Swallowing Disorders in Newborn and Small Children

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Chapter 5
Swallowing Disorders in Newborn and Small Children
Daniele Farneti and Elisabetta Genovese
Additional information is available at the end of the chapter
http://dx.doi.org/10.5772/intechopen.69921
Abstract
This chapter reviews the main aspects of dysphagia in children: epidemiology, etiology,
physiopathology, bedside assessment, and instrumental assessment in the perspective of
planning treatment. More details will be given on the endoscopic assessment in children
of dierent ages in consideration of the information useful in planning treatment. This
chapter oers a review of the literature on the topic and a simple diagram of the main
aspects of the management of dysphagia in children. This chapter aims to oer a simple
and useful guide for students and professionals working in the eld and suggestions for
the implementation of clinical steps in daily practice when and where managing children
with swallowing disorders is a reality.
Keywords: swallowing, deglutition disorders, children, newborn, feeding
1. Introduction
Swallowing disorders in children is a topic of great interest, from the epidemiological, clinical,
rehabilitative, and, not least, cultural perspective. If signicant steps forward have been made
in recent decades in all aspects of adult swallowing (under normal conditions and for dierent
comorbidities), medical knowledge about aspects of swallowing in childhood (normal, abnor-
mal, and deviant) has not improved at the same speed. This has created a major gap between
the more practical aspects of patient care and people requiring specic interventions.
Before proceeding to the discussion of the most typical physiopathological and clinical aspects
related with this disorder, a brief epidemiological and etiological framework of the problem
is appropriate.
© 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.

Coexisting diseases
Motor
Sensory and psychic
Perceptual
Praxis
Gnosis
Cognitive
Communicative behavioral
Table 2. Main pathological conditions associated with swallowing disorders.
2. Epidemiology
Data about the incidence (new cases) and prevalence (disorder in a given period of time) of
swallowing disorders in childhood are not reported separately in the literature. This is mainly
due to the heterogeneity of the population studied, in reference to the assumed consistency and
the dierent ways of detection of the disorder. It is estimated that 25–45% of normally develop-
ing children can have eating disorders and swallowing problems, and in children with devel-
opmental disorders, the prevalence is estimated to be 30–80%. Feeding problems associated
with serious sequelae (lack of growth and chronicity) were reported in 10.3% of children with
physical disabilities (26–90%), medical conditions, and prematurity (10–49%). This is due to an
improvement in survival rates of premature babies with low birth weight and with complex
medical conditions [1–3]. Tables 1 and 2 summarize the main morbid conditions and possible
interactions (comorbidities) that are associated with swallowing disorders in children.
Disease
Neurological Encephalopathies (cerebral palsy, perinatal anoxia),
Traumatic Brain Injury, Neoplasms, Mental delay,
Prematurity and developmental delays
Anatomical and structural Congenital (tracheoesophageal stula, palatal cleft),
Acquired
Genetic Chromosomal (Down S.), Syndromic (Pierre Robin,
Treacher-Collins), Dysmetabolisms
Systemic diseases Respiratory (chronic lung disease, bronchopulmonary
dysplasia), Gastrointestinal (GI dysmobility,
constipation), Cardiac
Psychosocial and behavioral Oral deprivation
Secondary reversible diseases Iatrogenic
Table 1. Main pathological conditions causing swallowing disorders.
Advances in Speech-language Pathology78

3. Etiology
From the etiological point of view, only a brief reference to the most common causes of dys-
phagia in children, including conditions associated with developmental abnormalities, that
is, early onset conditions, requiring prolonged or chronic measures of medical, rehabilitation,
and/or residential support, is necessary.
These conditions (Table 1) are mainly associated with neurological disorders (cerebral palsy,
meningitis, encephalopathy, pervasive developmental disorders, traumatic brain injury, and
muscle weakness): factors aecting neuromuscular coordination (prematurity and low birth
weight), complex diseases (heart disease, lung disease, gastroesophageal reux disease, and
delayed gastric emptying), structural anomalies (cleft lip and/or palate, laryngomalacia, tra-
cheoesophageal stula, esophageal atresia, cervical-facial abnormalities, and choanal atresia),
and genetic syndromes (Pierre Robin, Prader-Willi, Treacher-Collins, and deletion of chromo-
some 22q11).
To these conditions, the iatrogenic conditions related to the use of drugs (reduced reactivity,
hypotonus, and decreased appetite), surgery, or medical measures, which require alternative
ways of feeding or assisted breathing, and any other conditions that induce sensory depriva-
tion of orofacial and pharyngeal structures, including a limited availability of food, which
may be associated with social, emotional, and environmental problems (e.g., diculty of par-
ent-child interaction) (Table 2) [4], must be added.
