Hard To Swallow: Assessing Pediatric Dysphagia

[Dr. Nikhila Raol]
Yes. Three to six months, I think, or under three months, I think it's most commonly we're seeing these kids who are breastfed and coughing and choking with breastfeeding and may have some typical latch issues. I will say, I know it's super controversial and we're not going to get into the big tongue-tie conversation here, but I think that's one where some of these families when they come to us at that age range, they are having difficulty breastfeeding or they already had procedures done, like they went somewhere and got their tongue tie clipped and it didn't fix them. We're looking at what else could it be. Certainly, something that's impairing the suck, swallow, breathe mechanism is really common. I would say the two most common things we probably see are laryngomalacia and ankyloglossia in that age group, which doesn't mean that we always have to do surgery.

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[Dr. Gopi Shah]
Then once they get to like, nine to twelve months, are these the babies that they were fine with breast milk, but now we're trying solids or, "well, they always had something going on, but they slid by and now it's an issue"?

[Dr. Nikhila Raol]
Yes, I think you touched on both types of presentations that we see. Sometimes we'll see that they were just getting by okay, and now they're introducing the spoon and they can't really maneuver things well in their mouth. They may be coughing and choking on these things, or they may just be refusing. I think one extreme case I can actually think of is a kid who came to the behavioral program around eleven months of age and it had some breastfeeding issues early on, but not an obvious tongue tie that I think someone would say, "oh, just clip it and it'll fix everything." It had begun to refuse feedings, had an NG tube placed, ended up coming to the program because it was refusing solids, all these things, and actually ultimately got a G tube. At the same time that they got the G tube, because our astute speech-language pathologist said, "it just seems like they can't lateralize their tongue well with purees and stuff, other solids that they're taking."

We said, "Okay, they're already going under for the G tube, let's just clip it and see if it fixes it." Literally in the feeding program, the next three meals, they were already taking much more by mouth and the behaviors we think of like packing and interior expulsion and things like that, that we don't normally think about for a typical dysphagia aspiration type of stuff, that significantly improved. You do get that stuff in the history early on if you ask for it, but at that time it doesn't necessarily seem like a big issue because there's no obvious anatomic issue that we can just say, "oh, this will fix everything." Now I once had someone say to me, dysphagia is not an emergency. Absolutely, I agree with that statement, but I do think of it as somewhat of an urgency because now I see these kids in the whole spectrum of pediatric feeding disorder when if we don't manage the dysphagia early, then it starts to become behavioral in nature because it doesn't feel good.

It's either a lot of work to feed or it's going the wrong way or things like that has really changed how I support these families and also the urgency with which we do something for them.

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[Dr. Gopi Shah]
Every once in a while, especially if it's a newborn, the first four to six weeks, you worry about weight and failure to thrive. Do you have babies like that and to where you're like, maybe you need to go to the ER. Are there any red flags that you can tell us about?

[Dr. Nikhila Raol]
Yes. I would say definitely weight is a big issue. We trend weight really closely. We also look at if they have severe nasal congestion and that could be, we think about rhinitis of infancy and things like that typically like we do as otolaryngologists. We find that sometimes if they're not strong, like their oral skills are not strong enough, they could actually have some nasopharyngeal regurgitation because they're not pushing the liquid down with enough force or they're not controlling it well enough that some of it actually goes up their nose.

Then of course, with like laryngomalacia and suck, swallow, breathe and things like that, those are going to affect their ability to gain weight. Sometimes what we do is if we feel really like a kiddo is, it's not appropriate for outpatient management. There's not time, we do think of it as more urgent or emergent. We will send them to get admitted and get an NG tube placed with the plan for doing as much workup or intervention as we can as an inpatient. Then just making sure that the kid has adequate nutrition with the feeding tube, but also working up all of the potential causes so that hopefully the feeding tube is very much temporary

[Dr. Nikhila Raol]
I do a routine otolaryngology exam, but when I focus on, when I'm doing my initial exam, I'll look at tongue motion, lateralization, where the frenulum inserts into the tongue. I will tell you, I strongly dislike the terms anterior and posterior ankyloglossia. I just look at for the kid, how much free tongue do they have and how much can they move it around? Then I'll look at the palate, how high arch the palate is. I'll look at the tonsils because tonsils can definitely impact feeding. I think that has been understudied. Honestly, I can only think of one study off the top of my head that was done subjectively with parents saying that swallowing improved when their tonsils were, kids had their tonsils removed for other reasons, but they did get better.

Those are my routine things that I'll look at. Obviously, I look at the palate, look for, if there could be submucous cleft or bifidity of the uvula. If you come see me in clinic, you're probably going to get a FEES. That's what's become a part of our exam and workup. The initial regular physical exam focuses a lot on the oral cavity and oropharynx. I'll also look in the nasal cavity and see, do they have significantly narrowed nasal passages? Do they look very congested, as that can definitely impact the ability to coordinate sucking, swallowing, and breathing.

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[Dr. Gopi Shah]
All right. Let's talk about the FEES. Tell us sort of what is your setup like? What are some of the tricks or tips that you have that seem to work with you? If you can't see, how do when to stop, or temporize the situation?

[Dr. Nikhila Raol]
I think, the most important thing is to have a really good speech language pathologist who is comfortable with FEES, and not just comfortable with FEES, but comfortable with kids being uncomfortable during the exam. We've seen that at least in infants under one, under maybe 10 months and under, we can typically get them to calm enough to get something in them. You might have to wait two or three minutes for them to calm down. Don't give up. That's the biggest advice I would give you is don't give up too quick. You have to prep the families for this too.

We do allow parents, if they're comfortable, to stay in the exam room with us. I always advocate for the parent, unless we're breastfeeding, for the parent not being a part of the feeding. I don't like to associate that, I don't like the kids to have that association as much as possible. On our good days, when we have two SLPs available, one will hold the baby, I will drop the scope, and then the other will feed the baby. If we don't, then we'll involve the parents if we don't have another choice, if we only have one SLP available. We always make sure the parent is comfortable with being the bad guy a little bit.

We do use green dye. I know some other places have talked about using a white dye because of how it sticks to the surrounding tissues. We like the green, it has worked well for us. When we're doing breastfeeding FEES, you can either come from in front of the baby, or come over the shoulder of mom, whatever is more ergonomically feasible for you. Then we'll usually let the baby start feeding first, and then we'll pull off, put a little green dye either in the mouth or on the nipple, mom's nipple, and then let them start feeding again.

Now, it doesn't always work, the green doesn't always make it where we want it to. Even the breast milk has some color to it, so it's usually enough for us to be able to see. Worst case scenario, if we cannot get a baby to calm down, we do take a little liquid in a syringe, and we'll squirt it into the cheek, and then that forces them to control it as best as we can. We always note all of these things on our documentation, so we know, this is not a natural way the baby feeds, it's squirting something in their mouth.

It can help us identify potentially a site of entry. When we're doing bottle feeding, we'll try multiple different thicknesses, we'll try different nipple flow rates, and then if the baby's old enough, we'll try some purees. like I said, the two keys are having patience and having a good SLP. Then if you just cannot get good information, they're just not cooperating, we'll just pull the scope out and do a clinical evaluation.

You were talking about when you can't see. Usually, when you can't see, at least in my experience, it's one of two things. One, it's the baby just can't hold still enough, and those days I'll say, ah, the baby won, we lost. We lost this battle. Maybe that happens about 15%, 20% of the time.