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 ====== Neurogenic dysphagia ======
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 “Paediatric dysphagia” refers to any disturbance of the normal swallow sequence in infants and children, as difficulties in transporting a bolus from the oral cavity to the back of the tongue or moving food into the oesophagus, compromising safety and adequacy of nutritional intake[(cite:arvedson2002>Arvedson JC. Feeding with craniofacial anomalies. In: Arvedson JC, Brodsky LB, editors. Pediatric swallowing and feeding: assessment and management. Second edition. Albany, NY: Singular Publishing Group; 2002. pp. 527-61)][(cite:miller1999>Miller AJ. The neuroscientific principles of swallowing and dysphagia. San Diego: Singular Publishing Group; 1999. pp. 100-1.)][(cite:chantal2015>Chantal L. Development of suck and swallow mechanisms in infants. Ann Nutr Metab 2015;66:7-14. https://doi.org/10.1159/000381361.)][(cite:groher2010>Groher ME, Crary MA. Dysphagia: clinical management in adults and children. Second edition. Maryland Heights, MO: Mosby/Elsevier; 2010.)][(cite:miller2003>)][(cite:dodrill2015>Dodrill P, Gosa MM. Pediatric dysphagia: physiology, assessment, and management. Ann Nutr Metab 2015;66(Suppl 5):24-31.https://doi.org/10.1159/000381372.)].
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 (VFSS) is a radiographic procedure that provides a dynamic view of the swallowing process and is frequently considered to be definitive evaluation for objective assessment of dysphagia in paediatric patients.
+Pre- and post-natal development
+of swallowing mechanisms
+Through understanding of the development of feeding
+and swallowing skills, it is possible to shed light on how
+and why infants may demonstrate signs of oropharyngeal dysphagia.
+During embryologic life, between the 4th and the 7th
+weeks of gestation, many processes relevant to swallowing development take place.
+After the incorporation of the endoderm of the yolk sac
+into the embryo to form the primordial gut and rupture
+G. Lo Re et al.
+of pharyngeal membrane to form primitive choanae,
+separation of oesophagus and trachea from the primitive
+foregut is essential to avoid liquid aspiration during their
+passage through oesophagus 11.
+Thereafter, the foetal period (from the 9th week of gestation to birth) is characterised by continuous differentiation of tissues and organs 11 and by a dramatic development of swallowing, sucking and oral sensorimotor
+function; this latter depends from brainstem and cerebral
+system development and is the fundamental system for
+correct functioning of the former 5 12.
+Sensory cranial nerve input to the brain stem swallowing
+centre depends on the V, VII, IX and X cranial nerves
+while primary motor cranial nerve output is provided
+primarily by the V, VII, IX, X and XII nerves and by the
+cervical C1-C3 nerves 5
+. Correct development of cranial
+nerves is mandatory for adequate swallowing. Myelinisation of the roots of some cranial nerves is seen during
+the 20th-24th weeks of gestation, and during the 35th-38th
+weeks the nervous system matures sufficiently to carry
+out integrative functions as nipple feeding 13.
+Moreover, other cerebral regions are implicated in sensory and motor system development such as the nucleus
+tractus solitarius, nucleus ambiguous, dorsal motor nucleus, hypoglossal nucleus and cerebral cortex 14.
+Foetal swallowing is important to regulate amniotic fluid
+volume and composition, as well as maturation of the
+foetal gastrointestinal tract and renal foetal system 5 15.
+Oral motor skills also develop within a system that
+changes during post-natal life both in structural growth
+and neurological control: the successful use of the suckle
+reflex masters suckling and its coordination with breathing, the child’s motor function (mostly involving his/her
+tongue) masters the stabilisation of the jaw 16 17.
+The swallowing anatomic components of infants are different from adult ones. In the infant, the oral cavity is
+smaller and teeth have not erupted. We can also typically find a smoother tongue and harder palate. The larynx
+and hyoid bone are higher in the neck to the oral cavity,
+while in adults the larynx goes down to a lower area in
+the neck. The epiglottis is almost attached to the soft
+palate so that the larynx is open to the nasopharynx 18.
+The proper integration of the respiratory and feeding
+functions is mandatory because during feeding the time
+left for safe air exchange is reduced, minute ventilation
+is decreased, exhalation is prolonged and inhalation
+shortened. Thus, proper maturation and practice of the
+above functions during the first years of life enhances
+oral motor patterns, and this latter influences feeding
+performance 16.
+Swallowing requires both voluntary and involuntary
+actions and can be summed up into four phases (oral,
+triggering of swallowing reflex, pharyngeal and oesophageal) that involve structures and muscles of the nose,
+mouth, throat, chest, abdomen and digestive tract 19. The
+oral phase consists of both preparatory and transit phases. During the preparatory phase, food and/or liquid are
+prepared in the oral cavity by suckling or mastications in
+order to form a bolus that, in the transit phase, is moved
+posteriorly through the oral cavity. During the pharyngeal phase, bolus is transported through the pharynx, and
+then through the cervical and thoracic oesophagus into
+the stomach during the oesophageal phase 11 20.
+In neonates, the swallowing process is reflexive and involuntary and each of the abovementioned phases may
+mature at different times and/or rates. Later in infancy,
+the oral phase is voluntary and triggering of the swallow
+reflex is generally an involuntary activity, but it can be
+commanded voluntarily, while the pharyngeal and oesophageal phases remain involuntary 6 11.
+A child affected by chronic dysphagia will likely show
+delayed progression of normal feeding skills, recurrent
+respiratory disease and, consequently, growth deficiency. Aspiration is one of the abnormalities that may be
+encountered as an anomaly in the development during
+post-natal life and consists of passage of ingested material, refluxed contents, or oral secretions through the
+vocal folds into the lower respiratory tract. Recurrent or
+chronic aspiration is a serious risk factor in the paediatric population, resulting in infection, chronic lung disease and even death.
+The physiological avoidance of aspiration depends not
+only on anatomical separation of respiratory and digestive tracts in embryologic life, but also on central neural processing. Fluids contacting the laryngeal mucosa
+evoke laryngeal chemoreflexes 21 resulting in many possible responses such as rapid swallowing, apnoea, laryngeal constriction, hypertension and bradycardia, or
+cough; as the infant matures the formers reflexes (rapid
+swallowing and apnoea) become less probable, while
+cough and laryngeal constriction become more prominent 22. However, sex-related differences have been demonstrated between early oral, tongue, pharyngeal and
+laryngeal motor activities: oral and upper airway skills
+emerge earlier in females and the latter (pharyngeal and
+laryngeal movements) are less rhythmic and complete in
+males throughout the second semester 23.
+Paediatric swallowing disorders: aetiology
+An altered swallow sequence may compromise safety,
+efficiency, or adequacy of nutritional intake. Because
 ====== Diagnosis ======