Tratamiento Disfagia Pediatrica

Medical disorders and other etiologies of pediatric dysphagia

This section summarizes the major etiologies of pediatric dysphagia. The title of the topic is presented along with a description of the disorder. Clinical symptoms are lusted as well as current medical intervention. Finally, a short summary of a typical treatment plan is presented under the heading “what can we do?” Details of specific therapy guidelines are presented in section 5.

Gastrointestinal/gastroesophageal tract disorders

Many disorders can disrupt the successful digestion of food and ultimately infant feeding. They will often refuse or be unable to tolerate oral feedings because of the negative consequences (i.e., respiratory distress, pain) associated with moving food from the esophagus to the intestines. This section summarizes some of the common GI affecting children with swallowing/feeding problems.

Vascular Ring

Description

Vascular ring refers to variety of anomalies of the aortic notch in which a “ring” of vassels surround the trachea, esophagus, or both, causing compression/obstruction (Goella, Cunningham, & Eyal, 1994). Vascular rings are diagnosed early in infants; however, vascular anomalies that cause dysphagia have been reported in older children (Koko, Mose, Erhart, & Tunkel, 1998).

Clinical Symptoms/ Diagnosis

The infant presents with clinical signs of respiratory distress that worsens when eating, which in turn causes dysphagia. Diagnosis of this condition has been historically done with angiography (Kosko et al., 1998). With advances in imaging techniques, vascular rings now can be confirmed with a videofluoroscopic swallow study (to rule out aspiration) and esophagram (Gomella et al., 1994). Enhanced Computerized tomography (CT) or magnetic resonance imaging (MRI) is also used (Kosko et al., 1998)

Treatment Summary

Surgical treatment is recommended for severe cases. Surgery consists of division or suspension of the vessel (Kosko et al., 1998).

Tracheoesophageal Fistula/Esophageal Atresia

Description

In tracheoesophageal fistula (TEF) there is a communication between the esophageal and tracheal wall. Congenital TEF is caused by failure of the laryngotracheal tube to successfully separate from the esophagus during the embryonic period of neonatal development. This results in a variety of anomalies that can occur with esophageal atresia (EA). One classification of TEF/EA is presented in figure 2-1. In EA, the upper two thirds (proximal end) of the esophagus ends about 10 centimeters (cm) from the nasopharynx in a completely closed pouch. EA can occurs with or without TEF. In the majority of cases (85%), the distal esophagus is connected to the trachea (C-type TEF). Atresia alone occurs in only about 7% of the population (Gomella et al., 1994; Kosko et al., 1998). Together, tracheoesophageal/esophageal atresia constitute the most common congenital abnormality (Kosko et al., 1998). TEF also may be acquired through trauma (e.g., motor vehicle accident, intubation, tracheotomy).

Clinical Symptoms/Diagnosis

In TEF, liquids (formula or breast milk) enter the trachea during first feedings, causing the infant to choke, cough, gag, or become cyanotic and show other clinical signs of respiratory distress. If TEF is accompanied with EA, the infant may vomit during the first feeding. Inability to place a nasogastric tube may trigger a consult for videofluoroscopic swallow study (VFSS) with esophagram. Diagnosis of this condition is confirmed with a VFSS study (to rule out aspiration) with esophagram.

Treatment Summary

Surgical repair for all types of TEF/EA is required. The timing and extent of the repair depends on the classification. In some cases, esophageal reconstruction is necessary and can include grafts to lengthen the esophagus (i.e., colonic and jejunal grafts). The risk of morbidity increases with the length of the needed repair (Kosko et al., 1998). Surgical repair of TEF, and in some cases multiple repairs, can result in reduced esophageal motility during feeding.

Gastroesophageal Reflux

Description

Gastroesophageal reflux (GER) is the anterior return of the stomach contents into the esophagus and possibly the pharynx. Regurgitation or vomiting refers to the passage of stomach contents out of the mouth. Normal episodes of reflux can occur at least once per day in more than half of infants under the age of 3 months. Between 8 and 12 months, episodes of GER decrease dramatically (Nelson, Chen, Syniar, & Christoffell, 1997). GER can accompany many disorders seen in infants such as prematurity, cerebral palsy, incompetent lower esophageal sphincter (LES), and gastrostomy tube placement (Boyle, 1989; Canal, Vane, Gotto, Gardner, & Grosfeld, 1987; Omart ret al., 1998). Other etiologies include traumatic brain injury and nasogastric (NG) tube placement (Rossi, 1993). Children with a developmental disability often exhibit GER (Boyle, 1989). They may also show behavioral GER in which they gag, vomit, or ruminate stomach contents. In addition, poor posturing of high- and low-tone children can result in abdominal pressure that can push food into the esophagus through a normally functioning LES (Batshaw & Perret, 1995).

The amount of time its takes for the stomach to move food into the small intestine (gastric emptying) is also a factor in GER because this increases the time available for reflux to occur (Rossi, 1993). Left untreated, GER can lead to Gastroesophageal reflux disease (GERD), which in turn can cause pneumonia, esophageal strictures, and esophagitis (Nelson et al., 1997). GER has been associated with Sandifer’s sign (turning head to the left) latyngospasms, respiratory arrest, apnea, and apparent life-threatening events (ALTs) (Orentein & Orenstein, 1988; See et al., 1989). Children with GER are at risk for failure to thrive (FTT), poor weight gain, and oral thrush.

Clinical Symptoms/Diagnosis

Children with GER may demonstrate projectile vomiting, coughing(choking, gagging, abnormal posturing (back arching), and/or irritability after feeding. Some infants may refuse feeding. Apnea and bradycardia (as and Bs) and hypoxemia may also be present (Gomella et al., 1994; See et al, 1989). Other airway complications that may be symptoms of GERD include frequent pneumonia, wheezing, reactive airway disease, stridor, and cough (Rudolph, 1997). Medical diagnosis is typically through a reflux scintiscan (scintigraphy) or pH probe examination. A barium swallow or esophageal endoscopy may offer information regarding the structural integrity of the esophagus.

Treatment Summary

Both medical and behavioral management are combined in the treatment of GER. Drug therapy typically includes medications to increase the resting tone of

...