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Pediatric Dysphagia: Signs, Symptoms & Treatment
Dana Schmitz • Aug 30, 2023 • 36 hits
Ashley Brown, speech language pathologist (SLP), details the spectrum of signs that infants with dysphagia can display upon presenting to the clinic, from overt distress during feeding to subtler cues like watery eyes and coughing. It is imperative for clinicians, notably the SLP, to adopt a comprehensive strategy that not only observes physical cues like the infant's suck-swallow-breathe coordination but also appreciates silent symptoms like aspiration. As feeding assessment and therapy evolves, it incorporates more than just addressing the child's ability to eat, encompassing parent training and a continuous engagement of the family in the therapeutic process. Beyond the clinical and technical interventions lie the profound emotional and cultural nuances of feeding, which are deeply embedded in human bonding and traditions. Hence, while the exact cause of a feeding problem may sometimes be elusive, understanding the emotional weight it carries is essential. Balancing both clinical interventions and emotional needs ensures a more holistic care approach for both the child and the family.
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
• Failure to thrive, frequent pulling off during feeding, coughing, watery eyes, fussiness, and incomplete feeds are common presentation factors for infants at the outpatient clinic.
• Holistic examination techniques are used when assessing infants with feeding difficulties; providers observe posture, tone, trunk support, and parent handling during feeds, followed by an oral motor exam to check tone, range of motion and structural integrity.
• During an assessment in the clinic, the SLP will analyze the infant's oral motor skills, self-regulation, feeding pattern, and the coordination of the suck-swallow-breathe pattern, especially since infants are obligate nasal breathers.
• Breastfeeding evaluations should be sensitive to the needs of both mother and baby, with lactation experts playing a vital role.
• For infants with a history of intubation or other challenges, therapy might center around creating positive oral experiences and building trust.
• The sensory and motor elements in feeding are important considerations, and therapy techniques such as cold or sour stimulation, facial kinesio taping, and neuromuscular electrical stimulation (NMES) may be used during treatment.
• Dysphagia in children often entails a multidimensional challenge, not solely based on physiological difficulties. Feeding therapies should be as inclusive as possible, considering the emotional and societal importance of communal eating.
Table of Contents
(1) Assessing & Addressing Infant Feeding Challenges
(2) Supporting the Child & Family in Feeding Therapy
(3) The Emotional Impact of Dysphagia on Pediatric Patients & Families
Assessing & Addressing Infant Feeding Challenges
Infants with feeding difficulties often present to clinics due to concerns like failure to thrive, inconsistent weight gain, or disruptions during feeding sessions, such as pulling away or displaying physical signs of distress. While the referral reasons are multifaceted, ranging from infants frequently pulling off the breast or bottle to subtle signs like watery eyes during feeds, these challenges can manifest as early as a few days post-birth, extending up to the 12-month mark. Importantly, infants with craniofacial conditions like cleft lip and palate necessitate prompt and specialized care. Clinicians, particularly speech therapists, employ a holistic approach to these cases, factoring in aspects like posture, tone, and even parent-infant feeding dynamics. Observing the infant's feeding pattern, particularly the coordination of the suck-swallow-breathe sequence, is paramount. But it's essential to recognize that the majority of aspiration in infants can be silent, making clinical judgment crucial in determining whether to progress to feeding therapy or further diagnostic evaluation.
[Dr. Gopi Shah]
For infants, and again, we're talking about infants under a year, how do they usually present to you when they're feeding difficulties?
Whether it be in clinic or just a PCP referral from the community to our outpatient clinic, generally the infants present to us because they're a failure to thrive. They're not gaining weight. They are pulling off breast or bottle frequently. Maybe some reports of coughing, watery eyes, red eyes when they're eating, not completing their feeds, super fussy during feeds, refusing is I would say the general referral reasons that we get when it comes to infants.
[Dr. Gopi Shah]
How old are they usually? Are they usually early on, like a couple of weeks, a couple of days, or do some of them present a little bit later on?
We will get them when they are a few days, maybe a couple of weeks old, all the way up until, like you mentioned, that 12-month-old mark. Probably our youngest patients are seen within our craniofacial weight check clinics that we have, because when those babies are born with cleft lip and palate, they need to get in immediately, see the surgical team and the speech therapist, because they require such specialized feeding systems. Those are probably our youngest patients, but I've done swallow studies on a baby that's about two weeks old.
[Dr. Gopi Shah]
There's quite a range.
A very large range and within that range, you are looking at rapid developmental changes. A two-week-old infant does not equate a six-month-old infant.
[Dr. Gopi Shah]
When these babies come to you, how do you organize your thought process? Or like what kinds of questions? Are there the same basic handful of questions that you ask and then you tease it apart? How do you look at these and then what kinds of questions are you asking?
We definitely start with a standard set of questions, probably very similar to questions you would ask in your practice, asking about birth history and then getting into what brought you in today. What are your concerns? Tell me what a feed looks like in terms of quality, quantity, the time it takes the baby to finish. From there, then you start delving into specific questions that apply to that patient but there are definitely a set of standard questions that you start with that give you a good clue of what do I need to ask next.
