Dysphagia IN CHILDREN

Dysphagia IN CHILDREN

By:
Tutut SRIWILUDJENG T.
Dr. Wahidin Sudiro Husodo Mojokerto

INTRODUCTION
Dysphagia is difficulty eating as a result of interference from salaj one stage in the process of swallowing. Although it often accompanies dysphagia, odinofagia (pain upon swallowing) should be distinguished with dysphagia. Need attention also that dysphagia is not confused with globus. Globus is a feeling of living as if - there will be a lump in my throat even though there is no organic damage or disruption to swallow the truth.
Dysphagia is a serious threat because of a risk to the occurrence of aspiration pneumonia, malnutrition, dehydration and weight loss obtruksi airway. Patients with old age are most at risk of dysphagia and its complications, especially silent aaspiration.
Swallowing disorders in children - children, unlike adults, resulting in things - especially things that are not found in adult patients. child - the child is experiencing growth and development of organs - organs and swallowing reflex - reflex oro-motorok. Children - children are also going through the maturation of feeding behavior.
The approach is also different because the children - child relationship of parent and child are more important things. The effects of dysphagia on the fulfillment of child nutrition also must get more attention to grow and develop optimally.
The cause of dysphagia can be a disorder - a disorder of the oral phase, pharyngeal or esophageal from the normal swallowing process. A careful history and thorough physical examination is important in diagnosing and sting menatalaksanaan dysphagia. Anamnesis done carefully can help doctors determine the cause of 80 to 85% of dysphagia. Physical examination should include examination of the neck, mouth, oropharynx, and larynx. Neurological examination should be conducted.
The purpose of this paper is to assess dysphagia in children ..

1. Physiology of Swallowing Process
Action menalan called deglutisi, where food or liquid bolus from the oral cavity transported through the pharynx and esophagus into the stomach. Deglutisi the normal process is a delicate process that involves coordinated with a series of voluntary and involuntary contraction neuromoskuler complex. In general, the process deglutisi divided into 3 successive stages of the oral phase, pharyngeal phase and esophageal phase.
1.1 Oral Phase
Oral phase consists of two phases namely preparation (preparation) and propulsive (push). Preparation phase is the processing of the bolus for can easily be swallowed, while the propulsive phase is pushing the food of the oral cavity to the oropharynx.







Figure 1: The tongue forms a bolus of food and then pushing it toward pelatum ka durum.
In normal children the oral cavity serves as an organ of sensory and motor that physically alter the food good size, shape, pH, temperature and consistency to be safe to swallow and for food to reach the pharynx without entry into the larynx.
Porses begins with contraction of the tongue and muscles - muscles mastication. Muscles - auto works coordinated to mix the food bolus with savila and pushed from the oral cavity to the oropharynx, where the involuntary swallowing reflex is triggered.
Mongontrol output cerebellum is responsible for motor nucleus of nerve - cranial nerve n. V (trigeminus), n. VII (facial), and n, XII (hypoglosus).
At the time of swallowing the liquid whole process takes about 1 second. In this case swallow solid foods, can occur slowdown in 50-10 seconds while the food accumulates in the oropharynx.
   
1.2 Phase pharyngeal
Pharyngeal phase is the most important phase because without the protective mechanisms intact larynx, aspiration is likely to occur in this phase. Pharynx is a regional meeting of the respiratory tract and gastrointestinal tract, food travel through this area requires an efficient mechanism for safely directing food into the esophagus.
During this phase the process of swallowing is reflective and involves a complex series of rapid movements, overlapping and highly coordinated. Molle palate lifted to close the nasopharynx. Suprahyoid muscular contractions pull hyoid bone and larynx move upward and forward. Tongue pressed back and down towards the pharynx to push food down. At this time aided by the tongue pharyngeal wall that moves towards the inside with progressive contraction wave from top to bottom. Pilka vocalist moves to the center line and the epiglottis folds backward to protect the airway. Upper esophageal sphincter berelaksi during this phase and become erbuka because terikan hyoid bone and larynx to the front.
This sphincter closes after food through, and the structure of the pharynx and then returned to its original position. This swallowing reflex lasts only 1 second, and involve the sensory and motor nerve path right n. IX (glosso-faringeus) and n. X (vagus).
This phase runs involuntary and reflexive so that no movement occurred until the reflex pharyngeal swallow is triggered.








