Compensatory Strategies

Pacing is a compensatory strategy where the feeder periodically interrupts the feed, thereby slowing the rate of delivery. It can be used across all feeding situations and age ranges, e.g. breast, bottle, cup, liquids and solids feeding.

For infants, the aim of pacing is to increase safe oral intake by assisting the infant to coordinate their suck-swallow-breathe (SSB) cycle. Pacing also allows for re-establishment of normal respiration that supports coordinated SSB patterns.

The rate and frequency of pacing will be dependent on suck to swallow ratio, suck strength, age of the infant and feeding method. Also to be considered is equipment, for example the type of bottle chosen and nipple flow rates.  See Appendix 3 - Nipple Flow Rates

For children, the aim of pacing is to increase safe oral intake by preventing the child from overfilling their oral cavity, as well as to ensure proper coordination of their respiratory cycle during meals (Harding & Wright, Dysphagia: the challenge of managing eating and drinking difficulties in children and adults who have learning disabilities, 2010). Pacing allows necessary time for children who require multiple swallows to clear their oral cavity and pharynx before taking another bite of food or sip of drink.

Altering sensory properties of foods and liquids provides additional sensory input for swallowing. Taste, temperature, and tactile quality can be modified to facilitate motor action by stimulating receptors of the tongue and oropharynx.

Methods of bolus delivery, including nipples, cups, straws, and spoons may be considered to reduce aspiration risks, facilitate normal feeding patterns, and improve intake. Equipment selection should consider the child’s general development, oral anatomy, oral sensorimotor function and swallowing skills. See Appendix 5 - Feeding Equipment .

In addition to describing texture modifications to foods, IDDSI  also offers person-focused descriptions of thickened liquids for persons with dysphagia.

Thickening liquids creates a cohesive bolus and slows the flow rate of the liquid which may improve oral control, and reduce premature oral and pharyngeal spillage. This allows an infant more time to organize their SSB pattern, trigger a swallow for airway closure, and reduce the risk of aspiration. By improving swallow safety and efficiency with of the use of thickened liquids, feeding tube placement may be avoided, there may be decreased tube dependency with oral intake, and/or pulmonary injury from recurrent aspiration may be prevented (Gosa, Schooling, & Coleman, 2011); (Gosa & Corkins, 2015). 

While thickening may be highly beneficial and warranted in some clinical scenarios, it may not be suitable for all infants and children. There is evidence to suggest the potential for negative consequences including the onset of necrotizing enterocolitis (NEC), gastric distress, reduced feeding endurance and efficiency, as well as dehydration and malnutrition (Duncan, Larson, & Rosen, 2019); (Gosa, Schooling, & Coleman, 2011); Woods, et al., 2012). The use of thickening agents can also affect nutritional composition.

Thickening of liquids should only be considered when all other therapeutic options have been exhausted. Furthermore, thickeners should not be prescribed without first utilizing instrumental assessment. Studies, based on animal models, suggest that aspiration of thickened liquids may result in more injurious pulmonary complications (Nativ-Zeltzer, et al., 2018); (Nativ-Zeltzer, et al., 2021); & (Araie, et al., 2020). When instrumental evaluation is unsuccessful or unavailable, careful consideration should be given to the risks and benefits of thickened liquids specific to the patient, and in consultation with the interdisciplinary team. 

When choosing the type of thickener, consider the age of the child, what it is being mixed in, and accessibility (many products are special order) (Beal, Silverman, Ballant, & et al., 2012); (Woods, Oliver, Lewis, & et al., 2012); (Rosen, et al., 2019). Check with the manufacturer and review product specifications before prescribing a thickener for children less than three years of age (Kwok, Ojha, & Dorling, 2017). See Table 7.

Thickness of a liquid mixed with commercial thickener can change depending on the type and temperature of liquid, type of thickener, and stand time after mixing (Gosa & Dodrill, 2017). For bottle-fed infants and children, successful management with thickened liquids requires evaluating the effort required to effectively suck and swallow the desired thickness in relation to the bottle nipple opening and flow rate (Gosa & Dodrill, 2017).

Table 7: Thickener Types, Products, Considerations and Recommendations

*Nestlé Health Science adopted the Codex International Standards: Code of Hygienic Practice for Powdered Formulas for Infants and Young Children. As such, ThickenUp ® Original and ThickenUp Clear ® are subject to different quality requirements compared to products marketed for children less than three years of age and as such are not recommended for this population.

When prescribing thickened liquids that are either commercially available or to be prepared at home using a commercial thickener per Table 9 , consider the child’s risk for potential drug interactions. Starch-based thickeners and polyethylene glycol (PEG) laxatives may interact leading to a thinning of thickened liquids (ISMP Canada Safety Bulletin, 2019), (Carlisle, et al., 2016).

