsis that accompanies true vomiting is usually absent, and the esophageal contents that are ejected are undigested and nonacid.
- Chest Pain, Odynophagia Chest pain may be a sign of esophageal dysmotility, but inflammatory conditions are important in the differential diagnosis of chest pain or odynophagia. No multicenter pediatric series yet exists comparable to the adult series based on motility studies in the national Clinical Outcomes Research Initiative (CORI) database, which found that among 140 adults with isolated noncardiac chest pain who underwent esophageal motility studies, 70% had a normal motility study. Among those with dysmotility, hypotensive lower esophageal sphincter was the most common finding (61%), with nutcracker esophagus and nonspecific esophageal motility disorders diagnosed in 10% each. Of the 44 additional adults who had dysphagia as well as chest pain, at least 60% had dysmotility: 35% with achalasia and 25% with nonspecific esophageal motility disorder. A pediatric series of 83 children with chest pain from one center similarly found esophageal dysmotility in 25% (16% with normal endoscopy, 9% with esophagitis) and normal motility studies in 75% (57% with normal endoscopy, 18% with esophagitis). Of the chest pain patients with dysmotility, 33% had diffuse esophageal spasm, 30% had aperistalsis or hypotensive lower esophageal sphincter, 20% had hypertonic lower esophageal sphincter or nutcracker esophagus, and 19% had achalasia. Because of the prevalence of esophagitis in patients with chest pain or odynophagia, endoscopy generally should be performed as the primary investigation, with manometric evaluation reserved for those without esophagitis, or who do not respond adequately to therapy for any esophagitis found. In the young or neurologically impaired nonverbal child, intractable crying may be the only sign of chest pain, but the differential diagnosis of this symptom is huge, with gastroesophageal reflux disease a prominent consideration.
- Impactions (Bolus Impactions) Severe esophageal dysmotility may cause acute bolus impaction of ingested food. Esophagitis, particularly eosinophilic esophagitis, also causes impactions, although the nature of the poor esophageal propulsion in the latter disorder is not clear
Feeding history in infants and children with swallowing difficulty
|1. Symptom duration and progression a. Developmental b. Transient c. Chronic d. Progressive||2. Caretakers who present the food|
|3. Setting for feeding a. Home b. Institution c. Other||4. Characteristics of problematic food a. Liquid, puree, solid b. Texture c. Other|
|5. Utensils a. Bottle with nipple b. Spoon c. Other||6. Volume offered per swallow|
|7. Biting and chewing: presence or absence||8. Volumes, durations, and frequencies of feeds a. Volume offered per feeding b. Duration of feedings c. Number and frequency of feedings offered per day|
|9. Symptoms a. Signs of fatigue b. Dysphagia c. Odynophagia d. Turning from offered food when hungry e. Crying with swallowing f. Unusual drooling||10. Symptoms of misdirection of feeds a. Gagging b. Choking c. Coughing|
|11. Timing of symptom a. Pre-swallow b. With swallow|
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