What are the indications for fiberoptic endoscopic evaluation of swallowing (FEES) in pediatric patients (infants and children) with dysphagia, cough or choking during feeds, recurrent respiratory infections, poor weight gain, neurological impairment (e.g., cerebral palsy, muscular dystrophy, traumatic brain injury), structural anomalies (e.g., cleft palate, subglottic stenosis), postoperative airway or esophageal surgery, or refractory gastro‑esophageal reflux disease?

FEES Indications in Pediatric Patients

Fiberoptic endoscopic evaluation of swallowing (FEES) should be performed in children with cough or oxygen desaturation during feeding, suspected or confirmed vocal cord paralysis, failure to wean from respiratory support, poor weight gain, or chronic pulmonary symptoms—particularly when clinical feeding evaluation alone is unreliable, as it misses aspiration in 30-45% of pediatric cases. 1, 2

Primary Indications for FEES in Children

Respiratory Symptoms During Feeding

• Cough or persistent oxygen desaturation during feeding is a key indication for swallow evaluation, as aspiration occurs in 29-100% of at-risk premature infants undergoing instrumental testing 1, 3
• Recurrent pneumonia or chronic respiratory infections warrant FEES evaluation, as aspiration may be the underlying cause 1
• Persistent wheezing not relieved by bronchodilators or corticosteroids should prompt swallow evaluation to assess for aspiration 1
• Tachypnea, increased secretions, stridor, or wheeze during feeds are clinical signs suggesting aspiration risk 1

Neurological Impairment

• Children with neurogenic dysphagia (cerebral palsy, muscular dystrophy, traumatic brain injury) require FEES because clinical judgment alone is correct in only 55-70% of cases, missing aspiration in nearly half of patients 2
• Cognitive or behavioral impairment increases aspiration risk and warrants instrumental evaluation 1

Airway Anomalies and Structural Abnormalities

• Suspected or confirmed vocal cord paralysis is a high-risk condition for silent aspiration; 100% of premature infants with vocal cord paralysis who aspirate do so silently 1
• Other airway anomalies (subglottic stenosis, laryngomalacia, tracheomalacia) increase aspiration risk 1
• Structural anomalies such as cleft palate require swallow evaluation to assess pharyngeal function 1

Failure to Thrive and Nutritional Concerns

• Poor weight gain or failure to thrive despite adequate caloric intake suggests possible aspiration or swallowing dysfunction 1, 3
• Feeding refusal or aversion may indicate dysphagia requiring instrumental assessment 3

Postoperative Patients

• Postoperative airway or esophageal surgery patients should undergo FEES to assess swallowing function and aspiration risk 1
• History of prolonged intubation or multiple intubations increases risk for vocal cord dysfunction and aspiration 3

Failure to Wean from Respiratory Support

• Failure to wean from oxygen therapy or ventilatory support as expected may indicate occult aspiration 1, 3
• Persistent or worsening pulmonary hypertension in the context of feeding difficulties warrants swallow evaluation 1

FEES vs. Videofluoroscopic Swallow Study (VFSS)

When FEES is Preferred

• Bedside evaluation when patient cannot be transported to radiology 1, 4
• Direct visualization of pharyngeal and laryngeal structures to identify anatomic abnormalities 1
• Assessment of secretion management and pooling in the hypopharynx 4
• Evaluation of laryngeal morphology, motility, and cough reflex sensitivity 1
• Can be performed safely in premature infants and children of all ages 4

VFSS Remains Gold Standard

• VFSS is the gold standard for evaluating all phases of swallowing and should be the first-line test when available 5
• VFSS allows testing of multiple consistencies and identifies the safest diet modifications 5
• Real-time identification of aspiration and evaluation of compensatory strategies 1, 5

Critical Clinical Pitfalls

Silent Aspiration is Common

• Do not assume normal clinical feeding evaluation excludes aspiration—approximately one-third of children with normal clinical exams demonstrate silent aspiration on instrumental testing 1, 3
• 55% of aspiration in children is silent without any cough or overt signs 5
• Clinical judgment alone misses aspiration in 30-45% of pediatric cases with neurogenic dysphagia 2

High-Risk Populations Require Proactive Evaluation

• Premature infants with post-prematurity respiratory disease (PPRD) have aspiration rates of 29-100% when tested, even without obvious symptoms 1
• All premature infants with vocal cord paralysis should undergo swallow evaluation, as silent aspiration is universal in this population 1
• Neurologically impaired children require instrumental assessment regardless of clinical impression 2

Contraindications to Immediate Testing

• Lethargy or absent swallow response on command are contraindications to FEES or VFSS 1
• Inability to manage oral-pharyngeal secretions requiring frequent suctioning 1
• Respiratory rate >35 breaths/min 1

Therapeutic Applications of FEES

• FEES guides immediate dietary interventions that resolve swallowing dysfunction in >90% of children without neurologic pathology within 3-9 months 5
• Biofeedback and visual reassurance can be provided to patients and families during FEES, particularly useful in psychogenic dysphagia 6
• Identifies appropriate thickened liquid consistency to prevent aspiration 5
• Evaluates effectiveness of compensatory strategies such as chin-down posture or modified feeding techniques 1