Diagnosis

Feeding disorders and dysphagia in infants and in children can be both physiological and behavioral in nature.39 The evaluation of feeding and swallowing dysfunction is best performed as a multidisciplinary process with co-ordinated input from a variety of team members, including pediatricians, pediatric gastroenterologists, developmental pediatricians, speech-language patho-logists, occupational therapists, and pediatric dietitians.40 The goals of this evaluation include

History

A comprehensive history, obtained from individuals directly involved in caring for the child (e.g. parents, feeding specialist) is essential in evaluating children with swallowing disorders. The evaluation begins with a focused feeding history, including current diet, textures, route and time of administration, modifications and feeding position. Medical co-morbidites that may affect swallowing need to be investigated.

History Physical Examination

Oropharyngeal dysphagia

Esophageal dysphagia

Structural

Videoendoscopic swallow study

Functional

Surgery

Videoendoscopic swallow study

Examination under anesthesia

Videofluoroscopic swallow study

Surgery

Clinical swallow examination

Neurological evaluation

Structural Functional

Esophageal manometry Upper Gl series Upper Gl endoscopy

Upper Gl series Upper Gl endoscopy

Videoendoscopic swallow study

Videofluoroscopic swallow study

Reduce risk I_

Management plan _I_

Optimize hydration/nutrition

Non-oral feeds

Modify consistency

Modify posture

Supplements and dietary advice

Figure 15.2 Flow chart for the investigation and management of dysphagia in children. Adapted from reference 28. GI, gastrointestinal.

The child's caregivers should also be questioned regarding associated symptoms such as oral aversion, weak sucking, irritable behavior, gagging and choking, and disruptions in breathing or apnea. Postural or positional change during feeding may be reported in children with dysphagia. Odynophagia and emesis may be related to pharyngeal and/or esophageal disorders. A history of recurrent pneumonia may indicate chronic aspiration; a history of stridor in relation to feeding may indicate a glottic or subglottic abnormality contributing to feeding disorders. Determining whether these symptoms occur before, during or after the swallow helps localize the affected phase.16,17

In addition, nutritional and psychological assessment should be evaluated. Many patients with swallowing disorders have a concurrent illness that may increase metabolic needs. Psychological assessments help to identify behavioral and parental factors that may be contributing to a feeding disorder. Psychosomatic causes of dyspha-gia should be considered in adolescents with dysphagia.2,42,43

Physical and clinical evaluation

The aims of physical examination in dysphagic patients are: to identify underlying systemic or metabolic disease when present; to localize the neuroanatomic level and severity of a causative neurological lesion when present; and to detect adverse sequelae such as aspiration pneumonia or nutritional deficiency.18

The physical examination views the whole child and specifically focuses on the upper aerodigestive tract, beginning with an examination for structural and functional abnormalities. Oral cavity anatomic abnormalities, such as ankyloglossia, cleft lip or palate, or macroglossia, need to be excluded.2 The palatal gag is perhaps the most commonly assessed reflex and should be evalu-ated.29 A hyperactive gag can result in significant feeding difficulties; in the past an absent gag reflex was viewed as an indication to stop oral feeding.4,34

It is critical that observation of the feeding process be included.40 This part of the examination is best performed in conjunction with a feeding and swal lowing specialist, such as a speech-language pathologist or an occupational therapist. This examination includes assessments of posture, positioning, patient motivation, oral function, efficiency of oral intake and clinical signs of safety. During the feeding trial, the presence of abnormal movements such as jaw thrust, tongue thrust, tonic bite reflex and jaw clenching are noted. A variety of therapeutic positions, techniques and adaptive feeding utensils may be used.1,16

A variety of assessment scales may be used to detail and quantitate results of the swallowing evaluation. However, all assessments are based on similar observation of feeding structure and func-

tion.44

Usually, a careful developmental, medical and feeding history provides clues to the diagnosis that guide the selection of further diagnostic tests. Only after all reasonable physical causes have been ruled out should a feeding or swallowing disorder be attributed to a purely behavioral cause.2