4. Physiopathological premises
The cultural problem that has created such a gap between child and adult dysphagia is repre-
sented by the fact that the swallowing act evolves into a continuum that already starts during
intrauterine development and continues throughout the lifespan. The passage between these
two conditions, therefore, is slow, but the dierences between child and adult swallowing
and pathophysiological conditions of one and the other make the two realities very dierent
to each other and not comparable. An adequate approach to childhood dysphagia implies,
inevitably, a reminder of the pathophysiological aspects, with a short premise that a swallow-
ing act has, in the child, a predominantly nourishing component and a protective action on
the lower respiratory tract.
It all rests on the close relationship that exists, even in an evolutionary sense, between struc-
ture and function. If an organ evolves (morphologically and topographically), the functions it
performs also have to adapt to this evolution. If the functions that the organs perform are vital
functions (breathing and swallowing—aimed at nutrition), is it possible that the importance
of such functions conditions the structure?
So what is the role of external events, for example, environmental, which are able to aect the
relationship between shape and function? These considerations would lead us away from the
topic of our chapter. Going back to the initial topic, it must surely be said that the swallowing
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act, as a complex and integrated neuromotor event, begins “in utero” [5, 6]. The possibility of
developing swallowing acts precociously aects the close relationship that exists between the
digestive, respiratory, and cardiocirculatory apparatus in the embryo and fetus. Very early
on, these apparatus make connections with neural structures, which are themselves evolving
and beginning their myelination. All such structures are immersed in a liquid environment,
circumscribed by the wall of the uterus. The containment cavity and growing structures are
aected by the relationships with the nervous structures: such relationships involve a deli-
cate balance between growth and maturation, which takes place at the organ and apparatus
level. So the central and peripheral integration among neural structures is perfected in paral-
lel to the integration with the organs-apparatus integration and the functions they carry out
(Table 3).
Pharyngeal swallowing appears between 10 and 12 weeks of gestation and a complete suck-
ling appears in the 18–24th weeks: it is between the 34th and 36th weeks that the fetus pro-
duces ecient swallowing, able to contribute to volume adjustment of the amniotic uid.
This swallowing activity is also essential to the development of the gastrointestinal apparatus
and of the fetus itself [6, 7]. However, after birth, maturation structures and functions do not
guarantee an adequate oral feeding, suggesting that extrinsic factors, related to the learning of
external inputs, have a signicant role in this maturation [8]. This optimization of the organs
NS: nervous system; RS: respiratory system, GI: gastrointestinal tract; CC: cardiocirculatory tract.
Table 3. Organ-function integration between center and periphery.
Advances in Speech-language Pathology80

acquires the connotations of their real development toward an ecient and safe swallowing.
Such enabling requires a long time: a child develops motor paerns similar to adults, only
during adolescence. This underlines the complexity of this function, which, throughout life,
is enriched with more and more complex socializing and cultural meanings. The concept
of feeding, as an element intimately connected with swallowing, is established very early
on. This concept is linked to the set of functions that are linked to oral structures: rst of all,
neuromotor skills [2] and also communication and social functions, as previously mentioned.
As strictly regards feeding, it provides an increasingly sophisticated enabling of the oral
structures, which allows the management, in the oral cavity, of increasingly more diversied
boluses, in terms of consistency, volume, temperature, viscosity, and elasticity. The feeding
activities allow a perfect conformation of the oral cavity to the anatomical adaptations that
involve the head and neck fully during growth [9]. These same anatomical adaptations also
involve the pharynx, so the interaction between feeding and swallowing, and more properly
the interaction between the oral and pharyngeal phase of swallowing, becomes more and
more intimate and functional. This adaptation is aimed at creating a neuromotor act that has
to be eective (protective of the lower respiratory tract), ecient (complete transport of vol-
umes), and functional (supporting of hydration and nourishment), while maintaining its own
individual character and social pleasure. Table 4 summarizes the oromotor abilities required
by a small child (before 2 years) as a function of the consistencies managed [10]. In such a rap-
idly evolving system, the development of oral motor skills assumes great importance. These
skills are being developed within a system that is changing quickly in both the structural and
neuromotor sense: this occurs rapidly within the rst 3 years of life [5, 10]. During this period,
children are engaged in a great variety of oral experiences, sometimes oriented to satisfying
Months Progression of foods and
uids
Oromotor abilities Gross motor abilities
0–4 Liquid Sucking the nipple Head control
4–6 Purèe Sucking from spoon Siing position, hands
forward
6–9 Purèe, soft solid Drink from glass, vertical
mastication (reduced
lateral movements)
Hands to the mouth, pincer
hands, begins to hold the
spoon, and begins to eat
with hands
9–12 Ground, coarse purèe Drink from glass
independently
Rened pincer hands and
eating with hands
12–18 All consistencies Tongue lateral movements,
drinking from a straw
Greater autonomy at meals,
discovering foods and
bringing to the mouth
18–24 Research of chewable foods Lateral chewing
>24 Harder solids more mature chewing Autonomous, manages
utensils and glasses
without spilling
Table 4. Neuromotor skills and oral management of the bolus within 2 years of age.
