Signs, Symptoms, and Potential Causes of Pediatric Dysphagia

Possible Signs of a Feeding/Swallowing Disorder

  • Refusing to eat
  • Eating very little for a prolonged period of time
  • Spitting out food
  • Frequent coughing or throat clearing during or soon
    after eating
  • Excessive drooling
  • Food leaking from mouth
  • Refusing to eat certain textures or temperatures of
  • A “wet” or “gurgly” sounding voice or cry after
  • Excessive spitting up or vomiting after eating


  • Occurs when the contents of the stomach, including the stomach acid,
    return to the esophagus.
  • Can occur when eating or drinking but also when there is any kind of
    change in intra-abdominal pressure
  • Some symptoms of children with GERD may include:
    • Vomiting
    •  Coughing, gagging, or choking
    • Exhibit abnormal postures
    • Unexplained irritability
    • Failure to Thrive
    • Weight below the 3rd percentile for age
    • Organic, non-organic or mixed etiology
    •  Organic causes include endocrine deficiencies, chronic disease,
      enzyme defects or congenital/genetic anomalies or oral-motor
    • Non-organic causes include poor caregiver-child interaction, psychosocial
      issues, environmental deprivation, child abuse and poor feeding
    •  Factors related to caregiver-centered FTT include lack of nutritional
      information, improper feeding techniques, unrealistic expectations
      about feeding, inability to accurately assess the child’s needs, neglect
      and isolation


  • Occurs when food travels into the airway instead of into the stomach
  • Often suspected by observation of coughing, wet voice, throat
    clearing, or diagnosis of pneumonia
  • Aspiration may be seen on different textures so a child could be
    perfectly safe eating purees and solids but aspirate on thin liquids
  • If you suspect aspiration, contact your pediatrician to discuss the
    possibility of a swallowing evaluation

Sensory Issues

  • Reactive Sensory Defensiveness can occur when an infant has not
    received positive sensory input to the mouth
  •  When sensory input is provided, it may be experienced as very strong
    and uncomfortable
  • Primary Sensory Defensiveness to facial and oral stimulation occur
    as a primary difficulty in some children
  • Child’s basic perception is one of danger, and the sensory stimulus is
    often perceived as an attack
  • Not based on some past, negative experience
  • May occur as a response to touch, movement, smell, taste, and texture
    in food
  •  Eating Aversion is the result of a complex interplay of sensorimotor,
    gastrointestinal, and environmental responses
  • Typically perceived as a behavioral issue
  • Many of these children have subtle sensorimotor and gastrointestinal
    issues that make eating uncomfortable
  • These children may choose a non-eating behavior to reduce or
    prevent discomfort


-Sharon P. M.S. CF-SLP TSSLD


Spatial Concepts and Relationships – Early Skills with Preschoolers

Spatial concepts (a category of basic concepts) define the relationship between us and objects, as well as the relationships of objects to each other. As our language begins to develop, early spatial concepts such as in front of, behind, top, bottom, over, under, last, between, farthest, backward, in, on, etc., help us understand directions more precisely, ask detailed questions, and express our ideas to others. For preschoolers and young students, an awareness or understanding of spatial concepts and relationships usually predicts later success in math, reading, and following directions. Parents and preschool educators should begin teaching spatial concepts to children at a very early age. At age two, children are already absorbing, learning, and rapidly developing their vocabularies. They are beginning to understand the concepts of space in their environment; they are moving, touching, talking, and beginning to ask questions. This is the perfect time to immerse them in language that fosters their understanding of spatial relationships between their bodies and the objects in their environment. We ask toddlers, “Where is your nose?” They point to their nose. We follow up with different concept phrases like, “Your nose is on your face,” “Your nose is above your lips,” “Your nose is on the front of your head.” This type of response embeds concept words—expanding on and making them a regular part of language. Using concepts in “teachable moments” helps children understand, and later generalize, the concepts for further learning. I Spy and I See are examples of games that can use spatial concepts in a fun way. For example, “I see a book. Where is it?” When the child finds or points to it, an adult responds with, “The book is on the shelf…in the book bag… under the table… by the bed… above the table… beside the chair.”

