Basics
Description
- Feeding disorder: inability to consume by mouth in quantity or quality the nutrition that is developmentally appropriate for that child
- Dysphagia: disorder of swallowing characterized by difficulty in oral preparation for the swallow or in moving food or liquid from the mouth to the stomach
- Aspiration: Food or fluid enters the trachea and passes through the vocal cords to lungs.
- Penetration: Food or fluid enters the trachea but remains above vocal cords and can be cleared by patient through coughing to prevent aspiration.
- Oral motor disorder: inability to manipulate age-appropriate diet; often related to incoordination of facial muscles and/or tongue
- Pharyngeal dysphagia: inability to protect airway during swallow; may be due to anatomic abnormality or neurologic dysfunction
- Voluntary food or fluid refusal associated with maladaptive interactions at mealtimes; associated with learned fear when foods or textures are advanced before a child is developmentally or medically ready to swallow without dysfunction
Risk Factors
- Congenital heart disease
- Cystic fibrosis
- Metabolic disorders
- Autism spectrum disorder
- Developmental delay/cerebral palsy
- Prolonged tube feeders (>4 weeks)
- Prematurity
- Neuromotor dysfunction
- Anatomic deformities (i.e., Pierre Robin sequence, laryngomalacia, tracheotomy, cleft palate)
- GI disorders: gastroesophageal reflux, eosinophilic esophagitis, celiac disease
- Tachypnea (respiratory rate >40 breaths per minute)
General Prevention
- Monitor weight, height, head circumference, weight for height, and BMI percentiles at regular interval office visits to identify changes in nutritional status early, especially in high-risk populations.
- Selective eater: Educate parents on age-appropriate portion sizes and foods.
- Provide vitamin and mineral supplementation or refer to nutritionist for complete assessment if patient is at risk for deficiencies.
- Developmental delay: Evaluate diet and feeding skills to manipulate nutrition provided.
- Ensure foods offered match developmental readiness rather than chronologic age.
Diagnosis
History
- Past and present medical diagnoses
- Therapeutic management or procedures in past or at present, especially those aversive to face and upper body (e.g., suctioning, tracheostomy, intubation)
- 24-hour diet: Recall food and fluid consumed over a 24-hour period.
- Previous hospitalizations, especially those involving respiratory illnesses
- Allergies or food intolerances
- Growth history
- Developmental history
- History of snoring or sleep apnea (may indicate adenoidal or tonsillar hypertrophy)
- GI history: stool pattern, vomiting, gagging, spitting up, pain
- Family history: GI disease, allergies, developmental delays, genetic abnormalities
- Failure to thrive
- Poor linear growth
- Sucking and swallowing incoordination: Infant should demonstrate 1:1:1 suck, swallow, breathe pattern when sucking from breast or bottle.
- Recurrent pneumonia
- Coughing during or after feeding
- Refractory asthma
- Drooling
- Refusal to drink or eat
- Feeding selectivity
- Difficulty with texture progression
Physical Exam
- HEENT: dysmorphic facial features, shape of head and sutures, facial tone, intact soft and hard palate, shape of mandible, tonsillar size, patency of nares, movement of lips and tongue, presence of stridor, mouth closure, dentition, drooling
- Pulmonary: rate of breathing, use of accessory muscles for respiration, rales
- Cardiac: murmur, rate, and rhythm
- GI: bowel sounds, masses, stool palpable, tenderness, distension
- Neurologic: tone, positioning, cranial nerves, gait, affect, head control
- Extremities: subcutaneous stores, muscle development, adipose tissue
- Skin: rashes, alopecia
Diagnostic Tests & Interpretation
Perform feeding observation: Watch caregiver feed child, preferably thru 1-way observation mirror. Monitor child's behavioral response to placement in the feeding chair and presentation of bottle, breast, or cup and a variety of food types and textures; observe parental reaction to child's behaviors and child's ability to manipulate foods and fluids.
