Your child’s primary physician can assess and manage problems when they first begin. Speech and occupational therapists have training in the areas of sensory and motor issues of the mouth for assessing feeding skills. A speech therapist, along with a radiologist, performs a radiological study for assessing aspiration. Additional assessments may involve an otolaryngologist (ENT) to assess tonsils, adenoids or the larynx, a gastroenterologist to consider gastroesophageal reflux disease (GERD), and/or a dietician to assess calories, hydration and nutrition.
Swallowing and Dysphagia
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Swallowing is an automatic function that is controlled by the brain. Dysphagia is the medical term for having difficulty swallowing. Some children with SNI will exhibit signs of dysphagia at birth, while others may develop dysphagia over time as a result of increasing problems with the brain. When the swallowing motion does not work properly, your child may cough or gag. Food, liquid or even just saliva can be aspirated, meaning that it gets into the lungs (and may cause pneumonia). Children with swallowing difficulties can also have trouble taking in enough food and liquid to keep themselves hydrated and well-nourished. Children who cannot sit upright or stand may have more trouble with dysphagia since they do not have gravity helping move food down into their stomach.
Swallowing can be broken down into three phases:
Oral Phase
During the oral phase, sucking or chewing moves food from the mouth to the throat.
Pharyngeal Phase
In this phase, food or liquid moves down the throat and signals are sent from the brain to close off the airway to prevent choking and the risk of food or liquid entering the airway and lungs, potentially a cause of pneumonia.
Esophageal Phase
The third phase happens when muscles in the throat contract to move food or liquids through the esophagus (the tube connecting the throat to the stomach) and into the stomach.
Assessing Your Child’s Feeding and Swallowing
Speech and occupational therapists help children with difficulties eating and drinking. Speech therapists are traditionally educated in the anatomy and physiology of the swallowing mechanism (i.e., head and neck), while occupational therapists have extensive education in how individuals process sensations and coordinate their movements in response. Both professionals may hold additional certifications, such as a lactation consultant. Speech therapists can become board-certified swallowing specialists under their professional licensure. Either of these professionals may be a good fit for assessing your child’s feeding and swallowing impairment.
A typical feeding and swallowing assessment should include observing your child eating and drinking foods and liquids from their typical diet, either eating independently or being fed. The therapist will observe how your child is currently eating and will make recommendations.. These may include modifications to your child’s mealtime environment (e.g., where they are seated, how they are positioned, how they are being fed), dietary textures (e.g., chopping foods, offering purees, thickening liquids), flavors (e.g., increasing intensity of flavors), or promotion of oral motor skills (e.g., placing food items on the side of the mouth to minimize swallowing solid pieces whole and encourage chewing, teaching straw drinking).
Testing
It may be recommended that your child have a modified barium swallow study (MBS), also known as a videofluoroscopic swallow study (VFSS) or swallow study, to assess swallowing safety. The MBS is a special x-ray used to determine if food or liquid is entering the lungs and causing aspiration. During an MBS the medical team will observe the coordination of your child’s swallowing. Your child will be given foods of different textures and sizes (e.g., pudding, bread, cracker) to chew and swallow and will be asked to drink liquids of different consistencies. You may be asked to bring foods your child typically eats. The foods/drinks are mixed with barium, allowing the radiologist to observe food moving from the mouth to the stomach on the x-ray. Your child may be asked to move their head, sit upright, or lean back to help the radiologist determine whether different positions help or hinder the swallowing process.
It is a natural instinct to want to feed your child, and to see them enjoying their food. As you begin to see difficulties in drinking, chewing and swallowing, you may feel both frustrated and sad. It may take longer to prepare your child’s food and to feed them. You may notice that your child is enjoying their food less at the same time that you are noticing your own feelings about the process.
Deciding whether to pursue a swallow study can be influenced by how the results will be used. Some families feel more confident about allowing a feeding tube after a swallow study confirms that the tube would help their child get nutrition and hydration more safely and predictably. If feeding takes a lot of time, the prospect of having more time for other activities may also be appealing. Depending on your child’s condition and tolerance, there may be a solution that includes some feeding through a tube and other feeding by mouth. You can also develop a plan to introduce the tube over a period of time.
Some families believe that they would not want to restrict their child’s feeding by mouth, even if a swallow study were to indicate that a tube would be helpful. If you feel this way, it is also important to understand how your child is likely to react to their feeding over time; for example, how and whether they will get adequate nutrition and hydration. Is there a possibility that your feelings would change based on the study results? These are topics to explore with the medical team. There are no right or wrong answers, only what you want for your child and for your family.
