"It didn't take me long to figure out," says Jillian Hunnicutt of Atlanta, Ga., pausing to grin at her unintentional pun. "There was something about Mary."

Mary, now 6 years old, is the youngest daughter of Hunnicutt and her husband, Timothy. "Remember, I had already gone through two little girls, and I knew all about fussy eaters – or so I thought," Hunnicutt says. "Sure, I knew about tossed mashed potatoes, overturned bowls of spaghetti and little noses turned up at whatever we were offering. But with the older girls, the worst we had to handle was a 'raspberry' blown with a mouth full of peas."

"With Mary, eating dinner was living on the edge," Hunnicutt says. "She would have a hard time chewing even the softest of meals. Sometimes she would choke, her eyes would water and her breathing would slow. Eventually, she wouldn't want to eat at all. With that experience, who could blame her?"

Dissecting Dysphagia
Mary – and an estimated six to 15 million people in the United States, many of them children – is a victim of dysphagia, a mechanical dysfunction that manifests in a difficulty to chew or swallow. "Simply stated, a person with dysphagia is unable to pass food or liquid rapidly or efficiently from the mouth to the stomach," says Michael E. Groher, Ph.D., speech pathologist and author of Dysphagia: Diagnosis and Management.

To understand dysphagia, one should understand a little about something most of us take for granted – eating. A simple act of swallowing involves 26 pairs of muscles and seven cranial nerves. It begins with the sight of food and ends with that food entering (and staying in) the stomach. Dysphagia can occur at any point during the process, so symptoms could be as diverse as an inability to chew, chronic respiratory infections or choking.

"When food enters the mouth, a person uses his tongue, jaw and teeth to form the food into a ball," says Julie Reville, a speech language pathologist and clinical instructor at the University of Vermont. "The ball, clinically known as a bolus, is transferred backwards by the tongue into the posterior oral cavity. When this is done successfully, swallowing results."

In a patient with dysphagia, the swallow is defective. "The epiglottis usually covers the trachea and doesn't allow food into the airway," says Reville, who worked with pediatric dysphagia patients for more than eight years. "When the swallow is defective, the epiglottis doesn't do its job, and the bolus is mishandled." The result of such mishandling could be serious. "If food is misdirected, choking occurs," she says.

Another great danger of dysphagia in youngsters is also one of its best indicators. "Many of these children end up with recurring pneumonia," says Dr. Diane Barsky, medical director of the Pediatric Center for Dysphagia and Feeding Management at the Children's Seashore House of the Children's Hospital of Philadelphia. There are, however, less frightening symptoms of dysphagia, including changes in vocal quality, fussy feeding patterns, decreased alertness, reddened or watery eyes and a lowered or increased breathing rate while eating.

Just as there are numerous manifestations of dysphagia, its causes are also many. "You often see dysphagia in premature babies, who will develop very irregular suck patterns while nursing," Reville says.

For toddlers, older children and adults, the reasons for dysphagia could be as serious as a stroke or as correctable as a cleft palate. "Sometimes it's due to a structural problem, like a cleft palate, although it's more likely to be a dysfunction of the nerves that control swallowing," Reville says. "It can also be caused by neurological insult, inappropriate brain development, stroke, hemorrhage or damage to the muscles involved in swallowing. It could be that there's nothing really wrong with the child, but they do not like the feel of food in their mouth. Often this happens to young children who are tube-fed for a long period of time. They don't like the texture of food because they don't understand how to eat it."

Hunnicutt says Mary was a large full-term baby, who had no trouble nursing, but started to show signs of a problem during the transition to semi-solid baby food. "She would choke or gag on the softest items, even pureed and creamed foods," Hunnicutt says. "Eventually she'd start protesting as soon as we put her in the high chair, refusing to eat at all."

Treating Dysphagia
Before your toddler starts starving herself, you should express your concerns to your pediatrician, Dr. Barsky says. "From that point, the doctor will order a feeding observation to see where the problem is," she says.

"We send the patient to a swallow evaluation," Reville says. "Our feeding team – a speech pathologist, a developmental pediatrician, an occupational therapist and a nutritionist – will evaluate and make recommendations."

If the child is in danger of asphyxia, a modified barium swallow may be ordered. Barium is mixed with the child's favorite food, then an X-ray is taken of the swallow to see if it follows the proper path to the stomach. Once the problem is located, a feeding recommendation is made. "Sometimes it's just a change of food texture or change of nipple type," Dr. Barsky says. "More serious cases may require tube feeding or therapy. Sometimes the parents can help out with head inflexions."

"We teach strategies to help the patients compensate," Reville says. "Some kids simply have to tuck their chin or follow each bite with some fluid. Others have restricted diets, but as they age they are weaned from that while they are learning to compensate."

And the extreme? "I met one little boy who could not swallow water for some reason," Reville says. "He kept getting pneumonia, although at 18 months he seemed to be able to handle soft foods. Our strategy for this case, which is extremely rare, was to make gelatin jigglers with all his water. He had to take water like this for two years, but he eventually learned to compensate for dysphagia and now can drink water regularly."

There was a happy ending for Mary Hunnicutt, too. "After her swallow study, we learned how to make her foods more even textured, since her swallow reacted to the differences," Mary's mom says. "It took 18 months, but now she can eat most foods, as long as she remembers to sip water afterwards."

Want to see more?

• Hi, Ho, Cheerios: Pleasing Picky Palates
• Toddler Nutrition: Building a Healthy Relationship with Food
• Starting Solids Series
• Talk about it!

About the Author: Mary Dixon Weidler is a freelance writer living in New Jersey.