Lab
- Tailor labs obtained based on nutritional and/or developmental concerns, including the following:
- Failure to thrive: celiac panel, CBC, comprehensive metabolic panel, lead, urine analysis, thyroid function; other tests if suspect vitamin or mineral deficiency (i.e., zinc, iron)
- Developmental and/or genetic concerns: chromosomes, FISH test for 22q11 deletion, FISH test for Prader-Willi syndrome, fragile X (males), serum and urine organic acids, lactate, pyruvate, CPK
- Sweat test if suspected cystic fibrosis: failure to thrive, diarrhea, and/or recurrent pulmonary infections
Imaging
- Tests indicated based on history and physical
- Suspected pharyngeal dysphagia: modified barium swallow study (MBSS) (videofluoroscopic swallow study) evaluates swallow function and can visualize aspiration during swallow; usually performed by radiologist and speech therapist. Study visualizes function of pharyngeal muscles and structures. See below:
- Upper GI series (including esophagram) ensures normal anatomy of esophagus, stomach, and duodenum (evaluate for TEF, malrotation).
- Chest x-ray: determine if infiltrates or atelectasis is present; right upper and/or middle lobe changes indicative of potential aspiration.
- Gastric emptying scan: Assess gastric emptying and assess if gastroparesis is present
- Salivagram: radionucleotide study to evaluate if patient is aspirating oral secretions
- Chest CT scan: allows detection of subtle changes from silent aspiration not detectable by pulmonary exam or chest x-ray
Diagnostic Procedures/Other
- MBSS
- Speech therapist feeds a variety of textures: thin and thickened liquid of honey and nectar consistency, thin and thick purees, and chewable foods to determine safety of oral feeding.
- Allows visualization of oral and pharyngeal phases of swallowing
- Can determine appropriate positioning and type of infant bottles and cups to minimize the risk for aspiration
- Timing of aspiration is evaluated to determine if volume and fatigue result in aspiration; the patient may be safe to drink or eat for short periods of time before the swallow becomes uncoordinated and leads to aspiration.
- Fiberoptic endoscopic evaluation of swallowing (FEES)
- Usually performed by ENT specialist; direct visualization of airway structures and swallowing mechanism
- Provides information on pharyngeal phase of swallowing but not oral phase. Best used if pharyngeal or laryngeal abnormality is suspected, tracheostomy in place, and there is difficulty managing secretions.
- Can observe food or fluid falling below vocal cords (aspiration)
- Bronchoscopy
- Visualizes tracheobronchial tree and lungs, sample for lipid-laden macrophages in lungs indicative of aspiration
- Endoscopy
- To perform esophageal, gastric, and small bowel biopsies to determine presence of eosinophilic esophagitis, celiac disease (positive or inconclusive celiac panel), or presence of gastroesophageal reflux disease (GERD)
Differential Diagnosis
- Cardiorespiratory
- Congenital heart disease
- Infectious pneumonia
- Bronchopulmonary dysplasia
- Neurologic
- Diencephalic syndrome
- Congenital myopathy
- Arnold-Chiari malformation
- Hypoxic-ischemic encephalopathy
- GI/nutritional
- GERD
- Gastroparesis
- Eosinophilic esophagitis
- Failure to thrive
- Celiac disease
- Metabolic syndromes
- Psychological disorders
- Behavioral refusal
- Psychosocial deprivation
- Anxiety disorder
- Food allergies
- Anatomic
- Laryngeal cleft
- Tracheoesophageal fistula
- Genetic disorders
- Developmental disorders:
- Autistic spectrum disorder
- Sensory integration disorder
Treatment
- Pharyngeal dysphagia: Pulmonary referral, oral stimulation program, NPO as indicated by clinical exam and studies, initiate tube feeds; monitoring by speech therapist
- Feeding disorders are complex and should be evaluated and managed by multidisciplinary team involving medical, nutrition, psychology, occupational therapy, and speech therapy.
Medication
Medications are administered to treat underlying medical condition (e.g., GERD); refer to specific sections for treatment of identified medical issues resulting in feeding disorder.
Additional Treatment
General Measures
- Calorie counts
- Ensure adequate hydration
Additional Therapies
- Obtain a list of all supplemental vitamins, minerals, herbs, etc., that the parent may be providing to the patient.
- Investigate if parent is following any special diets (e.g., casein/gluten-free diet in autistic spectrum disorder).
Complementary & Alternative Therapies
- Speech therapy: Evaluate oral motor skill and safety of swallowing mechanism; perform MBSS when indicated.
- Occupational therapy: Evaluate fine motor skills, sensory processing, and posture to support feeding.
