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Wellness & Lifestyles Australia

SWALLOWING & DYSPHAGIA &


FOOD/FLUID CONSISTENCIES
E-BOOK
prepared by
Sarah Ciccarello

2007,2008,2009

Table of Contents

Page No.

IMPORTANT NOTICE ..................................................................................................... 1


INTRODUCTION .......................................................................................................... 2
CRANIAL NERVES AND MUSCULATURE INVOLVED IN SWALLOWING............................................... 3
CRANIAL NERVES ............................................................................................... 3
ANATOMICAL STRUCTURES FOR SWALLOWING (AND SPEECH) .......................................... 5
THE PHARYNX .................................................................................................. 6
THE NORMAL SWALLOW ................................................................................................ 7
OVERVIEW....................................................................................................... 7
THE ORAL PREPARATORY PHASE ............................................................................ 8
THE ORAL PHASE............................................................................................... 9
STRUCTURES INVOLVED IN THE ORAL PREPARATORY ................................................... 10
AND ORAL PHASES OF SWALLOWING....................................................................... 10
THE PHARYNGEAL PHASE .................................................................................... 11
STRUCTURES INVOLVED IN THE PHARYNGEAL PHASE OF SWALLOWING.............................. 12
THE OESOPHAGEAL PHASE .................................................................................. 13
A NORMAL SWALLOW - SUMMARY .......................................................................... 14
DYSPHAGIA .............................................................................................................. 15
SUMMARY ...................................................................................................... 15
CAUSES OF DYSPHAGIA ...................................................................................... 16
SIGNS AND SYMPTOMS OF DYSPHAGIA ..................................................................... 17
CONTRIBUTING FACTORS OF DYSPHAGIA ................................................................. 18
SAFE SWALLOWING PROCEDURES .......................................................................... 19
SAFE SWALLOWING POSITIONING .......................................................................... 19
SAFE SWALLOWING STRATEGIES............................................................................ 21
TEXTURE-MODIFICATION OF FOODS ................................................................................. 22
AND THICKENED FLUIDS ............................................................................................... 22
INTRODUCTION................................................................................................ 22
Unmodified Regular Foods Definition ................................................................... 23
Soft Diet Definition........................................................................................... 24
Soft Diet Examples ........................................................................................... 25
Minced & Moist Diet Definition ............................................................................. 26
Minced & Moist Diet Examples.............................................................................. 27
Smooth Pureed Or Vitamised Diet Definition ............................................................ 28
Smooth Pureed Or Vitamised Diet Examples ............................................................. 29
Unmodified Fluids Definition ............................................................................... 32
Mildly Thick Fluid Definitions............................................................................... 33
Moderately Thick Fluid Definitions ........................................................................ 34
Extremely Thick Fluid Definition........................................................................... 35
SUMMARY ................................................................................................................ 36
CONTACT US ............................................................................................................ 37

MANUAL LAST MODIFIED 4/8/2010

IMPORTANT NOTICE
The information provided in this document can only assist you in the most general way. This document
does not replace any statutory requirements under relevant State and Territory legislation.
Wellness & Lifestyles Australia (W&L) accepts no liability arising from the use of, or reliance on, the
material contained in this document, which is provided on the basis that the Office of W&L is not thereby
engaged in rendering professional advice. Before relying on the material, users should carefully make their
own assessment as to its accuracy, currency, completeness and relevance for their purposes, and should
obtain any appropriate professional advice relevant to their particular circumstances.
To the extent that the material in this document includes views or recommendations of third parties, such
views or recommendations do not necessarily reflect the views of the Office of W&L or indicate its
commitment to a particular course of action.
Copyright Australia 2009
This work is copyright. You may download, display, print and reproduce this material in unaltered form
only (retaining this notice) for your personal, non-commercial use or use within your organisation. Apart
from any use as permitted under the Copyright Act 1968, all other rights are reserved.

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INTRODUCTION
Welcome to the W&L series of eBooks. You have chosen the edition on:
Swallowing and dysphagia
Swallowing safety
Modified foods and thickened fluids
This resource will be beneficial for those who:
Want a clear and comprehensive description of the normal swallow
Want a clear and comprehensive description of dysphagia, including signs and symptoms and
causes.
Want a comprehensive guide to supporting those with a dysphagia, including safe meal assistance
and appropriate food and fluid consistencies
Want up to date information about modified food and thickened fluid.
This eBook may provide a comprehensive overview of the normal swallow and dysphagia. Causes of
dysphagia, signs and symptoms of dysphagia, contributing factors to dysphagia, safe swallowing
procedures and positioning, and the role of texture modified foods and thickened fluid are also included.
Anatomy and cranial nerves involved in the swallow are also included for your reference.
The information provided is up to date and follows industry standard. W&L recommend that individuals
with a dysphagia continue to consult their doctor and speech pathologist to ensure progress can be
monitored and strategies put in place to suit individual requirements. This is to ensure maximum safety
with meals and drinks, according to an individuals level of dysphagia.

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CRANIAL NERVES AND MUSCULATURE INVOLVED IN SWALLOWING


CRANIAL NERVES
There are six cranial nerves involved in swallowing (and speech). Below is a brief summary,
CNV: TRIGEMINAL

Chewing
(With IX) raises the larynx and pulls it forward during the pharyngeal stage of the swallow.
Taste, except from the front 2/3 of the tongue.
Sensation of the face, mouth and mandible (jaw).

