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Adorable tiny three month old Trisomy 18 special needs infant girl with nasogastric tube f

Aspiration is defined as the entry of food, liquids, or other foreign bodies beneath the vocal folds (aka. “voice box”) and into the trachea (aka “windpipe”) leading to the lungs. It can occur as a symptom in children and is sometimes associated with other diagnoses such as structural abnormalities, genetic disorders, and neuromuscular disorders. Although many children will have associated diagnoses, aspiration can also occur in the setting of otherwise typical child development. Aspiration can be classified as overt, in which the child demonstrates symptoms such as coughing and choking, or silent, in which the child does not produce a physiologic response following an aspiration event. Silent aspiration is most common in premature infants and newborns due to immature cough reflex integration, as well as children with neurological disorders which inhibit the brain from interpreting the sensory signals caused by aspiration (in other words, the child does not “feel” materials going down the wrong pipe). Aspiration is often, but not always, followed by other respiratory symptoms. In infants, aspiration is a leading cause of respiratory morbidity and mortality, and it can lead to serious health problems including pneumonia.

During the normal swallowing process, food moves from the mouth through the throat and into the esophagus.  The majority of this tract is shared with the respiratory system that carries air into the lungs. A soft piece of cartilage known as the epiglottis works to direct food, drinks, and saliva down towards the esophagus by covering the entry to the airway. These delicate systems rely on sensory information (sensations felt in the mouth and throat while we eat and swallow) in order to function correctly and direct food down the correct path. In some situations, there can be breakdowns in this systems due to structural differences, sensory awareness problems, or timing delays in the motor response (aka delay in initiating the swallow) which can lead to aspiration. 


To further complicate this system, some infants and children will experience what is known as reverse or retrograde aspiration, in which refluxed materials travel back up the esophagus and into the throat. If the throat does not have time to respond and close off the airway, refluxed materials may enter into the trachea or windpipe and travel to the lungs, causing inflammation or damage. 


Causes of Aspiration in Babies and Children

The most common cause of aspiration in infants and children is dysphagia, or swallowing impairment. Dysphagia occurs when the airway reflexes fail, and there are a number of possible factors which increase a child’s risk of dysphagia. Essentially, dysphagia happens when the muscles in the throat don't work normally, leading to difficulty swallowing. A variety of medical conditions can lead to this, including:


  • Gastroesophageal reflux disease (GERD)

The most common cause of aspiration in children is (GERD), also known as acid reflux. Particularly in premature infants, and usually resolves as children grow older. This occurs when the contents of the stomach return to the throat.

  • Anatomical disorders such as an abnormal connection between the air tube and food tube(tracheoesophageal fistula) and also cleft palate

  • Congenital syndromes such as Down syndrome

  • Brain damage or other problems, such as from cerebral palsy or infection

  • abnormalities of the cranial nerves that control the muscles of swallowing or neuromuscular disease, such as spinal muscular atrophy

  • Medical procedures, such as a nasogastric tube or a tracheostomy

  • Prematurity or early term birth, due to poorly developed coordination between swallowing and breathing. Suck swallow breathe incoordination is most common for infants born before 39 weeks gestation, but can affect full term newborns as well

  • Heart defects and congenital respiratory problems, due to decreased baseline oxygen levels and the need to take breaths more frequently


Symptoms of aspiration in babies and children

Aspiration can occur before or after a feeding. Signs and symptoms may vary depending on your child's age, as well as how frequently and how much he or she aspirates. Here are some signs and symptoms to look out for in a baby or older child:


  • Choking or coughing while eating

  • Faster breathing or stopping breathing while feeding

  • food stuck or coming back up

  • a red face, watery eyes, or hoarseness

  • Wet-sounding voice after meals.

  • Apnea, bradycardia, or cyanosis (noted by a grey, dusky, or blue-ish appearance spreading from the brow line and nasal bridge across the infant’s face. This is often accompanied by significant decrease in an infant’s number of breaths per minute and/or drop in heart rate).

  • Wheezing and Chronic respiratory illness (such as recurrent respiratory infections and in severe cases, pneumonia). Other chronic airway issues, such as Asthma, Reactive Airway Disease, and Chronic Lung Disease are also commonly associated with chronic or frequent aspiration. Children with medical comorbidities are more likely to develop severe pulmonary or respiratory symptoms versus their healthy counterparts. 


While all of the above symptoms are common with aspiration, children can aspirate without displaying any symptoms, which is known as silent aspiration. Silent aspiration is more common in people who have impaired senses. Drooling or changes in the sound of their breathing and talking may be indicators of swallowing difficulties in children who silently aspirate.


Diagnose of aspiration in babies and children.

A thorough physical examination, as well as a complete history of any past or current medical conditions, will be required to diagnose pediatric aspiration. Your child's growth pattern, feeding history, and breathing problems will also be discussed with the doctor. He will ask about what foods or beverages cause problems, as well as when your child's symptoms occur. A variety of tests may be used to diagnose your child's aspiration; these can look for problems and show if food or fluid is entering your child's lungs. 

The tests may include:  

  • Chest X-ray or CT scan

  • Pulmonary function test  and ABG test

  • Flexible and rigid bronchoscopy 

  • Modified barium swallow (MBS): Patient swallows a barium-containing liquid allowing muscle problems, physiological abnormalities, and degree of aspiration to be seen

  • Fiberoptic endoscopic evaluation of swallowing (FEES) exam


Complications of aspiration 

Lung damage may occur as a result of aspiration. Aspiration pneumonia occurs when food, drink, or stomach contents enter the child's lungs, causing a pulmonary infection that needs antibiotics. Chronic aspiration can also cause failure to thrive or trouble gaining weight. It is common for babies and children who aspirate to demonstrate persistent refusal behaviors or aversion to eating or drinking.


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