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their basic nutritional need: this need is associated with the exploration of the surrounding
environment, which should always be comfortable and rewarding. From a clinical point of
view, a problem exists when a child is “locked” into a specic feeding schedule, when it is
anchored to a feeding scheme beyond which they cannot progress. As the oral motor skills
represent a sequential progression of increasingly complex skills, any interruption in this pro-
gression can limit their development and cause the loss of previously acquired skills [11].
5. Stages of oromotor development
At birth, a child needs to be able to breathe on its own and to feed safely. This implies, as
already mentioned, a perfect cooperation of the swallowing eectors, which reects a state
of optimal health (relating to the development of the respiratory, gastrointestinal, and car-
diovascular apparatus), optimal nervous integration, and optimal mother-child relationship.
From the anatomo-functional perspective and aimed at sucking activity, it should be remem-
bered that the child, toothless at birth, has a high larynx (at the height of the rst two cervical
vertebrae), and a high respiratory rate (70–80/min, with minimal thoracic movements) but
mostly a large tongue inside a relatively small mouth. Swallowing of milk occurs with a
suckling neuromotor paern, characterized by in-out tongue movements, facilitated by an
opening-closing movement of the mandible, miming a squeezing act. During this activity,
the face musculature, mainly the lip muscles, is kept hypotonic and the iolaryngeal axis is
high and immobile. Swallowing triggers from the valleculae, and the pharyngeal passage
is realized with a suction/swallowing ratio equal to 1. Table 5 summarizes these events in
the light of an overall maturation of the child [12–14]. It should be remembered that, at this
Months Motor activity Feeding activities Jaw Tongue Lips
0–1 Reex
movements of
limbs
Raises the head
Sucking of nger
(if approached to
the mouth)
Phasic bite Tongue = jaw Mimic muscles
silent
1–2 Circular
movements of
limbs
Raises the head
Hands to the
mouth (if lying
down)
Phasic bite Tongue at rest
Tongue besides
gums
Lip synchronous
with other facial
muscles
3–5 Trunk control
Head control
Siing position
Head-trunk
control
Objects to the
mouth
Phasic bite
Stable jaw (head
control)
Movements of
tip-body-base
Gag from
mid-third of the
tongue
Inhibition lingual
movements
Development of
facial muscles
lips control
separate lips
movements
Lips-cheek
activities
Table 5. Neuromotor paerns and eectors: sucking.
Advances in Speech-language Pathology82

time, swallowing is purely reex, relegated to the activity of the bulbar swallowing center. At
weaning, anatomical changes allow the realization of new swallowing paerns. The tongue
tends to aen out and acquires the ability to perform up/down movements between the
mandible and the hard palate. Lips acquire tone to achieve a greater aachment to the nipple.
The laryngeal lowering allows the volumetric increase of the pharynx and the realization
of a negative pressure inside the mouth. The child is now able to move a greater volume of
liquids, reaching a sucking/swallowing ratio superior to 1. These events become possible
due to a progressive disappearance of oral reexes. Swallowing triggers from the valleculae,
as above, but the increased ow and the lower position of the larynx can facilitate episodes
of penetration. Table 6 summarizes these events [12]. The myelination of subcortical and
Months Motor activity Feeding activities Jaw Tongue Lips
6–9 Sits and turns
Objects from
hand to hand
Manipulates
objects
Explores with
indexes
He/she gets up
briey
Sucking of nger
(if approached to
the mouth)
Independent
movements
of tongue/jaw
(trunk control)
He/she holds
bole
Phasic bite
abolished
Stabilized
mandible
Lateral
movements
Up-down
movements
Gag reduced
Perceived
consistency
(bolus crush)
Lateralizes the
bolus
Lower lip
stabilizer active
Use of perioral
muscles
Bolus between
molars: use of the
lips and cheeks
10–12 Crawling
Gets up
Upright position
Fine motor skills
development
Controlled
pressure of soft
foods
Opening/closing
controlled
Circular-rotary
movements
Use of all
intrinsic tongue
muscles (various
shapes)
All moving
angles
Combination of
movements
Active lips/
cheeks used to
manage soft
foods
Contracts lower
lip: clearing from
teeth and gums
Occasional
packeting/
drooling
Rare drooling
13–24 Fast walking
Jumps with 2 feet
Walking on tiptoe
Draws closed
forms
Makes puzzles
Head-trunk
control
Objects to the
mouth
Circular-rotary
movements
No turning of
head to bite (most
mandibular
control)
Consistence
modies lingual
movements
Tongue on right
and left
Tongue clears the
mouth
Tongue/
mandible:
independent
movements
(12–24)
Lips licking
(18–20)
Maintaining
lip prehension
during lingual
and mandibular
movements
Table 6. Neuromotor paern and eectors: weaning.
