Pediatric emergency medicine trisk 1089 1089
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CHAPTER 56 ■ PAIN: DYSPHAGIA
RAHUL KAILA, RONALD A. FURNIVAL, GEORGE A. (TONY) WOODWARD
INTRODUCTION
The primary function of swallowing is the ingestion, preparation, and transport of
nutrients to the digestive tract. Secondary functions of swallowing are the control
of secretions, clearance of respiratory contaminants, protection of the upper
airway, and equalization of pressure across the tympanic membrane through the
eustachian tube. Dysphagia is defined as any difficulty or abnormality of
swallowing. Dysphagia is not a specific disease entity but is a symptom of other,
often clinically occult, conditions and may be life-threatening if respiration or
nutrition is compromised. Odynophagia (pain on swallowing) or sialorrhea
(drooling) may also be present in the dysphagic pediatric patient. Globus
pharyngeus refers to the feeling of a lump in the throat. This chapter briefly
presents the normal anatomy and physiology of swallowing, the differential
diagnosis of disturbances of this process, and the evaluation and treatment of the
pediatric patient with dysphagia.
PATHOPHYSIOLOGY
Swallowing begins in utero as early as the 10th to 14th week of gestation, playing
an important role in gastrointestinal development and regulation of amniotic fluid
volume. By the 34th week of gestation, this complex process, involving 26
muscles, 6 cranial nerves (V, VII, IX, X, XI, and XII), and cervical nerves C1 to
C3, is functional, although incompletely coordinated with breathing. In the first
few days after birth, each infant develops an individual pattern of sucking,
swallowing, and breathing, usually with a 1:1 or 1:2 ratio of breaths per suckle, to
prevent aspiration of material into the larynx. This stage of suckling, or suckle
feeding, is primarily under medullary control, with minimal input from the
cerebral cortex. A transitional period begins at 6 months of age, as the cortex
gradually exerts more control over the pre-esophageal phase of swallowing,
allowing for the introduction of solid foods. Swallowing in the esophageal region
remains an autonomic process, with vagal sensorimotor control coordinating
peristalsis of the upper striated and lower smooth muscle of the esophagus. By 3
years of age, the swallowing pattern is mature, although the pediatric patient,
unlike the adult, may regress to a less mature stage if normal swallowing is
disrupted.
