Treatment options

Optimal management strategies are critical for infants and children with feeding and swallowing problems. The management of swallowing dysfunction involves a team approach. Individuals involved in addition to the medical team include a swallowing expert (speech-language pathologist or occupational therapist), a nutritionist and the family. Since swallowing abnormalities arise from a diverse group of underlying disorders, management techniques must be individualized. This heterogeneity is also reflected in the fact that patients have different potentials for recovery.1

Although total oral feeding may not be a realistic goal, it is the universal hope of caregivers. Professionals are obliged to point out prerequisites for oral feeding and to discuss the probability that an individual child may reach the goal. These management decisions are typically made on the basis of clinical observations and assessments. In addition, important information is obtained through an instrumental assessment by videofluo-roscopic swallow study. A methodical videofluoro-scopic swallowing study defines the anatomy of the oropahrynx; detects dysfunction as evident by aspiration, poor clearance, or poor control of the bolus; determines the mechanism responsible for the dysfunction; and examines the short-term effects of the therapeutic strategies designed to eliminate or compensate for that dysfunction.53 Management decisions may incorporate nutritive recommendations, medical and surgical decisions, position guidelines, oral-motor swallowing practice and behavioral intervention.54

The clinical and instrumental evaluation of children with sucking and swallowing disorders should allow for the recognition of treatable anatomic or inflammatory lesions.

A child may refuse to eat even if his anatomic abnormality has been corrected, because of learned aversion to feeding. Behavior therapy can often overcome this type of conditioned food refusal.2,55

Various therapeutic approaches may improve the efficiency and safety of feeding. Management techniques involve devising compensatory strategies to minimize swallowing-related complications.56 These include changing the textures of foods; pacing of feeding; changing the bottle or utensils; and changing the alignment of the head, neck and body when feeding (Table 15.4).49

Frequently, children with severe anatomic disorders but normal neurological function develop their own adaptive strategies to allow for safe oral feeding. Unfortunately, many children with feeding disorders have non-correctable neurological or anatomic abnormalities that make oral feeding difficult or unsafe. Some patients cannot obtain adequate nutrition by mouth because of a risk for aspiration. Thus, supplying a portion of the patient's nutrition by nasogastric or gastrostomy feeding may be beneficial.2 For those children who have been intubated, management includes teaching techniques that will facilitate the transition from non-oral to oral feeding. However, there is little evidence that non-oral feeding reduces or eliminates the risk of aspira-tion.57-59

The strongest evidence-based recommendation that can be made pertains to diet modification. Furthermore, the literature provides reasonable evidence of the plausibility of swallowing therapy but minimal evidence of efficacy. Nonetheless, although no hard evidence supports its efficacy, the available data are inconclusive and swallowing therapy has not been proved to be ineffective. Thus, the current weight of opinion, combined with the convincing demonstration of biological plausibility for specific techniques and the consistency of low-grade evidence, is the basis for recommending that swallowing therapy should be used. Large-scale randomized, controlled trials are needed to clarify the current recommendations.18

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