Swallowing is a complicated process that is both voluntary and involuntary. Many people take swallowing for granted since it becomes second nature to most. Observe the complexity of a swallow by paying close attention to the many stages involved when taking a bite of food or sip of water. For some children, eating and swallowing can cause numerous difficulties leading to poor growth, failure to gain weight and inadequate nutrition. The medical term for swallow difficulty is called Dysphagia.
There are three types of Dysphagia: oral, oropharyngeal and esophageal. For the purpose of this article, we will focus on oral and oropharyngeal dysphagia as speech therapists can diagnose and treat these types.
Stages of a Swallow
There are four stages to an efficient swallow: oral preparation, oral stage, pharyngeal, and esophageal. Dysphagia can occur in one or more of the four phases of a swallow, possibly leading to food or liquid entering the airway causing aspiration.
Oral Preparation: In this stage, the teeth chew the food as saliva adds moisture in order to create a cohesive ball or bolus.
Signs/symptoms of difficulty in this stage:
Child has trouble chewing a variety of textured food that should be age-appropriate
Liquid or food spills out of the mouth while eating
Excessive amounts of drooling during meals or between meals
Takes over 30 minutes to finish a meal
Over-stuffing their mouth with food or only allowing small amounts of food into mouth
Oral Stage: In this stage, the person voluntarily pushes the food to the back of the mouth by the tongue in preparation to swallow food.
Signs/symptoms of difficulty in this stage:
Child holds food in the mouth for a long time before swallowing
Requires multiple swallows on one piece of food
Some food remains in mouth after swallowing
Pharyngeal Stage: The food passes through the throat into the esophagus. During this stage, the windpipe or airway is protected by a flap called the epiglottis so food does not enter the lungs.
Signs/symptoms of difficulty in this stage:
Breathing difficulty during meals as noticed by skin color change, changes in heart rate, or increased breathing
Coughing and choking during or after meals
Spitting up, vomiting or gagging during meals
After or during meals, the child talks with a raspy or wet sounding voice
Frequent congestion in chest after meals
Esophageal stage: Food travels from the esophagus into the stomach during this stage.
Signs/symptoms of difficulty:
Complaints of stomach pain
Sensation of food coming back up the pipe
Excess vomiting after meals
Signs and symptoms of swallowing problems may be difficult to notice if a child does not express complaints. Other signs to watch for during meals may include the following:
Crying during mealtimes because the child does not want to eat
Refusal of food and/or certain textures
Distracting behaviors such as excess talking, frequently getting up, or negative behaviors
Long meal times due to slow eating or refusal of meals
Facial grimacing during mealtime for older children and arching of the back for infants
For infants, decreased responsiveness such as blank stares during feedings
Food or liquid coming out of nose during or after feedings
There are two other types of feeding/swallowing disorders related to the oral preparatory stage: oral and sensory aversion.
Oral aversion is usually a self-defense mechanism that kids use to avoid foods that they know they cannot process due to lack of skills. Chewing and swallowing can be a very complicated process requiring adequate jaw strength, tongue elevation and lateralization and rhythmic chewing and coordination. For children that lack strength and/or coordination in one of these areas, swallowing can be complicated and even dangerous. To assess if your child may have oral motor difficulties, take a bite of a food, such as a cookie, and count the amount of chews it takes you before swallowing. Observe your child eating the same type of cookie and count the amount of chews it takes him or her, while observing the jaw movements. Adequate jaw movements should be a circular/diagonal motion, not simply up and down as in a munching pattern.
Sensory aversion is usually a symptom of a sensory-processing disorder. Sensory aversions may appear as hypo-sensitivity (lack of sensory awareness) or hyper-sensitivity (excessive sensory awareness). If the child is hyposensitive, the child lacks awareness of the food impacting his/her ability to manipulate the food before swallowing. Symptoms may appear as over-stuffing the mouth, leftover food in the mouth and excess drooling. If the child is hypersensitive, symptoms may include vomiting, gagging, spitting up food or refusing behaviors at dinner.
