Central Annals of Otolaryngology and Rhinology Review Article *Corresponding author Stave Salgado Karen, Pediatric doctor specialist in Child Gastroenterologist. Ex-scholarship of the Dysphagia in Children: Gastroenterology Service of Hospitalde Pediatría S.A.M.I.C. Prof. Dr. Juan P. Garrahan, Buenos Aires – Maipú 863, CP 1006, Buenos Aires, Argentina, Tel: +54 Gastroesophageal Causes 1126387622; E-mail: Stave Salgado Karen Vanessa* Submitted: 12 March 2018 Accepted: 05 April 2018 Pediatric doctor specialist in Child Gastroenterologist, Ex-scholarship of the Published: 06 April 2018 Gastroenterology Service of Hospitalde Pediatría, Argentina ISSN: 2379-948X Copyright Abstract © 2018 Karen Vanessa Dysphagia is any disruption to the swallow sequence that results in compromise to the safety, efficiency, or adequacy of nutritional intake. Pediatric dysphagia OPEN ACCESS has focused largely on a number of specific populations at risk for swallowing difficulties, such as children with cerebral palsy, acquired/traumatic brain injury, other Keywords neuromuscular disorders, craniofacial malformations, airway malformations, congenital • Dysphagia cardiac disease, and gastrointestinal disease. • Swallowing disorders • Children The gastroesophageal disorders that cause dysphagia and swallowing/feeding • Pediatric dysphagia difficulties, such as gastroesophageal gastroesophageal reflux disease, eosinophilic esophagitis and achalasia need an early diagnosis because they can compromise quality of life and produce complications at the patients. ABBREVIATIONS UES: Upper Esophageal Sphincter; OA: Oesophageal Atresia; pharyngeal an esophageal phase. In the first phase, also known TEF: Tracheo-Oesophageal Fistula; GER: Gastroesophageal as the oral preparatory phase, the food is taken into the oral cavity, chewed and moistened with saliva, and prepared into a Esophagitis; LES: Lower Esophageal Sphincter; VFSS: Reflux; GERD: Gastroesophageal Reflux Disease; Eoe: Eosinophilic bolus, which is held between the hard palate and oral tongue. This process first becomes evident at approximately 6 months Evaluation of Swallow; UGI: Upper Gastrointestinal Series. Videofluoroscopic Swallow Study; FEES: Fiberoptic Endoscopic of age [1]. The oral phase consists of salivation, mastication INTRODUCTION toand upper the transportation esophageal sphincter of the bolus (UES); towards and the the last pharynx. phase include In the pharyngeal phase the bolus is transported through the pharynx Dysphagia refers to problems in any of phases of swallowing. transportation of the bolus through the esophagus to the stomach When referring to pediatric populations, the terms feeding [3]. and swallowing difficulties are more frequently used and are The sequence of events during the pharyngeal and becoming more common, particularly in infants born prematurely diagnostic categories associated with pediatric swallowing and esophageal phases remains the same throughout a person’s life, and in children with chronic medical conditions [1,2]. General and these events can be summarized as follows: (a) closure of the nasopharyngeal port through movement of the velum; (b) feeding difficulties include neurological conditions, anatomical pharyngeal closure through contraction of the superior, middle, anomalies, gastrointestinal disorders, conditions affecting and inferior pharyngeal constrictors; (c) closure of the vocal folds sucking swallowing and breathing coordination, and genetic with brief cessation of respiration; (d) hyolaryngeal excursion conditions [2]. and closure of the larynx through epiglottic tilt; (e) opening The consequences of dysphagia can be debilitating of the upper esophageal sphincter through relaxation of the for children, as it may lead to failure to thrive, respiratory cricopharyngeus muscle and biomechanical forces contributed complications, and compromised quality of life therefore early through hyolaryngeal excursion, and (f) peristaltic contraction of diagnosis is critical [1,2]. the esophagus to move the food or liquid into the stomach [3]. The objective of this clinical review is to provide a global In neonates and young infants, all components of swallowing understanding of the common gastroesophageal causes of are reflexive and involuntary. Later in infancy, the oral phase dysphagia in children in order to make a suitable diagnosis and comes under voluntary control, which is important to allow treatment.Normal swallowing childrenAbnormal to begin swallowing to masticate solid food. The act of swallowing includes four stages: preparatory, oral, Any disruption to the swallow sequence is called dysphagia, Cite this article: Karen Vanessa SS (2018) Dysphagia in Children: Gastroesophageal Causes. Ann Otolaryngol Rhinol 5(2): 1208. Karen Vanessa (2018) Email: [email protected] Central of nutritional intake [3]. that results in compromise to the safety, efficiency, or adequacy etiology for dysphagia. Esophagography after OA repair should be performed because of the high index of suspicion for the presence of distal congenital esophageal stricture. Endoscopy Approximately 1% of children in the general population will with biopsies allows the evaluation of the anastomosis (stricture, experience swallowing disorders, though the incidence rate is diverticulum), the esophageal mucosa (peptic, eosinophilic or much higher in infants born prematurely and in children with infectious esophagitis) and the diagnosis of congenital stenosis, chronic medical conditions [4,5]. mucosal bridge, inlet patch or extrinsic compression (vascular It is important distinguish dysphagia as a skill-based disorder, anomalies, tight fundoplication wrap) (Figure 1) [10,11]. which is very different from a behaviorally based feeding Esophageal motility can be assessed by esophageal disorder. Behavioral feeding disturbances occur when a child manometry. The patterns of esophageal dysmotility in a cohort of is unwilling to consume a fluid/food despite sufficient physical children with OA were recently described using high resolution skills to do so. are [3]: manometry and were reported abnormal in all patients, with The common presentations of pediatric dysphagia symptoms 3 types of abnormalities observed: pressurization (15%), isolated distal contractions (50%) and a peristalsis (35%) [12]. The management of dysphagia must be conducted according • Oral phase: Absent oral reflexes, primitive/neurological to the underlying cause, such as feeding adaptation treatment oral reflexes, weak suck, uncoordinated suck, immature biting of esophagitis (peptic, eosinophilic or infectious), prokinetics, and/or chewing, disordered biting and/or chewing, poor bolus surgical repair of vascular anomaly, gastrostomy tube feeding or propulsion, poor bolus containment. dilationGastroesophageal of fundoplication reflux [10]. and gastroesophageal • Pharyngeal phase: Laryngeal penetration, aspiration, reflux disease choking,Causes pharyngealof dysphagia residue, nasopharyngeal reflux. Gastroesophageal reflux (GER) is the passage of gastric The causes of dysphagia in pediatric populations are often contents into the esophagus with or without regurgitation and somewhat different than in adult patients, and children can ofvomiting. infants [7,13].Repeated expulsion of gastroesophageal contents from present with multiple variations of swallowing impairments the oral cavity in GER is reported to occur in approximately 40% [3,6,7].affecting any or all of the phases of swallowing. Table 1 summarizes common causes of dysphagia in pediatric patients Gastroesophageal causes of dysphagia Gastroesophageal reflux disease (GERD) is present when the reflux of gastric contents causes troublesome symptoms and/or Oesophageal atresia: complications. The prevalence of symptomatic or pathologic GER or GERD is estimated to occur in 10% to 20% of infants in North Oesophageal atresia (OA) is a America. Some children are at higher risk of GERD, including congenital malformation, characterized by an interruption those with neurologic impairment, obesity, esophageal achalasia, in the continuity of the oesophagus and have an incidence of hiatal hernia, prematurity, bronchopulmonary dysplasia, and OA. around 1:2500 live-births. It may be divided anatomically into GERD can contribute to persistent dysphagia by reducing mucosal 5 types with the most common being oesophageal atresia with sensation and laryngeal reactivity during the pharyngeal phase a distal tracheo-oesophageal fistula (TEF) found in around 85% of swallowing owing to mucosal injury by caustic reflex contents cases. The condition consists of a discontinuity or atresia of the [7,13]. Coppens et al, confirmed the association of dysphagia with oesophagus; with the majority of infants exhibiting a connection GERD, with or without fundoplication, in children with repaired or fistula between the oesophagus and trachea. The exceptions OA. This is in accordance with previous research, which indicates to this are children born with an isolated OA and those with an abnormal oesophageal motility as common etiologic factor [9]. H-type TEF [8,9]. In infants and toddlers, there is no symptom or symptom Dysphagia is a common problem in children with repaired complex that is diagnostic of GERD or predicts response to OA, with ranges between 45-70%. The etiology of dysphagia therapy. In older children and adolescents, as in adult patients, may include inflammatory or anatomic causes such as peptic history and physical examination may be sufficient to diagnose esophagitis, eosinophilic esophagitis,