Dysphagia - guidance

Definitions

Dysphagia describes eating and drinking disorders in children and adults which may occur in the oral, pharyngeal and oesophageal stages of deglutition.

Contained in this definition are problems positioning food in the mouth and in oral movements, including sucking, mastication and the process of swallowing.

The ‘normal’ swallow needs the respiratory, oral, pharyngeal, laryngeal and oesophageal anatomical structures to function in synchrony, which is dependent upon the motor and sensory nervous system being intact.

Characteristics

Dysphagia is always secondary to a primary psychological, emotional, neurological or physical condition.

Dysphagia can result in, or contribute to, crucial negative health conditions including chest infections; choking; weight loss; malnutrition, and dehydration, sometimes with serious adverse clinical events.

Disorders of swallowing are associated with increased likelihood of:

• Chest infections
• Pneumonia
• Choking
• Weight loss
• Malnutrition
• Dehydration

Dysphagia is associated with:

• An increased morbidity
• An increased mortality
• A reduced quality of life

Difficulties in sensory perception may create sensitivities and may also lead to psycho-behavioural difficulties in relation to food and drink.

Children may have additional anatomical, learning, communication, and sensory, behavioural and physical needs. The nature of their difficulties may be acquired or congenital.

In both children and adults, dysphagia can present as acute or chronic, and within these categories, static or progressive in its presentation.

Aetiology

The ability to swallow normally can be influenced by a number of factors which can include coordination and strength of the musculature, posture, bolus size, texture of bolus, and disuse of swallow due to pain, illness, change in taste, nausea, ageing, cognition, respiratory, and cardiac problems.

Dysphagia in children

Eating and drinking difficulties in children can be associated with a number of different conditions:

• Prematurity
• Neurological deficits, e.g. acquired traumatic brain injury, Rett syndrome
• Oncology/tumours
• Cerebral palsy
• Infectious diseases, e.g. meningitis
• Neuromuscular disorders, e.g. muscular dystrophy
• Respiratory difficulties, e.g. chronic lung disease, structural abnormalities of the upper respiratory tract, tracheostomy
• Cardiovascular disorders, e.g. congenital heart disease
• Gastrointestinal difficulties, e.g. gastro-oesophageal reflux, oesophagitis, oesophageal atresia
• Craniofacial conditions, e.g. cleft palate, Pierre Robin sequence
• Congenital syndromes, e.g. Prader-Willi, Down’s syndrome
• Learning disability

Some children with autism may have difficulties with food due to sensory disturbances with smell and texture. This is particularly so for children with autism and those with a traumatic feeding history.

Dysphagia in adults

Dysphagia in adults can occur as a result of any of the following medical disorders:

• Neurological disorders, e.g. stroke, PD, MND, MS, PSP, GB, brain tumour, subarachnoid haemorrhage, Wilson’s disease, dementia, polyneuropathy, head injury
• Head and neck cancer, e.g. laryngeal cancer
• Oncology, e.g. lung cancer
• Cardiopulmonary disorders, e.g. chronic obstructive pulmonary disease
• Autoimmune disorders, e.g. HIV, lupus, rheumatoid arthritis
• Connective tissue disorders, e.g. scleroderma
• General medical disorders, e.g. UTI
• Disorders associated with the elderly, e.g. cervical osteophytes
• Disorders caused by trauma, e.g. smoke inhalation
• Vascular disorders, e.g. Bechet’s disease
• Swallow disorders as a result of surgery, e.g. base of skull surgery, thyroid surgery
• Tracheostomy
• Ventilator dependent individuals, e.g. post-extubation related dysphagia
• Drug-related causes, e.g. long-term use of some antipsychotic medications
• Psychogenic causes.

Dysphagia can also result from the treatment of diseases, e.g. radiotherapy.

Vulnerability and Risk Issues

Difficulty with swallowing may have life-threatening consequences and can lead to an impaired quality of life. This may be due to embarrassment and lack of enjoyment of food, which can have profound social consequences for both the person and members of the family.

