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BackTable / ENT / Article
The Functional Impact of Infant Dysphagia
Dana Schmitz • Aug 30, 2023 • 31 hits
In addressing pediatric feeding challenges, clinicians must delve deeper than superficial categorizations based on apparent syndromes or cardiac conditions. For instance, while tongue ties and laryngomalacia may seem benign upon visual assessment, their functional impact on feeding processes can be substantial. Ashley Brown, an experienced speech language pathologist (SLP), emphasizes the importance of functional evaluation over mere anatomical categorization. Additionally, though reflux is commonplace among infants due to their developing gastrointestinal systems, the concern is its direct impact on feeding patterns, including subtle indicators like lip smacking or feeding discomfort. The impact of function is substantial, but anatomical abnormalities such as nasal obstruction may cause difficulties. While minor congestion might briefly disrupt feeding, severe conditions like cranial atresia necessitate a comprehensive, multidisciplinary evaluation, often owing to associated comorbidities.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• Tongue tie and laryngomalacia concerns should focus on function over mere anatomical appearance. Relying solely on visual assessments can lead to inadequate or delayed interventions
• Infants may present with silent reflux, without visible spitting up. Observational cues can include pulling away during feeds, lip smacking, sour facial expression, and constipation.
• Reflux in babies can influence feeding volume, disposition, growth, feeding experience, and regularity of stools.
• For bottle or breastfed infants, discomfort during feeding may point to milk protein sensitivities and not dysphagia.
• Simple nasal issues generally do not result in significant feeding problems. Supportive care, including nasal saline, is effective for most infants with basic congestion who are temporarily struggling with a feed.
• Nasal obstruction can accompany more serious conditions like cranial atresia or pyriform aperture stenosis, which may impact feeding more substantially. Many infants with these serious conditions also have other comorbidities affecting feeding, and a multidisciplinary approach is necessary for addressing these complex feeding challenges.
Table of Contents
(1) Laryngomalacia, Tongue Tie & Feeding: Focus on Function Over Anatomy
(2) The Role of Reflux in Pediatric Feeding Evaluation
(3) Distinguishing Food Allergies from Dysphagia in Infants
(4) The Implications of Nasal Obstruction on Infant Dysphagia
Laryngomalacia, Tongue Tie & Feeding: Focus on Function Over Anatomy
In pediatric feeding challenges, the immediate thought often veers towards syndromic or cardiac children. However, the subtler challenges in seemingly "healthy" children, like those with tongue ties or laryngomalacia, are equally important and sometimes harder to discern. Ashley Brown emphasizes the need to focus on function rather than mere anatomical appearance. Tongue tie, for instance, is not just about the visual aspect but how it affects feeding. Similarly, laryngomalacia might present mildly in appearance but could disrupt the essential suck, swallow, breathe sequence in an infant. The conversation underscores the importance of individualized assessments and a multidisciplinary approach, cautioning against classifying children based on appearances alone.
[Dr. Gopi Shah]
I think, you know, there's such a spectrum, and we tend to think about the cardiac kids and the trisomy 21 kids and the syndromic kids as being the most difficult, but I find that sometimes in our otherwise “healthy” I don't know if nobody can see me, but I have my finger quotes, that sometimes the tongue tie or laryngomalacia kids or that six month old that's always had a little cough when they drink milk and are now finally coming to you, those are to me, can be very difficult as well, just because we know that not all tongue tie is the main issue. Even with that otherwise healthy six-month-old there might be something. Is there any details or ways to help tease those kids in terms of how to help think about etiology or things they might benefit from? How do you look at that group?
[Ashley Brown]
You mentioned laryngomalacia and that also is a large referral population that we have within ENT. If we think about it in terms of also tongue tie, I think sometimes we get stuck on the visual of it, and tongue tie is not about the anatomy. It's about the function. It's not about the visual. It's about the function. When we think about laryngomalacia when you think about it in that term as well, because we'll see notes that say, my laryngomalacia we'll continue to watch, but they're showing all of these signs that their astragalus during feedings is the time the parents notice it the most.
They get a little junky, a little congested. They're not gaining weight. Is that mild laryngomalacia in that baby just enough to throw off that suck, swallow, breathe sequence where in another child they were doing fine with the exact same maybe appearance of the rental tissue? It has to be patient by patient, kid by kid. It cannot be this box that we put them in of you have a tongue tie, therefore you have a feeding difficulty. Or it looks like a mild tongue tie, therefore you won't have a feeding difficulty. That's where best practice would be this multidisciplinary approach to everything. We should not expect our ENT colleagues to know it all about feeding and that's why we're here. We would rather you ask than order all of these exams or just say we'll see you in six months. There's a wide spectrum of how people handle it.