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subsequently cortical structures, as previously mentioned, interfere with the bulbar centers
(neuromotor control): now swallowing becomes an automatic act, submied to the sensorial
aerents coming from the periphery, mainly from the oral cavity. The growth of orofacial
structures allows for more and more precise and rened neuromotor paerns enabling the
development of oral skills and the ability to manage boluses of dierent volume and consis-
tency [15]. Table 7 summarizes these anatomical variations in young children up to 2 years
old and older than 6 years. Between 2 and 6 years of age, swallowing mainly reaches the
optimization of the oral activities and the stabilization of the pharyngeal phase. Even the
anticipatory phase of swallowing tends to stabilize in this age group. As regards chewing,
this activity is enriched by movements of laterality and circularity of the tongue and mandi-
ble, with transport of the bolus in the molar region and the beginning of trituration of harder
and harder consistencies. The duration and number of masticatory cycles, as well as their
eciency in terms of strength, precision, and coordination, develop progressively. From 6 to
12 years, chewing is further perfected. A reduction in the number and duration of the chew-
ing cycles occurs with a strengthening of the propulsive phase, due to the strengthening
of the masticatory muscles. In the meantime, the tone of mentalis and orbicularis muscles
decreases. Also in this phase the exposure to dierent consistencies and volumes is a pow-
erful stimulus to the optimal use of swallowing eectors, all activities that, in the nervous
system, are supported by mechanisms of neuronal sprouting (brain plasticity). The correct
knowledge of these events and of the time frames mentioned earlier underlies the correct
assessment of children with swallowing disorders. The failure to achieve abilities, chrono-
logically expected in an age band, will surely negatively compromise the achievement of
further abilities.
Younger child Older child
Oral cavity Tongue lls the mouth Tongue lies on the oor of mouth
Edentulia Primary teeth
Tongue at rest between the lips and
against the palate
Tongue behind your teeth and not
against the palate
Cheeks rich in fat Chewing using buccinator muscles
Small jaw Relationship between jaws almost
normal
Sulci important during sucking Sulci less important during sucking
Pharynx Oropharynx not well dened Lengthening of the pharynx with
oropharynx dened
Skull base with obtuse angle to the
nasopharynx
Skull base with right angle
Larynx 1/3 of the adult
1/2 glois cartilaginous 1/3 glois cartilaginous
Epiglois vertical and narrow Epiglois wider and aened
Table 7. Growth of structures in the younger and older child.
Advances in Speech-language Pathology84

6. Signs and symptoms
It has previously been said that the alterations of the oromotor development, in one or more
associations summarized in Table 3, result in an arrest in the development of the child’s feed-
ing skills, with the possibility of losing skills already acquired. Dysphagia, which is not prop-
erly diagnosed, can result in multiple clinical signs, in various combinations.
First, it can determine weight loss and a failure to thrive so as to require a parenteral or
enteral nutritional support. Dehydration, respiratory complications or aspiration pneumonia,
food adversion, and rumination (i.e., involuntary regurgitation of undigested food that can be
chewed and re-swallowed) are other possible signs of dysphagia.
From these assumptions, the major requests for phoniatric-logopedic evaluation of children
with swallowing disorders are derived. Most commonly, children refuse some consistencies
or have a dicult approach to meals, with lile interest in eating. All these conditions may
reect alterations in the physiology of swallowing such as a slow gastric motility or consti-
pation. A child who refuses new consistencies may suer from gastroesophageal reux and
other gastrointestinal disorders. A gastroesophageal reux can cause pain during or after the
meal, which children associate with feeding.
This can impede feeding and cause severe behavioral problems that make it dicult, if not
impossible, for the parents to feed the baby adequately. As mentioned earlier, a limited taste
experience related to oral intake may aect inadequacies in the oral sensorimotor develop-
ment. Parents can also signal that the child does not show a sense of hunger but rather shows
a sense of aversion or avoidance to sensory stimulation, making meal times a real struggle.
Every child is dierent and these conditions may be present in various combinations [16].
Table 8 summarizes some of the main conditions which lead to a request of consultation. The
Incoordination between sucking and swallowing (shockable rhythm)
Weak feeding
Alterations in breathing or apnea during the meal
Gagging excessive or frequent coughing during the meal
Occurrence of diculties in supply
Diagnoses associated with dysphagia, malnutrition, or craniofacial anomalies
Shutdown/reduction in body weight gain from 2 to 3 months (malnutrition)
Marked irritability during the meal
History of respiratory diseases and feeding diculties
Lethargy during the meal
Feeding time more than 30–40 min
Unexplained refusal of food and malnutrition (failure to thrive)
Drooling that persists beyond 5 years
Nasal regurgitation during the meal
Delay in the maturation and development of food habits
Table 8. Sending criteria to phoniatric-logopedic assessment.