Impact of dysphagia

Dysphagia can present in many ways, and the patient may demonstrate one or several of the following symptoms:

• Food spillage from lips
• Taking a long time to finish a meal
• Poor chewing ability
• Dry mouth
• Drooling
• Nasal regurgitation
• Food sticking in the throat
• Poor oral hygiene
• Coughing and choking
• Regurgitation
• Wet voice
• Weight loss; and/or
• Repeated chest infections

Individuals who do not have appropriate dysphagia management are at high risk of:

• Aspiration (Smithard et al, 1996)
• Developing respiratory infection (Doggett et al, 2001)
• Choking and death (Marik & Kaplan, 2003)
• Poor nutrition and weight loss (Wright et al, 2005)
• Dehydration
• Poor oral health
• Poor health (Hudson et al, 2000)
• Anxiety and distress within the family (Choi-Kwon et al, 2005)
• Hospital admission or extended hospital stay (Low et al, 2001) or
• Reduced quality of life (Nguyen et al, 2005)

Implications for children

Dysphagia can impact on a number of physical, social and psychological consequences including poorer quality of life. In children, there are serious implications for both survival and brain development if nutrition is insufficient for developmental needs (Boyle 1991). There is increasing awareness of compromised swallowing in preterm babies.

Respiratory disorders caused by aspiration can seriously affect the child’s ability to survive or thrive. In addition, dysphagia can cause significant impacts on life, for example the child’s ability to participate in mealtime tasks (Morgan et al., 2004). This can cause stress for the child and family (Morgan et al, 2012).

There is particular need to give support to families of children who are tube fed as it is important to develop systems to have a pleasant feeding/meal times to establish a good carer-child relationship (Sullivan et al., 2005). Stressful feeding and meal times can impact on wellbeing, social interaction and lead to behavioural issues.

Pneumonia

Pneumonia is a major cause of morbidity and mortality after stroke or head injury that can be associated with dysphagia. Sellars et al, (2007) in a study of 412 patients determined the key characteristics that would predict patients at high risk for post-stroke pneumonia. They concluded that it was associated with, older-age, dysarthria, severity of post-stroke disability and an abnormal water swallow test.

Furthermore, aspiration pneumonia is a leading cause of death in nursing homes. It has been reported that between 35-85% of people are malnourished in long-stay institutions such as nursing and residential homes. As well as being an alarming symptom, swallowing difficulties in the elderly lead to physical and psychosocial problems which reduce the quality of life.

Tibbling & Gustafsson (1991) found that elderly patients with dysphagia had significantly more frequent chest pain, heartburn and regurgitation than those without dysphagia. Difficulty with swallowing also caused anxiety at mealtimes; either the individual not wanting to eat alone for fear of choking, or feeling embarrassed at their slow and unusual eating behaviour (Costa Bandeira et al, 2008).

Elderly patients suffering from dysphagia

In elderly patients swallowing problems can confound existing problems such as diabetes and wound healing (Carrau and Murray, 1998). Guidelines produced by the Royal College of Physicians (2010) require the early diagnosis and effective management of dysphagia stating that it has been found to reduce the incidence of pneumonia and improve quality of care and outcomes.

There are cost implications associated with dysphagia. Length of stay in hospital is longer for those stroke patients with dysphagia compared with patients without dysphagia and patients with dysphagia were twice as likely to be discharged to a nursing home than those without (Odderson et al, 1995).

Role of speech and language therapy

Guidelines suggest that people who present with indicators of dysphagia should be referred to someone with relevant skills in diagnosis and assessment of dysphagia (NICE, 2006). Speech and language therapists have a unique HCPC recognised and registered role in identifying and managing oropharyngeal dysphagia associated with a broad range of developmental, neurological and head and neck disorders. There is evidence that interventions, behavioural and other, used by speech and language therapists in the treatment of dysphagia are effective.

The overall aims of the speech and language therapist working with an individual with dysphagia include:

• Detailed and accurate assessment (there may be multiple assessments over time) leading to accurate diagnosis of dysphagia which may assist with the differential medical diagnosis
• Ensuring safety (reducing or preventing aspiration) with regards to swallowing function
• Balancing these factors with quality of life, taking into account the individual’s preferences and beliefs
• Working with other members of the team, particularly dieticians, to optimise nutrition and hydration
• Stimulating improved swallowing with oral motor/sensory exercises, swallow techniques and positioning

It is recognised that prompt intervention in the management of dysphagia can prevent costly and life-threatening complications, such as aspiration pneumonia (Feng et al., 2019). Odderson et al., (1995) showed that the incidence of aspiration pneumonia due to dysphagia could be reduced from 6.7% to 0% through effective management.

