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Wellness & Lifestyles Australia SWALLOWING & DYSPHAGIA & FOOD/FLUID CONSISTENCIES E-BOOK prepared by Sarah
Wellness & Lifestyles Australia SWALLOWING & DYSPHAGIA & FOOD/FLUID CONSISTENCIES E-BOOK prepared by Sarah

Wellness & Lifestyles Australia

SWALLOWING & DYSPHAGIA & FOOD/FLUID CONSISTENCIES E-BOOK

Australia SWALLOWING & DYSPHAGIA & FOOD/FLUID CONSISTENCIES E-BOOK prepared by Sarah Ciccarello 2007,2008,2009
Australia SWALLOWING & DYSPHAGIA & FOOD/FLUID CONSISTENCIES E-BOOK prepared by Sarah Ciccarello 2007,2008,2009

prepared by Sarah Ciccarello

Australia SWALLOWING & DYSPHAGIA & FOOD/FLUID CONSISTENCIES E-BOOK prepared by Sarah Ciccarello 2007,2008,2009
Australia SWALLOWING & DYSPHAGIA & FOOD/FLUID CONSISTENCIES E-BOOK prepared by Sarah Ciccarello 2007,2008,2009
Australia SWALLOWING & DYSPHAGIA & FOOD/FLUID CONSISTENCIES E-BOOK prepared by Sarah Ciccarello 2007,2008,2009

2007,2008,2009

Table of Contents   Page No. IMPORTANT NOTICE 1 INTRODUC TION 2 CRANIAL NERVES AND

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

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.

INTRODUCTION Welcome to the W&L series of eBooks . You have chosen the edition on:

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 individual’s level of dysphagia.

CRANIAL NERVES AND MUSCULATURE INVOLVED IN SWALLOWING CRANIAL NERVES There are six cranial nerves involved

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

Diagram taken from: Massey, B. T. (2006). Figure 2 - Origin of cranial nerves invo
Diagram taken from: Massey, B. T. (2006). Figure 2 - Origin of cranial nerves invo

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

ANATOMICAL STRUCTURES FOR SWALLOWING (AND SPEECH) Swallowing is a complex process, wh ich involves many

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.

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

THE PHARYNX

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

parts: the nasopharynx, oropharynx and laryngopharynx. Diagram taken from: Anatomy of the respiratory system,

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.

THE NORMAL SWALLOW OVERVIEW Swallowing is complex process that we are usually not conscious of.

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).

THE ORAL PREPARATORY PHASE The first stage is the oral preparatio n stage, where food

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.

by-passed by dropping food/fluid to the back of the throat. Figure taken from: Dawodu, S. (2008).

Figure taken from:

Dawodu, S. (2008). Swallowing disorders, emedicine, viewed 21 October 2010 on

http://emedicine.medscape.com/article/317667-overview

THE ORAL PHASE The second stage is the oral stage, where the tongue pushes the

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.

(even without a dysphagia), particularly with dentures. Figure taken from: Dawodu, S. (2008). Swallowing disorders

Figure taken from:

Dawodu, S. (2008). Swallowing disorders, emedicine, viewed 21 October 2010,

http://emedicine.medscape.com/article/317667-overview

STRUCTURES INVOLVED IN THE ORAL PREPARATORY AND ORAL PHASES OF SWALLOWING  Lips  Open

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

THE PHARYNGEAL PHASE The pharyngeal stage of the swallow is involuntary, which mean s we

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.

However, 40% of the population do not have a gag reflex. Diagram taken from: Dawodu, S.

Diagram taken from:

Dawodu, S. (2008). Swallowing disorders, emedicine, viewed 21 October 2010,

http://emedicine.medscape.com/article/317667-overview

STRUCTURES INVOLVED IN THE PHARYNGEAL PHASE OF SWALLOWING Important pharyngeal structures and their func tion

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.

THE OESOPHAGEAL PHASE The oesophageal phase of the swallow begins once the food or fluid

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.

of food back into the pharynx, which may cause aspiration. Diagram taken from: Dawodu, S. (2008).

Diagram taken from:

Dawodu, S. (2008). Swallowing disorders, emedicine, viewed 21 October 2010,

http://emedicine.medscape.com/article/317667-overview

A NORMAL SWALLOW - SUMMARY 2. Food is chewed and prepared by the tongue, jaw

A NORMAL SWALLOW - SUMMARY

A NORMAL SWALLOW - SUMMARY 2. Food is chewed and prepared by the tongue, jaw and
A NORMAL SWALLOW - SUMMARY 2. Food is chewed and prepared by the tongue, jaw and

2.