[Dr. Gopi Shah]
Then what's your exam like?
With the exam after asking some of those questions, I feel like the whole time we as speech therapists are pretty good at looking at the whole patient. We are very holistic in our approach to any dysphagia, especially infant dysphagia. The whole time we are observing posture, tone, we do tone check, oral motor exam on the baby and not just focusing on the mouth. We're looking at trunk support. We're looking at how did the parents hold the baby during a feed. That's where we start when we delve into the oral exam. Again, we're looking at tone, but also range of motion, integrity of the structure.
[Dr. Gopi Shah]
Then do you watch them feed every time when they're with you?
Yes, we have instructions when they are scheduled for an appointment that hopefully they are hungry enough. We say for a snack, once you get a baby over a tipping point of so hungry, it works against us a lot of the time that they don't want to eat because they are so mad at that point. Yes, we do ideally observe a feed. Now, we do have some infants that come in that are NPO so that's a different exam but we observe a feed. During the observation of the feed, we are looking at the oral motor skills, the feeding pattern, the swallow pattern. We are looking at are they self-regulating? Are they pacing themselves during the feed? What does the coordination look like in terms of the suck, swallow, breathe pattern?
We know that small infants, they're obligate nasal breathers, so they suck, swallow, breathe, suck, swallow, breathe. If they are not pacing themselves and get into this bad pattern, you know, you're going to choose breathing over eating, and we get into some bad moments then if we're not coordinating the suck, swallow, breathe. You breathe when you should be swallowing. Those are all things that we look at during the feed.
[Dr. Gopi Shah]
How do you know which babies you're like we're going to do some feeding therapy or, hey, we need to do further workup or further imaging or testing?
So sometimes it's hard to tell is this just strictly a feeding therapy kit or do we need an instrumental because the great majority, if you look at the research, anywhere from 80% to 90% of aspiration is silent. They're not going to give you many cues that they are aspirating. You have to take some other cues from them. Given the comfort level, are they frequently pulling off the bottle? Do they sound a little wet, gurgly? Is there some sort of respiratory history that is the reason they were sent to us? Then that's where we would go for an instrumental.
Sometimes the families get into us and it is just a utensil change of maybe they are overloading baby with a too fast a flow nipple, and we just need to back them down a little bit. Sometimes they just need strategies to pace baby. I think it's always a good idea to start with the bedside and a speech therapist observing a feed so you are not getting into unnecessary exposure to radiation with a fluoro swallow study. Those are some of the clues that we take. Infants don't cough. That's not a-- small infants, that is not a reflex quite yet when they're very small, that that develops over time. That cough is not something you should rely on as a clue that they need an instrumental.
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Supporting the Child & Family in Feeding Therapy
Feeding therapy is not just about addressing a child's physical ability to eat; it encapsulates a broad array of support mechanisms and interventions. Central to successful feeding therapy is the pivotal role of family counseling, parent training, and their continuous involvement. Recognizing parents as instrumental stakeholders in the therapeutic process ensures a seamless transfer of skills and strategies from the clinic to the home environment. While some patients only need a few visits or a relatively quick fix, others need very long term therapy for sensory or motor work. Technical interventions, ranging from oral motor stretches to neuromuscular electrical stimulation, form the cornerstone of these longer term therapies. Recognizing and addressing the sensory aspects of eating are equally crucial. The ultimate goal is to transform eating from a daunting challenge into a pleasurable experience, necessitating a multifaceted and holistic approach from both providers and the patients’ families.
[Dr. Gopi Shah]
In terms of feeding therapy, what happens like when they, “You're going to go see speech pathology, they're going to evaluate you and decide” and now, “How are you doing? You're into feeding therapy, that's great. How are things going?” I don't really know what actually happens though.
Right. What happens during a session? I will say a very large part of what we do is family counseling and parent support and parent training. These are not adults that come into dysphagia clinic where it's up to them and their partner to navigate. This is a whole family. We have grandparents that come to every appointment with the parents. You are counseling an entire family and you can't forget that the parents are part of your evaluation and part of your therapy plan, because they are the ones that are going to have to implement these strategies at home.
You can't go home with them as much as maybe the families would like you to go home with them and do every feed with them. You have to do a lot of great parent training. That is a very large part of therapy is making sure the parents are comfortable with the strategies, they are continuing the exercises, if that's what you're doing at home, because one or two sessions a week does not necessarily translate to carry over. You've got to train these parents and they are their child's biggest advocate. They are a very large part of the therapy plan but in terms of focusing on the child during therapy, there is a wide range of do they just need a change in nipple flow, like we've talked about, and really just following them for a few sessions to make sure that that strategy worked well for them.
Sometimes these are very long-term therapy patients who need a lot of sensory and motor work. Sensory is a very large part of eating that sometimes I think gets missed and not talked about. Our little friends that like to overstuff their mouths are we looking at a sensory feeding problem that they really need that input where they just shove a bunch in their mouth and look like little chipmunks? You have to think about the sensory as well. They will do maybe some oral motor stretches. Do we have some hypertonia and we really need to work on stretching those lips for good lip rounding?
