My son is five years old. For about the last two weeks, he cannot eat food unless it is soft and cool. Even mashed potatoes and applesauce are a problem. He will hold food in his mouth until it is pureed and say, "It won't go down." He won't even eat his favorite things. He will eat yogurt, ice cream and milkshakes and will drink milk and water. He has been to his doctor and an ear, nose and throat specialist. He was given a prescription for a possible infection or bronchitis. There are no other problems, no fever or anything. What do I do?

Lori

The medical term for this swallowing difficulty is dysphagia. Specifically, your son has dysphagia for solids, of acute onset, which narrows the possibilities considerably. Here are the questions your son's doctors should be asking:

• Is there any chance that your son has swallowed a foreign body (coins being the most common examples)? Your son may confess to this, but even if he denies it, an X-ray is certainly called for. Some objects, however, will not show up on X-ray. Many plastics, wood and some types of glass will not appear on X-ray. Thus, a barium swallow may be necessary. In this study, your son would swallow a barium solution. Barium will create a "shadow" around an object that might not otherwise be seen on an X-ray.
  
• Has your son ever swallowed anything corrosive, such as Drano? Even if this occurred years ago, it is still possible that the scar tissue is only now severe enough to cause dysphagia.
  
• Is your son taking any new medications? Some medications are known to cause dysphagia.
  
• Does your son have any other known illnesses? Reflux, immune deficiencies, autoimmune diseases, connective tissue disorders and neuromuscular diseases may all be associated with dysphagia. These problems would each be associated with a variety of other symptoms. Thus, the doctor ought to ask whether your son is having any other unusual symptoms (vomiting, choking, coughing, hoarseness and so forth).
  

Only after the possibility of physical illness has been eliminated should the doctor consider the possibility of a behavioral/psychological problem. Is he under any unusual stress? Is there any upheaval in the family? Has he had unusual and unexplainable symptoms in the past?

His doctor's actions (prescribing an antibiotic) indicate that he/she thinks your son has an infection. One can certainly develop dysphagia from a very bad sore throat, but wouldn't your son tell you he had a sore throat? But he doesn't have a sore throat -- he says, "It won't go down." Thus, I doubt that he has a garden-variety sore throat (pharyngitis).

There are some fairly uncommon infectious diseases that may cause this problem, but they are rare enough to fall to the bottom of my list. The list of possible diagnoses includes: foreign body, chemical ingestion, medications, connective tissue disorders (such as lupus or rheumatoid arthritis), diabetes, thyroid problems and neuromuscular diseases (such as Duchenne muscular dystrophy or Guillain-Barre syndrome). There are a number of gastrointestinal diseases that ought to be considered (e.g., esophageal spasm, Crohn's disease, ulcerative colitis). There could be a malignant or benign growth compressing his esophagus. Finally, his problem may be psychological.

As you can see, there are a lot of real nasties on this list. This problem must not be ignored. If he still has this problem, you must bring him back to his doctor and insist that he or she reevaluate him.