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 .

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 and that sensitive periods for oral feeding skill acquisition are not neglected (Harris & Mason, 2017). 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) is a global standard with terminology and definitions to describe texture-modified foods and thickened liquids used for individuals with dysphagia of all ages, in all care settings, and for all cultures (© The International Dysphagia Diet Standardisation Initiative, 2019). Single IDDSI-only labeling for dysphagia products in Canada is targeted for January 1, 2023. At present, AHS has adopted some aspects of the IDDSI terminology and specifications. Additional terms may be included alongside IDDSI terminology to describe texture modified solids for children with or without dysphagia. See Appendix 4 - IDDSI Terminology .

Table 6: Signs of Swallowing Safety Concern in Infants and Management Strategies*

*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.

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