In therapy I like to play “I Spy”. “I spy a big, green book! I spy a little, square pillow. I spy a red, round ornament with a crooked hook.” It is easy to include concepts while interacting with your child by talking in great detail and description. For example, a mother may tell her kindergarten child, “Take off your coat and boots. Hang your blue coat in the closet on the little hook above the doorknob. Put your red boots on the rubber mat by the door. Now lie down and rest beside your dad before we have dinner.” In just a few seconds, this child must listen to over ten concepts, make sense of them, and then follow through with the directions. Think of all of the verbal directions a teacher gives each student every day at school. Spatial concepts, along with other basic concepts, are essential for success in school and daily activities at home.

Source: Superduper Publications



Helpful Strategies for Auditory Memory

Memory impacts a person’s ability to perform almost any activity. Memory is how
“knowledge is encoded, stored, and later retrieved” (Kandell, Schwartz, and Jessell, 2000).
Even mild memory deficits can impact a student’s success. There are different kinds of
memory, including long-term memory, short-term memory, working memory, auditory
memory, and visual memory. Auditory memory is the ability to take in information that is
presented orally (out loud), process it, retain it in one’s mind, and then recall it (Bellis, 2003;
Roeser & Downs, 2004; Stredler-Brown & Johnson, 2004). Auditory memory requires
working memory.
Working memory is “the management, manipulation, and transformation of
information drawn from short-term memory and long-term memory” (Dehn, 2008). Working
memory is responsible for processing higher level linguistic information, and if the task is
more complex, working memory spends more time processing (Daneman and Carpenter,
1980). Working memory capacity has significant relationships with reading decoding,
language comprehension, spelling, following directions, vocabulary development, note
taking, and GPA (Engle, Tuholski, Laughlin, and Conway, 1999).

Auditory Memory Deficits
Auditory memory deficits include remembering multi-step directions, relating new
information to prior knowledge, oral language comprehension, taking notes while listening,
verbal fluid reasoning, written expression, and oral expression (Dehn, 2008). Individuals with
deficits and weaknesses can benefit from direct teaching of strategies which can improve
working memory performance. According to Dehn (2008), effective strategy teaching
can include:
• Engaging in one-on-one brief, focused sessions over several weeks;
• Teaching one strategy at a time;
• Explaining purpose and rationale;
• Explaining and modeling the steps of the strategy;
• Providing plenty of practice and offering feedback;
• Teaching cues to help remember the strategy;
• Providing positive reinforcement and data tracking;
• Encouraging children to monitor and evaluate strategy use;
• Encouraging generalization across sessions.

Types of Auditory Memory Strategies
Different types of auditory memory strategies include:
• Verbal Rehearsal – repeating words or numbers, either vocally or subvocally
(e.g., Try saying the numbers over and over, like this: 2, 7, 5; 2, 7, 5; 2, 7, 5.);
• Elaborative Rehearsal – associating new information with prior
knowledge, such as creating sentences of the to-be-remembered word
or creating a story, or paraphrasing [reorganizing larger amounts of
information into smaller, more personally meaningful units (Donahue
& Pidek, 1993)];
• Chunking – pairing, clustering, grouping, or association of different items into larger
units (e.g., Try putting the numbers together. So if you hear 2, 4, 8, 3—think 24, 83.);
• Relational Strategies – making the information being memorized more meaningful
through mnemonics, imagery, or elaboration (e.g., Try to make a simple sentence
using the words you hear. If you hear dog, hat, bed, make a silly sentence like, “The
dog found a hat under the bed.”).

