Aspiration

What is aspiration?

Aspiration occurs when food, liquid, or saliva that’s intended to be swallowed enters the trachea, or airway, and in some circumstances the lungs, instead of going down the esophagus to the stomach. It also can occur when a child inhales a foreign body or when gastric reflux comes up from the stomach and enters the airway.

What are the symptoms of aspiration?

The classic symptoms of aspiration are a cough, wet or congested breathing, and watery eyes after swallowing during drinking or eating, or when introducing solid foods (such as with baby-led weaning). In babies, aspiration might also produce a wet or gurgling noise during or after breastfeeding. Although aspiration can occur with any food or liquid, thin liquids (such as water, juice, formula, or milk) are most frequently aspirated.

What children are at risk for aspiration?

Aspiration is more common in infancy, particularly in babies who are premature, but it can occur at any time in childhood. Premature babies are at a higher risk for aspiration because their ability to swallow is not completely developed, and they may not be able to produce a coordinated and timely swallow. An uncoordinated pattern during sucking, swallowing, and breathing may lead to mistimed swallowing, and liquid may enter the airway as a result. In older children, aspiration may be more likely to occur alongside neurological or neuromuscular disorders, such as during seizures or when anatomical (physical) or structural abnormalities are present. Often, aspiration has more than one cause.

Can my child outgrow aspiration?

Many young children outgrow swallowing problems that lead to aspiration. Our job is to keep them safe while they grow and to rule out chronic (ongoing) aspiration. This includes identifying any anatomical problems that may be causing aspiration and identifying silent aspiration (which occurs without any obvious signs or symptoms). When we catch aspiration early and treat it, your child will likely do very well.

How common is aspiration?

The prevalence of aspiration is largely unknown, and pathological (disease related) aspiration is likely underdiagnosed. Everyone has the ability to aspirate a little bit, such as swallowing small amounts of saliva that enters the airway during sleep. Our bodies can handle minor aspiration events like this every now and then. At times, children may choke on water when they drink too fast or have a coughing or choking event when they eat a certain food that’s not appropriate for their age. But if your child aspirates regularly, such as with every few swallows of a drink, then there is likely an underlying cause that needs to be identified. We call this chronic, pathological (disease related) aspiration, and it is important to recognize and treat.

What causes chronic aspiration?

Swallowing is a complex series of movements and neurological responses, so children with any type of coordination problem with that process are at risk for the chance of the swallowing and breathing sequence to be mistimed. Children who have anatomical abnormalities in the throat or airway (such as a cleft in the larynx or a hole or fistula in the esophagus) may also be at a higher risk for aspiration, even if the motor function used to swallow is otherwise normal. Occasionally, part of a child’s airway does not function properly during swallowing, as can be seen with vocal cord motion disorders such as vocal cord paralysis.

When do you suspect chronic aspiration?

In patients who have signs or symptoms of aspiration with each meal, such as coughing, congestion, or difficulty breathing during breastfeeding or bottle feeding, aspiration should be considered. On occasion, aspiration is silent, meaning it occurs without any cough response or abnormal reaction from your child. As a result, chronic aspiration may disguise itself as other conditions. For example, if your child has frequent or prolonged upper respiratory problems (such as repeated, long bouts of colds) or unexplained lung disease (such as recurring pneumonia) that cannot be attributed to another condition, he or she may have aspiration. Under these circumstances, your child may have symptoms that are similar to asthma but do not respond well to medication. If this sounds like your child, aspiration should be considered.

What type of specialist treats aspiration?

If your child frequently aspirates, he or she needs to be investigated by a pediatric otolaryngologist, otherwise known as an ear, nose, and throat (ENT) specialist. Ideally, your child should be seen at a center that specializes in airway and swallowing problems, such as our Aerodigestive and Airway Reconstruction Center or our Center for Pediatric Voice and Swallowing Disorders. That way, many experts from different specialties with specific training in feeding and swallowing disorders can weigh in, ensuring that your child gets an accurate diagnosis and comprehensive care.

How do you diagnose aspiration?

Aspiration is not always obvious or easy to diagnose. That’s why we offer a full gamut of testing options to identify aspiration and, when possible, the exact cause. Because we see a large volume of children with aspiration, and we work with a team of multidisciplinary experts, we are able to identify even subtle signs of aspiration.

