Dysphagia 137infants and young children are impor tant considerations. Dysphagia associated with cleft lip and
palate is unique to children. Indications for pediatric swallowing evaluations include failure to
thrive, dehydration, frequent choking, significant weight loss, and apnea during feeding. Perhaps
the best indication that a dysphagia evaluation needs to be conducted is the mother’s report of her
child’s sucking, swallowing, or feeding difficulties.
Dysphagia Therapy
Patients with dysphagia are usually highly motivated to participate in therapy because
relearning to eat normally is both a drive and a reward. Clinical experience has shown that
dysphagia therapy is usually successful, with most patients ultimately able to meet all or part
of their hydration and nutritional needs orally. Patients with a poor prognosis are those with
dementia, severe traumatic brain injury, and global aphasia.
Dysphagia therapies consist of commonsense changes in diet and modifications of chewing
and swallowing be hav iors. They can be separated into intervention procedures for oral intake,
mastication, transportation, and swallowing deficits. Using the broad definition of dysphagia,
oral intake prob lems can include the patient’s desire to eat, impulsiveness, response to the smell
of food, and recognition of liquids, food items, utensils, and other items. Therapies include
counseling, instruction, and be hav ior modification, often in conjunction with neuropsychologists,
occupational therapists, and other health care professionals.
To masticate properly, patients must have the proper dentition, jaw, and tongue mobility. When
dentition is insufficient for mastication, the clinician instructs the dietary department to provide
meals as liquids, puréed, chopped to vari ous textures, or in soft form. Be hav ior management and
instruction are provided to improve tongue mobility in creating a bolus, managing liquids, and
clearing the oral cavity after chewing and swallowing are completed. Patients are also shown how
to remove pocketed food from the cheeks. Properly selected patients can be trained to create a
bolus and move it posteriorly prior to swallowing using bread or similar soft, manageable food.
The patient can monitor liquid containment and movement by using hot or cold substances to
enhance the oral sensation.
Patients with dysphagia are instructed, counseled, and trained to time the swallow correctly
and to be more conscious of it. The temperature and texture of foods and the consistency of liquids
can be adjusted to facilitate the swallow ref lex. Tepid foods and thin liquids are usually avoided
because they are more difficult to sense and manage. As stated previously, for the patient with
laryngeal paralysis, turning the head to the affected side promotes the vocal cords’ protective
actions. Some patients benefit from body positioning to maximize the effects of gravity during the
swallow. Dry swallowing helps some patients clear food and liquids. Certain patients find it useful
to produce a voiced phoneme loudly after the swallow to clear the air passageways. It is helpful for
some patients to take deep breaths before swallowing to provide air support for clearing liquids
and dislodging food from the air passageways. Oral- motor muscular strengthening exercises may
be beneficial and can be incorporated into speech therapy when appropriate. Throat- clearing
exercises and activities to improve productive coughing are also helpful in reducing the negative
effects of aspiration.
For patients who have difficulty relearning the vari ous phases of swallowing, repeated video
swallow studies may provide additional therapies that may be of benefit. Even after patients
appear to have mastered safe swallowing, they should be monitored for aspiration and choking
risks. For home health patients and those being discharged home, family instruction and
counseling are also necessary.