- Psychology: may identify behaviors interfering with food acceptance and recommend strategies to improve oral acceptance
- Nutrition: Perform complete nutritional assessment, including evaluation of growth parameters, identifying patient's nutrition requirements, and adequacy of current diet. The nutritionist can develop a care plan to meet patient's nutritional requirements and monitor intake and weight gain during hospitalizations.
Surgery/Other Procedures
- Consider gastrostomy tube placement if tube feedings for >3 months are anticipated.
- For GERD not responding to medications, consider bypassing stomach and feeding into intestine with jejunostomy tube or placement of gastrostomy tube in conjunction with Nissen fundoplication.
Inpatient Considerations
Initial Stabilization
- Prior to initiation of behavioral program, ensure weight gain and growth are adequate.
- Evaluate and treat vitamin and mineral deficiencies.
- If weight-for-height ratio or BMI is <5%, inappropriate weight gain crossing down 2 percentiles on growth chart occurs, or weight loss occurs, consider initiating supplemental nasogastric tube feeds.
- If aspiration pneumonia is suspected, obtain blood cultures, chest x-ray; keep NPO and start IV fluids and antibiotics. Measure oxygen saturation and initiate supplemental oxygen if <95%.
Ongoing Care
Follow-up Recommendations
Appointment with multidisciplinary feeding team, if available within reasonable geographic radius
Patient Monitoring
- Patient's weight should be checked within 2 weeks of discharge.
- Pediatrician should monitor patients with respiratory difficulties related to aspiration every 2 weeks until stable.
Diet
- Keep patient NPO if aspiration is suspected until further evaluation (MBSS) can be performed.
- Order diet appropriate for child's current level of feeding skills (i.e., accepts baby food; may trial pureed diet).
- If nutritional intake is inadequate, offer nutritional supplements, monitor calorie counts, and initiate supplemental nasogastric tube feeds if unable to meet nutritional requirements.
- Caregiver education regarding administration of supplemental tube feeds
Prognosis
- Nutritional rehabilitation can be achieved with tube feedings if patient is monitored closely.
- Patients with pharyngeal dysphagia resulting in aspiration may improve over time.
- Static or degenerative neurologic conditions resulting in aspiration generally do not resolve.
- Patient demonstrating dysphagia during illness may improve when healthy.
Additional Reading
- Kral TV, Souders MC, Tompkins VH, et al. Child eating behaviors and caregiver feeding practices in children with autism spectrum disorders [published ahead of print August 11, 2014]. Public Health Nurs.
- Rudolph CD, Thompson LD. Feeding disorders in infants and children. Pediatr Clin North Am. 2002;49(1):97-112. [View Abstract]
- Williams KE, Field DG, Seiverling L. Food refusal in children: a review of the literature. Res Develop Disabil. 2010;31(3):625-633. [View Abstract]
Codes
ICD09
- 783.3 Feeding difficulties and mismanagement
- 787.20 Dysphagia, unspecified
- 933.1 Foreign body in larynx
- 307.59 Other disorders of eating
ICD10
- R63.3 Feeding difficulties
- R13.10 Dysphagia, unspecified
- T17.928A Food in resp tract, part unsp causing oth injury, init
- F98.29 Other feeding disorders of infancy and early childhood
SNOMED
- 74142004 Feeding disorder of infancy OR early childhood (disorder)
- 40739000 Dysphagia (disorder)
- 58849003 aspiration of food (finding)
- 192016008 Non-organic infant feeding disturbance (disorder)
FAQ
- Q: What is the difference between aspiration and penetration in a swallowing disorder?
- A: Penetration occurs when food or fluid enter the trachea but remains above the vocal cords and is cleared by the patient. Aspiration occurs when the food or fluid falls below the vocal cords, thus entering the lungs.
- Q: How is a modified barium swallow study used to evaluate dysphagia?
- A: A speech therapist in conjunction with the radiologist feeds the patient a variety of textures, including thin and thickened liquids, thin honey and nectar, thick purees, and chopped food if indicated, visualizing the pathway during swallowing to determine if it moves safely into the esophagus without entering the airway. The speech therapist also will engage in therapeutic endeavors, such as repositioning the patient, to determine if they can eliminate aspiration.