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

1.

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

by the tongue, jaw and lips. Fluid is also manipulated. 3. The bolus is propelled toward
by the tongue, jaw and lips. Fluid is also manipulated. 3. The bolus is propelled toward

3.

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

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

DYSPHAGIA SUMMARY Dysphagia means swallowing difficulty. A swallowing difficulty may occur within any of the

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.

CAUSES OF DYSPHAGIA Dysphagia is most often caused by: Stroke/CVA  50% of stroke patients

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

Individual’s 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

Huntington’s Chorea

Myasthenia gravis

Parkinson’s Disease

Local structural defects Including:

Cancers

Tumours

Fistula

Dystonia

Motor Neurone Disease

ALS

MS

Medications Some medications, such as those for depression, hypertension, cancer, and Parkinson’s disease, may impact swallowing by causing drowsiness, reducing consciousness, or impairing salivation.

Oesophageal disorders Including:

Reflux

Motility issues

Oesophageal sphincter difficulties

Other

Including:

Septic

Surgery

Depression

Trauma

Auto immune disorders

Behavioural issues, e.g. hysterical

Congenital

SIGNS AND SYMPTOMS OF DYSPHAGIA  Individuals may report increa sed difficulties with eating 

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.

CONTRIBUTING FACTORS OF DYSPHAGIA Level of alertness A reduced level of alertness may impact an

CONTRIBUTING FACTORS OF DYSPHAGIA

Level of alertness A reduced level of alertness may impact an individual’s 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 individual’s 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.

SAFE SWALLOWING PROCEDURES CORRECT POSITIONING FOR SWALLOWING  Ensure patients are seated comfortably, fully upright,

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.

positions for swallowing in a seated and bed environment. Ensure residents are seated fully uprigh t,

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.

If a resident is unable to be positioned appropriatel y in a chair, they may
If a resident is unable to be positioned appropriatel y in a chair, they may

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.

– a pillow may be useful to support this position. Residents should NEVER be in a

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.

SAFE SWALLOWING STRATEGIES Before implementing any of the below strategies, be su re to consult

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.

TEXTURE-MODIFICATION OF FOODS AND THICKENED FLUIDS Adapted from: Dieticians Association of Australia and The Speech

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 individual’s 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.

Unmodified – Regular Foods Definition Unmodified Most Modified Unmodified Regular Foods Texture A Soft

Unmodified – Regular Foods Definition

Unmodified Most Modified
Unmodified
Most Modified
Unmodified
Unmodified

Regular Foods

Texture A

Soft

Texture B

Minced and Moist

Texture C

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

Food inclusions and exclusions

By definition all food and textures can be included

Soft Diet Definition Unmodified Most Modified Unmodified Regular Foods Texture A Soft Texture B

Soft Diet Definition

Unmodified Most Modified
Unmodified
Most Modified

Unmodified

Regular Foods

Texture A
Texture A

Soft

Texture B

Minced and Moist

Texture C

Smooth Pureed

 

Texture A – Soft

Description

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

Characteristics

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

Soft Diet Examples Texture A – Soft   Recommended foods and those to avoid (examples

Soft Diet Examples

Texture A – Soft

 

Recommended foods and those to avoid (examples only)

Foods

Recommend

Avoid

Bread, cereals,

Soft sandwiches (a) with very moist fillings, for example egg and mayonnaise, hummus (remove crusts and avoid breads with seeds and grains)

Breakfast cereals well moistened with milk (b)

Dry or crusty breads, breads with hard seeds or grains, hard pasty, pizza

rice, pasta,

noodles

Sandwiches that are not thoroughly moist

Course or hard breakfast cereals that do not moisten easily, for example toasted muesli, bran cereals

Soft pasta (a) and noodles

Cereals with nuts, seeds and dried fruit

Rice (well cooked)

Soft pastry, for example quiche with a pastry base

Other, soft, cooked grains

Vegetables,

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

All raw vegetables (including chopped and shredded)

legumes

Hard, fibrous or stringy vegetables and legumes, for example sweet corn, broccoli stalks

Well cooked legumes (the outer skin must be soft), for example baked beans

Fruit

Fresh fruit pieces that are naturally soft, for example banana, well-ripened pawpaw

