Some children will be referred for a feeding and swallowing evaluation because of solid food dysphagia or difficulty swallowing solids. Caregivers might describe coughing, choking or gagging on solid food during mealtime.
What does this mean and how should it be evaluated? Solid food dysphagia can be related to several different etiologies.
In adult patients, solid food dysphagia is typically related to gastrointestinal issues such as gastroesophageal reflux, “globas pharyngeus” (the feeling of food getting stuck which is a common symptom in adult dysphagia) or a motility disorder where it is difficult to move the solid food through the esophagus. Some patients with GERD, can have a tightening of the upper esophageal sphincter which may make it more difficult to pass solid textures through.Therefore for some children, it may be related to gastroesophageal reflux. These children may also have other symptoms such as gagging, bad breath, poor sleeping, audible regurgitation, vomiting or spitting up.
For other children, it may be related to poor chewing skills. Caregivers may be feeding solid food textures that are too hard for the child to manipulate. If the child is swallowing pieces of food whole it may cause choking, coughing, or put the child at risk for airway obstruction. This is often the case when a child is stuck in an immature oral pattern or has oral motor delay. Caregivers may be feeding “age appropriate” foods not realizing that the child’s oral-motor skills are not at age level and therefore not competent for those harder textures. These children may also eat less during the meal because eating is too much work. They may hold or store food in their cheeks or chew food and then spit it out.
Children with eosinophillic esophagitis may have difficulty swallowing solid foods due to inflammation or narrowing in the esophagus. The may have symptoms of coughing or choking on solid foods. This child may also have food allergy/ intolerance or symptoms related to allergy such as eczema, rash, or hives.
Large Tonsils and Adenoids
Children with large tonsils and adenoids may also have difficulty moving solids from the oral cavity into the pharynx. They may feel that foods are getting stuck or that is it difficult to breathe while manipulating solid textures. These children may also have signs and symptoms of upper airway patency issues such as an open mouth posture, mouth breathing, drooling, and snoring at night.
How should the Feeding therapist evaluate?
Take a thorough case history: It is always important to take a detailed case history asking questions that help to decipher what the problem is.
Oral Motor Exam: assess for structural abnormalities and upper airway patency.
Observe a feeding: Observe the child with liquids, purees and solids (if age appropriate). Carefully, assess chewing skills to determine the child’s ability.
Make recommendations to caregivers to feed a diet the child can safely swallow without choking and work with the referring physician on need for referral to specialists for further assessment.
GI issues or eosinophillic esophagitis: Refer the child to to gastroenterology for medical management and further evaluation.
Poor chewing: Make recommendations for a diet texture the child can handle and provide oral-motor therapy for chewing.
Large tonsils & adenoids or mouth breathing: Refer the child to ENT (ear, nose, and throat physician) for evaluation of the upper airway.