Figure 2: Transfer of the food bolus by the tongue into the pharynx initiate deglutisi.
  
1.3 Phase oesophageal
In the esophageal phase, a bolus mekanan pushed down by the movement peristaltikm involuntary contraction of muscles - skeletal muscles upper esophagus push the food bolus into the middle and distal. Lower esophageal sphincter berlaksasi at the beginning of swallowing, and this relaxation lasts until the food has been pushed into the stomach.







Figure 3: Relaxation of the sphincter allows food to move into the proximal esophagus
Unlike the upper esophageal sphincter, lower sphincter is not pulled open by muskulatur kestrinsik. Lower esophageal sphincter mentup after bolus into the stomach, which prevents gastroesophageal reflux.
Spinal cord controls this involuntary swallowing movements. Thus Mekipun swallow volunteer movement can occur because of the influence of the cerebral cortex. Contraction takes 80-20 seconds so that the food into the stomach.

1.4 Development of Swallowing Process
Deglutisi prenatal occurs in about 16 -17 weeks of gestation, whereas the magnitude and location relative changes in the oral cavity and pharynx components terjad on post-natal period.
Changes in eating behavior development in children need attention. In the normal infant oral ingestion dtandai phase with the known picture of suckle feeding followed by development of transitional feeding (age 6-36 months) and then mature feeding is characterized by biting and chewing. Maturation of feeding behavior occurs mainly as a result of the development of central nervous system, accompanied by motor activity is controlled by higher centers such as the thalamus and the cerebral cortex.

2. Pathophysiology
In children - children swallowing disorders are rare disorders that are separate, but more often in infants and children - children with the disorder who mnultipel. Circumstances underlying the occurrence of dysphagia in children includes central and peripheral nervous system, muscle penbyakit, and structural anomalies mulutm cavity pharynx and esophagus.
The group with the risk of dysphagia and its complications include infants premtur with swallowing and respiratory coordination function that is not good, not a long baby mendaptkan peroral nutrition and infants with chronic lung disease.

2.1 Phase Disturbed Swallowing
Swallowing disorders can be categorized according to the phase of swallowing is impaired. Impaired oral phase of the preparation phase and propulsive phase is usually caused by damage to the control of the tongue. Patients may experience difficulty chewing solid mekanan and started swallowing. When people drink fluid to accommodate the liquid in the mouth before swallowing Ronggo. As a result of fluid entry into the pharynx prematurely who are not ready, so often menyababkan aspirations.

Table 1: Causes of dysphagia in children
Structural Abnormalities
Congenital
• oral atresia
• Labioskisis and palatoskisis
• Makroglosia, cysts, lymphoma of the tongue
• Makrognati, Pierre Robin syndrome
• joint ankylosis temproromandibuler
• Tumor or cyst pharyngeal
• Cysts epiglottis
• atresia, stenosis, web, diverticulum, esophageal duplication
• hernia on esophageal
• Abnormalities of the large blood vessels, the right subclavian artery aberans, vascular ring
Be obtained
• gastro esophageal reflux with peptic epiglotik
• Barrett's esophagus
• Infection: stomatis, esophagitis, tetanus
• Allergies: stomatis, esophagitis (Steven Johnson syndrome)
• Corrosive: stomatis, esophagitis (corrosive material)
• Epidermolosis bullous
• Foreign body
• Tumor
Neurology and neuromuscular disorders
• a late maturation, prematurity, mental deficiency
• cerebral palsy
• Bulbar palsy and saprubulbar
• Disease werdning - Hoffman
• Disotomia (Riley Day syndrome)
Mix
• Akalasia
• Akalasia kikrofaringeal
• esophageal spasm
• Fistula trakeoesofangeal
• cervical thymus aberans
• Dysphagia conversion
Quoted from Soeparto P, Djupri LS, Sudarmo BC, Ranuh RG. Gangguanmotilitas gastrointestinal syndrome: pathophysiological, diagnostic, treatment. 2004: 443-444.

