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Reflux and dysphagia overview
The process of feeding can be influenced by various biological, psychological, socio-cultural and environmental factors.1 Feeding problems are estimated to occur in 50% of children with normal growth and 85% of children with growth disorders.2,3 Gastrointestinal dysfunctions, such as reflux and dysphagia, are among common medical conditions that predispose infants to feeding issues.
Dysphagia, an immediate risk
The act of swallowing is complex. It involves coordination between neural reflexes and voluntary effort that matures with development.4 It has been shown that, in addition to an abnormality in neural or anatomical development, paediatric dysphagia may result from a disrupted hindbrain.4,5
Approximately 1% of children in the general population will experience swallowing difficulties. The incidence rate is much higher in children with cerebral palsy, traumatic brain injury, and airway malformation.6 Prematurity, reflux, congenital heart defects, autism, and iatrogenic complications such as tube feeding can be associated with dysphagia.6,7,8
Dysphagia can be serious.
Recent upper respiratory illness may be a sign of aspiration with oral feeds.2,7 A lack of weight gain in the past 2 to 3 months can have a detrimental effect on brain development and overall growth.7 Therefore, early diagnosis and intervention are essential to minimise complications and ensure optimal growth and maturation during crucial developmental years.7
Gastro-oesophageal reflux (GER), not always innocent
The involuntary passage of gastric contents into the oesophagus is a common physiological phenomenon in infants (40% are affected).9 Although worrying for parents, it usually resolves by the time infants reach their 12 months.10
However, GER can evolve into a more serious form: Gastro-oesophageal reflux disease (GERD). While GER is physiological, GERD is pathological.2 GERD occurs when10:
- GER causes symptoms, such as discomfort or pain, severe enough to merit medical treatment
- GER has associated complications, such as oesophagitis or pulmonary aspiration
GERD has been shown to contribute to dysphagia by reducing the mucosal sensation of the upper digestive tract.2,11
Feeding and health consequences
Feeding is an intricate process. It involves several steps1:
- The biological regulation of appetite and satiety
- The availability of food
- The passage of food into the mouth
- The preparation of bolus in the mouth
Various factors (biological, psychological, socio-cultural, or environmental) can affect the feeding process and lead to problems. Organic factors associated with upper gastrointestinal dysfunction, such as GERD and dysphagia, are also causes of feeding problems.1
In healthy children, these problems typically resolve with time.3 Serious issues that result in growth failure or nutritional deficiencies are uncommon in mostly healthy children who are developing and growing normally.3
However, some infants may be affected by a medical condition that requires longer-term support. Without adequate support, dysphagia and reflux can compromise their feeding and nutritional status, resulting in short- and long-term health consequences.
Diagnosing upper GI tract issues
The presenting symptoms of dysphagia vary depending on the cause of the dysphagia. However, the evaluation of children with feeding disorders is not standardised (no validated screening questionnaire). Nevertheless, the following ‘red flag’ symptoms should prompt to seek evaluation for feeding disorders2:
- Prolonged feeding time
- Little interest in feeding or food refusal
- Posturing, such as back arching and neck extension
- Failure to thrive
- Nasal regurgitation
- Wet respirations during and after feeding
- Increased effort in breathing
The evaluation should begin with a thorough history and physical examination performed by a physician.2
The next steps include common examinations such as4:
- Bedside swallow evaluation
- Upper gastrointestinal series
- Video fluoroscopic swallow study
- Flexible endoscopic evaluation of swallowing
- Flexible endoscopic evaluation of swallowing plus sensory testing
Because of the high rate of GER in infancy, it is important to distinguish between what is physiological and what is a pathological reaction or symptom. For example, in physiological regurgitation the process is mostly passive or effortless.9 Symptoms that are troublesome or cause pathological complications include2,9,10:
- Weight loss or inadequate weight gain
- Crying and fussing during and after feeding
- Emesis and/or haematemesis
- Bad breath
- Gagging or choking at the end of feeding
- Sleeping disturbance and frequent night waking
- Abdominal pain
- Dental erosion
- Dystonic neck posturing (Sandifer syndrome)
- Respiratory symptoms (aspiration, recurrent pneumonia, chronic stridor, wheezing)
These symptoms are often non-specific, and may also be caused by cow’s milk protein allergy (CMPA) or constipation.9,10 Therefore, thorough medical history and examination are crucial for appropriate diagnosis and management.9
Principles of management
A complete medical evaluation is essential to manage children with dysphagia or reflux.