CNVII: FACIAL

Controls the muscles of facial expression


Taste to the front two-thirds of the tongue
Secretions of tears and saliva

CNVIX: GLOSSOPHARYNGEAL

Secretions of saliva
Taste back 1/3 of the tongue
Involved in elevating the pharynx during swallowing and talking.

CNX: VAGUS

Raises the velum


(With IX) innervates/powers pharyngeal constrictor muscles
(With XI) innervates/powers musculature of larynx
Vocal fold adduction/closure during swallowing
Muscles involved in oesophageal stage of swallowing and respiration
Sensation in larynx
Taste

CNXI THE SPINAL ACCESSORY NERVE

Constricts the pharynx

CNXII: HYPOGLOSSAL

Movement of the tongue

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Diagram taken from:


Massey, B. T. (2006). Figure 2 - Origin of cranial nerves involved in swallowing, GI Motility online, accessed 27 August 2010 on
http://www.nature.com/gimo/contents/pt1/full/gimo2.html

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ANATOMICAL STRUCTURES FOR SWALLOWING (AND SPEECH)

Swallowing is a complex process, which involves many muscles in the face and throat. The following is a
brief summary for your reference.
The oral cavity
The muscles involved in chewing are innervated or powered by the trigeminal nerve. They include:
The temporalis raises, retracts, and assists in closing the mandible (jaw).
The masseter raises, closes the mandible.
The medial pterygoid raises the mandible, assists in its closure.
The lateral pterygoid depresses (lowers), opens, protrudes (pushes forward), and lateralises (side
to side movement) the mandible.
Other muscles involved in chewing include:
(Lip muscles)
The obicularis oris sphincter muscle that encircles the mouth, closes the mouth and puckers the
lips when it contracts.
The zygomaticus assists in movement of the lips, enable lips to show sadness and happiness.
(Cheek muscle)
The buccinator keeps food in contact with teeth.
These muscles are innervated/powered by the facial nerve.
Muscles involved in movements of the velum:
The palatoglossal raise velum
The levator veli palatini raise velum
(Both are innervated/powered by the vagus nerve)

The tensor veli palatini tenses the velum


(This is innervated/powered by the trigeminal nerve)

The palatopharyngus lowers the velum, constricts the pharynx


The muscularis uvula shortens the velum
(Both are innervated/powered by the spinal accessory nerve)

Poor velopharyngeal closure may result in food/fluid entering the nasopharynx (and will also impact
speech). While this may be unpleasant, it is not life threatening. It is important to be aware of this
condition, as patients experiencing this difficulty may feel that it is a very important issue to address.

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THE PHARYNX
The pharynx is divided into three parts: the nasopharynx, oropharynx and laryngopharynx.

Diagram taken from:


Anatomy of the respiratory system, chapter 36, accessed 27 August 2010 on
http://fau.pearlashes.com/anatomy/Chapter%2036/Chapter%2036.htm

There are three pharyngeal recesses. Food/fluid can lodge in these recesses. They include:
The vallecula - the space or depression between the base of the tongue and the epiglottis.
The two pyriform sinuses - located in the pharynx, beside the larynx. They are formed by the
shape of muscle attachments to the pharyngeal walls.
The following muscles form the external layer of the pharynx:
The superior, middle, and inferior pharyngeal constrictor muscles help move food toward the
oesophagus by a stripping action. The plunger action of the tongue also plays a major role in this
process.
The following make up the internal layer of the pharynx:
The stylopharyngeus muscle - elevates the larynx, elevates and dilates the pharynx
The salpingopharyngeus muscle - assists in elevating pharynx
The following muscle separates the pharynx from the oesophagus:
The cricopharyngeus muscle or pharyngeal-oesophageal (P.E) segment - at the end of the
pharyngeal phase of the swallow, the P.E segment relaxes, enabling the bolus (ball of food/fluid)
to enter the oesophagus. Usually, the P.E segment is closed to prevent reflux of materials and to
ensure air does not enter the digestive system. If the P.E. segment does not relax, food will
accumulate in the pharynx and may spill over the larynx into the airway. The P.E segment is
innervated/powered by the vagus nerve.

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THE NORMAL SWALLOW


OVERVIEW
Swallowing is complex process that we are usually not conscious of. There are a number of processes and
structures involved in swallowing, some of which are voluntary and some involuntary. As previously
highlighted, there are a number of cranial nerves and musculature involved in the swallowing process.
The swallowing process is usually broken down into four stages:

The oral preparatory stage (in the mouth)

The oral stage (in the mouth)

The pharyngeal stage (in the throat)

The oesophageal stage (in the oesophagus).

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THE ORAL PREPARATORY PHASE


The first stage is the oral preparation stage, where food or liquid is chewed in preparation for swallowing.
Chewed food is mixed with saliva to form a cohesive ball or bolus. The bolus is kept in the front of the
mouth by the tongue. The airway is open and nasal breathing occurs during this phase. Lip seal is
maintained to prevent food/fluid from leaking from the mouth. Buccal (cheek) muscles are tense to
prevent pocketing of food (or to prevent food getting stuck between the cheek and teeth).
This phase is voluntary, meaning that we have control of food/fluid in the oral cavity. For example, we
may control how long we chew and taste our food (for example, swishing food/fluid around the mouth for
a long time, or swallowing straight away). This phase may be by-passed by dropping food/fluid to the back
of the throat.