Consequences of a swallowing disorder
Difficulty with swallowing may cause an array of complications if not properly treated. These complications may include, but are not limited to, the following:
Malnutrition: Malnutrition is when the body is not receiving enough nutrients and vitamins through the consumption of food needed to keep tissues and organs working properly. Malnutrition may occur due to undernourishment or overnourishment. Undernutrition is when the child is not receiving essential nutrients due to lack of food consumption. Overnutrition occurs when the child consumes an abundance of food but lacks the necessary vitamins in those foods. Overnutrition may also involve lack of exercise, excessive eating, and/or taking too many vitamin supplements.
Signs of malnutrition:
Pale and dry skin complexion
Thin hair or hair loss
Gums that bleed easily
Swollen or cracked tongue
Sensitivity to light
Rashes or changes in skin pigmentation
Treatment for malnutrition: Pediatricians will recommend speech therapy as well as working closely with a dietician to increase oral intake of nutritious food. If malnutrition continues, treatment may involve inserting a thin tube through the nose that carefully enters the stomach or small intestine. If long-term tube feeding is recommended, a tube may be placed directly into the stomach or small intestine through an incision in the abdomen.
Dehydration: Dehydration is when children lose an excessive amount of water and salts without replacing the fluids through diet.
Signs of dehydration:
Limited tears when crying
Decreased need to go to the bathroom
Eyes that have a sunken look
Dry or sticky mouth
Dizziness or lethargic tendencies
Treatment for dehydration: Treatment varies based on the severity of dehydration. For mild cases, children will be advised to drink plenty of fluids (preferably water) and rest in a cool room. For more severe cases, children may be required to drink oral rehydration solution (ORS) which is a combination of sugar and salts that rehydrate the body. If a child refuses liquids, alternative feedings such as tube feeding may be required.
Aspiration pneumonia: When food, saliva or stomach acid enters your lungs, it is called pulmonary aspiration. Healthy lungs are able to clear foreign bacteria, but if the lungs are unable to clear the food or liquid, pneumonia may occur.
Symptoms of aspiration pneumonia:
Shortness of breath
Excessive coughing, and sometimes coughing up blood or phlegm
Chest pain or wheezing
Treatment of aspiration pneumonia: Treatment usually involves antibiotics and supportive care for breathing such as oxygen, steroids or breathing machine.
Ongoing need for a feeding tube. As mentioned before, a feeding tube may be deemed necessary if your child is unable to consume enough nutrition through the mouth. There are four types of feeding tubes: nasogastric tubes, nasoduodenal tubes, nasojejunal tubes and gastric or gastrostomy tubes. (Our next blog will focus on the types of feeding tubes and provide more information.)
Inadequate weight gain: Attending regular pediatrician check-ups can ensure your child is growing at a healthy rate.
Treatment for Swallowing Disorders
Treatment depends on the child’s age, health conditions, physical and cognitive abilities, and most importantly, specific feeding and swallowing concerns. Feeding therapy is a a team approach consisting of the child, speech therapist, dietician, occupational therapist, pediatrician and family members. The main goals of therapy are to support adequate nutrition and hydration, minimize complication risk and maximize the child and family’s quality of life.
If you feel your child may have difficulty with any stage of the swallow process, express concerns with your pediatrician immediately. Lumiere Children’s Therapy can provide feeding therapy to help your child reach their highest potential for adequate nutrition and quality of life. Contact us here.
Children's Hospital. “Dysphagia.” Children's Hospital of Philadelphia, The Children's Hospital of Philadelphia, 24 Aug. 2014, www.chop.edu/conditions-diseases/dysphagia.
“Dehydration.” Edited by Patricia Solo-Josephson, KidsHealth, The Nemours Foundation, June 2017, kidshealth.org/en/parents/dehydration.html.
“Pediatric Dysphagia: Causes.” Averican Speech-Language-Hearing Association, ASHA, www.asha.org/PRPSpecificTopic.aspx?folderid=8589934965§ion=Causes.
Lowsky, MS, CCC-SLP, Debra C. “Food Refusal - Is It Oral Motor or Sensory Related?” ARK Therapeutic, 10 Nov. 2014, www.arktherapeutic.com/blog/food-refusal-is-it-oral-motor-or-sensory-related/
“Malnutrition.” Is There Really Any Benefit to Multivitamins?, www.hopkinsmedicine.org/healthlibrary/conditions/adult/pediatrics/malnutrition_22,Malnutrition.
“Tube Types.” Feeding Tube Awareness Foundation, www.feedingtubeawareness.org/tube-feeding-basics/tubetypes/.