Dysphagia (swallowing disorders) in children

What are the main groups of dysphagias (swallowing disorders) in children?

These can be divided into two main groups:

The first group – pharyngeal dysphagia

This is a swallowing disorder that originates in the oral cavity or in an abnormal swallowing technique. Children with this disorder will find it difficult to effectively chew their food or will find it difficult to swallow. Sometimes they can present with drooling.
The workup is performed with the help of x-ray series that assess the swallowing mechanism and the management often entails the combination of occupational therapists and speech therapists. On the one hand, these helps strengthen the muscles that help us chew and at the same time we often try to adjust the food consistency to an optimal consistency that will help with swallowing and prevent food from going into the airways (a condition referred to as aspiration).

The second group – esophageal dysphagia

This is a disorder that stems from abnormal contraction of the esophagus. The esophagus is an organ made up of two different types of muscles and when food enters its top part, a series of synchronized contractions begin, and these advance its contents downwards into the stomach. These are the main causes of esophageal swallowing disorders:
# Structural disorder – congenital/acquired strictures in the esophageal area may cause swallowing difficulties. The strictures can be either congenital or secondary to esophageal injury due to exposure to certain substances. Usually, the complaint will be that of difficulties with swallowing solids.
# Reflux disease – this is a condition in which acidic contents of the stomach enter the esophagus and cause irritation to the esophageal tissue, which is not used to being exposed to acid (the same kind of condition that cause the heartburn that is well known to us). A local inflammation develops, sometimes with ulcers and even scarring. Diagnosis of reflux, its prevention and management with antiacids assist with the recovery of the esophagus and its function. In rare cases where there is a secondary strictures, there could be a need for dilatation of the narrowed region during a gastroscopy.
# Eosinophilic inflammation of the esophagus – this is an inflammation that involves the esophagus, and mainly includes eosinophilic cells, a type of white blood cell that becomes active in allergic reactions. If this inflammation is not treated it can cause structural changes to the esophagus, affects it motility and may even lead to scarring of the tissue. This is an important disease in pediatrics and early detection is cardinal and therefore we will soon dedicate a chapter to discuss this disease separately.
# Motility disorders of the esophagus – this is a condition in which there is no active inflammation and no structural abnormality in the esophagus. Nonetheless there is a problem with the contraction of the esophagus and this leads to a disorder in its functioning. There are several different types of motility disorders in the esophagus, from complete lack of ability to contract, a disorder in the opening of the lower esophageal sphincter (referred to as achalasia) and up to complete contracture, that is still weaker than the normal.

What is the workup required for children with swallowing disorder?

This can be divided into 3 different stages:
1. Structural assessment – this requires imaging with the help of x-rays. The child is required to swallow contrast material and several x-rays are taken while the child is swallowing. The series of x-rays allow us to assess the structure of the esophagus, demonstrate any strictures of dilatations, and give some basic information about the lower sphincter of the esophagus.
2. Assessment of the mucosa – in order to assess whether there is an inflammatory process, a gastroscopy is required as it allows examination of the esophageal mucosa and allows for biopsy samples which give information about the inflammatory process if it exists.
3. Assessment of function – the function of the esophagus can be assessed with the help of a manometry test. During this test, which is done when the patient is awake, the pressures along the esophagus are measured while the patient is swallowing. The test demonstrates the activity of the esophageal sphincters and the activity of the esophageal body. The esophageal manometry is the test of choice for assessment of esophageal functioning.
Recently a new testing method has been introduced, called EndoFlLIP – this is a test that is performed only in specific medical centers, and it allows assessment of the esophagus while doing a gastroscopy as well as assessment of how severe strictures are and how dilatable they are.

The importance of early detection of dysphagia (swallowing disorders) in children

There is an importance in early detection of swallowing disorders also in order to relieve the child that experiences daily difficulties, but also to avoid long term complications.
In pharyngeal swallowing disorders, the most dangerous complication is aspiration (aspiration of food to the lungs), which can cause severe pneumonia and recurrent episodes of pneumonia that could lead to irreversible changes in the structures of the lungs.
In esophageal swallowing disorders (dysphagia), complications include:
1. Aspiration – mechanistically similar to what has been described above
2. Food that gets stuck in the esophagus – this could be mild and resolve after a change in position and drinking lots of water, and sometimes these could be more severe and complex and require a visit to the emergency department with emergent intervention to evacuate the food with the help of a gastroscopy.
3. Changes to the esophageal structure – this is a complication that could occur in diseases that have an inflammatory component such as in reflux disease or eosinophilic disease. If these are not treated – there could be scarring in the esophagus and the scarred tissue leads to strictures and disorders of function. It’s important to keep in mind that motility of the esophagus in the scarred area will not be normal even if the stricture is opened.

How can swallowing disorders be treated in children?

First of all, it’s important to understand what the origin of the problem is. If the problem involves the pharyngeal cavity, the management is working with a speech therapist and occupational therapy.
If the problem is anatomical – strictures can be dilatated in gastroscopies and in cases where the dilatation cannot be done, the patients are referred to a surgical correction.
In inflammatory problems – it is important to treat the problems. If the problem is reflux, an emphasis is placed on reducing the acidity in the stomach, nutritional changes and less frequently surgical interventions. In cases of eosinophilic inflammation there are variable treatment methods, from pharmacological to nutritional changes that have been found to be effective.
In motility disorders of the esophagus – the treatment includes changes in lifestyle, pharmacological treatments that promote motility, and in cases of achalasia (where the lower esophageal sphincter is closed tightly) there are treatment options that include dilatations under gastroscopy, or endoscopic or laparoscopic surgeries.

In summary, this content is very professional and important because swallowing disorders always require medical investigations. It is important to perform the investigations at an early stage, prior to the presentation of severe complications. Because the treatment of swallowing disorders changes depending on the cause, it is very important to perform gradual workup that can, on one hand, prevent any unnecessary investigations and on the other hand make sure to find the correct diagnosis.
Fortunately, most cases of swallowing disorders in children can be managed well and allow for significant improvement and relief of the symptoms they are suffering from.