Figure taken from:


Dawodu, S. (2008). Swallowing disorders, emedicine, viewed 21 October 2010 on
http://emedicine.medscape.com/article/317667-overview

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THE ORAL PHASE


The second stage is the oral stage, where the tongue pushes the food or liquid to the back of the mouth,
starting the swallow response. This phase is also voluntary. In this phase, the tongue moves the bolus
backward, the lips are sealed to ensure food/fluid stays in the mouth, the soft palate is raised (to prevent
food/fluid from entering the nasal cavity), and the epiglottis (a flap that covers the airway during
swallowing) tips down to protect the airway.
The elderly may demonstrate prolonged chewing (even without a dysphagia), particularly with dentures.

Figure taken from:


Dawodu, S. (2008). Swallowing disorders, emedicine, viewed 21 October 2010,
http://emedicine.medscape.com/article/317667-overview

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STRUCTURES INVOLVED IN THE ORAL PREPARATORY


AND ORAL PHASES OF SWALLOWING

Lips
Open and close
Maintain labial or lip seal to keep food, fluid and saliva in the oral cavity
Maintain oral pressure

Jaw
Rotary (around, rather than up and down) movement during mastication
Strength is required for tougher foods

Tongue
May protrude (move forward) and move laterally (side to side movement)
Pushes food toward teeth for chewing
Helps to form a cohesive bolus by mixing food and saliva
Helps to remove leftover food from gums and cheeks
Controls and holds food or fluid in preparation for swallowing
Pushes the bolus backward for swallowing

Cheeks
Tension prevents food falling in sides of mouth

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THE PHARYNGEAL PHASE


The pharyngeal stage of the swallow is involuntary, which means we no longer have control over the
muscles or structures pushing the food/fluid backward. It is the most critical stage of the swallow; airway
closure must occur to prevent the bolus from entering the airway. A number of events occur almost
simultaneously:
In this phase, the soft palate closes off the nasopharynx (to prevent food/fluid from entering the nasal
cavity). The hyoid and larynx rise and move forward, the epiglottis lowers and the vocal folds close to
protect the airway. The cricopharyngeal sphincter opens to enable food/fluid to pass from the pharynx
into the oesophagus. Contraction of the pharyngeal constrictor muscles propel the bolus toward the
oesophagus. The gag reflex helps to stop aspiration. However, 40% of the population do not have a gag
reflex.

Diagram taken from:


Dawodu, S. (2008). Swallowing disorders, emedicine, viewed 21 October 2010,
http://emedicine.medscape.com/article/317667-overview

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STRUCTURES INVOLVED IN THE PHARYNGEAL PHASE OF SWALLOWING


Important pharyngeal structures and their function during swallowing are outlined below:

Soft plate
Seals off the nasal cavity (so food/fluid does not come out of the nose).

Pharyngeal (throat) muscles


Helps to push food down toward the oesophagus

Larynx (voice box)


Closure of the larynx during swallowing protects the airway

Cricopharynx
This muscle relaxes to allow food or fluid to pass from the back of the throat (pharynx)
into the oesophagus.
Peristalsis (muscle contraction) occurs when food is in the oesophagus to help push
food/fluid down into the stomach.

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12

THE OESOPHAGEAL PHASE


The oesophageal phase of the swallow begins once the food or fluid bolus has passed through the
cricopharynx. It is an involuntary action which propels the food down to the stomach. After food enters
the oesophagus, automatic wavelike movements (peristalsis) in the oesophageal muscles push food/fluid
down to the stomach. The cricopharyngeal muscle closes to prevent food being regurgitated into the
throat.
Usually, this phase may last between eight and twenty seconds. However, in elderly individuals peristalsis
may be slower.
Oesophageal problems can cause the reflux of food back into the pharynx, which may cause aspiration.

Diagram taken from:


Dawodu, S. (2008). Swallowing disorders, emedicine, viewed 21 October 2010,
http://emedicine.medscape.com/article/317667-overview

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A NORMAL SWALLOW - SUMMARY

2. Food is chewed and


prepared by the
tongue, jaw and lips.
Fluid is also
manipulated.

3. The bolus is propelled


toward and into the
oesophagus. The
epiglottis tips down to
protect the airway.

1. Food is chewed and


prepared by the
tongue, jaw and lips.
Fluid is also
manipulated.

4. Peristalsis (muscle
contractions) move
food toward the
stomach.

Diagrams taken from:


Dawodu, S. (2008). Swallowing disorders, emedicine, viewed 21 October 2010,
http://emedicine.medscape.com/article/317667-overview

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DYSPHAGIA
SUMMARY
Dysphagia means swallowing difficulty. A swallowing difficulty may occur within any of the phases of
swallowing. Dysphagia may involve difficulty chewing, moving food around the mouth, pushing food/fluid
backward with the tongue, initiating the swallow, or pushing food/fluid toward the stomach. Dysphagia
may also result in difficulties managing saliva. Dysphagia may lead to choking and can result in food, fluid
or saliva passing into the lungs (aspiration) causing aspiration pneumonia.
Dysphagia occurs in as many as:

45% of individuals aged over 75 years

33% of residents in acute care

66% of residents requiring long term care

40-75% of stroke residents

It is a Speech Pathologists role to assess, diagnose and manage dysphagia. Speech Pathologists may
provide safe swallow strategies, and alter food/fluid consistencies to increase safety when swallowing.

