Common Questions About Swallowing Disorders, IDDSI, and More!

Many factors can cause or worsen dysphagia, including but not limited to:

• Premature birth
• Neurologic conditions or injuries (e.g., stroke, Parkinson’s, Alzheimer’s, brain tumors, hypoxic-ischemic encephalopathy in infants)
• Structural or anatomical differences
• Intensive care treatments (e.g., prolonged intubation and medications that affect swallowing)
• Autoimmune diseases (e.g., Multiple Sclerosis)
• Cancer and oncological treatments (e.g., head and neck cancer, such as HPV)
• Gastrointestinal issues (reflux, strictures, achalasia, and other esophageal dysphagia)
• Pulmonary/respiratory compromise (COPD, congestive heart failure, lung surgery, lung transplants, prematurity, and even the use of high flow nasal cannula)
• Behavioral factors (e.g., shoveling in food at a fast rate and other mealtime issues)
• Fear of swallowing, requiring a thorough instrumental evaluation to rule-out actual difficulty swallowing versus aversions (see this DysphagiaCafe webinar by Karen Sheffler called: Ask What Else – From Interview through Documentation).

A full evaluation with a speech-language pathologist, who specializes in swallowing and works with the broader medical team, is needed to identify multi-factorial causes. Swallowing is complex and often needs multiple disciplines involved.

Person-centered care means that the individual with dysphagia (and/or caregivers/proxy) is the “driver” of that team. The medical professionals need to make sure that person is informed to make decisions.

Silent aspiration is when material falls into the larynx and below the vocal cords, entering the lungs without triggering any obvious response. There is no coughing, throat clearing, or discomfort felt and/or reported by the person.

People who silently aspirate do not show any obvious outward signs, which makes it especially dangerous, particularly in vulnerable populations like older adults or compromised infants.

Choking needs to be considered differently than simply aspiration. This is when an object (food, toy, etc.) falls into the larynx or top of the airway and lodges there – blocking airflow. The object does not fall through in an aspiration. There is an obstruction that can be partial or complete.

• A partial obstruction might cause a wheezing sound;
• A full obstruction prevents breathing, coughing, or any sound.
  • Signs include struggling to breathe, color changes (red/purple/blue), bulging eyes, inability to speak, or the universal choking sign.
  • Quick intervention (e.g., Heimlich Maneuver by trained individuals) is critical. Brain damage can occur in under 4 minutes.
  • Seek out training in CPR and Choking through the American Heart Association.
  • Reducing risk is the key, especially for young children and older adults with dysphagia. Sticky foods like bread with peanut butter can be problematic. Peanut butter may lodge in the airway and not be able to be ejected with the Heimlich Maneuver. Choking often cannot be prevented 100% of the time, but with appropriate evaluations and management from your qualified team of professionals, your risks can be drastically reduced!
  • Please also see the International Dysphagia Diet Standardisation Initiative (IDDSI) for more information. The IDDSI mission is to mitigate (reduce) choking risks and save lives. Their Soft & Bite-Sized, Level 6 diet specifically cuts the foods into 1.5cm cubed size bites for adults and 8mm cubed for pediatrics. This size is designed to fall through the airway and not block the airway.

• Frequent throat clearing or coughing during eating/drinking
• Wet/gurgly vocal quality or congestion during/after swallowing
• Increased work of breathing or shortness of breath with meals
• Food or liquid coming out of the nose
• Feeling food stuck in throat or a “lump” sensation (globus)
• Difficulty chewing
• Spilling food from the mouth (normal in infants learning)
• Food stuck in mouth or cheeks after swallow
• Fatigue while chewing or eating
• Getting full quickly (aka, “Early satiety”), like not being able to eat more than the size of your fist during a meal.
• Long meal times (over 30 minutes)
• Reduced appetite, pushing the plate away after a few bites
  Unexplained weight loss
• Signs of dehydration and malnutrition (feeling thirsty, dry mouth, dark strong-smelling urine, muscle cramps, headaches, feeling tired, low energy, and more)
• Pain with chewing/swallowing

1. If swallowing is impaired, a person may not eat enough and:
   • Lose weight
   • Become malnourished
   • Become dehydrated
2. Choking risks can be life-threatening if not evaluated and managed appropriately for risk reduction.
3. Repeated aspiration may lead to aspiration pneumonia or pneumonitis (infection from bacteria, food/liquid/pills/secretions, non-acidic vomitus, or tube feeding contents enter the lungs).

Your risk for aspiration pneumonia is higher if:
a. You are bedbound
b. You are aspirating a lot
c. You have poor mouth cleaning, brushing and hygiene (aka, poor oral infection control – see my webinar).
     i. See also my many blogs on how oral hygiene is linked to aspiration pneumonia prevention and aspiration pneumonia risks.
     ii. See this new blog oral health and oral frailty.
d. You are smoking
e. Your lungs are already compromised
f. You have a weakened immune system.
g. Note: Aspiration pneumonitis (inflammation from acidic material from your stomach) is distinct from infection. However, keep in mind that many people are on medications that neutralize the acid in the stomach; therefore, bacteria can grow easily.

