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In the severely affected child with impaired swallowing, poor oral and/or pharyngeal function may lead to decreased energy intake as a consequence of prolonged feeding time and the inability to ingest adequate volumes, and malnutrition may result.1 Malnutrition has many adverse effects. The most significant effects are on behavior and immune status. Malnutrition negatively influences immune status. This leads to recurrent infections that increase caloric requirements but decrease intake, leading to a worsening nutritional status. In addition, malnutrition causes behavioral apathy, weakness and anorexia, which can all profoundly affect feeding and secondarily, nutritional status. Thus, although malnutrition is often a direct result of poor feeding skills, it can also have a compounding, and even perpetuating, effect on feeding problems in children.14

Complications 239

Table 15.3 Clinical signs and symptoms of dysfunctional sucking and swallowing

Clinical signs


Failure to thrive

Atypical chest pain

Meal-time distress

Respiratory manifestations

Refusing food


Nasal regurgitation


Wet or hoarse voice



Change in respiration pattern after swallowing


Apnea and bradycardia (predominantly in infants)


Noisy breathing after feeding

Gastroesophageal or pharyngeal reflux

Chronic recurrent wheezing


Chronic recurrent bronchitis, pneumonia and

Oral-tactile hypersensitivity


Feeling of obstruction

Sialorrea (excessive drooling) is defined as the unintentional loss of saliva and other oral contents from the mouth. Drooling usually occurs in patients with neurological disease complicated by abnormalities of the oral phase of deglutition. Clinical complications of drooling include soaking of clothes, offensive odors, macerated skin and, if 'posterior' drooling occurs, aspiration.29

Respiratory complications

Respiratory complications of swallowing disorders include apnea and bradycardia, choking episodes, chronic or recurrent pneumonia, bronchitis and atelectasis.30

Apnea and bradycardia may result from stimulation of laryngeal chemoreceptors without evidence of aspiration or as a consequence of hypoxemia. Hypoxemia may result from the effects of direct aspiration on gas exchange, from apnea triggered by laryngeal and nasopharyngeal chemoreceptors, or in patients with compromised lung function as a result of a normal decrease in minute ventilation that occurs with suckle feeding.31-33 Symptoms such as chronic recurrent coughing, choking and postprandial congestion or wheezing generally indicate the occurrence of aspiration. Infants, especially premature infants, appear to be at increased risk of respiratory disease from dysfunctional swallowing.4 Clinical manifestations of dysfunctional sucking and swallowing in infants are primarily apnea and bradycardia during feeding, although chronic or recurrent respiratory problems (congestion, cough, wheezing) are also seen.30 Congested or noisy breathing during and following feeding is also a common complaint of parents of infants with dysfunctional swallowing. Dysphagia can also be an important but under-recognized cause of chronic or recurrent bronchitis, asthma and pneumonia in infants.4

Respiratory disease secondary to dysphagia in an older child is typically seen in a neurologically impaired host.34,35 Apnea and bradycardia are uncommon in an older child. Bronchitis, pneumonia, atelectasis and recurrent wheezing are more likely to be seen in this population. Feeding and swallowing evaluation should be considered in those with central nervous system (CNS) injury affecting cranial nerve function and difficult-to-control chronic or recurrent bronchitis, wheezing, pneumonia, or asthma. Tracheobronchomalacia, a complication of chronic inflammation of the major airways, occurs commonly. Dysfunctional swallowing is also encountered in children with a tracheostomy. The tracheostomy may interfere with normal laryngeal function during swallowing and predispose to aspiration.28

Aspiration may also occur in children with disorders of swallowing after an episode of gastroesophageal reflux; also acid reflux may result in bronchospasm, pneumonia or apnea.36,37 The most obvious sign that a person may have aspirated is the post-swallow cough, but in the swallowing-impaired child other more insidious indicators may be present. 'Silent aspiration' with no clinical signs can account for over half of all cases of radi-ologically defined aspiration.28,38

the following: ascertaining whether oropharyngeal dysphagia is likely, and identifying the etiology; identifying structural etiologies of oropharyngeal dysfunction; ascertaining the functional integrity of the oropharyngeal swallow; evaluating the risk of aspiration pneumonitis; and determining whether the pattern of dysphagia is amenable to therapy.41 The investigation and management of swallowing disorders are summarized in the Figure 15.2.

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