Large/round fruit pieces that pose a choking risk, for example whole grapes, cherries

Dried fruit, seeds and fruit peel

Stewed and canned fruits in small pieces

Fibrous fruits, for example pineapple

Pureed fruit

Fruit juice (b)

Milk, yoghurt,

Milk, milkshakes, smoothies (b)

Yoghurt with seeds, nuts, muesli or hard pieces of fruit

cheese

Yoghurt (may contain soft fruit) (b)

Soft cheeses, (a) for example Camembert, ricotta

Hard cheeses, for example cheddar and hardened/crispy cooked cheese

Meat, fish,

Casseroles with small pieces of tender meat (a)

Dry, tough, chewy, or crispy meats

poultry, eggs,

Meat with gristle

nuts, legumes

Moist fish (easily broken up with the edge of a fork)

Eggs (a) (all types except fried)

Fried eggs

Hard or fibrous legumes

Pizza

Well cooked legumes (the outer skin must be soft), for example baked beans

Soft tofu, for example small pieces, crumbled

Desserts

Puddings, dairy desserts, (b) custards, (b) yoghurt (b) and ice-cream (b) (may have pieces of soft fruit)

Dry cakes, pastry, nuts, seeds, coconut, dried fruit, pineapple

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

Miscellaneous

Soup (b) —(may contain small soft lumps, e.g. pasta)

Soups with large pieces of meats or vegetables, corn, or rice

Soft fruit jellies or non-chewy lollies (a)

Sticky or chewy foods, for example toffee

Soft, smooth, chocolate

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

Jams and condiments without seeds or dried fruit

(a) These foods require case-by-case consideration. (b) These foods may need modification for individuals requiring thickened fluids.

Minced & Moist Diet Definition Unmodified Most Modified Unmodified Regular Foods Texture A Soft

Minced & Moist Diet Definition

Unmodified Most Modified
Unmodified
Most Modified

Unmodified

Regular Foods

Texture A

Soft

Texture B
Texture B

Minced and Moist

Texture C

Smooth Pureed

 

Texture B – Minced and Moist

Description

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

Characteristics

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)

 

Recommended particle size for infants and children = 0.2 – 0.5cm (based on tracheal size) 28

Testing Information

Recommended particle size fir children over 5 years and adults = 0.5cm 10.27.30

Minced & Moist Diet Examples Texture B – Minced and Moist   Recommended foods and

Minced & Moist Diet Examples

Texture B – Minced and Moist

 

Recommended foods and those to avoid (examples only)

Foods

 

Recommend

Avoid (in addition to the Foods to Avoid listed for Texture A—Soft)

Bread, cereals,

Breakfast cereal with small moist lumps, for example porridge or wheat flake biscuits soaked in milk

All breads, sandwiches, pastries, crackers, and dry biscuits

rice, pasta,

noodles

Gelled breads that are not soaked through the entire food portion

Gelled bread

 

Small, moist pieces of soft pasta, for example moist macaroni cheese (some pasta dishes may require blending or mashing)

Rice that does not hold together, for example parboiled, long-grain, basmati

Crispy or dry pasta, for example edges of a pasta bake or lasagne

Vegetables,

Tender cooked vegetables that are easily mashed with a fork

Vegetable pieces larger than 0.5 cm or too hard to be mashed with a fork

legumes

Well cooked legumes (partially mashed or blended)

Fibrous vegetables that require chewing, for example peas

Fruit

Mashed soft fresh fruits, for example banana, mango

Finely diced soft pieces of canned or stewed fruit

Fruit pieces larger than 0.5 cm

Fruit that is too hard to be mashed with a fork

Pureed fruit

 

Fruit juice (a)

Milk, yoghurt,

Milk, milkshakes, smoothies (a)

Soft cheese that is sticky or chewy, for example Camembert

cheese

Yoghurt (a) (may have small soft fruit pieces)

Very soft cheeses with small lumps, for example cottage cheese

 

Meat, fish,

Coarsely minced, tender, meats with a sauce. Casseroles dishes may be blended to reduce the particle size

Casserole or mince dishes with hard or fibrous particles, for example peas, onion

poultry, eggs,

nuts, legumes

Dry, tough, chewy, or crispy egg dishes or those that cannot be easily mashed

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

Desserts

Smooth puddings, dairy desserts, (a)