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CAUSES OF DYSPHAGIA
Dysphagia is most often caused by:
Stroke/CVA

50% of stroke patients acquire dysphagia at some stage. The severity of dysphagia may or may not
lessen over time.
The severity of dysphagia will depend on the location and degree of damage.

Dementia

Individuals with more advanced dementia may spit food out or forget how to swallow/use
utensils. Individuals typically require increased meal assistance as dementia progresses.

Neuromuscular diseases/disorders
Including:

Atrophies/dystrophies
Huntingtons Chorea
Myasthenia gravis
Parkinsons Disease

Dystonia
Motor Neurone Disease
ALS
MS

Local structural defects


Including:

Cancers
Tumours
Fistula

Medications
Some medications, such as those for depression, hypertension, cancer, and Parkinsons disease, may
impact swallowing by causing drowsiness, reducing consciousness, or impairing salivation.
Oesophageal disorders
Including:

Reflux
Motility issues
Oesophageal sphincter difficulties

Other
Including:

Trauma
Septic
Surgery
Depression

Congenital
Auto immune disorders
Behavioural issues, e.g. hysterical

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SIGNS AND SYMPTOMS OF DYSPHAGIA

Individuals may report increased difficulties with eating

Others (nursing or care staff/family members) may notice the individual experiencing difficulties
eating.

Drooling/dribbling

Coughing/choking before/during/post food/fluid

Gurgly or wet voice post food/fluid

Multiple swallows to clear

Sneezing during or post food/fluid

Pneumonia

Pocketing food (food remaining in mouth post swallowing)

Difficulties chewing food or taking a long time to chew food

Spitting food out

Reduced level of alertness

Poor labial/lip seal

Nil or reduced gag reflex

Dysarthria (slurred speech)

Reduced ability to manipulate bolus in oral cavity/mouth

Nil or weakened cough reflex

Important note: 40% of people are silent aspirators, and therefore demonstrate no symptoms of
coughing/choking. It is important to monitor patients with nil or a weakened cough reflex.

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CONTRIBUTING FACTORS OF DYSPHAGIA

Level of alertness
A reduced level of alertness may impact an individuals ability to chew and swallow food/fluid safely.
Individuals should only eat or drink when they are fully alert.

Environment
Reduce distractions

General Health
Reduced general wellbeing may impact an individuals ability to swallow safely.

Poor oral hygiene


Poor oral hygiene may allow bacteria to breed, leading to an increased risk of infection.

Posture
Fully upright, with the head tilted forward offers the safest swallowing position. Use pillows to ensure an
upright position if necessary. Ensure patients are not leaning to one side. Do not feed patients if their
head is tilted backward this will increase the risk of aspiration, as the airways will be more open.

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18

SAFE SWALLOWING PROCEDURES


CORRECT POSITIONING FOR SWALLOWING

Ensure patients are seated comfortably, fully upright, and with a slightly forward head position.
This helps to reduce the risk of aspiration.
Ensure impacted sides are positioned appropriately.
Use pillows to prop patients if necessary. Pillows are often useful in achieving an upright position.
Ensure the head does not tilt backward this opens the airway and increases the risk of aspiration.
If in a hospital bed, request assistance to move the patient/resident upward in the bed before
raising the back. This helps to ensure a fully upright position, as the whole back, not just the
neck, are positioned upright.
Remain upright for at least half an hour post food/fluid.

SAFE SWALLOWING POSITIONING


The below pictures demonstrate appropriate positions for swallowing in a seated and bed environment.

Ensure residents are seated fully upright, as demonstrated in the picture.

Ensure the affected side is appropriately positioned pillows may be useful to facilitate an upright
position.
The head should be tilted slightly forward a pillow may be useful to support this position.

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19

If a resident is unable to be positioned appropriately in a chair, they may require appropriate positioning
in bed.

Pillows may be required on either side to ensure an upright position.


The head should be tilted slightly forward a pillow may be useful to support this position.

Residents should NEVER be in a position where the head can extend backward for eating and drinking (as
displayed in the picture) this opens up the airway and may increase the risk of aspiration.

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SAFE SWALLOWING STRATEGIES


Before implementing any of the below strategies, be sure to consult a doctor and a speech pathologist.
General guidelines

Ensure patient is alert & upright (90) with head tilted forwards and chin towards chest (chin
tuck).

Avoid distracters at meal times, concentrate on chewing and swallowing rather than talking,
watching television, etc.

Modified cutlery, crockery & non-slip mats may assist with independence of feeding.

Ensure dentures are clean and fit firmly.

Clear throat whenever voice sounds wet or gurgly.

Resident may require daily special feeding to be undertaken by an RN or EN

Eating and drinking

Encourage patient to eat/drink slowly, take small amounts to prevent build up and rest between
mouthfuls.

Encourage the patient to chew on the stronger side of their mouth if one side is weaker.

Swallow twice after each mouthful to help clear any food that is left behind.

Alternate eating with drinking- to clear leftover food & encourage drinking between mouthfuls.

Ensure the patient has swallowed what is in their mouth before the next mouthful.

Check and clear pocketing in mouth

Cough or clear throat if voice sounds wet, gurgly or food sticking.

Discontinue if patient fatigues, coughs excessively or fails to swallow.

Leave upright for at least thirty minutes at completion of meal/drink.

Mouth toilet at completion of every meal.