SOURCE: SuperDuper Publications

-Sharon P. M.S. CF-SLP TSSLD

Vocal Fold Nodules and the Role of the SLP in Assessing Voice Disorders

In order to understand how vocal pathologies occur we must first understand the anatomy and physiology of the airway and speech mechanism.  The vocal folds are house within the larynx, when you speak the air from your lungs moves from up to your larynx and to your mouth. The vocal folds vibrate in order to produce sound.

Vocal fold nodules are growths that form on the vocal folds. They are benign, or not cancerous. When you use your voice the wrong way, your vocal folds may swell. Over time, the swollen spots can get harder, like a callous. These nodules can get larger and stiffer if your vocal abuse continues.

Polyps can be on one or both of the vocal folds. They may look like a swollen spot or bump, a blister, or a thin, long growth. Most polyps are bigger than nodules. You may hear them called polypoid degeneration or Reinke’s edema. It may be easiest to think of a nodule as a callous and a polyp as a blister.

Signs of Vocal Fold Nodules and Polyps

Nodules and polyps cause similar symptoms. These include:

  • hoarseness
  • breathiness
  • a “rough” voice
  • a “scratchy” voice
  • a harsh-sounding voice
  • shooting pain from ear to ear
  • feeling like you have a “lump in your throat”
  • neck pain
  • less ability to change your pitch
  • voice and body tiredness

Causes of Vocal Fold Nodules and Polyps

Most of the time, vocal abuse or misuse causes nodules. Long-term vocal abuse can cause polyps, too. But polyps may happen after just one instance of vocal abuse, like yelling at a concert. Smoking cigarettes for a long time, thyroid problems, and reflux may also cause polyps.

Vocal abuse can happen in many ways, including from:

  • allergies
  • smoking
  • tense muscles
  • singing
  • coaching
  • cheerleading
  • talking loudly
  • drinking caffeine and alcohol, which dries out the throat and vocal folds

The Role of the Speech-Language Pathologist for Voice Disorders 

The first step of voice therapy is to assess the patient’s voice production and voice quality and structure the therapeutic program accordingly. Often, SLPs consult with otolaryngologists and neurologists to ensure a proper diagnosis.

If a voice disorder is suspected, SLPs first perform a screening. This generally involves evaluating vocal characteristics related to respiration, phonation, and resonance, as well as vocal range and flexibility.

If deviations from a normal voice are detected, SLPs suggest further evaluation through a comprehensive assessment. There are several standardized and non-standardized measures that SLPs use, and diagnostic therapy is often performed as part of the comprehensive assessment process.

SLPs look at a variety of factors when making an assessment, such as:

  • Any impairments in the patient’s body structure and function that could affect sound production and verbal/nonverbal communication
  • Any deficits, health conditions, or medications that can affect the voice
  • The patient’s limitations (if any) in terms of activity or participation in interpersonal interactions
  • The existence of any environmental or personal factors that may present obstacles to successful communication

A comprehensive assessment to identify voice disorders includes:

  • Case history
    • Patient’s description of voice problem, including onset and symptoms
    • Medical status and history
    • Previous voice treatments
    • Daily habits related to vocal hygiene
  • Self-Assessment: The patient’s assessment of how the voice problems affect:
    • The ability to communicate in social, work settings, and everyday activities
    • Emotions and self-image
  • Oral-Peripheral Examination: Assessment of:
    • Structural and motor-based deficits that could affect communication
    • Symmetry and movement of the face, head, neck, and respiratory system
    • Sensation of the face and mouth
    • Taste and smell
    • Laryngeal sensations (burning, pain, tickling, dryness, etc.)
  • Assessment of Respiration
    • Respiratory pattern
    • Coordination of respiration with phonation
    • Maximum phonation time
  • Auditory-Perceptual Assessment
    • Voice quality (strain, pitch, loudness, overall sensitivity
    • Resonance
    • Phonation
    • Rate
  • Instrumental Assessment, such as laryngeal imaging
  • Acoustic Assessment
  • Air Flow Assessment


-Sharon P. M.S. CF-SLP TSSLD