Dysphagia in children swiss medical forum

Term-born children who show reduced or conspicuous drinking or eating behavior as well as increased vomiting and lack of weight gain or unclear pulmonary symptoms also require further clarification. Already initially the symptoms listed in table 1 should be considered, which partly also allow a conclusion on the localization: disturbed sucking-swallowing pattern respectively inadequate breathing pattern, coughing/choking during food intake, nasal or oral discharge of food, moist voice, frequent infections of the lower respiratory tract respectively aspirations, failure to thrive, continuous loss of appetite, feeding time over 30-40 minutes or a change in the eating habits.

Learning to swallow and the associated maturation of oral motor skills are also an essential basis for speech development.

Physiology

The swallowing act is divided into four phases: oral preparation phase (food intake and crushing, if necessary), oral (positioning of food on the tongue, triggering of the swallowing reflex), pharyngeal (transport of food through the pharynx, closure of the larynx, opening of the upper esophageal sphincter), and esophageal phase (transport of food through the esophagus [4]). While in the older child the two oral phases are voluntary, in early childhood they are reflexive. At this time, the search reflex is possible by brushing the cheek or perioral region, the sucking reflex can be triggered by stimulation enorally. The pharyngeal and esophageal phases are always reflexive. As long as only liquid food is ingested, the tongue movement is unidirectional. The introduction of food, which has to be crushed, requires a multidirectional tongue movement.

Diagnostics

In addition to the anamnesis, the physical examination of the structural and neurological conditions with cranial nerve status and age-appropriate physiological reflexes is a basis for evaluation. In the examination, food introduction is adjusted to the child's current feeding habits. This refers to both the tool (breast, teat, spoon, straw, sippy cup, etc) and the feeding tube.), as well as consistency (liquid, mushy, solid). It is useful to try to evaluate problematic consistencies, but this is often limited by the child's cooperation. If possible and useful, the use of thickening agents can also be connected to evaluate possible consistency adjustments. Endoscopic examination is used to evaluate organic changes and functional limitations. This examination requires special expertise, taking into account age-appropriate conditions.

Common signs of oropharyngeal dysphagia in children are listed in Table 1. Clinical examination alone is often insufficient to rule out silent aspiration. Is partly also limited by the ability to cooperate. Therefore, in case of a wet voice, cough during or after feeding, and pulmonary symptoms, it is recommended to perform a videofluoroscopic examination. This is especially useful in neurological pathology, since, for example, reflex triggering cannot be recorded in the clinical examination.

In epigastric complaints to clarify whether there is a correlation between possible episodes of reflux, to distinguish between acid and nonacid reflux, nonerosive reflux diseasehypersensitive esophagus and functional heartburn, a pH-impedance examination should be performed. An esophago-gastro-duodenoscopy is performed to check for possible complications of reflux, to detect an anatomic abnormality, or if eosinophilic esophagitis is suspected. The following must be included in the care according to the clinical symptoms. Not only various medical disciplines (e.g., neurology, neurology, neurology, neurology, neurology, neurology, neurology, neurology).B.B. gastroenterology, ENT, orthodontics, oral and maxillofacial surgery, neuropediatrics, pneumology, radiology), but also specialists in nutritional counseling, prosthetics and, above all, speech therapy, in order to ensure that medicinal and surgical measures as well as oral sensorimotor therapy are coordinated. The logopedic therapy contributes to the improvement of the function of the lips, tongue and pharyngeal structures as well as the induction of maturation processes. Food, feeding times and duration must be adapted to the child's capabilities. A modification of the food consistency by means of thickening agents [5] can be useful as well as the use of special spoons, bottles and teats. Special attention should also be paid to the positioning of the child. Tube feeding should remain the ultima ratio, as it often leads to long-term feeding problems. We gladly refer to the consensus paper of the Swiss Society for Dysphagia for further information [6].

Clinical pictures

An overview of possible causes of dysphagia are listed in Table 2. Rare etiologies of dysphagia cannot be discussed here.

