What you need to know about Dysphagia

What is it?

I think it’s really important to iron out what Dysphagia actually means. You may have come across the term when being referred to Speech and Language Therapy for eating and drinking support. Or you may not. Either way, having some understanding of this will underpin all the work you do with your child to help them make progress. 

Dysphagia is the medical umbrella term for eating, drinking and swallowing difficulties. These difficulties can present from birth to death and for many different reasons.

What causes dysphagia?

In infants and children, Dysphagia is usually caused by developmental difficulties, birth abnormalities or prematurity. Sometimes, it can be caused by childhood illnesses such as cancer or chronic lung disease. Sometimes, children who experience lots of vomiting can be put off eating and drinking and sometimes, there is no organic cause at all and it can just be something that happens. https://www.cedars-sinai.org/health-library/diseases-and-conditions---pediatrics/d/dysphagia.html

The normal swallow 

You may be surprised to learn that swallowing is not a reflex and isn't subconscious. We mean to do it and plan to make it happen. There are 4 stages to a swallow:

1. Anticipatory stage

2. Oral stage

3. Pharyngeal stage 

4. Oesophageal stage

We need to line all these up and they need to work in order for a swallow to happen successfully.

Have a look at this clip and see how it works.

The stages in more detail

1. The anticipatory stage is all about what happens before the meal or swallow. Literally getting the juices going. This is where the senses really start to come together.

When we are approaching a mealtime, we start to receive lots of different sensory information. We might be cooking the meal which is a great cue for anticipation. We might hear the sizzling of a pan, a whisk whirring or if you're anything like me the smoke alarm buzzing! A lot of the strategies we discuss will have a major focus on this stage rather than the actual act of swallowing.

2. The oral stage is what's happening once the food or drink enters the mouth, how it’s munched, chewed, sucked and moved back ready to swallow. There are different developmental stages to learning the oral stage. The aim of this stage is to taste, to build saliva, to break down and form a ‘bolus’ which is when the food has become one ball of soft food, and then the tongue gets it in the right position for stage 3. Usually, an SLT will identify what stage your child is at and work from that point forwards. 

3. The pharyngeal stage is where the swallow is triggered. Once the bolus is in the right position. The velum (membranous flap) lifts up and closes off the airway that goes up through the nose at the back of the throat. This stops any food or drink from escaping through the nose; I’m sure you’ve seen your child do that once or twice! There is also another flap - called the epiglottis that works as a guide for the airway. When the swallow is activated, it moves from over the oesophagus (food pipe) and covers the trachea (wind pipe) to make sure the food/drink travels down the right way and doesn’t cause choking. 

4 The oesophageal stage is where the food/drink is moved down the oesophagus to the stomach. The oesophagus works a bit like a snake, using its muscles to push the food down stage by stage. It then has one final push through the lower oesophageal sphincter (the tight hole into the tummy) so the food can be digested.

What about when it goes wrong?

Swallowing difficulties happen for many different reasons. Generally, SLTs talk about levels of risk when they are talking about the severity of the swallowing difficulty. They mean how likely is aspiration going to happen for that child. Aspiration is when food / drink / saliva or other foreign objects enter the airway or ‘go down the wrong way’. This can happen to anyone at any time; we've all been there coughing and spluttering at the dinner table. Individuals are classed as having a swallowing difficulty if the frequency of symptoms of aspiration starts to increase.

Something that shouldn't be in the lungs can cause damage. It's hard to say how much damage, some children might get a chest infection every time this happens to them and others might not but be experiencing damage over a period of time, others might not get ill at all. SLTs work with care givers and  multidisciplinary teams to manage the risk, prevent further risk and improve skills to continue to make progress with eating and drinking. Signs and symptoms of aspiration are:

• Coughing

• Choking

• Watery eyes or tear drops when eating or drinking

• Changes to colour - turning red or developing a blue tinge around the nose and lips

• Changes to breathing - breathing usually becomes more rapid or more difficult and is harder work.

Identifying Dysphagia

SLTs will carry out consultations, assessment and observations of a child eating and drinking to determine whether they feel dysphagia is present or not. If it is, working to reduce the risk of aspiration will be the primary goal. Once the risk is managed then working on other aspects of eating and drinking such as building variety or developing skills will follow.

I urge you to seek support by speaking to your local healthcare provider if you feel your child is experiencing swallowing difficulties.

Why it's important to understand this first..

There is such a broad range of eating and drinking difficulties in infants and children. More often than not, there is no dysphagia present. However, many caregivers and care providers don't always have the information to know that some difficulties will be present without having a swallowing difficulty and a different course of action is required.

This service is for those of you who have children in your care that have eating and drinking difficulties without swallowing difficulties present because there isn't much out there for you. Stay tuned for more information that could help your child.