When the pharyngeal phase ganggaun experience severe, the patient may be unable to swallow food and beverages in amounts sufficient to sustain life. In the case of muscle weakness - pharyngeal muscle or movement coordination disorder or fewer esophageal sphincter opening up, the patient may hold excessive amounts of food and overflows falam pharyngeal aspiration setela swallow. Disturbances in this phase may be due to disease neuromoskular. Obstruction can be due to the tumor, during inflammation, trauma / surgical resection, Zenker's diverticulum, esophageal web, extrinsic structural lesions, masses mediatinal anterior cervical spondilosis.
Greenle and friends - friends, in 2002 has menliti children - children with Chiari type 1 Malfromasi (hindbrain herniation) and showed that 35% of the main complaints experienced by the child - the child is malfunctioning, causing oropharyngeal dysphagia.
The function of the esophagus that can lead to impaired food and fluid retention in the esophagus after mediastinal or subkarnial limfonode enlargement, which is caused by infection (turbekolosis, histoplasmosis) or a malignancy such as lymphoma. Anomaly vskular can also press the esophagus, which is most often caused aberans right subclavian artery or double aortic arch is located on the right side.
Narrowing of the lumen of the esophagus may occur in congenital or acquired. Peptic structures are most numerous in the lower esophagus membranus thin ring, including ring Schatzki skuamokular situated at the meeting, also clogs up the area. Kengenital lumen narrowing can occur in the middle esophagus associated with esophageal or fistula atersia trakeo-esofagel, where some lesions that may involve tualng prone to berdilarasi safely.

Table 2: Diagnosis of Appeals Dysphagia
Oropharyngeal
Neuromuscular disease
CNS disease
Tomur brainstem
Amytropic lateral scelerosis
Multiple scelerosis
Huntington's Disease
Post-infection
Poliomyelitis
Syphilis
Nervous system erifer
Neuropathy erifer
Motor end-plate dysfunction
Myasthenia gravis
Striated muscle disease (myopathy)
Polimiositis
Dermatomiositis
Muscular dystrophy (disttrofi miotonik
dystrophy okulofaringeal)
krikofaringeal (esophageal sphincter
above), akalasia
Lesions Obtruktif
Tomur
Inflammatory mass
Trauma / surgical resection
Zenker's diverticulum
Web Oesophagus
Extrinsic structural lesions
Anterior mediastinal mass
Spondilosisi Oesophagus
Neuromuscular disorders
Akalasia
Motor disorders
Esofangeal diffuse spasm
Lower esophageal sphincter
hypertensive
Nutracker esophagus
Scleroderma
Lesions Obtruktif
Intrinsic structural lesions
Tumor
Stricture
Peptic
Radiation - induced
Chemical - induced
Medication - induced
Lower esophangeal rings
(Schatzki's ring)
Esophangeal webs
Foreign body

Extrinsic structural lesions
Vascular compression
Enlargement of the aorta or left atrium
Vassa aberan
Mediastinal mass
Lymphadenopathy
Thyroid Substernal


Dysphagia in children - children can also be caused by foreign objects menenlan, where the circumstances in the complaint dysphagia may switch to respiratory complaints. Foreign body in the esophagus will easily push the membrane posterior to the trachea or larynx that produces a rich bautk stidor, wheezing or choking.

