Paediatric dysphagia is exactly as it sounds. Having already defined and discussed dysphagia in adults, it is also having difficulty with eating and drinking but in the population of children. However, paediatric dysphagia can occur at all levels of learning to eat and drink, from breastfeeding to chewing solids. It has the same consequences and risks as adults in the form of medical complications such as aspiration and subsequent pneumonia, however, as a child, there is the additional caveat of complications related to development that adults don’t have to worry about having already fully developed through childhood without dysphagia.
What is the difference between paediatric dysphagia and a feeding disorder? Good question. While in most cases, dysphagia refers to difficulties or impairments directly related to the act of swallowing and the pharyngeal stage of eating and drinking, paediatric feeding disorder (PFD) is defined as “impaired oral intake that is not age-appropriate, and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction.” It is quite normal for children to experience some difficulty while they learn to eat and drink such as food selectivity or perhaps being a little late to eat solids but it’s when the difficulty persists, becomes entrenched and increases in severity that it is then considered a disorder. Loving food one day and not the next, only to eat it again the next fortnight, for example, is not a disorder but part of the (exciting) process.
The prevalence of feeding difficulties (not disorders) amongst children in Australia is up to 20-50% in typically developing children, which is a normal part of development. Whereas, up to 80-90% of children with diagnosed developmental delays and chronic illnesses are estimated to experience dysphagia and/or feeding disorders. Similarly to adults, the severity and duration of dysphagia can vary hugely and is underpinned by the nature and cause.
Some of the most common causes of paediatric dysphagia and PFD include:
Neurological conditions such as cerebral palsy and meningitis
Respiratory conditions such as asthma
Reflux and other gastrointestinal problems
Premature birth and/or low birth weight
Heart disease
Cleft palate or cleft lip, and other conditions related to the ear, nose and throat
Autism
Acquired brain injury
Muscle weakness of the face and neck
Side effects to medications such as fatigue and reduced appetite
Side effects to surgery or treatment including pain or swelling to the mouth, tongue, jaw and throat
Sensory profiles including avoidance of textures, colours, smells and taste
Mealtime behaviours
Learning to eat and drink has many stages and the growth a child goes through in this time is significant. Therefore, identifying paediatric dysphagia in an infant, a toddler and an older child can all look somewhat different. However, some common symptoms of paediatric dysphagia and PFD across all ages can include:
Arching of the back or stiffening when feeding
Crying or fussing when feeding
Falling asleep while feeding
Difficult breastfeeding
Spitting up or throwing up more than typical
Not gaining weight or growing
Less energy than usual
Watery or teary eyes
Nasal congestion
Excess drooling and/or runny nose
Coughing, gagging and/or choking when eating and drinking
Eating only specific textures such as soft or crunchy foods
Taking a long time to feed or eat
Difficulty chewing or food pocketing in the mouth and cheeks
Refusing feed, food and drink or certain textures
Regurgitation of food and/or drink
Having a wet or gurgly voice after eating and drinking
Rapid increase in breath rate or apnoea (pauses in breathing)
Wheezing
Recurrent chest infections.
As explained earlier, paediatric dysphagia and PFD can occur in various severities and can be both temporary or long term depending on the cause. This means that the risks can also vary depending on these factors. Some of the most common risks and complications associated with paediatric dysphagia include:
Dehydration and loss of weight or malnutrition
Aspiration or food and drink going the wrong way (into the airway)
Pneumonia as a result of aspiration of food and drink, or vomit/regurgitation
Negative feelings about eating due to pain, frustration or embarrassment
Oral aversions to food and drink or specific textures
Chronic lung disease.
Just like in dysphagia management for adults, paediatric dysphagia and PFD are best and often managed under a team of health professionals of different disciplines including speech pathology, dietetics, occupational therapy, physiotherapy, nursing and medical, among others. This varies from child to child dependent on their presentation and needs, and what services are available to them in their context. This care can also occur across different settings such as the hospital (including NICU), rehabilitation and community centres, and schools. At the end of the day, therapeutic input aims to optimise feeding methods for safety and efficiency, reduce the risk of (respiratory) infections and adverse events, support both the child’s and caregivers’ needs, create a positive mealtime environment and maximise quality of life for everyone. Some common approaches to achieve these means through treatment include:
Diet and fluid modifications
Incorporating preferred foods and textures
Altering food temperatures and introducing new food textures
Implementing swallowing strategies
Altering feeding positions and postures
Engaging in swallowing rehabilitation or therapy exercises
Medication and/or surgery (per doctor/medical team)
Finding ways to introduce new foods to the child’s diet
Learning new ways to manage the child’s mealtime related behaviours
Learning to eat and drink is a complex process that involves a child’s social, emotional, physical, sensory, oromotor, communicative and cognitive development. All of these areas undergo important growth and evolution at different stages through childhood and must integrate through practice and repetition to result in what we understand to be mealtime. Should these areas and stages of development not be sufficiently supported it can result in poor psychosocial outcomes and reduced quality of life such as:
Learned feeding aversions
Distressing mealtimes
Disruptive behaviours related to mealtime
“Picky” eating
Difficulty advancing through age-appropriate milestones
Grazing tendencies
Maladaptive behaviours from the caregiver in order to increase oral intake
Social isolation and/or impact to the child’s self esteem
While a child is learning to eat and drink, both the parent and the child’s perspective should be considered as both play their own vital roles in the process. In reference to Ellyn Satter’s theory of division of responsibility, a parent decides on what is being eaten and drinken, when and where, while the child decides on how much will be consumed, if at all. The Fourth Place has always been about optimising the experience of both the person with dysphagia, the caregiver and everyone else involved so that mealtimes can be a positive experience for everyone. This is just as important in children where they are learning to socialise as well as eat and drink, and while parents are trying to raise their children, meet all of their needs, all the while looking after themselves too. Therefore, both roles must be considered to make mealtime a fun, social and positive experience while aiming to achieve appropriate developmental milestones and build autonomy and independence in the child themselves.
Useful Links:
The Ellyn Satter Institute
Feeding Matters
QLD Gov
Royal Children’s Hospital (RCH) https://www.rch.org.au/feedingdifficulties/resources/Key_Messages/
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