What can an Ear, Nose, and Throat (ENT) doctor do for an infant with feeding difficulties and dyspnea (trouble breathing) during meals?

ENT Management for Infants with Feeding Difficulties and Respiratory Distress During Feeding

An ENT specialist should perform a video-fluoroscopic swallowing study (VFSS) as the primary diagnostic procedure for infants experiencing feeding difficulties and respiratory distress during meals, as this can identify swallowing dysfunction in 10-15% of infants with respiratory symptoms and guide appropriate feeding interventions. 1

Diagnostic Approach

Primary Evaluation: Swallowing Function

• Video-fluoroscopic swallowing study (VFSS) is the recommended first-line diagnostic test for infants with:

  • Cough or oxygen desaturation during feeding
  • Suspected or confirmed vocal cord abnormalities
  • Difficulty weaning from oxygen or ventilatory support
  • Failure to thrive
  • Chronic respiratory symptoms disproportionate to viral infections 1

• VFSS can detect:

  • Silent aspiration (occurs in approximately one-third of infants with normal clinical feeding evaluations)
  • Tracheal aspiration or laryngeal penetration
  • Specific swallowing dysfunction patterns 1

Secondary Evaluation: Airway Assessment

• Airway endoscopy (flexible laryngoscopy, flexible bronchoscopy, or direct laryngobronchoscopy) should be considered when:

  • Swallowing dysfunction is identified
  • Vocal cord paralysis is suspected
  • Persistent respiratory symptoms during feeding continue despite interventions 1

• Airway endoscopy can identify:

  • Tracheomalacia (present in up to 48% of infants with severe respiratory issues)
  • Bronchomalacia (present in approximately 40.7%)
  • Airway edema (present in approximately 48%)
  • Vocal cord paralysis (particularly important after certain surgical procedures) 1

Treatment Interventions

Feeding Modifications

1. Thickened feeds:

   • Primary intervention for most infants with swallowing dysfunction
   • Can reduce aspiration risk by more than 90% compared to thin liquids 1
   • Should be tailored to the specific type of dysphagia identified

2. Alternative feeding routes (for severe cases):

   • Nasojejunal feeding
   • Gastrostomy tube placement
   • Temporary cessation of oral feeding 1

Airway Management

• Surgical interventions may be indicated if anatomical abnormalities are identified:
  • Correction of subglottic or tracheal stenosis
  • Management of subglottic cysts
  • Treatment of tracheomalacia 1

Expected Outcomes

• In most infants with swallowing dysfunction, the condition resolves within 3-9 months with appropriate feeding interventions 1
• More than 90% of patients will improve with feeding modifications while waiting for swallowing coordination to improve with age 1
• Early identification and management can prevent:
  • Chronic respiratory infections
  • Failure to thrive
  • Long-term feeding aversions 1, 2

Important Considerations and Pitfalls

• Silent aspiration is common in infants and can only be detected through diagnostic studies, not clinical observation alone 1

• Multidisciplinary approach is essential:

  • ENT specialist for airway assessment
  • Speech pathologist for swallowing evaluation
  • Occupational therapist for feeding strategies
  • Radiologist for proper VFSS interpretation 1

• Follow-up is critical:

  • Regular reassessment of swallowing function
  • Monitoring for improvement or worsening of symptoms
  • Adjusting feeding strategies as the infant develops 1

• Avoid common pitfalls:

  • Don't rely solely on clinical feeding evaluations (miss ~33% of silent aspiration)
  • Don't assume gastroesophageal reflux is the only cause of symptoms
  • Don't delay diagnostic evaluation while trying empiric treatments 1, 2

By following this structured approach to evaluation and management, an ENT specialist can significantly improve feeding outcomes and reduce respiratory complications in infants with feeding difficulties.