Health Library

Chronic Aspiration

What Causes Chronic Aspiration?

There are several reasons a child might develop chronic aspiration. Some causes are related to how the body is built. Others have to do with how the brain and muscles work together to swallow.

Some children are born with differences in how their throat, windpipe or food pipe are formed. These physical differences can make it easier for food, liquid or saliva to go down the wrong way.

Physical Conditions

Common physical issues include:

• Tracheoesophageal fistula (TEF) is an abnormal connection between the windpipe and the food pipe. This opening lets food or liquid slip from the esophagus into the airway, especially when a child swallows.
• Laryngeal cleft is an opening between the voice box and the food pipe. It allows food, liquid or saliva to pass into the windpipe instead of going down to the stomach.
• Esophageal stricture is a narrowing of the food pipe that makes it hard for food to pass through. When food or liquid gets stuck, it may come back up and enter the airway by mistake.

Neurological Conditions

Some children have problems with how the brain and muscles work together to coordinate swallowing. This can make it harder to feel or control where food and liquid go.

Common neurological causes include:

• Cerebral palsy, a condition that can affect the muscle control and coordination needed for safe swallowing.
• Brain injuries, which can disrupt the signals between the brain and the muscles used for swallowing.
• Genetic syndromes such as CHARGE or Opitz, which affect the face, throat or airway and can raise the risk for aspiration.
• Chiari malformation, a condition where part of the brain presses on the spinal cord and affects nerves that control swallowing.

Reflux and Other Esophageal Issues

In some cases, chronic aspiration is caused by stomach contents or leftover food moving the wrong way back up the esophagus and into the airway, especially when a child is lying down.

This can happen when:

• A child has gastroesophageal reflux that reaches the throat.
• The esophagus has trouble moving food down, which can cause things to back up into the airway.
• A tight surgical wrap or other scarring causes food or saliva to pool in the esophagus.

What Are the Signs and Symptoms of Chronic Aspiration?

Some signs of aspiration are obvious. Others are harder to catch. That is why it is important to keep a close eye on your child, especially if they are already at higher risk.

More noticeable signs:

• Coughing or choking while eating or drinking
• Wet or gurgled breathing or voice
• Vomiting or food coming out of a tracheostomy tube (if your child has one)

More subtle signs:

• Frequent respiratory infections or pneumonia
• Needing oxygen when sick or while sleeping
• Slower-than-expected weight gain
• A gradual decline in oxygen levels over time

Some kids do not show any signs until they start needing more breathing support or have unexplained lung damage on a scan.

How Is Chronic Aspiration Diagnosed?

Diagnosing chronic aspiration often takes a team approach. Doctors will want to know what your child is aspirating, like food, saliva, reflux or a combination, and why it is happening.

Tests may include:

• Video swallow study (VSS): An X-ray shows how your child swallows different foods and drinks.
• FEES (flexible endoscopic evaluation of swallowing): A thin camera is gently passed through the nose to watch how your child swallows up close.
• Dye testing: A drop of green food dye is added to food, drinks or feeding tube formula to see if any of it ends up in the trachea.
• CT scan: This special X-ray looks for signs of long-term lung damage.
• Bronchoscopy: A scope (a thin, flexible tube with a light and camera) is used to look inside the lungs and airways and may include collecting fluid for testing (biopsy).
• Triple scope: This exam is done under anesthesia where ear, nose and throat (ENT), gastrointestinal (GI) and lung specialists all take a look to check for physical issues like a cleft or stricture.

These tests help doctors figure out what’s happening so they can create the best treatment plan for your child.

What Are the Treatment Options for Chronic Aspiration?

Chronic aspiration is not something you manage on your own. Treatment is led by a team of specialists like ear, nose and throat doctors, stomach doctors (gastroenterologists), lung doctors (pulmonologists) and speech-language pathologists trained in swallowing and feeding.

The right treatment depends on what is being aspirated and why.

If your child is aspirating food or drink:

• Your doctor may suggest trying thicker liquids or soft purees to make swallowing safer.
• A swallowing therapist (often a speech-language pathologist) might recommend changes to how or when your child eats, including different feeding positions or pacing.

In some cases, your care team may recommend limiting or stopping feeding by mouth for a period of time to protect the lungs. If this happens, a feeding tube may be used to make sure your child still gets the nutrition they need while their body rests or heals.

If your child is aspirating saliva:

• Your doctor may try medications that reduce saliva production, although these can have side effects.
• In some cases, Botox injections may be used to temporarily shrink the salivary glands.
• If other treatments do not work, your child’s team may recommend a drool procedure, a surgery to remove or block the main salivary glands and reduce the amount of saliva going into the airway.

If your child is aspirating reflux or stomach contents:

• Your care team may recommend a GJ tube, a type of feeding tube that goes into the stomach but sends food directly into the small intestine. This helps lower the risk of reflux by bypassing the stomach and keeping food from backing up into the airway.
• Some children may benefit from a fundoplication, a surgery that helps prevent stomach contents from coming back into the esophagus.
• In rare cases, more complex surgeries may be considered if reflux or esophageal issues are severe and not responding to other treatments.

For children who still aspirate even after other treatments, a surgery called laryngotracheal separation may be an option. This procedure completely separates the airway from the food pipe, stopping all aspiration. But it also means your child will not be able to use their voice. This is only considered when nothing else works and the child’s health is at serious risk.

What Is the Prognosis for Children with Chronic Aspiration?

The outlook depends on what is causing the aspiration. Some children outgrow it as they develop stronger swallowing skills. Others improve with therapy, feeding changes or surgery. When an underlying issue is fixed, like repairing a cleft or fistula, the problem may go away entirely.

If chronic aspiration is left untreated, it can lead to permanent lung damage, frequent infections and a lower quality of life. In severe cases, it may even shorten a child’s lifespan.

With early diagnosis and the right team of specialists, many children with chronic aspiration can stay healthy, active and thrive.

If you are worried your child might be aspirating, especially if they are part of a high-risk group, talk to your doctor. Getting help early can make a big difference.