When working with individuals who are undergoing surgery or treatments, such as chemotherapy or radiotherapy, the speech and language therapist has a preventative role in strengthening the individual’s swallow pre-treatment.

Videofluoroscopy

RCSLT position paper: Videofluoroscopic evaluation of oropharyngeal swallowing function (VFS) the role of SLTs (2013).

See Learning page for VFS competency frameworks.

Fibreoptic endoscopic evaluation of swallowing (FEES)

The RCSLT Fibreoptic endoscopic evaluation of swallowing (FEES): the role of speech and language therapy position paper, competency framework and training logs and other supporting resources can be accessed here.

Dysphagia devices

There are a range of products that claim they may be used in the treatment of dysphagia. The RCSLT’s position on the use of these is the same as for any new intervention. For further guidance, please see our section on the use of new interventions.

IQORO

In March 2019, the National Institute of Health & Care Excellence (NICE) issued a Medtech innovation briefing about the use of IQoro for stroke-related dysphagia. These briefings are designed to support commissioners and healthcare professionals who are considering whether to use a new medical device or technology and thus they particularly consider safety issues.

NICE Medtech briefing on IQoro for stroke-related dysphagia

NICE’s briefing describes key evidence around the product, but does not provide specific guidance or recommendations. Some of its key conclusions are:

• Swallowing therapy is the usual treatment for dysphagia after a stroke. The company claims swallowing exercises can be more accurately and effectively done using IQoro. No similar technologies are currently recommended in care guidelines.
• Key uncertainties around the evidence are the lack of high-quality, randomised studies and the unclear effect of IQoro compared with NHS standard care or spontaneous improvement.

More detail on NICE’s overall assessment of the evidence can be found here. The RCSLT recommend careful consideration of this guidance, as part of an evidence-based approach to practice, when considering usage of this device. NICE recommend that when using a new treatment device or approach that it should be part of service evaluation, audit or research. Thus, gathering data associated with its use is suggested.

Transcutaneous Neuromuscular Electrical Stimulation (NMES)

In December 2018 the National Institute for Health and Care Excellence (NICE) issued guidance to the NHS in England, Wales, and Northern Ireland on one group of electrical stimulation interventions: Transcutaneous neuromuscular electrical stimulation for oropharyngeal dysphagia in adults.

• NICE Guidance on Transcutaneous neuromuscular electrical stimulation for oropharyngeal dysphagia in adults

The RCSLT recommends carefully reviewing and following this guidance if you are considering using this approach. For questions on indemnity cover while acting on the NICE guidelines, please refer to the use of new interventions section for more information.

Please note that the RCSLT does not “endorse” any intervention or medical device.

International Dysphagia Diet Standardisation Initiative

Find out information about the International Dysphagia Diet Standardisation Initiative (IDDSI) here.

National guidance

RCSLT guidance and statements

• Mouth care guidance – best practice guidelines for SLTs delivering mouth care and collection of useful resources (2020)
• Guidance on the management of dysphagia in care homes (PDF) (2018)
• Paediatric dysphagia: workforce review and training needs analysis report (PDF) (2023)

NICE guidelines

• NICE guideline CG32: Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition (2006)
• NICE guideline CG35: Parkinson’s disease: diagnosis and management in primary and secondary care (2006)
• NICE guideline CG 101: Chronic obstructive pulmonary disease in over 16s: diagnosis and management (2010)
• NICE guideline CG68 Stroke: Diagnosis and initial management of acute stroke and transient ischaemic attack (TIA) (2008)
• NICE guideline CG 106: Barrett’s oesophagus: ablative therapy (2010)
• NICE guideline CG162: Stroke rehabilitation: long-term rehabilitation after stroke (2013)
• NICE Interventional procedures guidance [IPG634]: Transcutaneous neuromuscular electrical stimulation for oropharyngeal dysphagia in adults (2018)
• NICE guideline NG1: Gastro-oesophageal reflux disease in children and young people: diagnosis and management (2015)
• NICE Guideline (2017) Intermediate care including reablement (NG74)
• NICE Guideline (2018) on people’s experience in adult social care services: improving the experience of care and support for people using adult social care services (NG86)

