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Aspiration due to swallowing dysfunction in infants and children

Paul C Stillwell, MD
Emily M DeBoer, MD
Section Editor
George B Mallory, MD
Deputy Editor
Alison G Hoppin, MD


Aspiration is defined as the entry of foreign material into the airway below the true vocal cords. Some aspiration occurs in normal individuals, especially when the airway protective mechanisms are stressed, such as while talking, laughing, eating, or sleeping [1]. In most instances, an inconsequential amount of material is aspirated. In contrast, children with swallowing dysfunction are at risk for pathologic aspiration. The amount of aspiration that results in airway inflammation is variable and the risks are unknown. Pathologic aspiration may result in acute or chronic pulmonary disease, and impaired nutritional intake may lead to failure to thrive.

Swallowing dysfunction leading to aspiration presents major diagnostic and therapeutic challenges that often require the efforts of a coordinated multidisciplinary team consisting of the patient's primary caregiver, health care providers with expertise in swallowing (speech and occupational therapists), and selected pediatric subspecialists (pulmonologist, gastroenterologist, otolaryngologist, neurologist, and developmental pediatricians). Aerodigestive programs specializing in patients with swallowing problems are becoming common at large pediatric centers [2].


The process of swallowing matures during infancy, beginning with suckling movements in utero and progressing to the development of chewing during early childhood [3,4]. Recognition of these developmental states is important in the evaluation of swallowing disorders.

Suckling, the earliest form of sucking, begins in utero with suckling and swallowing of amniotic fluid. It is characterized by a primitive anterior to posterior movement of the tongue. In premature infants, disordered patterns of suckling with bursts and pauses can persist through 32 to 34 weeks gestational age [5]. After this time, sucking becomes more rhythmic and organized. (See "Neonatal oral feeding difficulties due to sucking and swallowing disorders".)

At three to four months of age, lateral tongue movements allow some bolus formation. By six months, children can eat pureed foods from a spoon.

