Why expert care is crucial for aspiration

Dr. Rachel Rosen explains her new study about aspiration
PHOTO ILLUSTRATION: PATRICK BIBBINS/BOSTON CHILDREN’S HOSPITAL

Aspiration, or the entrance of food or liquid into a child’s airway, is associated with oropharyngeal dysphagia and other swallowing problems. It is more common in premature babies and those with neurological abnormalities, although it can occur in any child. Parents typically bring their children to pediatricians when they observe choking, regurgitation, coughing and other symptoms related to feeding.

Yet such classic symptoms can’t be relied upon to accurately diagnose oropharyngeal dysphagia-related aspiration, says Rachel Rosen, MD, MPH, director of the Aerodigestive Center at Boston Children’s Hospital. In a recent study published in the Journal of Pediatrics, she and her colleagues found that relying on a child’s presenting symptoms can be misleading and that these symptoms do not reliably predict which patients in fact aspirate.

Surprising findings

To determine whether symptoms are predictive of a diagnosis of aspiration with these methods, Rosen, Daniel Duncan, MD, and their colleagues reviewed the records of 412 children under age 2 were referred to Boston Children’s for the evaluation of oropharyngeal dysphagia. These children underwent a video fluoroscopic study (VFSS), which uses fluoroscopy to assess the oropharynx, larynx and upper esophagus during feeding.

The study had several surprising results. First, more than 80 percent of aspiration was silent, meaning the child did not sense the food or drink going into the airway and therefore did not cough. This explains why many children don’t have symptoms during a meal. In fact, in this study, more than 25 percent of patients did not have symptoms during meals.

Rosen, Duncan and colleagues also found that observed feedings, even by very skilled clinicians, are not sensitive enough to diagnose aspiration in children because of the high rates of silent aspiration. Based on statistical analyses, the degree of agreement between observed feeding and the VFSS was poor for the diagnosis of aspiration.

Indeed, many symptoms traditionally associated with aspiration — such as recurrent pneumonia —actually occurred infrequently in the children studied, while symptoms such as vomiting were more common than expected. Almost a third of the patients experienced symptoms during or after meals, which may help explain why physicians frequently misdiagnose oropharyngeal dysphagia with aspiration as gastroesophageal reflux disease (GERD).

When to refer

These findings highlight the importance of specialty evaluation and care for children with aspiration. Most children with oropharyngeal dysphagia and aspiration can be treated successfully thickened liquids.

“It’s really important to make the diagnosis of oropharyngeal dysphagia to insure that patients receive the right treatment. For years, these infants and toddlers were diagnosed with GERD because the symptoms overlap completely. As a result, they were put on multiple reflux therapies that had no benefit,” says Rosen. “Now, patients can be successfully diagnosed and managed as part of a multidisciplinary team of gastroenterologists, speech language pathologists, pulmonologists and otolaryngologists.”

Learn about the Aerodigestive Center.