Aspiration in Infants and Children

Safe swallowing of solid foods and liquids is the result of a complex interaction of cranial nerves and muscles of the oral cavity, pharynx, and proximal esophagus. During the voluntary oral phase, the food bolus is altered in the mouth and propelled past the pharynx where the respiratory and gastrointestinal tracts meet; precise coordinating mechanisms are crucial to prevent aspiration into the respiratory passage. Normal mechanisms of safe swallow include raising of the palate, epiglottic tilt, cord closure, primary peristalsis of the esophagus, and the tone and sequential relaxation of the upper and lower esophageal sphincters. Disorders affecting the central and peripheral nervous system and muscles of the previously noted structures, therefore, can affect swallowing mechanisms and lead to potentially dangerous sequelae.Aspiration may be defined as the accidental entry of a foreign substance into the respiratory tract. The consequences may be devastating, chronic, or subtle, ranging from sudden death to hoarseness. The aspirated material may be solid or liquid components of food, foreign bodies (eg, seeds or toys), or even saliva. Aspiration of large amounts of acidic gastric content (macroaspiration) can lead to mechanical obstruction or chemical pneumonitis, resulting in severe hypoxia. Microaspirations may stimulate upper airway neuronal elements that, in turn, may cause reflex brochospasm or laryngospasm.Aspiration may occur during a swallow or during episodes of gastroesophageal reflux (GER), which should be differentiated from each another because the diagnostic methods and management differ. GER occurs commonly in infancy. Aspiration during reflux episodes is a serious manifestation of GER, particularly in the preterm infant. However, preterm infants also are at risk of aspiration during swallowing because they exhibit poor integration and lack of coordination between swallowing and breathing. Among older infants and children, swallowing disorders are seen mostly as part of a generalized developmental or neurologic abnormality. They include cerebral palsy and mental motor delay from a variety of causes, such as hypoxic brain damage, intraventricular bleeding, central nervous system infections, trauma, or progressive neurologic diseases. The differential diagnosis should include neuromuscular diseases such as muscular dystrophy, Guillian-Barré syndrome, oropharyngeal abnormalities such as cleft palate, Pierre Robin syndrome, and laryngeal anomalies such as vocal cord paralysis from brainstem lesions or surgical trauma. Rarely, isolated cricopharyngeal dysfunction or achalasia may manifest as feeding difficulties and aspiration.Overt aspiration presents with signs and symptoms that can include gagging, choking, cyanosis, or apnea. Episodes of apnea and bradycardia are ominous signs of aspiration in preterm infants. Recurrent respiratory infections, wheezing not responding to conventional therapy, chronic cough with feeding, poor feeding, malnutrition, and excessive drooling may be subtle features of silent aspiration that often are seen in children who have neurologic impairments. The typical symptoms of vocal cord paralysis include stridor, ineffective cough, feeding difficulties, and an abnormal or weak cry. Occasionally, aspiration may be witnessed in an asymptomatic patient during a routine barium swallow.A detailed history, a complete physical examination, and a trial feeding are the basic requirements for diagnosing aspiration. A barium swallow to define the upper gastrointestinal anatomy and a radionuclear scan (“milk scan”) to quantify reflux episodes are the primary tools for diagnosing GER. A more extensive 24-hour pH study helps to establish the presence of silent GER associated with episodes of apnea or respiratory distress. The most appropriate test for diagnosing aspiration during swallowing is a modified barium swallow (MBS) or videofluoroscopy. By using different textures of foods and liquids, this study can differentiate various abnormalities of the oropharyngeal phase of swallowing.Management of aspiration includes treatment of the causative factors. The management of GER consists of positioning, thickening of feedings, and pharmacologic agents. By virtue of the nature of the causative factors, the management of swallowing dysfunction is more complex and includes alteration of food bolus, adjustment of head and neck, jaw stabilization, minimization of oral hypersensitivity, and swallowing exercises, often supervised by an occupational therapist or a speech pathologist. If aspiration is significant enough to preclude safe oral feeding, nasogastric or gastrostomy feeding may be necessary.

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