2.2 Complications of Dysphagia in Children
Dysphagia causing the patient susceptible to aspiration, which will then be menybabkan aspiration pneumonia. Some factors that influence the occurrence of this aspiration is the sum of them, the physical nature and location of the depth of aspiration and meknisme clearance by the lung. Aspirations of the more dangerous on the aspirations of a larger number, the location of the distal and the more acidic nature. When aspiration followed infectious organisms or even normal flora mouth though, it will be menbyebabkan pneumonitis.
Malnutrition and dehydration is itself a risk factor for the occurrence of pneumonia. Malnutrition causes a person vulnerable to changes in bacterial colonization in the oropharynx and lower defend against infection by pressing the immune system. Malnutrition also causes lethargy, weakness and a decrease in consciousness which in turn increases the likelihood of aspiration. Moreover that manutrisi reduce the strength cough and lung clearance mechanisms as a defense factor against aspiration.
Dysphagia can lead to dehydration because of lack of fluid intake. Conversely, dehirasi also a risk factor for pneumonia. This is due to the first due to reduced flow of saliva, which can change in oropharyngeal colonization, both because of lethargy and mental status changes that can improve the aspiration, and the third because of the declining immune system.


Table 3: Symptoms associated with and probably etiology of dysphagia
Condition
Progressive dysphagia
Dysphagia is a sudden
Difficulty swallowing memulau
Fixed time swallowing food
Cough
 
At the beginning of swallowing
At the end of the swallowing
Weight loss

With regurgitation
Symptoms - symptoms that are intermittent

Pain with dysphagia




Pain dliperparah
Only solid food
Solid and liquid foods
Regurgirtasi from old food
Weakness and dysphagia

Halitosis
Dysphagia improved with repeated swallowing
Dysphagia Diagnosis diperperah with cold food being considered
Dysphagia neuromuscular
Dysphagia obtructif, esofagitas
Oropharyngeal dysphagia
Dysphagia esofangeal


Dysphagia neuromuscular
Dysphagia obstructif

Carcinoma
Akalisasi

Sleroderma peptic Structure
Web rings and diffuse esophageal spasm,
Nutcracker esophagus
Esophagitis
Post-radiation
Infections: herpes simplex monilia Viru
Pill-induced

Dysphagia obstructif
Dysphagia neuromuscular
Zenker Diverkulum
Stroke, muscular dystrophy, myastheniagravis
Skelrosis multiple
Zenker diverticulum
Akalasia
Impaired neuromuscular modalities



3. Anamnesis
Careful history taking will enable doctors to identify the causes of dysphagia 80-85 percent. Hrus distinguished difficulty swallowing or pain when swallowing (odinofagia). Odinofagia menendakan inflammatory process or the process of malignancy.
In history it is important to note onset, duration and severity of dysphagia. A variety of symptoms associated with dysphagia (Table 3) can help direct the diagnosis towards the specific diagnosis or the diagnosis-related anatomical pathophysiological. Dsfaga of solid food showed esophageal obstruction or structural. Dysphagia to liquid showed pharyngeal disorders such as neuromuscular disease.
Children with dysphagia may experience symptoms of choking, coughing, shortness or to blue (cyanosis) when eating or drinking. If these symptoms occur during swallowing, where the disorder is usually oropharyngeal, if the cough immediately after swallowing may be a disturbance esofagial pharynx. Symptoms that appear after a meal may indicate a gastrointestinal reflux esofagual or a retention of food in an esophageal diverticulum or who have dilated.
Anamnesis which carmat supposed to mejawab two general questions. Whether or esophageal dysphagia is orofarineal and whether dysphagia disebabakan obtruksi mechanical and neuromuscular motility disorders.
Weight loss and growth disorders in patients with dysphagia is an indicator of the degree and duration of disease. Portfolio surgery or trauma to the pharynx, chest or abdomen should be explored. Patients should also be asked if swallowed caustic substances or medical drugs that can damage the mucosa.
Talaah systems often show sestemik disease causing dysphagia. These include spinal osteo artitis, turbekolosus and thyroid enlargement. Autoimmune disease systemic or neuromuscular diseases may menyababkan problems with esophageal motility.
History of digestive disorders in the family should be sought, such as a history of dysphagia distrosi okulofaringeal and muscular. The use of drugs such as antihistamines, anticholinergics, anti epresan and antihiertensi can affect salivary gland function or innervation in the process of swallowing.