Eat with Teaspoon to limit amount taken.

Drink through a straw to help maintain chin down position.

Avoid drinking through a straw.

Turn head to the left/right when swallowing, to stop food catching in throat.

Tilt head to the left/right when swallowing, to help food pass through throat.

Provide verbal cues to eat, swallow.

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21

TEXTURE-MODIFICATION OF FOODS
AND THICKENED FLUIDS
Adapted from:
Dieticians Association of Australia and The Speech Pathology Association of Australia Limited (2007).
Texture-modified foods and thickened fluids as used for individuals with dysphagia: Australian standardised
labels and definitions. Nutrition and dietetics, 64(Suppl. 2): S53-S76.

INTRODUCTION
The ability to swallow normal food and fluid requires strong muscle control and coordination of both
respiration and swallowing. Reduced control and coordination can indicate a dysphagia, which impacts an
individuals ability to swallow. As a result of dysphagia, food and fluid may require modification to ensure
safety when swallowing. In individuals with dysphagia, unmodified foods may enter the lungs, causing
aspiration and aspiration pneumonia. Dysphagia may result in poor nutrition and hydration, reduced well
being, aspiration and poor health.
Speech Pathologists may implement modified foods or fluid following assessment, forming individualised
dysphagia care plans, to ensure swallowing safety. Thickened fluids slow the act of swallowing and by doing
so, facilitate safer swallowing. Modified foods prepare food for swallowing and reduce the amount of
chewing and effort an individual may have to put in before swallowing.
Many people do not enjoy a modified diet; however, unmodified foods may impact safety during
swallowing. If recommended diet plans are not completely adhered to, individuals may aspirate, as food or
fluid enters the lungs, which can lead to aspiration pneumonia. Aspiration pneumonia can lead to death,
and care facilities may be left liable if directives from health care professionals are not met.
The following information outlines the current standardised food and fluid consistencies recommended for
people with dysphagia.

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22

Unmodified Regular Foods Definition

Unmodified

Most Modified

Unmodified

Texture A

Texture B

Texture C

Regular Foods

Soft

Minced and Moist

Smooth Pureed

Unmodified Regular Foods


Description

Everyday foods

Characteristics

There are various textures of regular foods


Some are hard and crunchy and some are naturally soft

By definition all food and textures can be included

Food inclusions and


exclusions

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23

Soft Diet Definition

Unmodified

Most Modified

Unmodified

Texture A

Texture B

Texture C

Regular Foods

Soft

Minced and Moist

Smooth Pureed

Texture A Soft
Description

Characteristics

Food may be naturally soft (e.g. ripe bananas), or may be


cooked or cut to alter its texture

Can be chewed but not necessarily bitten


Minimal cutting is required, and can be easily broken up with a
fork
Food should be moist or served with a sauce or gravy top
increase the moisture content. (NB: Sauces and gravies should
be served at the required thickness level)
Refer to special notes (page S72)

Testing Information

Targeted particle size for infants and children = less than half
of that for adults and children over 5 years or equal to 0.8cm
(based on tracheal size)28
Targeted particle size for children over 5 years and adults =
1.5cm x 1.5cm 10.27.30

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Soft Diet Examples


Texture A Soft
Recommended foods and those to avoid (examples only)
Recommend
Avoid

Foods
Bread, cereals,
rice, pasta,
noodles

Soft sandwiches(a) with very moist

Vegetables,
legumes

Fruit

Milk, yoghurt,
cheese

Meat, fish,
poultry, eggs,
nuts, legumes

Desserts

Miscellaneous

(a)
(b)

fillings, for example egg and mayonnaise,


hummus (remove crusts and avoid breads
with seeds and grains)
Breakfast cereals well moistened with
milk(b)
Soft pasta(a) and noodles
Rice (well cooked)
Soft pastry, for example quiche with a
pastry base
Other, soft, cooked grains
Well cooked vegetables(a) served in small
pieces or soft enough to be mashed or
broken up with a fork
Soft canned vegetables, for example peas
Well cooked legumes (the outer skin must
be soft), for example baked beans
Fresh fruit pieces that are naturally soft,
for example banana, well-ripened
pawpaw
Stewed and canned fruits in small pieces
Pureed fruit
Fruit juice(b)
Milk, milkshakes, smoothies(b)
Yoghurt (may contain soft fruit)(b)
Soft cheeses,(a) for example Camembert,
ricotta
Casseroles with small pieces of tender
meat(a)
Moist fish (easily broken up with the edge
of a fork)
Eggs(a) (all types except fried)
Well cooked legumes (the outer skin must
be soft), for example baked beans
Soft tofu, for example small pieces,
crumbled
Puddings, dairy desserts,(b) custards,(b)
yoghurt(b) and ice-cream(b) (may have
pieces of soft fruit)
Moist cakes (extra moisture, e.g. custard
may be required)
Soft fruit-based desserts without hard
bases, crumbly or flaky pastry or
coconut, for example apple crumble
Creamed rice, moist bread and butter
pudding
Soup(b)(may contain small soft lumps,
e.g. pasta)
Soft fruit jellies or non-chewy lollies(a)
Soft, smooth, chocolate
Jams and condiments without seeds or
dried fruit

Dry or crusty breads, breads with hard seeds


or grains, hard pasty, pizza

Sandwiches that are not thoroughly moist


Course or hard breakfast cereals that do not

moisten easily, for example toasted muesli,


bran cereals
Cereals with nuts, seeds and dried fruit

All raw vegetables (including chopped and


shredded)