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Literature review current through: Dec 2017. | This topic last updated: Dec 28, 2016.
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  1. Colombo JL, Hallberg TK. Aspiration: a common event and a clinical challenge. Pediatr Pulmonol 2012; 47:317.
  2. DeBoer EM, Prager JD, Ruiz AG, et al. Multidisciplinary care of children with repaired esophageal atresia and tracheoesophageal fistula. Pediatr Pulmonol 2016; 51:576.
  3. Darrow DH, Harley CM. Evaluation of swallowing disorders in children. Otolaryngol Clin North Am 1998; 31:405.
  4. Derkay CS, Schechter GL. Anatomy and physiology of pediatric swallowing disorders. Otolaryngol Clin North Am 1998; 31:397.
  5. Kakodkar K, Schroeder JW Jr. Pediatric dysphagia. Pediatr Clin North Am 2013; 60:969.
  6. Domenech E, Kelly J. Swallowing disorders. Med Clin North Am 1999; 83:97.
  7. Tutor JD, Gosa MM. Dysphagia and aspiration in children. Pediatr Pulmonol 2012; 47:321.
  8. Jackson A, Maybee J, Moran MK, et al. Clinical Characteristics of Dysphagia in Children with Down Syndrome. Dysphagia 2016; 31:663.
  9. Aloysius A, Born P, Kinali M, et al. Swallowing difficulties in Duchenne muscular dystrophy: indications for feeding assessment and outcome of videofluroscopic swallow studies. Eur J Paediatr Neurol 2008; 12:239.
  10. Khoshoo V, Edell D. Previously healthy infants may have increased risk of aspiration during respiratory syncytial viral bronchiolitis. Pediatrics 1999; 104:1389.
  11. Shaker R, Milbrath M, Ren J, et al. Deglutitive aspiration in patients with tracheostomy: effect of tracheostomy on the duration of vocal cord closure. Gastroenterology 1995; 108:1357.
  12. Venkatesan NN, Pine HS, Underbrink M. Laryngopharyngeal reflux disease in children. Pediatr Clin North Am 2013; 60:865.
  13. Weir KA, McMahon S, Taylor S, Chang AB. Oropharyngeal aspiration and silent aspiration in children. Chest 2011; 140:589.
  14. Tutor JD, Srinivasan S, Gosa MM, et al. Pulmonary function in infants with swallowing dysfunction. PLoS One 2015; 10:e0123125.
  15. Arvedson JC. Assessment of pediatric dysphagia and feeding disorders: clinical and instrumental approaches. Dev Disabil Res Rev 2008; 14:118.
  16. Morton RE, Bonas R, Fourie B, Minford J. Videofluoroscopy in the assessment of feeding disorders of children with neurological problems. Dev Med Child Neurol 1993; 35:388.
  17. Wright RE, Wright FR, Carson CA. Videofluoroscopic assessment in children with severe cerebral palsy presenting with dysphagia. Pediatr Radiol 1996; 26:720.
  18. Arvedson J, Rogers B, Buck G, et al. Silent aspiration prominent in children with dysphagia. Int J Pediatr Otorhinolaryngol 1994; 28:173.
  19. Hiorns MP, Ryan MM. Current practice in paediatric videofluoroscopy. Pediatr Radiol 2006; 36:911.
  20. Hersh C, Wentland C, Sally S, et al. Radiation exposure from videofluoroscopic swallow studies in children with a type 1 laryngeal cleft and pharyngeal dysphagia: A retrospective review. Int J Pediatr Otorhinolaryngol 2016; 89:92.
  21. Delzell PB, Kraus RA, Gaisie G, Lerner GE. Laryngeal penetration: a predictor of aspiration in infants? Pediatr Radiol 1999; 29:762.
  22. Newman LA, Keckley C, Petersen MC, Hamner A. Swallowing function and medical diagnoses in infants suspected of Dysphagia. Pediatrics 2001; 108:E106.
  23. Alnassar M, Oudjhane K, Davila J. Nasogastric tubes and videofluoroscopic swallowing studies in children. Pediatr Radiol 2011; 41:317.
  24. Friedman B, Frazier JB. Deep laryngeal penetration as a predictor of aspiration. Dysphagia 2000; 15:153.
  25. da Silva AP, Lubianca Neto JF, Santoro PP. Comparison between videofluoroscopy and endoscopic evaluation of swallowing for the diagnosis of dysphagia in children. Otolaryngol Head Neck Surg 2010; 143:204.
  26. McVeagh P, Howman-Giles R, Kemp A. Pulmonary aspiration studied by radionuclide milk scanning and barium swallow roentgenography. Am J Dis Child 1987; 141:917.
  27. Baikie G, South MJ, Reddihough DS, et al. Agreement of aspiration tests using barium videofluoroscopy, salivagram, and milk scan in children with cerebral palsy. Dev Med Child Neurol 2005; 47:86.
  28. Somasundaram VH, Subramanyam P, Palaniswamy S. Salivagram revisited: justifying its routine use for the evaluation of persistent/recurrent lower respiratory tract infections in developmentally normal children. Ann Nucl Med 2012; 26:578.
  29. Drubach LA, Zurakowski D, Palmer EL 3rd, et al. Utility of salivagram in pulmonary aspiration in pediatric patients: comparison of salivagram and chest radiography. AJR Am J Roentgenol 2013; 200:437.
  30. Colombo JL, Hallberg TK. Pulmonary aspiration and lipid-laden macrophages: in search of gold (standards). Pediatr Pulmonol 1999; 28:79.
  31. Emilsson OI, Gíslason T, Olin AC, et al. Biomarkers for gastroesophageal reflux in respiratory diseases. Gastroenterol Res Pract 2013; 2013:148086.
  32. Alves LR, Soares EG, Aprile LR, et al. Chlorophyllin-stained macrophages as markers of pulmonary aspiration. Am J Respir Crit Care Med 2013; 188:1470.
  33. Lightdale JR, Gremse DA, Section on Gastroenterology, Hepatology, and Nutrition. Gastroesophageal reflux: management guidance for the pediatrician. Pediatrics 2013; 131:e1684.
  34. Ulualp S, Brown A, Sanghavi R, Rivera-Sanchez Y. Assessment of laryngopharyngeal sensation in children with dysphagia. Laryngoscope 2013; 123:2291.
  35. Meyer TK, Hillel AD. Is laryngeal electromyography useful in the diagnosis and management of vocal fold paresis/paralysis? Laryngoscope 2011; 121:234.
  36. Kaneoka A, Krisciunas GP, Walsh K, et al. A comparison of 2 methods of endoscopic laryngeal sensory testing: a preliminary study. Ann Otol Rhinol Laryngol 2015; 124:187.
  37. Arvedson JC. Management of pediatric dysphagia. Otolaryngol Clin North Am 1998; 31:453.
  38. Wisdom G, Blitzer A. Surgical therapy for swallowing disorders. Otolaryngol Clin North Am 1998; 31:537.
  39. Adams RC, Elias ER, Council On Children With Disabilities. Nonoral feeding for children and youth with developmental or acquired disabilities. Pediatrics 2014; 134:e1745.
  40. Gisel EG, Applegate-Ferrante T, Benson J, Bosma JF. Oral-motor skills following sensorimotor therapy in two groups of moderately dysphagic children with cerebral palsy: aspiration vs nonaspiration. Dysphagia 1996; 11:59.
  41. Boesch RP, Daines C, Willging JP, et al. Advances in the diagnosis and management of chronic pulmonary aspiration in children. Eur Respir J 2006; 28:847.
  42. Mathei J, Coosemans W, Nafteux P, et al. Laparoscopic Nissen fundoplication in infants and children: analysis of 106 consecutive patients with special emphasis in neurologically impaired vs. neurologically normal patients. Surg Endosc 2008; 22:1054.
  43. Kane TD, Brown MF, Chen MK, Members of the APSA New Technology Committee. Position paper on laparoscopic antireflux operations in infants and children for gastroesophageal reflux disease. American Pediatric Surgery Association. J Pediatr Surg 2009; 44:1034.
  44. Vandenplas Y, Rudolph CD, Di Lorenzo C, et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr 2009; 49:498.
  45. Srivastava R, Downey EC, O'Gorman M, et al. Impact of fundoplication versus gastrojejunal feeding tubes on mortality and in preventing aspiration pneumonia in young children with neurologic impairment who have gastroesophageal reflux disease. Pediatrics 2009; 123:338.