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table shows conditions referring to a variety of swallowing disorders, some mentioned in the
section on etiology. It is obvious that if the baby is born with a craniofacial malformation, the
oral and/or pharyngeal phase of swallowing will consequently result as compromised.
7. The bedside evaluation (non-instrumental clinical evaluation)
The clinical approach to children with swallowing disorders does not dier substantially
from the approach to other pathological conditions. In children, as in adults, it has to be
borne in mind that dysphagia is a symptom, underlying one or more morbid or comorbid
conditions. The approach to children is complicated by the inability of the young patients to
directly express their discomfort and this is often mediated by caregivers.
To summarize, possible goals of the non-instrumental clinical evaluation are as follows: to
identify the possible etiology of dysphagia, to formulate hypotheses about its nature and
severity, to estimate functions and their integration (sensory-motor skills and breathing), to
induce therapeutic modications, to investigate safe food options for the child and to raise
awareness among family members, to indicate the best instrumental evaluation, and to iden-
tify the possibilities of and the patient’s ability to cooperate in medical examinations.
Therefore, the clinical approach to children with swallowing disorders is inuenced by the
age of the child, the main pathology, and the comorbidities. The importance of age has already
been emphasized: depending on their age, the children should have specic oromotor skills
and there is the gradual disappearance of reex activities. Table 9 summarizes the main steps
of the non-instrumental clinical evaluation.
In clinical practice, the absence of standardized assessment protocols is a serious concern: the
literature oers us dierent protocols (Table 10) [17–22] but their application is not always
standardized and veried by an instrumental gold standard. This lack of tools interferes with
the collection of information and the comparison of the skills of the young patients.
The non-instrumental clinical evaluation has to provide the proposal of foods in dierent vol-
umes and consistencies, depending on the age of the child. It will occur with specic modali-
ties depending on whether the child is fed (Table 11) or not fed orally [nill per os (NPO)]
(Table 12).
In children with tracheotomy, non-instrumental evaluation will be conducted in the same
way as in children with an intact airway considering that, in children, few data are avail-
able about the impact of tracheotomy on swallowing abilities. When possible, the tests with
bolus are performed verifying the presence of bolus traces or blue-dyed water in the airway.
The use of speaking valves has to be encouraged, allowing phonation, increasing laryngeal
reexivity with a beer lower airway protection, and clearing secretions. The use of speaking
valves reduces mechanical ventilation dependence time and stay in NICU, and accelerates
decannulation and recovery of oral feeding.
Advances in Speech-language Pathology86

At the end of the non-instrumental clinical evaluation, with respect to what has been previ-
ously reported, it is necessary to identify those children for whom a referral for an instrumen-
tal clinical evaluation is worthwhile. Table 13 summarizes the assessment process up to this
point.
Clinical history
• Prenatal infections,
medications, drugs
• Delivery (Apgar)
• Peri/neonatal (dietary
history)
• Beginning and description of the disorders
• Other medical or nutritional disorders
• Prolonged hospitalization or surgery
• Age of acquisition of food mode
• Supply adequacy and behavior at meal
General observation:
• Facies
• Muscle tone
• Vestibule and the oral
cavity
• Jaw mobility
• Veil mobility
• Chest and breathing
• Neuropsychological
development
• Postures and positions
Anatomy
• Abnormalities
• Malformations
• Deformity
Reexes
• Swallowing
• Gag
• Rooting
• Cough
• Mouth opening
• Tongue lateralization
• Biting
• Babkin
Behaviour
• Postural control of the
body
• Oral postural control
• Voice
• Oral praxis and blow
Observation during the
meal
• Alert
• Activity level: quiet, active, weeping
• Receptivity to food
Swallowing osbervation:
• Respiratory signs
(cough, apnea,
desaturation)
• Gurgling voice
• Other: bradycardia,
pallor, sweating
NPO child
• From 1 to 3 ml of liquid
• From 1 to 3 ml semi-solid
PO child
• Teat: usual liquid bolus
• Spoon: viscous semi-solid,
dense and grainy, soft
solids
• Fingers: solid chewable
• Spoon: soft solids, soft
complex solid, hard solid
and dense liquids
• Cup: liquid and thickened
liquids
Table 9. Steps of non-instrumental clinical evaluation (bedside evaluation).
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Neonatal oral motor assessment Scale (NOMAS) (Palmer et al [17]) (Breast feeding/Bole feeding)
Systematic assessment of the infant at the breast (SAIB) (Association of Women’s Health, Obstetric and Neonatal
nurses, 1990)
Preterm infant breast-feeding behavior scale (PIBBS) (Nyqvist et al. [19])
Breast feeding evaluation (Tobin [20]) (term infants)
Feeding ow sheet (Vandenberg [21]) (bole feeding)
Infant feeding evaluation (Swigert [22])
Table 10. Main bedside protocols of evaluation.
