To facilitate suckle feeding and breathing, the infant oropharynx is anatomically different from the adult, with a relatively larger tongue, smaller oral cavity, and more anterior and superior epiglottis and larynx As the face and mandible grow, the oropharynx enlarges, creating more room for the eventual voluntary use of the tongue and dentition, and the larynx descends, eventually allowing for mouth breathing Although breathing continues to cease during swallows, the older child depends less on close coordination between eating and breathing A normal swallow, using the suckling infant as an example, begins with rhythmic movement of the lips, tongue, and mandible These parts function as a unit, creating negative intraoral pressure, while also compressing the nipple The milk expressed from each suckle is stored in the posterior oral cavity until a larger fluid bolus is formed As the tongue delivers the bolus to the pharynx, the nasopharynx is closed off by the posterior tongue and by elevation of the soft palate The larynx elevates to a position under the tongue, closing the airway, as the epiglottis inclines to direct the bolus posterior A pharyngeal wave of contraction sweeps the bolus toward the upper esophagus, where the cricopharyngeal sphincter relaxes, allowing passage into the esophagus As the esophagus begins peristaltic contractions and the bolus moves past a relaxed lower esophageal sphincter into the stomach, the airway reopens, the cricopharyngeal sphincter constricts to close the upper esophagus, and respirations resume Dysphagia can result from disruption of normal mechanisms at any stage of the swallowing process DIFFERENTIAL DIAGNOSIS Acute dysphagia is an urgent symptom needing immediate evaluation While this may be an acute symptom in a healthy child, it may be a new or recurrent symptom in the increasing number of children surviving with chronic conditions The incidence and prevalence of pediatric dysphagia is increasing, probably due to improved early medical and supportive care for prematurity and other conditions The differential diagnosis for dysphagia is extensive and is commonly divided into pre-esophageal or esophageal disorders ( Table 56.1 ) Preesophageal causes of dysphagia are further subdivided into anatomic categories, including nasopharyngeal, oropharyngeal, laryngeal, and generalized problems Infectious and inflammatory disorders of either anatomic region may disrupt swallowing, whereas neuromuscular problems tend to be predominantly preesophageal, given the autonomic function of the esophagus However, the esophagus can be affected by motility disorders intrinsic to smooth muscle