Maturation disorder

Coordination between sucking, swallowing, and breathing should be mastered by 34-36 gestational weeks of age. Clinical signs that this stage of development has not yet been reached are bradycardia associated with drinking, desaturations, coughing, gagging, overextension, irritability and refusal to drink. Infants born earlier may require gastric tube support until the infant can safely reach a sufficient drinking level on its own. Maturation disorders also include the failure to learn to eat solid food or the rejection of certain food consistencies.

Dysmorphia

Cleft palate and cleft lip, whether isolated or part of a syndrome (z.B. Pierre-Robin, CHARGE), result in the inability to build up sufficient prere for sucking and lead to nasal regurgitation. Therapeutic options include initial prosthetic measures (Habermann aspirator, obturator, etc.).) in the foreground, later surgical interventions are performed, whereby the timing varies depending on the center and is not discussed here.

Dyspnea with possible cyanosis during drinking may indicate choanal atresia. The clinical suspicion can be substantiated by frustrated attempts of a nasal gastric tube insertion. Imaging or endoscopy can not only confirm the diagnosis but also differentiate between partial stenosis and complete obstruction. The presence of bilateral complete choanal atresia is an emergency, since the lungs are supplied with oxygen only during crying via mouth breathing.

A short lingual frenulum rarely leads to feeding problems (u.a. lack of weight gain or meal duration over 40 minutes). Surgical intervention is required if the tongue cannot be moved over the alveolar ridge or articulation problems occur. If possible, the intervention should be performed only after the introduction of solid food by means of plastic surgery, as this reduces the risk of recurrence.

The most common congenital anomaly of the esophagus is esophageal atresia (usually type IIIB according to Vogt with esophagotracheal fistula) with an incidence of 1 per 2500-4000 live births. In about 10% of the cases this structural anomaly with a polyhydramnios is noticed in the prenatal ultrasound, postpartum the newborn may present with increased salivation, cyanotic episodes and coughing. Failure to place a feeding tube in this clinical picture. Radiological imaging usually directly confirms the suspicion by the typical air distribution in the gastrointestinal tract, therefore a conventional image without contrast is usually sufficient. Associated syndromes (VACTERL, CHARGE) must be systematically excluded. Even after successful surgical intervention, these patients may present with dysphagia due to anastomotic stenosis and persistently impaired esophageal motility, associated with a significantly increased incidence of gastroesophageal reflux and consecutive esophagitis as well as a relevant risk of metaplasia. Regular gastroenterological controls are therefore also recommended in adulthood (Fig. 1A).

Figure 1: A) contrast imaging of the esophagus: marked anastomotic stenosis in the esophagus in a 6-month-old girl with condition after corrected esophageal atresia and inability to swallow complementary food.B) Contrast imaging of the esophagus: stasis of contrast in the esophagus in a 13-year-old adolescent with achalasia who complained of dysphagia and odynophagia that had been increasing for months.C) Endoscopy: Pronounced reflux esophagitis in a 7-year-old boy with psychomotor retardation, dysphagia and recurrent vomiting. Endoscopic image of eosinophilic esophagitis with whitish exudates. Prominent longitudinal furrows in a 4-year-old girl with a putative eating disorder.

Neurological diseases

The largest group of patients with chronic swallowing difficulties are children of any age with an underlying neurological condition (usually cerebral palsy), which often results in a reduced nutritional status. Up to 90% of these patients are affected by central (primarily neurological) dysphagia. There is a positive correlation between the severity of neuromotor impairment, usually manifested by means of oropharyngeal symptoms, and dysphagia. At the same time, children with cerebral palsy are also significantly more likely to be affected by gastroesophageal reflux disease [7], which may also contribute to dysphagia symptomatology.

Finally, esophageal motility disorder in achalasia must also be considered a neurologic cause (Fig. 1B). Achalasia, although rare in childhood and adolescence, does occur. Unfortunately, young patients often have long suffering periods behind them. The disease is sometimes misdiagnosed as an eating disorder or bulimia. Therefore, it is important to think about achalasia also at this age.

Inflammation

The most common causes of dysphagia in infants are passive and infectious (coxsackie, herpes, cytomegalovirus), are diagnosed clinically and treated symptomatically. Usually, infants present with stomatitis aphthosa (herpes simplex) or herpangina (coxsackie). In patients undergoing chemotherapy, "graft versus host disease" must be considered, and in immunosuppressed patients, candidiasis must also be considered. Dysphagia may also occur in the presence of a peritonsillar abscess or even marked tonsillar hyperplasia and is usually treated surgically.