Hard, fibrous or stringy vegetables and

legumes, for example sweet corn, broccoli


stalks

Large/round fruit pieces that pose a choking


risk, for example whole grapes, cherries

Dried fruit, seeds and fruit peel


Fibrous fruits, for example pineapple
Yoghurt with seeds, nuts, muesli or hard
pieces of fruit

Hard cheeses, for example cheddar and


hardened/crispy cooked cheese

Dry, tough, chewy, or crispy meats


Meat with gristle
Fried eggs
Hard or fibrous legumes
Pizza

Dry cakes, pastry, nuts, seeds, coconut,


dried fruit, pineapple

Soups with large pieces of meats or


vegetables, corn, or rice

Sticky or chewy foods, for example toffee


Popcorn, chips, biscuits, crackers, nuts,
edible seeds

These foods require case-by-case consideration.


These foods may need modification for individuals requiring thickened fluids.

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25

Minced & Moist Diet Definition

Unmodified

Most Modified

Unmodified

Texture A

Texture B

Texture C

Regular Foods

Soft

Minced and Moist

Smooth Pureed

Texture B Minced and Moist


Description

Characteristics

Food is soft and moist and should easily form into a ball

Individual uses tongue rather than teeth to break the small


lumps in this texture
Food is soft and moist and should easily form into a ball
Food should be easily mashed with a fork
May be presented as a thick puree with obvious lumps in it
Lumps are soft and rounded (no hard or sharp lumps)
Refer to special notes (page S72)

Testing Information

Recommended particle size for infants and children = 0.2


0.5cm (based on tracheal size)28
Recommended particle size fir children over 5 years and
adults = 0.5cm 10.27.30

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Minced & Moist Diet Examples


Texture B Minced and Moist
Recommended foods and those to avoid (examples only)
Recommend
Avoid (in addition to the Foods to Avoid
listed for Texture ASoft)

Foods
Bread, cereals,
rice, pasta,
noodles

Breakfast cereal with small moist lumps,

Vegetables,
legumes

for example porridge or wheat flake


biscuits soaked in milk
Gelled bread
Small, moist pieces of soft pasta, for
example moist macaroni cheese (some
pasta dishes may require blending or
mashing)

Mashed soft fresh fruits, for example

Fruit pieces larger than 0.5 cm


Fruit that is too hard to be mashed with a

Miscellaneous

(a)

pasta bake or lasagne

Fibrous vegetables that require chewing, for

mashed with a fork

Desserts

example parboiled, long-grain, basmati

Crispy or dry pasta, for example edges of a

Well cooked legumes (partially mashed or


banana, mango

Meat, fish,
poultry, eggs,
nuts, legumes

the entire food portion

Rice that does not hold together, for

Vegetable pieces larger than 0.5 cm or too

Finely diced soft pieces of canned or

Milk, yoghurt,
cheese

and dry biscuits

Gelled breads that are not soaked through

Tender cooked vegetables that are easily


blended)

Fruit

All breads, sandwiches, pastries, crackers,

stewed fruit
Pureed fruit
Fruit juice(a)
Milk, milkshakes, smoothies(a)
Yoghurt(a) (may have small soft fruit
pieces)
Very soft cheeses with small lumps, for
example cottage cheese
Coarsely minced, tender, meats with a
sauce. Casseroles dishes may be blended
to reduce the particle size
Coarsely blended or mashed fish with a
sauce
Very soft and moist egg dishes, for
example scrambled eggs, soft quiches
Well cooked legumes (partially mashed or
blended)
Soft tofu, for example small soft pieces
or crumbled
Smooth puddings, dairy desserts,(a)
custards,(a) yoghurt(a) and ice-cream(a)
(may have small pieces of soft fruit)
Soft moist sponge cake desserts with lots
of custard, cream or ice-cream, for
example trifle, tiramisu
Soft fruit-based desserts without hard
bases, crumbly or flaky pastry or
coconut, for example apple crumble with
custard
Creamed rice
Soup(a)(may contain small soft lumps,
e.g. pasta)
Plain biscuits dunked in hot tea or coffee
and completely saturated
Salsas, sauces and dips with small soft
lumps
Very soft, smooth, chocolate
Jams and condiments without seeds or
dried fruit

hard to be mashed with a fork


example peas

fork

Soft cheese that is sticky or chewy, for


example Camembert

Casserole or mince dishes with hard or

fibrous particles, for example peas, onion

Dry, tough, chewy, or crispy egg dishes or


those that cannot be easily mashed

Desserts with large, hard or fibrous fruit

particles (e.g. sultanas), seeds or coconut

Pastry and hard crumble


Bread-based puddings

Soups with large pieces of meats or


vegetables, corn, or rice

Lollies including fruit jellies and


marshmallow

These foods may require modification for individuals requiring thickened fluids.