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The Role of Reflux in Pediatric Feeding Evaluation
In pediatrics, understanding the nuances of gastroesophageal reflux (GERD) is pivotal when evaluating feeding difficulties. All infants experience some level of reflux due to their immature gastrointestinal system. Yet, it's not the mere presence of reflux that concerns practitioners, but its impact on the feeding process. Silent reflux may also present in infants who don't exhibit traditional spitting up. Key indicators to watch for include behaviors during feeding such as pulling away from the bottle, frequent lip smacking, and facial expressions that suggest discomfort. Additionally, observing the frequency and nature of the child's stool can provide insights into gastrointestinal health.
[Dr. Gopi Shah]
Well, good thing I sent you an epic message about once a week then for all my kids that I see.
[Ashely Brown]
We never mind those questions because there are things that we have not thought of that you can offer, and then we might pick one little clue out of the message that you sent that you're like, “Oh, actually this kid probably needs to go to GI. This sounds like they are having some major GI difficulties and let's pull those colleagues in.” If we could see every dysphagia patient in the aerodigestive clinic, that would be wonderful but the bandwidth is not quite there.
[Dr. Gopi Shah]
Let's talk about some of the GI. I feel like I'm always asking, is there any history of reflux spitting up? Tell us a little bit about what you're asking when you're looking for GERD or reflux. Do they need to be actively spitting it up for them to have it? How does that play a role into your feeding evaluation?
[Ashley Brown]
All babies have reflux, right? They have immature guts and they are messy and they spit up. There is silent reflux as well. They are not necessarily going to spit up all the time. Spit up does not mean that it's affecting them in any sort of negative capacity. All babies do it. It again, is really looking at the parents have told me they spit up a lot. They're smacking their lips a lot during a feed, have this sour look on their face. Is it affecting the feed? Is it affecting their growth? Is it affecting a happy, pleasant feed? Are the parents struggling and they're feeding the baby every hour because the baby has started to volume limit because they don't feel good?
The way, unfortunately, babies show you that they don't feel good is crying or not necessarily cooperating the way that they want them to because they cannot tell you how they feel. Looking at those signs of pulling away from the bottle, lots of maybe tummy discomfort, gas, sound like they're maybe swallowing a lot of air, which would then in turn with aerophagia, you get more reflux with that. Is it affecting the feed is what you need to know. Are they stooling like they should? Do they have constipation? They're going to volume limit at that moment. If you have constipation, there's only some place the food, liquid can go and it's going to start to possibly go back up the other way. Again, looking at how is this affecting the feed because do our GI colleagues get a little annoyed with us that sometimes we want to blame reflux all the time?
[Dr. Gopi Shah]
All the time.
[Ashley Brown]
Probably. It's like, you got reflux. Oh, yes. Is there a place? Those are the two things. Yes. They probably do get slightly annoyed with us but if you think of it in terms of is it affecting their feed? Is it affecting the volume? Is it affecting their growth? That's when you start thinking I need to rope in my GI friends because the baby's only job when they're very small is to eat and go to the bathroom. If both of those, either of those are messed up, we need to get our GI colleagues involved as well.
Distinguishing Food Allergies from Dysphagia in Infants
In the early stages of infancy, concerns related to food allergies might not be as prominent as suspected. While food allergies in very young infants can manifest, it's more likely to be food sensitivities, particularly sensitivities to milk proteins. These sensitivities can present challenges, especially for mothers who breastfeed or provide expressed breast milk. As infants transition to spoon-feeding, introducing solids like fruits and vegetables may raise concerns about potential allergic reactions, such as rashes or signs of discomfort. However, for exclusively breast or bottle-fed infants, signs of discomfort are more indicative of milk protein sensitivities rather than outright food allergies.
[Dr. Gopi Shah]
In the infancy, how much does something like a food allergy come into play or does and present as dysphagia, does that come at all?
[Ashley Brown]
I mean, I think probably some food sensitivities, maybe some dairy, milk protein sensitivities. A lot of our moms do elimination diets if they're breastfeeding or doing express breast milk. How many babies really have food allergy? I don't think that that is necessarily maybe what we're looking at. It's more because infants are going to be more formula, express breast milk or breast feeding, human milk based. Maybe a milk protein sensitivity, which, again, is where our GI colleagues get involved. Now once they start transitioning to spoon feeding and parents are trying fruits and veggies and we start seeing rashes or some other signs of discomfort, once they start introducing more solid type foods, then that's when we maybe start thinking food allergy. In terms of very small infants that are still just breast or bottle based, you would think more milk protein discomfort type signs when they're eating.