4. Physical examination
A general physical examination and investigation that focused on organ or specific symptoms based on history of disease often can identify the cause of dysphagia.
Sptula tongue and glass to help see molie palate and vocal cords meobilitas, of course, the children of this examination can only be done when children cooperate. The ball allows palpation bemanual with mememakai gloves can be done to examine the ground floor of the mouth, tongue and lips to detect masses or abnormal motor function. Palpation was also performed to palpate the neck region of the mass or lymphadenopathy can cause dysphagia obtruktif.
Neurological examination should include assessment of mental status of patients, motor and sensory function, deep tendon reflexes and cranial nerves and serebelar examination. Patients with cognitive ganugguan should be assessed with caution. Cranial nerves have special diperhaitkan mainly associated with the ingestion of motor components of nerve V, VII, IX, X and XII and sensory components of nerve V, VII, IX, X and XII. Gag reflex decrease associated with an increased risk of aspiration. The voice that might be associated with wet long-term laryngeal aspiration, whereas weak voice sighed indicate interference with the vocal cords.
Truedson report a case of old orng disfgia on its way menglami Wernicke encephalopathy, dirtandai with triad oftalmoplegia, ataxia, and mental disrientasi diseebabkan severe thiamine deficiency.
Observations on feeding includes observation of the presence or absence of oral motorilk abilities and skills at mealtime is the closure of the lips, jaw impulse, the urge of the tongue, bite reflex, jaw closure, and so forth. In children with impaired swallowing reflex and swallowing movements may be elongated. The position of the neck, head and body during swallowing also must be considered, as well as behavioral makanseperti tongue movement, mouth discrepancy. Symptoms of choking, barrier (gagging), changes in voice quality can also be observed a minute or more to notice a cough that occurs slow response. Direct observation begins with the patient tries to swallow a little (glass) of water. When mungkn patients were then asked to try to swallow a variety of foods.

5. Laboratory examination
Basically laboratory tests performed should be based on the direction of a thorough anamnesis and a thorough physical examination. Complete blood examination to meunnjukkan an infection or inflammation that causes disgfagia. Melnutirsi presence indicates the need for examination of serum proteins. Examination of thyroid levels can cause dysphagia membantumencari berkaita with hipotiroisme with hipotiroisme or hyperthyroidism.

6. Radiological examination
Further investigation is usually necessary to confirm diagnosis and determine the risk of aspiration, although history and physical examination sufficient to identify the etiology of dysphagia.
Plain neck examination is an examination of a rapid and inexpensive but can not know the mechanics of swallowing and kealinan mucosa, therefore, only indicated on suspicion of disfaia specific causes such as inflammation (epiglottitis, abscesses retrofaring), or a radio opaque foreign body. Plain chest examination is a simple examination to see the result asirasi pneumonia.
CT scans and MRI provides a structural abnormality of very bail, particularly for evaluating patients suspected of dysphagia due to central nervous system disorders.
Ultrasonography of the tongue and posterior pharynx to evaluate the tongue from the hyoid bone and may help to see the ekstramural and submukosal lesions of the esophagus. Another advantage is this examination can demonstrate the mobility and bolus transit and identify any static. This examination does not use radiation, portable, and can meamakai able to evaluate the run movement for genuine food to eat.
The term vidiofluorongoscopic swallowing study (VFSS) or also called modified barium swallow (MBS) is designed to study the anatomical and physiological processes ranging from phase deglutisi oral, pharyngeal and esophageal and swallowing movements to determine strategy in patients with dysphagia. If there is aspiration, or if the food caught after a patient swallows, the next step is to evaluate the quantity of food that stuck, the mechanism of retention or aspiration and the response from the patient. In general, many-consistency and volume of food, postural techniques and swallowing maneuvers to enhance security and efficiency of swallowing can be studied during the examination. Clinical considerations can be determined, such as changing food group, find a posture and friends - friends in 2001 to do research with this examination on the baby - a baby suspected of having dysphagia. They have the disorder - disorders that appear in the form of laryngeal penetration, aspiration and nasopharyngeal backflow. Most baby - this baby looks normal at the beginning of their swallowing, but swallowing function began to decline.
Appear when melajutkan eat. Research suggests the use of this examination on the baby - a baby with dysphagia due to the high number of quiet aspiration (silent aspiration).
Manometri use a catheter to measure pressure at various intervals throughout the esophagus. Each klai swallowing data about the strength, duration and sequence of events pengingkatan measured pressure. The main advantage is that these tests show the actual picture of the physiology of the pressure wave. Kerugaiannya lasi is unable to show that looks are not pleasant for the patient and not widely available.
Fiberoptic endoscopic examination of swallowing (fees) using transnasal endoscopy to see faringea ingestion phase. Prosesdur is sensitive to see the release bolus at an early stage, laryngeal penetration, tracheal aspiration and pharyngeal residue. Because pharyngeal closing lumenmn construction, this examination did not show band structure at the time of swallowing food.