Children with dysphagia benefit from multidisciplinary efforts. The team may consist of paediatricians, developmental paediatricians, neurologists, otolaryngologists, pulmonologists, gastroenterologists, dieticians and speech language pathologists (SLP).2
The first-line treatment is often feeding therapy. It may consist of:
- Altering the means of food delivery, including the nipple flow or spoon
- Changing the feeding position
- Pacing the feeds in an attempt to improve the suck-swallow-breathe sequence
If these measures are not successful, the consistency of the food bolus may need to be thickened. Thickeners change the swallowing mechanics and improve pacing during feeds by slowing bolus transit and improving bolus cohesion during swallow.2
Other options include2:
- Sensory and motor-exercises to improve strength, movement, and coordination of the lips, tongue, jaw, soft palate, and pharyngeal muscles2
- Surgical management, which is indicated when an anatomical abnormality is identified as the cause of dysphagia
In most cases, no treatment is necessary for GER apart from reassurance, because the condition is benign and self-limiting. However, if regurgitation is frequent and problematic, thickened feeds, postural therapy and lifestyle changes should be considered.12 It has been shown that the use of thickened formula is associated with increased weight gain and is superior to postural therapy in reducing episodes of regurgitation.12
In conclusion, maintaining oral feeding is the preferred choice to ensure adequate nutrition for infants with dysphagia and reflux. Current NASPGHAN and ESPGHAN guidelines recommend using thickeners that will help manage drinking and feeding in infants and young children with:
- dysphagia, aspiration, or GERD
- regurgitation or vomiting
Not all thickeners are the same. The right thickener must support safe oral feeding in young children with dysphagia or reflux in order to:
- Ensure safe and enjoyable feeding
- Improve food appreciation and diet diversification
- Improve nutritional status and hydration
Improving children’s oral feeding experience
The right thickener will help:
- Reduce the risk of aspiration, laryngeal penetration, gastro-oesophageal reflux disease (GERD) and respiratory infection
- Reduce regurgitation, reflux and vomiting
- Re-establish adequate feeding and hydration
Preserving the original taste of liquid
A more palatable liquid will:
- Help children develop their sense of taste
- Increase drink enjoyment and diversification
- Improve the positive experience of oral feeding and long-term taste and swallowing education
Providing the right and consistent level of thickness in all liquids
Appropriate thickness in all liquids is important to ensure safe drinking and support natural swallowing:
*Locust bean gum is also known as carob gum.
Thickeners that over-thicken liquids can lead to dehydration and choking, while thickeners that do not thicken liquids sufficiently can cause aspiration, coughing, nasal regurgitation and laryngeal penetration.
Providing the right level of thickness in liquids to support each child’s needs
Drink thickness required by each child varies according to their age and extent of dysphagia. The right thickener should provide the recommended IDDSI (International Dysphagia Diet Standardisation Initiative) thickness (levels 1 to 4), to ensure safe drinking according to children’s needs:
Thickeners should be easy to prepare according to IDDSI standards:
1. Sdravou K, et al. Ann Gastroenterol. 2019;32(3):217-33.
2. Lawlor CM and Choi S. JAMA Otolaryngol Head Neck Surg. 2020;146(2):183-91.
3. Borowitz KC and Borowitz SM. Pediatr Clin North Am. 2018;65(1):59-72.
4. Kakodkar K and Schroeder JW. Pediatr Clin North Am. 2013;60(4):969-77.
5. LaMantia AS, et al. Dev Biol. 2016;409(2):329-42.
6. Dodrill P and Gosa MM. Ann Nutr Metab. 2015;66(Suppl 5):24-31.
7. Prasse JE and Kikano GE. Clin Pediatr (Phila). 2009;48(3):247-51.
8. Miller CK, et al. Int J Pediatr Otorhinolaryngol. 2009;73(4):573-9.
9. Rybak A, et al. Int J Mol Sci. 2017;18(8):1671.
10. Davies I, et al. BMJ. 2015;350:g7703.
11. Durvasula VSPB, et al. Otolaryngol Clin North Am. 2014;47(5):691-720.
12. Leung AK and Hon KL. Drugs Context. 2019;8:212591.