Diagnostic tests Radiographic assessment

Videofluoroscopy represents the gold standard for evaluation of children with swallowing disorders. A videofluoroscopic swallow study is ideally performed by a consultant radiologist and specialist speech and language therapist.45 A series of swallows of varied volumes and consistencies of contrast material are imaged in a lateral projection, and framed to include the oropharynx, palate, proximal esophagus and proximal airway. Studies are recorded on videotape to permit instant replay, in slow motion if necessary, and examination of both the presence and mechanism of the swallowing dysfunction. The videofluoroscopic study provides evidence of all four categories of oropha-ryngeal swallowing disorders: inability or excessive delay in initiation of pharyngeal swallowing; aspiration of ingestate; nasopharyngeal regurgitation; and residue of ingestate within the pharyn-geal cavity after swallowing. Furthermore, the procedure allows for testing of the efficacy of compensatory dietary modifications, postures, swallowing maneuvers and facilatory techniques in correction of observed dysfunction. Generally, the videofluoroscopic evaluation is completed by esophagography to evaluate the esophageal phase of deglutition (Figure 15.3).18

Ultrasonography

Ultrasound imaging has been used to a limited extent in the assessment of oral phase dysphagia.

Figure 15.3 Lateral fluoroscopic projection of an infant showing contrast material in the valleculas, pyriform sinuses, laryngeal vestibule and esophagus.

Using a transducer positioned in the submental region, ultrasonography allows observation of the motion of structures in the oral cavity such as the tongue and floor of the mouth during feeding and deglutition, but lacks sensitivity in visualizing pharyngeal motion and for determining whether aspiration has occurred. Ultrasonography represents the only method of imaging that can study infants during breast feeding, and may be particularly useful in distinguishing an infant's inability to attach from maternal factors contributing to feeding difficulties.16 Unfortunately, laryngeal penetration and aspiration are not easily detected, because of the shadows cast by the laryngeal structures (Figure 15.4).4-46'47

Pharyngeal manometry

Intraluminal manometry, performed using a transnasally positioned manometric assembly, can quantify the strength of pharyngeal contraction, the completeness of UES relaxation and the relative time of these two events. Most studies have indicated that manometry of the UES and pharynx provides useful information, primarily in patients who have symptoms of oropharyngeal dysfunction.

Figure 15.4 Transverse ultrasound scan of the larynx at the level of the vocal cords. During swallowing the vocal cords (white arrow) adduct and the glottis closes (black arrow).

The co-ordination of muscle activity at various levels can be obtained by simultaneous recording of pressure in the pharynx, at the level of the crycopharyngeus, and in the esophagus. Anatomical references are not avalaible with this technique (Figure 15.5).27,48

Fiberoptic endoscopic examination

Pediatric fiberoptic endoscopic examination is a relatively new diagnostic method to complement the current armamentarium of techniques for evaluating dysphagia and/or aspiration. The procedure is performed by passing a flexible laryngoscope into the oropharynx after anesthetizing the nares and nasopharynx.49 It provides the ability to diagnose many of the laryngeal disorders that may affect the child, while at the same time evaluating the swallowing mechanism itself. The procedure involves five components: assessment of the anatomy as it affects swallowing; evaluation of movement and sensation of critical structures; assessment of secretion management; direct assessment of swallowing function for food and for liquid; and the patient's response to therapeutic maneuvers. In experienced hands, this test can be performed in children with minimal dis-comfort.50,51

Figure 15.5 Upper esophageal sphincter (UES) motility in a control child. The pressure is recorded in the pharynx, in the UES, and in the cervical esophagus. Note that the onset of UES relaxation precedes pharyngeal contraction, which is terminated before the return of UES pressure to resting values. UES relaxation is complete to the level of the esophageal resting pressure (dashed line). Contraction of the UES continues into the cervical esophagus as the primary wave (dots) of swallowing. From reference 27.

Figure 15.5 Upper esophageal sphincter (UES) motility in a control child. The pressure is recorded in the pharynx, in the UES, and in the cervical esophagus. Note that the onset of UES relaxation precedes pharyngeal contraction, which is terminated before the return of UES pressure to resting values. UES relaxation is complete to the level of the esophageal resting pressure (dashed line). Contraction of the UES continues into the cervical esophagus as the primary wave (dots) of swallowing. From reference 27.

Scintigraphy

Scintigraphy is a radionuclide evaluation using technetium-99m-labeled sulfur colloid mixed in the infant's formula. It has been proposed as an alternative and perhaps more sensitive way of quantifying aspiration, transit times, gastroesophageal reflux and pharyngeal residue. Based on a case report, the radionuclide salivagram has also been used to document aspiration of saliva. The major limitations of this technique are the poor definition of the anatomy and the poor sensitivity for detecting aspiration during swallowing in known aspirators. At present, the use of this technique in pediatric patients is limited.51,52

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