7. Management
Dysphagia occurs mostly in children with abnormal or slow development, namely cognitive development, oral motor, fine and gross motor skills. Management should consider the age of the child's development, the level of functional ability to swallow at the time, for example, chewing ability, the ability to control the bolus memenipulasi Dysphagia need the expert handling of multidisciplinary terdri from doctors, fisioterpis, dieticians, nurses.
Inadequate nutrition can be caused by oral motor function, difficulty in communicating the desire to eat or a favorite. The inability to eat independently, fefluks gastro esofangeal and aspirations. Dietary assessment by a dietitian who berengalaman in the field of pediatric nutrition can help solve problems. Besides, it is necessary to record fluid intake and loss, food intake mancatat pertmabahan child and monitor his weight and length of feeding
VFSS examination can help to determine the texture of foods which are the most secure. Modified food can depend based berfariasi different food textures and the child's ability to chew. Usually the recommended size of a small bite. In some sensory kepakaan increase in the oral cavity, assisting the formation of a bolus and to reduce transit time in the pharynx.
Children - children with neuromuscular gangguna accompanied by weakness dam hillangnya swallowing coordination easier to swallow food with reduced aspiration. In the child - the child should be given different - different flavors of tolerated should be recorded to determine which are most effective.
Children - children with the control head and an ugly body stability requires the appropriate positioning techniques and the individual. Children with severe palsy serebal and eating disorders, eating position depending on the degree of dysphagia and whether oral or pharyngeal dysphagia in particular. In children with major abnormalities in the pharyngeal phase, recommended an upright position with neck and hip flexion. Assessment of visually tranquil position just swallowed a safe and effective is not enough, so that the required examination VFSS.

SUMMARY
Dysphagia in children is often a part of other, more komleks disease and rarely stand alone. The cause of dysphagia children generally caused structural kalianan of organs - organs swallowing (obtruksi mechanical) or because of interference neomuskular.
Complications may include aspiration pneumonia, malnutrition, dehydration and weight loss obtruksi airway. Handling dysphagia dysphagia is basically solve itself, and prevents or treat complications.
A careful history and thorough physical examination is helpful in finding the cause of dysphagia and determine the phase of swallowing is needed to better explain the underlying disorder and complications arising from such aspirations. Videofluroscopy swallowing study is an examination that is very useful for identifying the phase of swallowing is disturbed sekaigus can help plan an appropriate governance for the patient.
Penatalaksaan dysphagia in children primarily is a modification of diet and positioning Saar swallow. The main objective is to reduce the risk of dysphagia as a result komlikasi pneumonis aspiration, malnutrition and dehydration.

 
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