Gastroesophageal reflux per se is a physiological phenomenon. This must be distinguished from gastroesophageal reflux disease (GERD), which is associated with symptoms (pain, apnea, stridor/hoarseness, cough, failure to thrive, etc.).) or complications (esophagitis, laryngitis, recurrent pneumonia, Barrett's, etc).) accompanies. The symptoms of a reflux disease differ in the different age groups. Thus, infants often present with increased crying, overextension, irritability, and food refusal (Fig. 1C). Usually children complain of epigastric or classically retrosternal pain only after school age, however, chronic nausea or a "lumpy feeling in the throat" may also be an expression of a gastroesophageal reflux disease.

In children with appropriate symptoms, a proton pump inhibitor (PPI) can be started for 4-8 weeks; prolonged empiric use of a PPI should be avoided. Infants with GERD can be switched to a formula diet free of cow's milk protein or to an appropriate diet of the nursing mother, since about half of the cases at this age are due to an allergy to cow's milk protein.

The prevalence for eosinophilic esophagitis (EoE) is reported to be 1-4/10 000 children. Male patients and those with an atopic diathesis have a slightly higher risk of developing it. EoE is also found somewhat more frequently in autism spectrum disorder, which can exacerbate what is often already a difficultEating situation. Clinical symptoms in infants can range from regurgitation, vomiting, refusal to eat to failure to thrive. School-aged children complain of upper abdominal pain or nausea, adolescents report reflux-like symptoms, dysphagia, and bolus impaction. Since there is no reliable laboratory chemical parameter that correlates with a possible EoE, the diagnosis must be made by endoscopy with biopsy collection and histologic confirmation (Fig. 1D). Last but not least, the differentiation from GERD is often not possible at first, so that follow-up endoscopies are usually necessary. In children, the preferred therapeutic approach for EoE is the elimination of the allergenic antigen from the diet, which is usually done empirically in a fractionated manner due to the lack of adequate in vitro testing procedures (there is usually no IgE-mediated allergy). Alternatively, therapy consists of local steroids; rarely in childhood, systemic steroids or dilatation are needed for strictures [8].

Especially in infants or children and adolescents with a disability who suddenly do not want to drink/eat, may appear to salivate more or have pain, the possibility of foreign body ingestion must also be considered [9]. Whether conventional radiologic imaging with or without contrast is initially done depends on the symptoms and the presumed radiopacity of the presumed ingested object. In case of doubt, an endoscopy must be performed. In this context, we would like to point out that a button battery located in the esophagus is an emergency that requires immediate intervention.

In childhood and adolescence, functional complaints of the pharyngoesophageal area are not uncommon: Rumination, the effortless bringing up of previously eaten food, or a globus syndrome may occur. The latter manifests itself in the sensation of having a lump, a foreign body or a feeling of prere/tightness, especially during empty swallowing and not during eating. Frequent throat clearing is the result. This represents a diagnosis of exclusion. Possible initial contributing factors may be an upper respiratory tract infection (pharyngitis, sinusitis, rhinitis), hypertrophy of the base of the tongue, or gastroesophageal reflux. In interaction with psychological factors, a somatization disorder may develop. Therapeutic approaches include relaxation techniques or cognitive behavioral therapies.

Summary

Causes and symptoms of infantile dysphagia are varied and complex. Therefore, a multidisciplinary, well-networked team with extensive experience in the field of this problem is required for diagnosis and therapy.

Most important for practice

– Dysphagia is a common symptom in childhood, which can hide a variety of causes.

– Pain during eating, repeated vomiting or diarrhea, cardio-respiratory symptoms during feeding, food getting stuck in the esophagus, or lack of weight gain are symptoms that need further evaluation by a pediatric gastroenterology specialist.

– Apparatus-diagnostically, a pH-impedance examination, an endoscopy or a contrast medium examination may be indicated.

We thank PD Dr. Georg Eich, Pediatric Radiology, Cantonal Hospital Aarau, who kindly provided us with images 1A and 1B.

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