Desserts with large, hard or fibrous fruit

custards,

(a)

yoghurt

(a)

and ice-cream (a)

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

(may have small pieces of soft fruit)

Pastry and hard crumble

Soft moist sponge cake desserts with lots of custard, cream or ice-cream, for example trifle, tiramisu

Bread-based puddings

Soft fruit-based desserts without hard bases, crumbly or flaky pastry or coconut, for example apple crumble with custard

Creamed rice

 

Miscellaneous

Soup (a) —(may contain small soft lumps, e.g. pasta)

Soups with large pieces of meats or vegetables, corn, or rice

Plain biscuits dunked in hot tea or coffee and completely saturated

Lollies including fruit jellies and marshmallow

Salsa’s, sauces and dips with small soft lumps

Very soft, smooth, chocolate

Jams and condiments without seeds or dried fruit

(a) These foods may require modification for individuals requiring thickened fluids.

Smooth Pureed Or Vitamised Diet Definition Unmodified Most Modified Unmodified Regular Foods Texture A Soft

Smooth Pureed Or Vitamised Diet Definition

Unmodified Most Modified
Unmodified
Most Modified

Unmodified

Regular Foods

Texture A

Soft

Texture B

Minced and Moist

Texture C
Texture C

Smooth Pureed

 

Texture C – Smooth Pureed

Description

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)

 

Smooth and lump free but may have a grainy quality

Characteristics

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

Testing Information

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)

Special Note

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

Smooth Pureed Or Vitamised Diet Examples Texture C – Smooth Pureed   Recommended foods and

Smooth Pureed Or Vitamised Diet Examples

Texture C – Smooth Pureed

 

Recommended foods and those to avoid (examples only)

Foods

 

Recommend

Avoid (in addition to the Foods to Avoid listed for Texture B—Minced and Moist)

Bread, cereals,

Smooth lump-free breakfast cereals, for example semolina, pureed porridge

Cereals with course lumps or fibrous particles, for example all dry cereals, porridge

rice, pasta,

noodles

Gelled bread

 

Pureed pasta or noodles

Gelled breads that are not soaked through the entire food portion

Pureed rice

 

Vegetables,

Pureed vegetables

 

Coarsely mashed vegetables

legumes

Mashed potato

Particles of vegetable fibre or hard skin

Pureed legumes, for example baked beans (ensuring no husks in final puree)

Vegetable soups that have been blended or strained to remove lumps (a)

Fruit

Pureed fruits, for example commercial pureed fruits, vitamised fresh fruits

Pureed fruit with visible lumps

Well mashed banana

 

Fruit Juice (a) without pulp

Milk, yoghurt,

Milk, milkshakes, smoothies (a)

All solid and semi-solid cheese including cottage cheese

cheese

Yoghurt (a) (lump-free), for example plain or vanilla

Smooth cheese pastes, for example smooth ricotta

 

Cheese and milk-based sauces (a)

Meat, fish,

Pureed meat/fish (pureed with sauce/gravy to achieve a thick moist texture)

Soufflés and mousses, for example salmon mousse

Minced or partially pureed meats

poultry, eggs,

Scrambled eggs that have not been pureed

nuts, legumes

Sticky or very cohesive foods, for example peanut butter

Pureed legumes, hummus

Soft silken tofu

 

Pureed scrambled eggs

 

Desserts

Smooth puddings, dairy desserts, (a)

Desserts with fruit pieces, seeds, nuts,

custards,

(a)

yoghurt

(a)

and ice-cream (a)

crumble, pastry or non-pureed garnishes

Gelled cakes or cake slurry, for example fine sponge cake saturated with jelly

Gelled cakes or cake slurries that are not soaked through the entire food portion

Soft meringue

 

Cream (a) , syrup dessert toppings (a)

Miscellaneous

Soup (a) —vitamised or strained to remove lumps

Smooth jams, condiments and sauces

Soup with lumps

Jams and condiments with seeds, pulps or lumps

(a) These foods may require modification for individuals requiring thickened fluids.

