Treatment of dysphagia is dictated by the underlying diagnosis Disorders with the potential to become life-threatening should be treated in the hospital under the care of appropriate specialists Chronic dysphagia with actual or potential aspiration should be identified If nutrition has been severely compromised from chronic dysphagia, one should consider nasogastric, nasojejunal, or gastrostomy tube feedings Many pediatric facilities have developed multidisciplinary feeding/swallowing teams to provide subspecialty expertise, while maintaining continuity and coordination of patient care If such a specialty service is not available, involvement of appropriate individual specialists for the management of the patient with dysphagia is imperative as mentioned in Figure 56.2 However, therapy for many disorders can be initiated on an outpatient basis Gastroesophageal reflux and resultant esophagitis can be managed with small volume thickened feeds, although supporting evidence has been inconclusive, since these steps pose minimal risk or cost, they may be considered before other interventions There is no evidence to support a switch to protein hydrolyzed formula or amino acid–based formula for treatment of gastroesophageal disease (GERD) especially in patients who not have milk protein allergy A minimum of weeks trial is recommended for any of the above-mentioned nonpharmacologic therapies Evidence is limited for the use of positioning therapy, either head elevation, prone position, or left side up to improve signs and symptoms of GERD in infants Massage therapy, dietary supplementations, or probiotic use have not been adequately studied, but may pose more risk and cost, and cannot be recommended for reduction of symptoms of GERD Medical therapy consisting of liquid antacids, histamine receptor antagonist like cimetidine, protein pump inhibitors (PPI) such as omeprazole, or the addition of metoclopramide have limited evidence for benefit in the reduction of signs and symptoms of GERD in infants In older children with GERD symptoms, a 4-week trial of PPI treatment is reasonable Studies have noted that GERD symptoms often overlap with dysphagia, and swallowing dysfunction should be considered for persistently symptomatic patients already on appropriate reflux treatment, especially those with extreme prematurity, developmental delay, or who not respond to antireflux medication Children who have failed reflux therapy may also be candidates for an evaluation for eosinophilic esophagitis Eosinophilic esophagitis is defined as vomiting and abdominal pain with solid dysphagia in children and esophageal impaction in postpubertal age Endoscopy and biopsy is diagnostic Treatment of eosinophilic esophagitis includes topical or oral steroids, proton pump inhibitors, and leukotriene inhibitors Disease recurrence is high As a result, dietary restriction and chronic medication usage may be indicated