Maltodextrin is a short chain polysaccharide that has undergone partial hydrolysis and therefore does not function as a starch. Xanthan gum may not interact with PEG laxatives in the same way as a starch. SimplyThick® has indicated on their website that their product can be mixed with PEG laxatives.

However, most thickeners are designed and tested exclusively for use with foods and drinks. They are not developed, tested or intended for use with medications, and therefore most manufacturers cannot provide guidance for use with medications. 

When prescribing or recommending thickened liquids as part of dysphagia management, determine whether the child is using polyethylene glycol (PEG) laxative. Have the family consult with their interdisciplinary team including the pharmacist for consideration of alternative laxative therapy or an alternative delivery method of PEG laxative. Altering medications for administration is complex and requires clinical assessment and informed decision-making. It is unknown if PEG laxative will fully dissolve or alter the natural consistency of a naturally thick food product such as yogourt or applesauce. Selecting an alternate thickener to be administered with medication may still impact drug bioavailability and dissolution and therefore may not be a suitable option. 
 

Children with dysphagia may be at increased risk of poor hydration and inadequate intake and should be monitored carefully. Children with respiratory compromise (or increased work of breathing) typically have poor feeding endurance and as such may not have the capacity to take full oral feeds to sustain nutrition. Alternatively, some infants and children may experience increased energy expenditure associated with oral feeding and as such they may require additional nutritional support such as high calorie feeds or enteral nutrition.

It is important to consider the types of textures managed by the child and whether the food texture is impacting the child’s nutrition and hydration:

• Children should be offered food textures in line with their developmental capacity. If children are offered foods beyond their oral sensorimotor function level, it may negatively impact the volume of food and fluid consumed and subsequently their nutritional intake. Modifying the texture, by making it easier for oral processing and swallowing, may result in increased nutrition intake and weight gain (Patel, Piazza, Layer, Coleman, & Swartzwelder, 2005). More challenging textures could be offered at snack times for skill development.
• Thickened liquids may negatively impact fluid intake for some children. It is important to assess and monitor the amount of fluid a child is able to swallow and their overall intake for optimal hydration. 
• Children on texture modified food and fluids should still be offered a variety of healthy food choices and flavours within their managed textures and viscosities. 

If the strategies listed above prove ineffective at maintaining safe and sufficient oral intake of food and fluids to meet hydration or nutritional needs, enteral nutrition therapy may be required.
 

Not all oral medications are available in a composition that is safe for an infant, toddler, or child with dysphagia to swallow. For instance, infants, toddlers, and children with dysphagia may not be safe to swallow tablets or capsules (solid medication). Physicians and pharmacists can recommend suitable alternatives for infants and toddlers under their care. For children with dysphagia, consider consultation with a dysphagia practitioner who will collaborate with the physician and pharmacist to enable safe consumption of medications.
 
The recommended age for introducing solid medication to children without a diagnosis of dysphagia is between age 4 and 5; at this age, a child can reasonably follow instructions and learn how to control a solid floating in a liquid to swallow it safely. Signs of readiness to learn to swallow solid medications include drinking from an open cup, swallowing mouthfuls of liquid, and adequately chewing bites of chunky foods. Red flags include gagging, choking, or coughing on any of these. 

Learning to swallow a solid medication may take practice. The following educational websites have been created to support families to coach their children to learn to swallow solid medications through creating positive experiences that build their confidence (Forough, et al., 2018); (Patel, Jacobsen, Jhaveri, & Bradford K.K., 2015); (Kaplan, et al., 2010).

Refer to:
•    www.pillswallowing.com/ready
•    www.youtube.com/watch?v=TBpxKwiSDL0

Modifying a medication may alter its effectiveness or stability or increase the risk of toxicity. Medications that are intended to be swallowed whole should never be crushed or chewed. Medications that function over a specific time instead of all at once (e.g. modified-release dosage tablets or capsules) should not be crushed. Modifying a medication may make taste or texture unacceptable to children. It is important to consult a pharmacist prior to recommending alterations of medication to improve administration and palatability, e.g. accessing compounded liquid formulations, cutting or crushing tablets, or mixing with small amounts of food or drinks. Each medication should be administered separately and as per the physician or pharmacist order. Consider consultation with a compounding pharmacist to discuss options to create personalized medications to meet the specific needs of a child, such as creating medications into gummy bear shapes and using different flavours.
 

Refer to:

• MyHealth.Alberta.ca: Helping Children Take Medicine
• Alberta Referral Directory