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Smooth Pureed Or Vitamised Diet Definition

Unmodified

Most Modified

Unmodified

Texture A

Texture B

Texture C

Regular Foods

Soft

Minced and Moist

Smooth Pureed

Texture C Smooth Pureed

Description

Characteristics

Smooth and lump free but may have a grainy quality


Moist and cohesive enough to hold its shape on a spoon (i.e.
when placed side by side on a plate these consistencies
would maintain their position without bleeding into one
another
Food could be moulded, layered or piped

Cohesive enough to hold its shape on a spoon (i.e. when


placed side by side on a plate these consistencies would
maintain their position without bleeding into one another)

Some individuals may benefit from the use of a runny


pureed texture. This texture would be prescribed on a case
by case basis. (Runny pureed textures do not hold their
shape; they bleed into one another when placed side by side
on a plate

Testing Information

Special Note

Food is smooth and lump free. It is similar to the


consistency of commercial pudding. At times, smooth
pureed food may have a grainy quality, but should not
contain lumps.
Refer to special notes (page S72)

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Smooth Pureed Or Vitamised Diet Examples


Texture C Smooth Pureed
Recommended foods and those to avoid (examples only)
Recommend
Avoid (in addition to the Foods to Avoid
listed for Texture BMinced and Moist)

Foods
Bread, cereals,
rice, pasta,
noodles

Vegetables,
legumes

Smooth lump-free breakfast cereals, for

Fruit

Milk, yoghurt,
cheese

Meat, fish,
poultry, eggs,
nuts, legumes

Desserts

Miscellaneous

(a)

example semolina, pureed porridge


Gelled bread
Pureed pasta or noodles
Pureed rice
Pureed vegetables
Mashed potato
Pureed legumes, for example baked
beans (ensuring no husks in final puree)
Vegetable soups that have been blended
or strained to remove lumps(a)
Pureed fruits, for example commercial
pureed fruits, vitamised fresh fruits
Well mashed banana
Fruit Juice(a) without pulp
Milk, milkshakes, smoothies(a)
Yoghurt(a) (lump-free), for example plain
or vanilla
Smooth cheese pastes, for example
smooth ricotta
Cheese and milk-based sauces(a)
Pureed meat/fish (pureed with
sauce/gravy to achieve a thick moist
texture)
Souffls and mousses, for example
salmon mousse
Pureed legumes, hummus
Soft silken tofu
Pureed scrambled eggs
Smooth puddings, dairy desserts,(a)
custards,(a) yoghurt(a) and ice-cream(a)
Gelled cakes or cake slurry, for example
fine sponge cake saturated with jelly
Soft meringue
Cream(a), syrup dessert toppings(a)
Soup(a)vitamised or strained to remove
lumps
Smooth jams, condiments and sauces

Cereals with course lumps or fibrous

particles, for example all dry cereals,


porridge
Gelled breads that are not soaked through
the entire food portion

Coarsely mashed vegetables


Particles of vegetable fibre or hard skin

Pureed fruit with visible lumps

All solid and semi-solid cheese including


cottage cheese

Minced or partially pureed meats


Scrambled eggs that have not been pureed
Sticky or very cohesive foods, for example
peanut butter

Desserts with fruit pieces, seeds, nuts,

crumble, pastry or non-pureed garnishes

Gelled cakes or cake slurries that are not


soaked through the entire food portion

Soup with lumps


Jams and condiments with seeds, pulps or
lumps

These foods may require modification for individuals requiring thickened fluids.

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Special Notes
Foods and other items requiring special considerations for individuals with dysphagia

The following foods were identified as requiring emphasis

Bread

Is often excluded on diets for individuals who require thickened fluids.


This is because ice-cream melts and becomes like a thin liquid at room
temperature or within the oral cavity

May be excluded from diets for individuals who require thickened fluids.
this is because jelly particulates in the mouth if not swallowed promptly

Individuals who require thickened fluids will require their soups


thickened to the same consistency as their fluids unless otherwise
advised by a speech pathologist

These textures are difficult for people with poor oral control to safely
contain and manipulate within the mouth
These are consistencies where there is a solid as well as a liquid present
in the same mouthful
Examples include individual cereal pieces in milk, fruit punch,
minestrone soup, commercial dried fruit in juice, watermelon

Ice Cream

Jelly

Soup

Mixed or dual
consistencies

Special occasion
foods or fluids

Nutritional
supplements

Requires the ability to both nite and chew. Chewing stress required for
bread is similar to that of a raw apple. The muscle activity required for
each chew of bread is similar to that required to chew peanuts.35 For
this reason, individuals who fatigue easily may find bread difficult to
chew
Bread requires moistening with saliva for effective mastication. Bread
does not dissolve when wet; it clumps. It poses a choking risk if it
adheres to the roof of the mouth, pockets in the cheeks or if swallowed
in a large clump. This is similar to the noted choking effects of chunks
of peanut butter

These foods (e.g. chocolates, birthday cake etc) should be well planned
to ensure that they are appropriate for individuals requiring texture
modified foods and / or thickened fluids

For individuals who also require thickened fluids, nutritional


supplements may require thickening to the same level of thickness

Individuals on Texture C Smooth Pureed are unsuitable for oral


administration of whole tablets or capsules. Consult with medical and
pharmaceutical staff.
Individuals requiring any form of texture-modified food or fluids may
have difficulty swallowing medications. Seek advice if in doubt

Medication

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Characteristics of foods that pose a choking risk


