Strategies to Facilitate Safe Swallowing
Table 8 summarizes signs of swallowing safety concerns and management strategies in infants.
Pacing is a compensatory technique that 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 4 - Nipple Flow Rates ). For some children, multiple swallows may be required to clear the oral cavity and pharynx.
Children with dysphagia may be at increased risk of aspiration and choking as they transition to more challenging textures. When a child is at increased risk of choking, parents should be trained by a healthcare professional in what to do if their child is choking.
Children should be assessed for safety to progress onto more challenging food textures. Safe and timely progression will ensure they are meeting their developmental potential. The child’s oral sensorimotor function and swallowing function should be taken into consideration when making management decisions regarding texture progression (Sheppard, 1997).
In practice there are many ways to describe the variation in textures and forms of solid foods. The International Dysphagia Diet Standardisation Initiative (IDDSI) terminology may be used in some settings to describe dysphagia diets in detail to support appropriate food selection. At present, AHS has adopted some aspects of the IDDSI terminology and specifications. As AHS transitions toward a common terminology, additional terms may be used in practice to describe texture modified solids for children with or without dysphagia. See Appendix 5 - IDDSI Terminology .
Table 8: Signs of Swallowing Safety Concern in Infants and Management Strategies*
|
Presenting Problems |
Pacing |
Equipment Selection |
Texture Modification |
Positioning & Handling |
Therapy Suggestion |
|
Weak Latch |
compensatory |
|
not applicable |
|
|
|
Weak Suck |
compensatory |
|
not applicable |
|
|
|
Fluid pooling and spilling from mouth |
compensatory – |
|
+/- depending on suck strength and effect of pacing |
|
|
|
Prolonged sucking – minimal intake |
compensatory – |
|
not applicable |
|
|
|
Short sucking bursts,⇧respiratory rate, ⇧work of breathing |
compensatory – |
|
+/- trial of thickened fluids depending on suck strength |
|
|
|
Respiratory compromise |
compensatory – |
|
+/- thickened fluids depending on swallow safety and instrumental swallowing assessment results |
|
|
|
Coughing or choking |
compensatory – |
|
thickened fluids or modified diet (based on instrumental swallowing assessment results) |
|
|
*Note for table above: These strategies can be modified for older children demonstrating oral sensorimotor and, or swallow incoordination. The pacing and texture modification strategies can be applied in the same way for cup (sip and swallow) and solid (chew and swallow) feeding. Equipment selection should consider the child’s general development, oral anatomy, oral sensorimotor function and swallowing skills. Many of the strategies that facilitate oral-motor function can be applied alongside specialized seating and positioning. Thickened fluids may be beneficial when there are signs of aspiration, difficulty controlling fluids in the mouth and signs of delayed initiation of swallow.
For infants, thickening fluids slows the flow rate of the liquid which may improve oral control, reduce premature oral and pharyngeal spillage, allowing an infant more time to organize their SSB pattern, trigger a swallow for airway closure, and reduce the risk of aspiration.
The International Dysphagia Diet Standardisation Initiative (IDDSI) offers person-focused descriptions of texture modified foods and thickened fluids for persons with dysphagia. Thickened fluids can be defined in the following way (IDDSI, 2019), (Alberta Health Services, 2019):
- slightly thick (level 1; previously half nectar): thicker than water but able to flow through a straw or nipple
- mildly thick (level 2; previously nectar consistency): fluid runs freely off the spoon but leaves a thin coating on the spoon
- moderately thick (level 3; previously honey consistency): fluid slowly drips in dollops off the end of the spoon; can be drank from a cup or taken with a spoon
extremely thick (level 4; previously pudding consistency): the fluid sits on the spoon and does not flow off it; cannot be drunk from a cup, straw or nipple.
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, physician, dysphagia expert and, or dietitian before prescribing a thickener for children less than three years of age (Kwok, Ojha, & Dorling, 2017). See Table 9.
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 9: Thickener Types, Products, Considerations and Recommendations
|
Thickeners |
Product information |
General mixing information See product website for additional details |
Recommendations for use |
|
SimplyThick ® Easy Mix™
Xanthan gum |
|
|
|
|
Tapioca maltodextrin and carob bean gum
|
|
|
|
|
Tara gum, tapioca maltodextrin |
|
|
|
|
Modified food starch (corn) |
|
|
|
|
Nestle Resource Thicken Up Clear ®
Modified food starch (corn and potato maltodextrin) with xanthan gum |
|
|
|
|
Iron fortified infant cereal (i.e. rice cereal, oat cereal) |
|
|
|
*Nestle Health Science adopted the Codex International Standards: Code of Hygienic Practice for Powdered Formulas for Infants and Young Children. As such, ThickenUp ® 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.
Thickeners and Polyethylene Glycol (PEG) Laxatives
When prescribing thick fluids 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 fluids (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. Simply Thick ® 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 thick fluids for dysphagia management, assess whether the child is using polyethylene glycol (PEG) laxative. Have the family consult with their healthcare team 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 in a naturally thick food or alter the natural consistency of a food product such as yogurt or applesauce. Selecting an alternate thickener to be administered with medication may still impact on drug bioavailability and dissolution and therefore may not be a suitable solution.
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 6 - Feeding Equipment .
Head or facial posture, including jaw, lip, or cheek support, are compensatory strategies to facilitate safety when swallowing. For older children, rehabilitation techniques promote safe swallowing by improving underlying anatomy and physiology. The modified Shaker exercise or head lift maneuver are examples of rehabilitation techniques (Speech Pathology Australia, 2012). Strengthening exercises may support safe swallowing by improving physiology, e.g. jaw, lips, cheek, and tongue. Any strengthening exercise should be functional, e.g. to improve swallowing, practice swallowing.
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. 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 fluids 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.