• Place the baby in an optimal way to elicit swallowing and coordination:
• Semi-reclined
• 3–4 months
• After weaning
• Diculties in oral transport
• Neurological disorders (diculty with boluses by spoon)
• Seat supporting the head (preferred)
• Behavior during the meal: failure, drowsiness, avoidance or refusal of food, food preferences
• Evaluate praxis with:
• Teats or tools
• Bolus: volume, consistency, order of presentation
Table 11. Bedside evaluation and test with bolus in orally fed child (PO).
• Breathing and eating disorders not related to oral intake of foods
• In case of correlation instrumental evaluation (airway protection)
• Clinical judgment on the possibility of oral feeding
• Pooling:
• Impaired early oral or pharyngeal phase: stop the test
• Impaired oral preparation:1 cc of liquid back in the mouth (pipee)
• Adequate oral preparation: bolus to the lips or with a spoon
• Tests: very small bolus (1–3 ml) via pipee or teat
• Proceed to check the appearance of respiratory signs.
Table 12. Bedside evaluation and test with bolus in non-orally fed child (NPO).
Advances in Speech-language Pathology88

8. The instrumental clinical evaluation
The two main instrumental tools for assessing swallowing in children, as in adults, are rep-
resented by the dynamic radiological and the dynamic endoscopic evaluations, respectively,
known with the Anglo-Saxon acronyms of VFSS (videouoroscopic swallowing study) [23]
and FEES (beroptic endoscopic evaluation of swallowing) [24]. These procedures evaluate
the behavior of swallowing eectors during the passage of the bolus, which implies that the
child, who is a candidate for such procedures, can be fed orally [25]. During the procedure,
the clinician can rely on monitoring the heart activity, breathing, and O2 saturation, in order to
obtain additional information about physical or behavioral changes associated with the swal-
lowing disorder. Similarly, the colorimetric variations of the skin (pallor or cyanosis), nasal
regurgitation, and alterations of sucking-swallowing/breathing rhythm may be considered.
Broadly, the instrumental evaluation, compared to the bedside evaluation, has the advantages
shown in Table 14. It is worth remembering that with regard to the information they provide,
FEES and VFSS are not equivalent but complementary. The clinician chooses the procedure
most appropriate in relation to the characteristics of the young patient or to the information
being sought, in the awareness that the two procedures have both advantages and disadvan-
tages [26] (Table 15).
Table 13. Evaluation process: synthesis.
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• Display of upper aerodigestive tract (oral cavity, velopharyngeal sphincter, pharynx, larynx, and cervical
esophagus)
• Evaluate muscular activities (symmetry, force, pressure, tone, range and degree of motion, coordination, and
speed)
• Evaluate sensation
• Evaluate aspiration and cough
• Evaluate residue in hypopharynx and larynx
• Evaluate the esophageal etiology of dysphagia
• Evaluate the safest and most ecient way of nutrition and hydration
• Evaluate the ecient protection of postures and maneuvers
Table 14. Advantages of the instrumental clinical evaluation compared to the clinical non-instrumental evaluation.
Advantages Disadvantages
FEES Less invasive
Easy to perform
Well tolerated
Possible for a long time (fatigue
viewing)
Portable (acute and sub-acute
patients)
Routine
Economic
Therapeutic feedback
Decision making of oral feeding
Natural foods
Direct visualization of structures
Motor and sensory activities
Three-dimensional similar view
Optimal pooling evaluation
Pooling management viewing
Pharyngeal phase only
White-out
Indirect consideration about
• Oral
• Esophageal phase
Fear and discomfort
Poor vision in repeated swallowing
acts
Not possible if changes in upper
airway
VFSS Whole deglutition evaluation
Time parameterization
Invasive (radiological exposure)
Uncomfortable execution
Environment and suitable personnel
Expensive
Bi-dimensional view (under
estimation of pooling maer)
Motor activity only (reaction to
aspiration, if documented)
Fatigue evaluation missing
Table 15. Advantage and disadvantage comparison between VFSS and FEES.
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8.1. VFSS
It is a procedure that uses ionizing radiation and should be used sparingly, especially in
very young children. When indicated, the tool veries the actual usefulness in improving the
safety and ecacy of the swallowing act, under dierent examination conditions: varying
the consistency or the viscosity of the bolus, verifying the clearing of the mouth, pharynx,
or esophagus; varying the position of the child, implementing postures or maneuvers (when
possible); varying the speed of feeding, child position, and changing pacier or spoon char-
acteristics [27, 28].
