Pediatric emergency medicine trisk 1109 1109
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Treatment of dysphagia is dictated by the underlying diagnosis. Disorders with
the potential to become life-threatening should be treated in the hospital under the
care of appropriate specialists. Chronic dysphagia with actual or potential
aspiration should be identified. If nutrition has been severely compromised from
chronic dysphagia, one should consider nasogastric, nasojejunal, or gastrostomy
tube feedings. Many pediatric facilities have developed multidisciplinary
feeding/swallowing teams to provide subspecialty expertise, while maintaining
continuity and coordination of patient care. If such a specialty service is not
available, involvement of appropriate individual specialists for the management
of the patient with dysphagia is imperative as mentioned in Figure 56.2 .
However, therapy for many disorders can be initiated on an outpatient basis.
Gastroesophageal reflux and resultant esophagitis can be managed with small
volume thickened feeds, although supporting evidence has been inconclusive,
since these steps pose minimal risk or cost, they may be considered before other
interventions. There is no evidence to support a switch to protein hydrolyzed
formula or amino acid–based formula for treatment of gastroesophageal disease
(GERD) especially in patients who do not have milk protein allergy. A minimum
of 2 weeks trial is recommended for any of the above-mentioned
nonpharmacologic therapies. Evidence is limited for the use of positioning
therapy, either head elevation, prone position, or left side up to improve signs and
symptoms of GERD in infants. Massage therapy, dietary supplementations, or
probiotic use have not been adequately studied, but may pose more risk and cost,
and cannot be recommended for reduction of symptoms of GERD. Medical
therapy consisting of liquid antacids, histamine receptor antagonist like
cimetidine, protein pump inhibitors (PPI) such as omeprazole, or the addition of
metoclopramide have limited evidence for benefit in the reduction of signs and
symptoms of GERD in infants. In older children with GERD symptoms, a 4-week
trial of PPI treatment is reasonable. Studies have noted that GERD symptoms
often overlap with dysphagia, and swallowing dysfunction should be considered
for persistently symptomatic patients already on appropriate reflux treatment,
especially those with extreme prematurity, developmental delay, or who do not
respond to antireflux medication. Children who have failed reflux therapy may
also be candidates for an evaluation for eosinophilic esophagitis. Eosinophilic
esophagitis is defined as vomiting and abdominal pain with solid dysphagia in
children and esophageal impaction in postpubertal age. Endoscopy and biopsy is
diagnostic. Treatment of eosinophilic esophagitis includes topical or oral steroids,
proton pump inhibitors, and leukotriene inhibitors. Disease recurrence is high. As
a result, dietary restriction and chronic medication usage may be indicated.
