Swallowing Disorders

Swallowing disorders are also referred to as dysphagia, which means difficulty swallowing. It is the inability of food or liquids to pass easily from the mouth, into the throat and down into the esophagus to the stomach during the process of swallowing.

What causes dysphagia?

To understand dysphagia, it helps to first understand how swallowing occurs. Swallowing involves four stages. These stages are controlled by nerves that connect the digestive tract to the brain.

• Oral preparation stage: Food is chewed and moistened by saliva.
• Oral stage: The tongue pushes food and liquids to the back of the mouth toward the throat. (This phase is voluntary: people have control over chewing and beginning to swallow.)
• Pharyngeal stage: Food enters the pharynx (throat). A flap called the epiglottis closes off the passage to the windpipe so food cannot get into the lungs. Next, the muscles in the throat relax, and food and liquid are quickly passed down the pharynx (throat) into the esophagus. The epiglottis opens again to allow for breathing. (This phase starts under voluntary control, but then becomes an involuntary phase that cannot be consciously controlled.)
• Esophageal stage: Liquids fall through the esophagus into the stomach by gravity. Muscles in the esophagus push food toward the stomach in wave-like movements known as peristalsis. A muscular band between the end of the esophagus and the upper portion of the stomach (known as the lower esophageal sphincter) relaxes in response to swallowing, allowing food and liquids to enter the stomach. (The events in this phase are involuntary.)

Swallowing disorders occur when one or more of these stages fails to take place properly. Children’s health problems that can affect swallowing include:

• Cleft lip or cleft palate
• Dental problems (teeth that do not meet properly, such as with an overbite)
• Large tongue
• Diseases that affect the nerves and muscles, such as a stroke, tumor, nerve injury, brain injury or muscular dystrophy, and can cause paralysis or poor function of the tongue or the muscles in the throat and esophagus
• Large tonsils
• Tumors or masses in the throat
• Problems with the prenatal development of the bones of the skull and the structures in the mouth and throat (known as craniofacial anomalies)
• Prenatal malformations of the digestive tract, such as esophageal atresia or tracheoesophageal fistula
• Oral sensitivity that can occur in very ill children who have been on a ventilator for a long period of time or were unable for any reason to start feeding by mouth for a prolonged period after birth
• Irritation of the vocal cords after being on a ventilator for long periods of time (as may occur with premature babies or very ill children)
• Paralysis of the vocal cords
• Having a tracheostomy (artificial opening in the throat for breathing)
• Irritation or scarring of the esophagus or vocal cords by acid in gastroesophageal reflux disease (GERD). Learn more about GERD.
• Compression of the esophagus by other body parts, such as enlargements of the heart, thyroid gland, blood vessels or lymph nodes
• Foreign bodies in the esophagus, such as a swallowed coin
• Developmental delays
• Prematurity.

Why is dysphagia a concern?

Dysphagia can result in aspiration, which occurs when food or liquids go into the windpipe and lungs. Aspiration of food and liquids may cause pneumonia or other serious lung conditions. Swallowing disorders are also cause for concern because children with this disorder usually have trouble eating enough, leading to poor nutrition and failure to gain weight or grow properly.

What are the symptoms of dysphagia?

The symptoms that children with dysphagia have may be obvious, or they can be difficult to associate with swallowing trouble. The following are the most common symptoms of dysphagia. However, each individual may experience symptoms differently. Symptoms may include:

• Eating slowly
• Trying to swallow a single mouthful of food several times
• Using liquids to wash foods down frequently
• Difficulty coordinating sucking and swallowing
• Gagging during feeding
• Drooling
• A feeling that food or liquids are sticking in the throat or esophagus, or that there is a lump in these areas
• Arching or stiffening of the body during feedings
• Congestion in the chest after eating or drinking
• Coughing or choking when eating or drinking (or very soon afterward)
• Wet or raspy sounding voice during or after eating
• Frequent respiratory infections
• Spitting up or vomiting frequently
• Food or liquids coming out of the nose during or after a feeding
• Irritability or lack of alertness during feedings
• Weight loss.

Symptoms of dysphagia may resemble other conditions or medical problems. It is important to speak with your child’s pediatrician if there is a suspected swallowing disorder. Learn when it is time to seek help for a child’s swallowing or feeding problems.

How is dysphagia diagnosed?

Your child’s doctor will examine your child and obtain a medical history. You will be asked questions about how your child eats and any problems noticed during feeding. Imaging tests may also be done to evaluate the mouth, throat and esophagus. These tests can include:

• Modified barium swallow study. Also referred to as “MBSS,” this test is used to see how your child is swallowing foods and liquids. An X-ray “movie” called a fluoroscopy is made of your child’s mouth and throat while they eat and drink. Learn more about the modified barium swallow study.
• Barium swallow/upper GI series. Your child is given a liquid containing barium (a metallic, chemical, chalky, liquid used to coat the inside of organs so that they will show up on an X-ray) to drink, and a series of X-rays are taken. Your child’s doctor can watch what happens as your child swallows the fluid, and note any problems that may occur in the throat, the esophagus or the stomach.
• Endoscopy. A test that uses a small, flexible tube with a light and a camera lens at the end (endoscope) to examine the inside of part of the digestive tract. Under anesthesia, an endoscopy is performed. Pictures are taken of the inside of the throat, the esophagus, and the stomach to look for abnormalities. Small tissue samples, called biopsies, can also be taken to look for problems. Learn more about endoscopy.
• Esophageal manometry. A thin tube containing pressure gauges is guided through your child’s nose and into the esophagus. The pressure and pressure waves inside the esophagus are then measured to evaluate esophageal motility or how well food moves through the esophagus.
• Laryngoscopy. Your child’s doctor uses a tube to look at the back of your child’s throat for narrowed areas and other problems. This test may be done with or without sedation depending upon how far the doctor needs to look and the age and condition of your child.

What is the treatment for dysphagia?

Specific treatment for dysphagia will be determined by your child’s health care team based on the following:

• Your child’s age, overall health and medical history
• The extent of the swallowing disorder
• Your child’s tolerance for specific medications, procedures or therapies
• Expectations for the course of the swallowing disorder
• The family’s opinion or preference.

The first step in treating a swallowing disorder is establishing a safe food consistency and method of feeding. Holding your child in a certain position, thickening liquids, or blending solid food may help your child to swallow safely. Your child’s therapist will establish a unique plan to address your child’s specific needs. Your child will complete exercises to strengthen the muscles of his or her mouth and throat to improve their ability to swallow and do it safely. Learn more about swallowing therapy at CHOC.

Some patients may be a candidate for a treatment modality called neuromuscular electrical stimulation. This treatment is used with traditional swallowing exercises and can further improve the coordination, endurance, sensory response and strength of the swallowing mechanism. This state-of-the art therapy, offered at CHOC, has been approved by the Food and Drug Administration and has had positive results with many children. Neuromuscular electrical stimulation therapy is only found at a handful of children’s hospitals in the United States. Learn more about electrical stimulation therapy.