8.2. FEES
When performing an endoscopy, the possibility of achieving the maximum collaboration of
the child is crucial. Any device useful for making the child and its parents less anxious and
for increasing compliance has to be adopted. The family is asked to bring paciers, boles,
or utensils commonly used during meals and also to bring the dishes commonly eaten by the
child: either the most liked or those that create the greatest diculties. The choice of endo-
scope size is based on the age of the child: obviously, the smaller the endoscope, the lower
the imagine denition. With a child of over 3 years of age, it is possible to use standard size
endoscopes (2.4 mm in diameter), with a younger age group smaller devices are advisable
(1.5 mm diameter). To optimize cooperation and minimize discomfort, anesthetic spray pus
or a small amount of coon, soaked in a 1:1 mixture of 4% lidocaine and oxymetazoline, can
be introduced into the nasal cavity [29]. A viable alternative is to lubricate the tip of the endo-
scope with a 2% lidocaine gel. This is always desirable in patients with airway lability (very
young children or of low weight) in compromised general conditions or with tracheotomy.
For the endoscopic evaluation, the baby may be supine in a cot or a pram but for the dynamic
study of swallowing he/she should preferably have the chest lifted: the baby can be held in
the mother’s arms or on her knees.
Older children can be seated in a high chair without any help. If the child tends to assume specic
postures during the meal (due to a physical impairment, as in cerebral palsy) they will be main-
tained after the introduction of the endoscope and veried during the test. Similarly, the eciency
of therapeutic postures or maneuvers will be checked. The procedure substantially does not dier
from that used for adults [30]: the static, anatomical, dynamic, and non-swallowing assessments
are performed with the tip of the endoscope in the naso-nasopharyngeal, high, and low position.
The tests with bolus are performed with the tip of the endoscope in the high position.
9. The anatomo-functional evaluation
In the naso-rhinopharyngeal position, the clinician will evaluate hypertrophy of the nasal mucosa
and turbinate, secretions pooling, septal bumps and other anatomical anomalies, shrinkage
or choanal atresia, hypertrophy of adenoid, and the upper surface of the soft palate. During
phonation and deglutition, the contraction of the veil, if symmetrical, will be evaluated. While
swallowing, a veil incompetence is always pathological and the cause of nasal regurgitation of
secretions or bolus.
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In the high position (beyond the free edge of the soft palate), the clinician evaluates the hypo-
pharyngeal region: base of the tongue, tonsils, and the larynx position, considering that it
descends gradually in the neck with age: from C1 to C4 from birth to puberty. Particular aen-
tion should be given to material pooling: if present at the beginning and during the evalua-
tion. Its increase not followed by clearing is abnormal [31, 32]. The clearing of secretions is
assessed during spontaneous swallowing acts or on request [26, 30]. Secretions that engulf the
pyriform sinus must induce a swallow, even if the child cries.
In the low position, a careful assessment of the larynx is performed. Particular aention should
be paid to abnormalities that may interfere with the sphincterial function: malacia, cleft, and
cyst. Mobility is evaluated during respiration, phonation, or crying. Signs of reux disease
have to be evaluated: hyperemia, hypertrophy of the posterior commissure, circumscribed or
diused edema involving the vocal cords, and endolaryngeal secretions.
The delicate touch of the aryepigloic folds with the tip of the endoscope activates the adduc-
tion reex, mediated by the superior laryngeal nerve: the reex is essential for an adequate
protection of the lower airways during swallowing. For the same purpose, pulsed air can be
used, supplied with variations of pulsing or of intensity [exible endoscopic evaluation of
swallowing with sensory testing (FEESST)] [33, 34]. In children who are noncooperative, who
have cognitive disorders, or are very young, only the adduction reex can be appreciated [34].
10. The test with bolus
After the anato-functional assessment and in relation to age, foods of dierent consistencies
and volume will be proposed to the child. The foods preferably have a natural color or are
dyed. The child is fed by its parents. It is always advisable to start with pleasing food, in order
to increase the compliance to the test, then subsequently, as for adults, to use food which
is more dicult to manage in the oral cavity [30, 35]. During the test with bolus, dierent
parameters have to be considered.
The rst parameter to evaluate is the site and latency of the swallowing reex, in children this
is more dicult to dene in relation to the small size of the pharynx. Liquid bolus can hesitate
in the valleculae before being swallowed, as a normal variant of the swallowing act. If the
bolus falls by gravity into the pyriform sinuses before swallowing and remains in this site,
the possibility of false route is greater. The delivery of the bolus from the oral cavity into the
pharynx without swallowing is referred to as premature spillage. When milk is sucked from
a bole, it is collected up to the pyriform sinuses before being swallowed and only an appro-
priate rhythm, sucking-swallowing-breathing, prevents aspiration [28]. The datum, however,
will be included and considered in the context of a complete clinical assessment.
