What Causes Dysphagia?

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Patient Presentation
A 3-year-old female came to clinic with a 6 week history of painful swallowing. The mother cannot remember a triggering event but the girl would complain or make faces when eating solids. This did not occur with liquids and the child would point to her throat when asked where the pain was. She would complain with all textures of food. It did not occur when the patient was not eating solids. The mother denied any drooling, choking, emesis or spitting up, coughing, cyanosis, dysphonia or pain elsewhere such as chest or abdomen, as well as any social problems at home. She denied any infectious disease symptoms. The duration of the pain could not be discerned and the mother said the girl still wanted to eat but would eat slower. The past medical history was negative. The family history was positive for a sibling with a feeding tube but the mother was not able to say why, only stating that the child didn’t eat right but noting that this child had not been premature nor had a neurological or genetic problem. She did not have pneumonias but had had two otitis medias treated in the past.

The pertinent physical exam showed a smiley female with normal vital signs. Her weight had increased since her previous visit 6 months previously but at a slower rate. Her weight was at the 25th percentile, slightly down from between the 25-50%. HEENT was normal including movement of the tongue, elevation of the palate and no masses were seen around the tongue. There was normal dentitia. Neck had no masses and the skin was negative for possible branchial cleft cyst tracts. Heart, lungs and abdomen were normal and she had a normal neurological examination.

The diagnosis of dysphagia was made. The pediatrician referred the girl to both the speech pathologist who worked with the otolaryngology department as well as gastroenterology as possibly this was the same problem as the sibling had. The pediatrician recommended to continue to monitor the patient and also keep a symptom diary to try to discern the types of foods, duration and severity of the problem with followup in 2 weeks to monitor weight.

Discussion
Swallowing is a complex process with 4 phases:

  • Preparatory – food is moistened with saliva, chewed and prepared into a bolus by teeth, tongue and hard palate.
  • Oral – food bolus is moved into oropharynx by tongue and triggers the swallow reflex. Soft palate elevates to prevent nasopharyngeal reflux.
  • Pharyngeal – food bolus is moved through the oropharynx and hypopharynx to the esophagus. Respiration stops briefly with vocal fold adduction and larynx elevation to prevent aspiration.
  • Esophageal – the cricopharyngeaul muscle relaxes which allows the food bolus into the esophagus where it is propelled into the stomach by smooth muscle action.

Dysphagia is difficulty swallowing and is thought to occur in about <1% of the pediatric population. Although a 10 week fetus can do some swallowing, a fully organized swallow does not develop until approximately 34 weeks. Some children may not be very efficient in swallowing until term (38 weeks +). Dysphagia is more common in premature infants (~10%) and in those that are premature and < 1500 grams and occurs in about 25% of these patients. Oral food aversion occurs when a patient refuses to eat but has the ability to eat. This is distinct from dysphagia.

Common problems patients present with include refusing to eat, slow eating, drooling and residual food retention, reflux into nose or mouth, posturing with feeding, choking, aspiration (overt or silent), stridor, coughing, throat clearing, pain in the throat or chest. If patients cannot eat well then they may have poor weight gain, nutritional deficiencies, and also develop behavioral feeding problems.

By phase

  • Oral phase – patient can have hyper- or hypo-sensitivity to textures or tastes and poor manipulation of food bolus. Patients can refuse to eat, eat slowly, drool or have residual food in the mouth, and choke.
  • Pharyngeal – poor contraction or timing of the swallow, problems with airway closure/sensation of the larynx. Patients can have nasopharyngeal reflux, choking, aspiration, and throat clearing.
  • Esophageal – poor or no relaxation of the upper esophageal muscles to accept the bolus, esophageal motility disorders

Evaluation and treatment can include a multidisciplinary team including speech pathology, nutritional services, otolaryngology, gastroenterology, developmental pediatrics, psychology, and pulmonology. A modified barium swallow study (also known as a video fluoroscopic swallow study) can evaluate the patient’s swallowing at all phases. Patients are placed into normal feeding position and different textures are given with fluoroscopy showing how the patient swallows providing real-time assessment. Limitations include not being able to assess a breastfeeding patient and radiation exposure. Fiberoptic endoscopic evaluation uses a laryngoscope to evaluate the swallowing process. Limitations are that it only assesses the pharyngeal phase and there can be intolerance of the laryngoscope. It can assess a breastfeeding patient.

Feeding therapy helps the patient and family to improve the swallowing skills over time. A safe feeding plan is important which may include by-passing swallowing by tube feeding, or using a modified diet of different textures. “According to the National Dysphagia Diet there are four levels of solid foods and four levels of liquids. Solids include pureed, mechanical altered, advanced (which include items in a regular diet with the exclusion of “very hard, sticky, or crunchy foods”) and regular diet. Liquids consistencies include thin liquids, nectar-like liquids, honey-like liquids and spoon-thick liquid.”

  • Thin liquids pour easily and examples include water, milk, carbonated beverages, coffee, tea, broth, popsicles, gelatin.
  • Nectar liquids have more body but still pour easily. Examples include fruit nectars, tomato juice, lemonade, cream-based soups, thin milk shakes.
  • Honey thick liquids pour slowly and the fluid slowly drizzles. Examples include thick milk shake or smoothie.
  • Spoon thick liquids can be eaten with a spoon. Examples are puddings and custards.

Foods can be thickened with commercial thickeners or different food products (ex. adding mashed potato into a soup). Similarly, thicker foods can be thinned (ex. pureed food thinned with milk)

Learning Point
Some causes of dysphagia include:

  • Multifactorial or multiorgan system – very common
  • Prematurity
  • Neuromuscular and genetic problems where muscle tone (especially hypotonia) or innervation affect the swallow
  • Gastrointestinal
    • Gastroesophageal reflux disease
    • Eosinophilic esophagitis
  • Intubation or tracheostomy that are prolonged
  • Anatomic
    • Nose
      • Choanal atresia
      • Adenoid hypertrophy
      • Cleft lip/palate
      • Midface hypoplasia
    • Oral cavity
      • Ankyloglossia
      • Micrognathia
      • Macroglossia
      • Craniofacial anomalies
    • Pharynx and larynx
      • Laryngomalacia
      • Vocal cord paralysis
      • Glottic or subglottic stenosis
      • Laryngeal cleft
    • Trachea
      • Tracheoesopheal fistula
      • Tracheal stenosis
      • Tracheobronchomalacia
    • Esophagus
      • Cricopharyngeal achalasia
  • Masses that compress including in the neck, trachea, or esophagus such as hemangiomas, congenital neck masses, thyroid masses, vascular rings/slings, etc.

Questions for Further Discussion
1. What causes coughs? A review can be found here
2. What are potential complications of feeding tubes? A review can be found here
3. What are common problems with late premature infants?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Swallowing Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Duffy KL. Dysphagia in Children. Curr Probl Pediatr Adolesc Health Care. 2018;48(3):71-73. doi:10.1016/j.cppeds.2018.01.003

Lawlor CM, Choi S. Diagnosis and Management of Pediatric Dysphagia: A Review. JAMA Otolaryngol– Head Neck Surg. 2020;146(2):183-191. doi:10.1001/jamaoto.2019.3622

Moroco AE, Aaronson NL. Pediatric Dysphagia. Pediatr Clin North Am. 2022;69(2):349-361. doi:10.1016/j.pcl.2021.12.005

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Published