Generally, we start by observing your child in the clinic while he or she eats and drinks, looking for any signs or symptoms of aspiration. This is performed with a speech-language pathologist and otolaryngologist, who simultaneously observe feeding and swallowing and perform a physical exam. We also assess for anatomical differences that may lead to aspiration. To get more information, we frequently perform a swallow study. The studies complement each other and provide different information, so your child might require more than one:

• Videofluoroscopic swallow study (VFSS), also called a modified barium swallow (MBS) study. In this study, a moving x-ray shows the workings of your child’s mouth and throat muscles while he or she swallows a liquid dye called barium. We observe the path that the dye takes as it travels from the mouth into the esophagus (feeding tube to the stomach). This study is performed by a speech-language pathologist and a radiologist.
• Fiberoptic endoscopic evaluation of swallowing (FEES). In this study, which is a modified form of laryngoscopy, we place a flexible laryngoscope (a thin flexible camera) through the nose to visualize the throat, tongue, and airway as your child eats or drinks. We are able to view the larynx (voice box) to see if there are any visible anatomical defects, determine if it is functioning normally, and test for sensation. While your child eats and drinks, we watch to see if the liquid or food being swallowed follows the usual path to the esophagus. We can see if it deviates from the normal pathway and instead enters the airway above the vocal cords (penetration) or through the vocal cords (aspiration) into the trachea (windpipe) and lungs. It’s performed in our ear, nose, and throat clinic with a pediatric otolaryngologist and speech-language pathologist. Radiation is not required.
• Advanced swallowing diagnostics. If further evaluation is needed, your child can be seen in our advanced Motility Program, where multiple specialists will evaluate for aspiration. When we suspect a problem with the GI tract or lungs, we partner with pediatric gastroenterologists and/or pulmonologists within our Aerodigestive and Airway Reconstruction Center. The gastroenterologist assesses the GI tract for reflux, allergic problems, or motility issues; the pulmonologist views and evaluates the lungs for evidence of inflammation or infection; and the otolaryngologist evaluates the larynx (voice box) and central airway for the presence of inflammation and/or anatomical differences. This multidisciplinary approach ensures that your child only has to undergo one procedure, and receives anesthesia just once, to investigate a range of possible causes.

How do you treat aspiration?

Our multidisciplinary Center for Pediatric Voice and Swallowing Disorders is one of the most advanced clinics in California, where otolaryngologists, speech-language pathologists, occupational therapists, and nutritionists provide care for simple to complex voice and swallowing disorders. Our speech-language pathologists (SLP) are all members of the American Speech-Language-Hearing Association (ASHA) and dedicated to the management of aspiration. We treat aspiration in a number of different ways, depending on your child’s needs. Feeding and/or swallowing therapy improves how your child eats and drinks, and it is often an important component of treatment. For example, we can improve an infant’s aspiration by changing breastfeeding positions, altering the flow rate of milk from a bottle, or thickening liquids. Sometimes we combine feeding therapy with surgical intervention if aspiration is caused by an anatomical abnormality.

When might a child need surgery for aspiration?

If your child’s anatomy is not normal or is not functioning correctly, we may consider surgery. The majority of our surgeries are minimally invasive, and we are able to perform them through the mouth without making any incisions in the skin. For example, your child might have vocal cord immobility, where one of the vocal cords is not closing properly to protect the airway during swallowing, or a short laryngeal cleft, where the larynx does not separate completely from the pharynx or esophagus.

If your child has a more complex anatomical condition, such as a tracheoesophageal fistula, where there’s a hole between the trachea (tube to lungs) and esophagus (tube to stomach), or a severe or long laryngeal cleft, he or she might need a more extensive surgery. For rare and severe cases of aspiration, we have a multidisciplinary team that performs advanced operations. The team includes pediatric general surgeons, our airway reconstruction team, and our pediatric cardiothoracic surgeons. We are one of a few children’s hospitals in the Western United States to offer the entire spectrum of these complex operations and procedures.  

For more information, listen to our PedsTalks discussion on aspiration or contact our Aerodigestive and Airway Reconstruction Center or our Center for Pediatric Voice and Swallowing Disorders.