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

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

 

The following foods were identified as requiring emphasis

 

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

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

Ice – Cream

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

Jelly

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

Soup

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

‘Mixed’ or ‘dual’ consistencies

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

Special occasion foods or fluids

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

Nutritional

For individuals who also require thickened fluids, nutritional supplements may require thickening to the same level of thickness

supplements

Medication

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

  Characteristics of foods that pose a choking risk    Rhubarb Stringy  Beans
 

Characteristics of foods that pose a choking risk

 

Rhubarb

Stringy

Beans

Celery is considered a choking risk until 3 years of age 37,38

 

Popcorn

Toast

Crunchy

Dry biscuits

Chips/crisps 39

Crumbly

Dry cakes

Biscuits 39

 

Nuts

Raw broccoli

Raw cauliflower

Hard or Dry Foods

Apple

Crackling

 

Hard crusted rolls / breads

Seeds

Raw carrots are considered a choking risk until 3 years of age 37-41

 

Lettuce

Cucumber

Floppy Textures

Uncooked baby spinach leaves (adheres to mucosa when moist – conforming material) 42

Fibrous or ‘tough’ foods

Steak

Pineapple 39

 

Corn

Skins and Outer Shells

Peas

Apple with peel

 

Grapes 38,40,41

 

Whole grapes

Whole cherries

Round or Long Shaped

Raisins

Hot dogs

 

Sausages 40,41

 

Lollies (adhere to mucosa)

Cheese chunks

Fruit roll ups

Chewy or Sticky

Gummy lollies

Marshmallows

 

Chewing gum

Sticky mashed potato

Dried fruits 36,41-43

 

Corn

Husks

Bread with grains

Shredded wheat

 

Bran 38,41

‘Mixed’ or ‘dual’ consistencies

Food that retain solids within a liquid base (e.g. minestrone soup, breakfast cereal)

watermelon

Unmodified Fluids Definition Unmodified Most Modified Unmodified Regular Fluids Level 150 Mildly Thick

Unmodified Fluids Definition

Unmodified Most Modified
Unmodified
Most Modified
Unmodified
Unmodified

Regular Fluids

Level 150

Mildly Thick

Level 400

Moderately Thick

Level 900

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

‘Very fast – fast flow’

Characteristics

Drink through any type of teat, cup or straw as is appropriate for age and skills

Testing Information

N/A

Mildly Thick Fluid Definitions Unmodified Most Modified Unmodified Regular Fluids Level 150 Mildly Thick

Mildly Thick Fluid Definitions

Unmodified Most Modified
Unmodified
Most Modified

Unmodified

Regular Fluids

Level 150 Mildly Thick
Level 150
Mildly Thick

Level 400

Moderately Thick

Level 900

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

Steady, fast flow

 

Pours quickly from a cup but slower than regular, unmodified fluids

Characteristics

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

 

Subjectively, fluids at this thickness run fast through the prongs of a fork, but leave a mild coating on the prongs

Testing Information

Testing scales for viscosity exist but are not formalised or standardised and therefore are not included

Special Notes

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 ‘Anti- regurgitation’ (AR) formula

Consideration should be given to flow through a teat as determined by case-by-case basis

Moderately Thick Fluid Definitions Unmodified Most Modified Unmodified Regular Fluids Level 150 Mildly Thick

Moderately Thick Fluid Definitions

Unmodified Most Modified
Unmodified
Most Modified

Unmodified

Regular Fluids

Level 150

Mildly Thick

Level 400
Level 400

Moderately Thick

Level 900

Extremely Thick

 

Level 400 – Moderately Thick

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

Flow Rate

Slow flow

 

Cohesive and pours slowly

Possible to drink from a cup, although fluid flows very slowly

Characteristics

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

 

Subjectively, fluids at this thickness slowly drip in dollops through the prongs of a fork

Testing Information

Testing scales for viscosity exist but are not formalised and are therefore not included

Extremely Thick Fluid Definition Unmodified Most Modified Unmodified Regular Fluids Level 150 Mildly Thick

Extremely Thick Fluid Definition

Unmodified Most Modified
Unmodified
Most Modified

Unmodified

Regular Fluids

Level 150

Mildly Thick

Level 400

Moderately Thick

Level 900
Level 900

Extremely Thick

 

Level 900 – Extremely Thick

Is similar to the thickness of pudding or mousse

Flow Rate

No flow

 

Cohesive and holds its shape on a spoon

It is not possible to drink this thickness using a straw

Characteristics

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 Information

Testing scales for viscosity exist but are not formalised or standardised and therefore are not included

SUMMARY In summary, dysphagia can occur in any of the fo ur stages of swallowing

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

CONTACT US Wellness & Lifestyles Australia 2/59 Fullarton Road, Kent Town SA 5067 P: +61

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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