Assessing the Role of Aspiration in Pediatric Lung Disease

Safe swallowing is a highly complex process. It requires the normal structure and function of the oral, nasal, pharyngeal, and laryngeal cavities with a reliable intestinal tract to ensure that the feed continues in an intestinal direction. We all aspirate small amounts—probably daily, and especially in sleep. The lungs and upper airways have developed careful strategies to deal with accidental soilage. Mostly, it is successful, and the lung damage is prevented. In children, the growing lung is particularly vulnerable to insults from aspiration. Proving that pathological aspiration has occurred and is responsible for the pulmonary findings can be extremely difficult. In addition, there are age-specific features of feeding and swallowing throughout childhood that need special consideration. Lung damage from aspiration is a common feature in pediatric practice, but it is not inevitable, and neither is it linear. The result of acute or repeated aspiration events on the airways produces a wide spectrum of unpredictable pathological end points. This article looks at the failings of the swallowing mechanism in children of different ages, in health and disease, and reviews the tests available to determine whether aspiration is occurring. The important role of the videofluoroscopic swallow study in children is highlighted. Steps to intervene and prevent damage in vulnerable children are reviewed, including the ethical dilemma of the child in whom aspiration is occurring, and yet oral feeding continues.