Other guidelines

• Supporting people with eating, drinking and swallowing difficulties (Dysphagia) – Scotland, 2020
• Scottish Intercollegiate Guidelines Network (SIGN) Guideline 118 – Management of patients with stroke: Rehabilitation, prevention and management of complications, and discharge planning. (2010)
• SIGN Guideline 119 – Management of patients with stroke – Identification and management of dysphagia. (2010)
• Royal College of Physician (RCP) report – Oral feeding difficulties and dilemmas: A guide to practical care, particularly towards the end of life, (2010) Co-published with the British Society of Gastroenterology.
• Royal College of Physicians. National clinical guidelines for stroke. 5th edition (2016).
• NHS Guidance Ensuring Safer Practice for Adults with Learning Disabilities who have Dysphagia (2007) – Highlights best practice and provides resource materials to give practical help. The tools can be adapted for local use and for any adult who has dysphagia.

British Geriatrics Society Best Practice Guide – Dysphagia Management for Older People Towards the End of Life (2012)

Please note: the resources on this page are provided for informational purposes only. No endorsement is expressed or implied, unless otherwise stated. While we make every effort to ensure this page is up to date and relevant, we cannot take responsibility for pages maintained by external providers.

Policy – England

Here you will find links to relevant national legislation, policy and frameworks.

Please note that this list is not exhaustive. Please contact us if you have any suggestions.

Please note: the resources on this page are provided for informational purposes only. No endorsement is expressed or implied, unless otherwise stated. While we make every effort to ensure this page is up to date and relevant, we cannot take responsibility for pages maintained by external providers.

Royal College of Physicians, National clinical guidelines for stroke. 5th edition (2016)

Robert Francis Inquiry report into Mid-Staffordshire NHS Foundation Trust, 2010 (initial inquiry)

The Mid Staffordshire NHS Foundation Trust Public Inquiry, 2013

Mental Capacity Act 2005

Mental Capacity Act 2005 – Code of practice (PDF)

Winterbourne View Hospital: Department of Health review and response

Winterbourne View: Transforming Care One Year On (PDF)

The National Confidential Enquiry into Patient Outcome and Death (NCEPOD): A review of the quality of dysphagia care provided to patients with Parkinson’s disease aged 16 years and over who were admitted to hospital when acutely unwell 2021

Policy – Wales

Here you will find links to relevant national legislation, policy and frameworks.

Please note that this list is not exhaustive. Please contact us if you have any suggestions.

Please note: the resources on this page are provided for informational purposes only. No endorsement is expressed or implied, unless otherwise stated. While we make every effort to ensure this page is up to date and relevant, we cannot take responsibility for pages maintained by external providers.

Regulations and National Minimum Standards – What a registered care provider must do by law to provide a care service in Wales.

Mental Capacity Act 2005

Mental Capacity Act 2005 – Code of practice

National Clinical Guidelines for Stroke – fourth edition (2012)

Written Statement – An update on the action taken in Wales following the BBC Panorama Programme on abuse at Winterbourne View Hospital near Bristol.

Trusted to Care: An independent review of the Princess of Wales Hospital and Neath Port Talbot Hospital at Abertawe Bro Morgannwg University Health Board.

Policy – Scotland

Here you will find links to relevant national legislation, policy and frameworks.

Please note that this list is not exhaustive. Please contact us if you have any suggestions.

Please note: the resources on this page are provided for informational purposes only. No endorsement is expressed or implied, unless otherwise stated. While we make every effort to ensure this page is up to date and relevant, we cannot take responsibility for pages maintained by external providers.

National Care Standards – includes standards for hospice care; independent hospitals; and care homes for older people, people with learning disabilities and people with physical and sensory impairment.

Policy – Northern Ireland

Here you will find links to relevant national legislation, policy and frameworks.

Please note that this list is not exhaustive. Please contact us if you have any suggestions.

Please note: the resources on this page are provided for informational purposes only. No endorsement is expressed or implied, unless otherwise stated. While we make every effort to ensure this page is up to date and relevant, we cannot take responsibility for pages maintained by external providers.

Eating Drinking and swallowing guidelines in Dementia

Care Standards – eight sets of standards for a range of health and social care services including nursing homes and residential care homes.

Mental Capacity Act (Northern Ireland) 2016

References

Bandeira, A.K.C., Azevedo, E.H., Vartanian, J.G., Nishimoto, I.N., Kowalski, L.P. and Carrara-de Angelis, E. (2008) Quality of life related to swallowing after tongue cancer treatment. Dysphagia, 23(2), pp.183-192.