Stringy

Crunchy
Crumbly

Hard or Dry Foods

Floppy Textures
Fibrous or tough
foods
Skins and Outer
Shells

Round or Long
Shaped

Chewy or Sticky

Husks
Mixed or dual
consistencies

Rhubarb
Beans
Celery is considered a choking risk until 3 years of age37,38
Popcorn
Toast
Dry biscuits
Chips/crisps39
Dry cakes
Biscuits39
Nuts
Raw broccoli
Raw cauliflower
Apple
Crackling
Hard crusted rolls / breads
Seeds
Raw carrots are considered a choking risk until 3 years of age37-41
Lettuce
Cucumber
Uncooked baby spinach leaves (adheres to mucosa when moist
conforming material)42
Steak
Pineapple39
Corn
Peas
Apple with peel
Grapes38,40,41
Whole grapes
Whole cherries
Raisins
Hot dogs
Sausages40,41
Lollies (adhere to mucosa)
Cheese chunks
Fruit roll ups
Gummy lollies
Marshmallows
Chewing gum
Sticky mashed potato
Dried fruits36,41-43
Corn
Bread with grains
Shredded wheat
Bran38,41
Food that retain solids within a liquid base (e.g. minestrone soup,
breakfast cereal)
watermelon

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Unmodified Fluids Definition

Unmodified

Most Modified

Unmodified

Level 150

Level 400

Level 900

Regular Fluids

Mildly Thick

Moderately Thick

Extremely Thick

Unmodified Regular Fluids

There are various thickness levels in unmodified fluids.


Some are thinner (e.g. water and breast milk) and some are thicker (e.g. fruit
nectar)
Unmodified regular fluids do not have thickening agents added to them

Flow Rate

Characteristics

Testing Information

Very fast fast flow

Drink through any type of teat, cup or straw as is


appropriate for age and skills

N/A

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Mildly Thick Fluid Definitions

Unmodified

Most Modified

Unmodified

Level 150

Level 400

Level 900

Regular Fluids

Mildly Thick

Moderately Thick

Extremely Thick

Level 150 Mildly Thick

Is thicker than naturally thick fluids such as fruit nectars, but for example, not as
thick as a thick shake

Flow Rate

Characteristics

Steady, fast flow

Pours quickly from a cup but slower than regular, unmodified


fluids
May leave a coating film of residue in the cup after being
poured
Drink this fluid thickness from a cup
Effort required to take this thickness via a standard bore straw

Testing Information

Special Notes

Subjectively, fluids at this thickness run fast through the


prongs of a fork, but leave a mild coating on the prongs
Testing scales for viscosity exist but are not formalised or
standardised and therefore are not included
Breast milk or infant formula may be thickened for the
therapeutic treatment of dysphagia in infants. This fluid
thickness is thinner than level 150 Mildly Thick, however it is
thicker than unmodified breast milk or infant formula. It is
the same thickness as commercially available Antiregurgitation (AR) formula
Consideration should be given to flow through a teat as
determined by case-by-case basis

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Moderately Thick Fluid Definitions

Unmodified

Most Modified

Unmodified

Level 150

Level 400

Level 900

Regular Fluids

Mildly Thick

Moderately Thick

Extremely Thick

Level 400 Moderately Thick

Is similar to the thickness of room temperature honey or a thickshake

Flow Rate

Characteristics

Slow flow

Cohesive and pours slowly


Possible to drink from a cup, although fluid flows very slowly
Difficult to drink using a straw, even if using a wide bore
straw
Spooning this fluid into the mouth may be the best way of
taking it

Testing Information

Subjectively, fluids at this thickness slowly drip in dollops


through the prongs of a fork
Testing scales for viscosity exist but are not formalised and
are therefore not included

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Extremely Thick Fluid Definition

Unmodified

Most Modified

Unmodified

Level 150

Level 400

Level 900

Regular Fluids

Mildly Thick

Moderately Thick

Extremely Thick

Level 900 Extremely Thick

Is similar to the thickness of pudding or mousse

Flow Rate

Characteristics

Testing Information

No flow

Cohesive and holds its shape on a spoon


It is not possible to drink this thickness using a straw
Spoon is the optimal method for taking this type of fluid
This fluid is too thick if the spoon is able to stand upright in
it unsupported

Subjectively, fluids at this thickness sit on and do not flow


through the prongs of a fork
Testing scales for viscosity exist but are not formalised or
standardised and therefore are not included

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SUMMARY
In summary, dysphagia can occur in any of the four stages of swallowing - chewing, propelling
the food/fluid bolus toward the back of the mouth with the tongue, initiating the swallow, and moving
food/fluid toward the stomach. It is important to understand that dysphagia will range in severity and
impact individuals differently, thus dysphagia will require different management approaches, which will
be implemented by a speech pathologist to best suit the individual.
An assessment by a speech pathologist is important to ensure dysphasic individuals receive treatment to
ensure safe swallowing and appropriate food and fluid consistencies, which can reduce issues, including
dehydration, malnutrition, aspiration and aspiration pneumonia.
Please use this resource as a guide to expand your knowledge and awareness of dysphagia and its
management. W&L recommend that carers of in dividuals with dysphagia and individuals with dysphagia
continue to consult their doctor and speech pathologist to ensure appropriate management is
implemented, to facilitate maximum safety with meals and drinks, according to an individual's level of
dysphagia.
All the best for a speedy recovery,
The W&L Team

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CONTACT US
Wellness & Lifestyles Australia
2/59 Fullarton Road, Kent Town SA 5067
P: +61 8 8331 3000
F: +61 8 8331 3002
E: contact@wellnesslifestyles.com.au
W: www.wellnesslifestyles.com.au www.wleducation.com.au
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