Do we just by getting in there and maybe doing some sour or cold stimulation, are we increasing that sensory input and working on their sensory system for oral motor but also for swallowing? Then they move on to maybe some more of the complex like facial kinesio taping for also sensory input but for some support we use that a lot for our droolers, our facial management. Kids that need a little help with lip rounding to keep lips closed so that they can't actually swallow their secretions and then all the way on to neuromuscular electrical stimulation.
Some people know it as their brand name, VitalSim, but that is just the company. NMES is the actual therapy. There's a wide range. If you are looking at a infant that has had a long-standing feeding problems, we talked about they are intubated for a long time and are very defensive, you are also just working on them having pleasurable oral experiences and being okay within you getting to the exercises and wanting to take some flavor-taste PO trials.
The Emotional Impact of Dysphagia on Pediatric Patients & Families
Pediatric dysphagia management goes beyond the technicalities of diagnosis and treatment; it demands an appreciation for the emotional weight it carries for families. Feeding is deeply ingrained in human bonding and societal traditions, making its challenges especially poignant for affected families. The multifaceted nature of feeding problems, combined with the high stakes of ensuring a child's growth and well-being, creates a complex clinical landscape. In many cases, the root cause may remain elusive. While technical interventions are crucial, acknowledging the emotional and sociocultural implications of feeding disorders is equally vital. Care teams should always aim to balance clinical interventions with family needs.
[Dr. Gopi Shah]
Well, as we start to wrap things up, do you have any final tips or pros? I mean, these are hard patients and like you said, there's a whole family aspect to that. You're looking at everybody and feeding such an important-- especially for growing and quality of life that is so valued as part of life, if you will. Do you have any other final pearls for us or things that we should be thinking about, or how we can make our practice better or how we should be looking at these kids differently?
Dysphagia is very difficult. There are days that I wonder why I do this all day, every day, but you get those.
[Dr. Gopi Shah]
It's so hard. It’s so hard.
It is but you get those small victories and it makes it all worthwhile but it is very difficult because there are probably more times than not, I would have to say is we often had to tell the families I don't know, and I don't know why. I think it's okay to say I don't know. We're so afraid to not have an answer for families and that's why they come to us. They want an answer but so much of it is unknown, and you are there to support them through the journey which means they may be with you for several years, especially in pediatrics.
It's hard to tell a family I don't know. We've put you through therapy, we've done a DLB, we've injected a look you know a deep notch for laryngeal cleft and nothing is working. Sometimes maturation is just our best friend. We definitely see that, that it just takes them a little time developmentally when we're looking at maybe now, they're walking, maybe now they're running, we have better core support, we have better neck control. Sometimes maturation is just our best friend in terms of feeding and swallowing and that's a hard thing to tell a family.
That's a hard thing to admit to yourself that you don't have the answer, but sometimes you're not going to, a lot of times you're not going to in pediatrics. Feeding is very emotional. You think about bringing this baby home and your only job is to keep them alive, and that is to feed them, and it is such a bonding emotional experience for Mom and Dad, especially when me a mom is trying to breastfeed and she's having difficulty with that. You need to remember especially when it comes to breastfeeding evaluations, tongue-tie evaluations that Mom is also your patient, and where a multidisciplinary including lactation and speech really come into play there because maybe baby is doing okay but mom needs help with her supply.
There are mouth and you know nipple mismatches and problems there that your lactation friends can really help you with positioning baby for optimal feeding. Mom is your patient at that moment too, it is not just baby. Like I mentioned when we're thinking tongue-tie we need to think function, just not how it looks, and we'll tell you a lot. These are very difficult evaluations and they can be very frustrating, but I think as long as the families know that you're really trying to help them navigate this very tough part of their life, because it seems like our parents are okay with their kid not walking.
They're okay sometimes even if they're not saying as many words as they like, but feeding is such a family community-based activity, we take such pleasure from eating. Even if the child is not showing the parents that they really have any interest in eating, that's a very hard thing for people who eat okay to connect with because we take such pleasure from eating. We're coming up on Thanksgiving so I mean that is what we base a lot of our celebrations and holidays around, so if you are the family that has that one kid that doesn't get to participate in that that is very difficult.
I think that that is why a lot of us in terms of our feeding therapy colleagues try not to go this NPO route. We try to give the family something because they will say “I just want him to have some icing on his first birthday so I can get that smash cake picture.” Is that something we're really taking away from families because there is a big mental health component around this as well.
[Dr. Gopi Shah]
I think that's a great point. Ashley, thank you so much for taking the time to talk with me today, and more so for just answering all my questions all the time and helping me with these patients. I find them to be truly difficult and wanting to make sure because there's so much at stake that we're doing the right thing. Thank you for being such a resource and my partner in this. I appreciate it.
Yes, of course. I would always rather be there to answer those questions and make sure the kids get what they need than people trying to blindly walk through this journey with these families for sure.
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
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