Boyle, J.T. (1991) Nutritional management of the developmental disabled child. Pediatric surgery international, 6(2), 76-81.

Carrau, R.L., Murry, T. (1998) Comprehensive management of swallowing disorders. San Diego: Singular Publishers Group, pp 377–381.

Choi-Kwon, S., Kim, H.S., Kwon, S.U. and Kim, J.S. (2005) Factors affecting the burden on caregivers of stroke survivors in South Korea. Archives of physical medicine and rehabilitation. 86(5), 1043-1048.

Doggett, D.L., Tappe, K.A., Mitchell, M.D., Chapell, R., Coates, V. and Turkelson, C.M. (2001) Prevention of pneumonia in elderly stroke patients by systematic diagnosis and treatment of dysphagia: an evidence-based comprehensive analysis of the literature. Dysphagia, 16(4), pp.279-295.

Feng, M.C., Lin, Y.C., Chang, Y.H., Chen, C.H., Chiang, H.C., Huang, L.C., Yang, Y.H. and Hung, C.H. (2019) The mortality and the risk of aspiration pneumonia related with dysphagia in stroke patients. Journal of Stroke and Cerebrovascular Diseases, 28(5), pp.1381-1387.

Hudson, H.M., Daubert, C.R. and Mills, R.H. (2000) The interdependency of protein-energy malnutrition, aging, and dysphagia. Dysphagia, 15(1), pp.31-38.

Low, J., Wyles, C., Wilkinson, T. and Sainsbury, R. (2001) The effect of compliance on clinical outcomes for patients with dysphagia on videofluoroscopy. Dysphagia. 16(2), 123-127.

Marik, P.E. and Kaplan, D. (2003) Aspiration pneumonia and dysphagia in the elderly. Chest. 124(1), 328-336.

Morgan, A.T., Dodrill, P. and Ward, E.C. (2012) Interventions for oropharyngeal dysphagia in children with neurological impairment. Cochrane Database of Systematic Reviews, (10).

Morgan, A., Ward, E. and Murdoch, B. (2004) A case study of the resolution of paediatric dysphagia following brainstem injury: clinical and instrumental assessment. Journal of Clinical Neuroscience, 11(2), pp.182-190.

Nguyen, N.P., Frank, C., Moltz, C.C., Vos, P., Smith, H.J., Karlsson, U., Dutta, S., Midyett, A., Barloon, J. and Sallah, S. (2005) Impact of dysphagia on quality of life after treatment of head-and-neck cancer. International Journal of Radiation Oncology* Biology* Physics. 61(3), 772-778.

Odderson, I.R., Keaton, J.C. and McKenna, B.S. (1995) Swallow management in patients on an acute stroke pathway: quality is cost effective. Archives of physical medicine and rehabilitation. 76(12), pp.1130-1133.

Royal College of Physicians (RCP) (2010) Oral feeding difficulties and dilemmas report: A guide to practical care, particularly towards the end of life (PDF). Co-published with the British Society of Gastroenterology.

Sellars, C., Bowie, L., Bagg, J., Sweeney, M.P., Miller, H., Tilston, J., Langhorne, P. and Stott, D.J. (2007) Risk factors for chest infection in acute stroke: a prospective cohort study. Stroke. 38(8), 2284-2291.

Smithard, D.G., O’neill, P.A., Park, C.L., Morris, J., Wyatt, R., England, R. and Martin, D.F. (1996) Complications and outcome after acute stroke: does dysphagia matter? Stroke. 27(7), 1200-1204.

Sullivan, P.B., Juszczak, E., Bachlet, A.M., Lambert, B., Vernon-Roberts, A., Grant, H.W., Eltumi, M., McLean, L., Alder, N. and Thomas, A.G. (2005) Gastrostomy tube feeding in children with cerebral palsy: a prospective, longitudinal study. Developmental medicine and child neurology. 47(2), 77-85.

Tibbling, L. and Gustafsson, B. (1991) Dysphagia and its consequences in the elderly. Dysphagia. 6(4), 200-202.

Wright, L., Cotter, D., Hickson, M., and Frost, G. (2005) Comparison of energy and protein intakes of older people consuming a texture modified diet with a normal hospital diet. Journal of Human Nutrition and Dietetics. 18(3), 213-219.