[Dr. Gopi Shah]
Then what about, we've talked about intubation history.
The Implications of Nasal Obstruction on Infant Dysphagia
Nasal obstruction in infants, while common due to colds or other minor illnesses, does not typically lead to significant feeding issues unless the baby is dealing with more severe or rare conditions like cranial atresia or pyriform aperture stenosis. In such cases, the obstruction can impact their feeding habits more profoundly. However, many infants who present with these rare conditions often have additional comorbidities, which further complicate their feeding challenges. Thus, while general nasal congestion can momentarily disturb an infant's suck, swallow, and breathe pattern, it's the more severe nasal pathologies – often coupled with other medical conditions – that warrant a closer, multidisciplinary look.
[Dr. Gopi Shah]
We've talked about laryngomalacia, craniofacial, but what about just nasal obstruction? How often do you see nasal obstruction in infancy that is enough to cause trouble feeding? They get six to eight colds a year, we say, I feel like that's your main group. Then, of course, you're going to have the history of pyriform aperture or cranial atresia, but those are not common. How often is in the nose and how does that present?
[Ashley Brown]
I don't feel like we have too many families that come to us that everything seems solely based on just a junky nose and they can't eat. Like you mentioned, it's going to be cold based if they go to daycare, maybe just some seasonally based kinds of things. Then it seems to be a fairly simple conversation of talking about nasal saline, those kinds of things to help them with that. If it's just some of that junk, yes, when they are obligate nasal breathers, can it throw off their suck, swallow, breathe pattern? Yes. That's what we just talk about. Let's help baby along with some pacing to help with that coordination sequence.
Cranial atresia, pyriform aperture stenosis, they will, as we have seen, have difficulty with feeding, but generally I feel like they do well with just some strategies. I don't know what you've seen necessarily with your patients that have come through, but most of the time they do very well with some strategies by getting your feeding therapy colleagues involved to help them with some pacing strategies generally helps them through.
[Dr. Gopi Shah]
Yes, I agree. I think that the otherwise healthy kid that catches a cold all the time isn't necessarily going to be the ones having the issues, because you're right, once they're about two months, they're not as much of an obligate nasal breather, and then the colds, that's when they start getting affected more. I mean, I feel like we do see a lot of, in our clinic for four-month-old with nasal, the nose has been clogged since they were born type of picture. Like you said, it's supportive care, lots and lots of saline and going from there and just letting them grow.
I think with the cranial atresia or pyriform stenosis, whether, cranial atresia, if it's bilateral, you're going to have had to repair it and do surgery. Every once in a while, not a lot, not very often might you see an infant with unilateral that has some feeding difficulties with a URI or perhaps they have trisomy 21 or something. There's other factors also playing a role like tone or every time that kid gets sick, there's issues with feeding.
I think that with bilateral cranial atresia or prefrontal stenosis whether you've repaired it or not, there can-- when the nose is getting tighter, if there's re-stenosis or scoring that, feeding is always going to be one of the first things that tends to be affected and nasal flaring, not being able to stay on. Again, those things aren't that common, right? Those pathologies aren't that common but that is always in my mind of, we need to take a look, maybe we need to go back and do something and re-dilate and things like that.
[Ashley Brown]
Yes, I think the babies who've had the most difficulty with feeding when cranial atresia is one of the diagnoses on the table, generally, like you said, have some other comorbidities other than just cranial atresia. There are degrees of obstruction, like you mentioned unilateral versus bilateral, and when you're going to have to get surgically involved, these are not these long-term kids that pop up in our clinic over the years that that's their only history.
[Dr. Gopi Shah]
Yes, you're right, because if it's CHARGE or something else, we're also thinking about a nerve, a vocal cord precess or a cleft or some other, there's stuff that we're thinking about that might also play other roles.
[Ashley Brown]
Right. Yes, CHARGE is a tricky one with a lot of cranial nerve involvement, and that is a difficult diagnosis in terms of feeding as well.
Podcast Contributors
Ashley Brown, SLP
Ashley Brown, SLP is a pediatric speech language pathologist at Children's Health in Dallas.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2022, February 8). Ep. 48 – Feeding Difficulties in Infants [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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