Pediatric Dysphagia

What are the differences between adult and infant swallowing anatomy?

• infant tongue size

• infant epiglottis position

• infant hyoid and larynx

• infant buccal pads

Infant tongue size

tongue is large compared to mouth; the entire surface is within the oral cavity and may completely fill the space

Infant epiglottis position

assumes a high position, often allowing contact with the soft palate

Infant hyoid and larynx

lie at a higher level in the infant, located almost directly beneath the base of the tongue

Infant buccal (sucking) pads

provide stability during sucking

What are the physiologic differences between adult and infant swallowing?

• infant swallowing = reflexive, adult swallowing = volitional in oral stages with automatic pharyngeal and esophageal transit

• infants have suckling patterns where swallowing is embedded in respiratory cycle to prevent aspiration while adults swallow boluses with a disruption of breathing

Neonatal swallowing phases

all phases are involuntary/reflexive and brainstem-mediated in neonates

Neonatal oral phase control

requires more input from the cerebral cortex for motor control and decision making, but young babies do not have mature enough cortexes yet

Oral phase development

starts to become voluntary in older infants and children

What is the difference between adaptive and protective reflexes?

adaptive reflexes help direct feeds to the gut, whereas protective reflexes keep feeds out of the airway

Examples of Adaptive Reflexes

rooting and suckling

Rooting Reflex

• head turns toward tactile oral stimulation

• diminishes at 3-6 mos

Suckling Reflex

• extension-retraction (forward-backward) tongue movements

• diminishes at 3-6 mos

Examples of Protective Reflexes

• tongue protrusion

• tongue lateralization

• phasic bite

• gag

Tongue Protrusion Reflex

• tongue protrudes when lips, gums, or front of tongue are touched

• diminishes at 3-6 mos

Tongue Lateralization Reflex

• tongue moves to the side that has been touched

• integrated at 6-9 mos

Phasic Bite Reflex

• rapid jaw movements (looks like biting or chewing) when gums are touched

• diminishes by 9-12 mos

Gag Reflex

retained through adulthood

What is the difference between nutritive suckling and and non-nutritive suckling?

nutritive suckling is used during feeding to draw fluid into mouth while non-nutritive suckling is used to self-soothe

Nutritive suckling ratio

suck-swallow ratio is 1:1

Nutritive suckling immature pattern

features bursts of suck-swallows followed by forced, apneic breaks to catch breath

Non-nutritive suckling ratio

suck-swallow ratio is 6:1-8:1, no fluid so less need to swallow

Non-nutritive suckling pattern

• variable pattern of sucking bursts and pauses

• often 6-8 sucks per burst followed by several second pauses

Cue-based feeding strategies

• feeding readiness cues

• delay feeding cues

• caregiver feeding attunement

Feeding readiness cues

staying awake, bringing hands to mouth, and rooting

Delay feeding cues

body tension, grimace, reduced engagement, gaze aversion, hiccup, and yawning

Pediatric Feeding Disorder (PFD)

impaired oral intake that is not age-appropriate and lasts longer than 2 weeks

PFD components

encompasses medical, nutritional, feeding skill, and psychosocial dysfunction

Distinction between PFD and Dysphagia

a child may have the physical skills to swallow (no dysphagia) but suffer from a PFD due to extreme food selectivity or medical pain during feeding

Main point of perspective that supports breastfeeding

• infants who aspirate should keep breastfeeding due to health benefits, maternal bonding, and reduced allergies

• these benefits outweigh risk of aspiration

Main point of perspective that wants to minimize risk of aspiration during breastfeeding

• infants who aspirate and were not told to stop breastfeeding had increased lung inflammation, infections, and more hospitalizations

• thickened breastmilk that is bottle fed may help but is not proven