The term silent aspiration refers to aspiration before, during, or after swallowing in the absence of cough or visible signs of choking and distress.2 Silent aspiration has been well studied, particularly in adults who have suffered traumatic brain injury or stroke. In adults, silent aspiration is associated with neurologic impairment, and adults with silent aspiration have a 13-fold increase in risk for developing pneumonia. The “gold standard” for diagnosing oropharyngeal aspiration is the videofluoroscopic swallow study (VFSS), more commonly known in North America as the modified barium swallow. In this issue of CHEST (see page 589), Weir and colleagues3 report a prospective evaluation of 300 children (median age 1.4 years) identified as having feeding difficulties by using a standardized feeding assessment. These children were then referred for VFSS, and it was found that one-third of them had oropharyngeal aspiration. Of those with aspiration, 81% had silent aspiration, and this was significantly associated with neurologic impairment, developmental delay, and enteral feedings. Children born prematurely and those with congenital heart disease were at no increased risk of oropharyngeal aspiration or silent aspiration if they did not have associated multiorgan disease or neurologic impairment. These results serve to highlight the importance of clinical feeding assessments and VFSS in young children at high risk for oropharyngeal aspiration.