The progression of the bolus into the laryngeal vestibule is called penetration, being possible up
to the true vocal cords. Penetration is clearly evaluated using endoscopy [28, 30, 35]. When the
valleculae are obliterated with lymphatic tissue, the bolus (in particular liquid) can spill over
the free edge of the epiglois before swallowing: in this case, the risk of penetration remains
low. If the general conditions of the baby are serious, penetration can have the same signicance
as aspiration so, when performing tests, it would be beer not to expose the patient to this risk.
Advances in Speech-language Pathology92

Aspiration is the progression of secretions or bolus below the true vocal cords. In FEES, this
event can occur before or after swallowing: they are events well evaluated in endoscopy
[36]. Pre-swallowing aspiration can be due to a delayed triggering or a late laryngeal valve
activation. Post-swallowing aspiration can be due to an overowing from the pharyngeal
containment cavities. At the highest point of swallowing, the white-out prevents the direct
visualization of aspiration (intra-swallowing aspiration). In this case, aspiration can be
inferred after swallowing, by evaluating residue of food in the larynx or cervical trachea or
evaluating the expulsion of streaked secretions by coughing [28, 30, 35].
The evaluation of swallowing abilities with bolus can be quantied by the same test as is
available in FEES. The progression of bolus through the upper airway can be quantied using
the penetration-aspiration scale [37], and the presence of residue can be quantied with the
pooling score (p-score) [32, 37] both applied with the same characteristics as seen for adults.
11. The treatment plan
The clinical non-instrumental and instrumental evaluations should enable the clinician and
the rehabilitator to set up an ideal treatment plan for the child (Table 13).
In general, a treatment plan should (1) guarantee the child an adequate nutritional and water
intake, (2) be protective of the respiratory tract, (3) support the child in eating and drinking, (4)
guarantee the optimal oral sensory stimulation, (5) improve the QoL of the child and family,
and (6) help the family in conceiving new therapeutic strategies [38–40].
All of these respecting the actual clinical condition (morbidity and comorbidities) inside the
evolutive temporal windows are linked to age of the child. The treatment plan should also
consider all the possible seings of a child’s life: home, kindergarten, school, and leisure
environments. The treatment plan must consider all the indications aimed at achieving the
objectives mentioned earlier, by means of medical, surgical, and nutritional strategies. For
example, if the child suers a major reux, he/she will be treated pharmacologically or surgi-
cally, to prevent the negative feedback that the reux has on swallowing and feeding. Other
general considerations, previously underlined, are the importance of ensuring the child the
best sensory oral-pharyngeal stimulation and the best oromotor stimulation. Only in this
way will the swallowing abilities of the baby progress through all the steps of a satisfactory
development.
In planning treatment, the clinician has to consider if the children can be safely fed orally
or not, and the general performance of the child during mealtimes. In practice, useful thera-
peutic strategies are represented by dietary modications, such as the food being thickened,
diluted, chopped, blended, mixed, and viscosity varied, depending on the functional age and
disease of the baby. These changes must guarantee a nutritional and water intake able to
ensure the growth of the child. Within the rst year of life, the use of commercial thickeners
should be limited. Sometimes, it could be advantageous to vary the bolus presentation with a
break during the feed. With older children, the same eect is produced by varying consisten-
cies. The same strategies should also be considered in tube-fed children (NGT or PEG/JPEG)
when the possibility of assuming per os even a single consistency is veried.
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The time windows in the physiological growth of the eectors, previously mentioned, should
be considered and respected, as far as possible. The use of devices or adapted utensils has
the purpose of fractioning the presentation of the bolus, in terms of volume and speed: with
younger children, paciers in dierent shapes and with dierent holes can be used, while
with older ones, utensils with modied handles are more appropriate [41, 42]. The use of
maneuvers (forced swallowing, Mendelsohn, supragloic, super-supragloic, and Masako)
changes the timing and strength of the swallowing act: their implementation requires that the
child can learn them and be motivated for their execution. Relatively simpler is the use of pos-
tures, which can also be implemented passively, very small children can be held in the arms,
or older children can be placed in adjustable seating [43]. The use of oromotor exercises [44]
provides active or passive activities of the eectors, always without the use of foods. These
exercises are aimed at optimizing the eciency of the lips, jaw, tongue, soft palate, pharynx,
larynx, and respiratory muscles. Sensory stimulations act on the swallowing reex. These
gustatory, thermal, or tactile stimulations can be applied on dierent eectors: cheeks, lips,
and tongue. They are indicated for children with reduced responses or reduced opportunities
for stimulation. At other times, it is possible to intervene on children who have an excessive
response or aversion to stimulations: in this case, the treatment is expected to reduce the
reexivity of the child.
Author details
Daniele Farneti1* and Elisabea Genovese2
*Address all correspondence to: lele.doc@libero.it
1 Audiology and Phoniatry Service, AUSL della Romagna, Infermi Hospital, Rimini, Italy
2 Audiology Service, University of Modena and Reggio Emilia, Policlinico Hospital of
Modena, Italy
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