• Referral: Talk with your doctor; get an order to see a swallowing specialist (speech-language pathologist/SLP who specializes in swallowing – not all SLPs work in dysphagia/swallowing disorders).
• Screening: A nursing swallow screen can be performed by a trained nurse or doctor, but this needs to be documented in the medical record. This is also known as a stroke swallow screen. See the Yale Swallow Screening Protocol for example. Here is the book. Here is a handy form.
• Outcome Measures to show to your doctor and track your own progress: Healthcare providers and the person with difficulty swallowing can use a patient-reported outcome measure, called PROMs (e.g., EAT-10 for adults, PEDI-EAT-10 for children). The the 10 question form for adults on page 1 here.
• Clinical/Bedside Swallowing Evaluation: Performed by an SLP to assess cognition, speech, voice, airway/cough, oral-sensorimotor function, and oral intake trials with saliva, ice chips, foods, liquids, and sometimes medication delivery (medications only with nurse present). This evaluation cannot determine what happens to the bolus (food/liquid/saliva material in the mouth), once the lips are closed. The evaluation cannot reliably comment on the pharyngeal and laryngeal phases of the swallow. The clinician can state what they suspect to be occurring and what the risks are. The clinician cannot rule-in or rule-out aspiration and or residue in the pharynx and esophagus. Therefore, Instrumental Swallowing Evaluations are often needed.
• Instrumental Studies:
  • Videofluoroscopic Swallow Study (VFSS) / Modified Barium Swallow Study (MBSS)
  • Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
  • High Resolution Pharyngeal Manometry (HRPM) (less common)
• Please see Garand & colleagues (2020) in their article titled: “Assessment Across the Life Span: The Clinical Swallow Evaluation. Authors provide an algorithm for when an instrumental evaluation is needed and when it may be challenging or not offer much information to further decision-making.

Multidisciplinary referrals may include neurology, ENT, gastroenterology, and radiology depending on findings.

Treatment is individualized and guided by thorough evaluation:

• Compensatory strategies: Changing how/what/where you eat.
  • Diet modifications: Texture or liquid consistency changes, adding moisture, cutting food, thickening liquids, and more.
  • Swallowing maneuvers (aka, safer swallowing strategies): Specific head/neck positions, effortful swallows, and other techniques tailored to the person.
  • Rate control and pacing: smaller bites/sips, use of single small cup sips versus rapid drinking by straw, alternating liquids and solids, and more. However, adding strategies needs to be guided by the SLP and your comprehensive evaluation, as sometimes taking larger bites/sips may be helpful – depending on the type of swallowing problem you have. These are not one-size-fits all!
  • Environmental adjustments: Quiet setting, limited stimuli, optimal feeding setup, one item at a time (i.e., one bowl and one cup to reduce distractions), etc.
• Rehabilitation or habilitation in the case of infants/pediatrics: Strengthening, timing, coordination exercises to improve swallowing physiology.

Consistent, person-centered therapy is not one-size-fits-all; it’s tailored based on instrumental findings. Therapy involves a lot of education and counseling to seek what works and is best for you based on your own goals and preferences.

Prevention: We say “prevention is key;” however, we cannot truly prevent risk 100% of the time. We try to reduces risk of complications like aspiration pneumonia through:

• Mobility, exercise, and activity
• Oral hygiene improvements (aka, oral infection control described above using electric toothbrush, water pik, flossing, and mouthwash)
• Pulmonary clearance (e.g., chest PT and devices that can help raise up and clear out sputum)

Advocacy: People with dysphagia and caregivers should ask about prognosis, request re-evaluations, and stay engaged. Keep asking questions! If diet changes were made without sufficient testing, ask for instrumental reassessment. You are the driver—ask questions, stay active, and push for clarity.

• Talk with your doctor about any symptoms related to eating and swallowing. Your primary care doctor or other doctors, nurse practitioners, or physician assistants can give you a prescription (doctor’s order) to see a speech-language pathologist who specializes in swallowing.
• You may have a specialist to address your issue in a location near you. Find a Specialist in the area of swallowing and swallowing disorders. These are speech-language pathologists with specialty board certification.

https://www.iddsi.org/images/AroundTheWorld/UnitedStates/faq/USIRGFAQRecipeRegulatoryNov2024.pdf

1. IDDSI does not have specific IDDSI recipes. The main reason for this is that food ingredients can change the end product. For example, if a recipe calls for one banana, the outcome will be different if the banana is mushy in one kitchen versus the green and hard banana at another kitchen. IDDSI is also global, so the testing methods can apply to foods around the world.

2. Recipes are required for all food products prepared in healthcare facilities, which are in accordance with standard healthcare foodservice operation procedures.

3. IDDSI encourages the facilities and menu creators to develop and test menu items themselves.

• Testing is essential. Use IDDSI Testing Methods.
• Results are dependent upon the following variables: product differences, ingredient characteristics, final recipe characteristics, temperature, equipment, culinary skills, holding time, and more.

HELPFUL TIPS:

1. Start with current recipes for texture modified diets that you serve.
2. Prepare them, test them, and adjust the recipes according to The IDDSI Framework and Testing Methods per the IDDSI.org resources.

Appropriately serving physician-ordered texture modified foods and drinks will continue to have increased focus during state and federal survey processes in the United States.

IDDSI is considered best practice and the only professionally recognized diet framework (per the Academy of Nutrition & Dietetics/AND, the American Speech-Language-Hearing Associations/ASHA, and the Association of Nutrition & Foodservice Professionals/ANFP).

Clear orders, communication, and documentation support compliance and person-centered care.

(see person-centered care statement at the bottom of this FAQ)

IDDSI assists with person-centered care, as we can all finally “speak the same language,” using standardized diet labels and descriptors. So, when you go from the hospital to home or a facility, your providers are using the same words to discuss your options for eating and drinking. Your healthcare team should have a conversation with you. It is so important to use IDDSI terminology during this conversation, as that assists the team to speak clearly about diets and testing methods you can use at home or in your next facility.

Person-centered care reinforces that You are the driver of your own healthcare team (or your healthcare proxy when you are unable to make your own decisions). Healthcare providers will explain your options and the potential risks and benefits of each option. The rest of the healthcare team will support you in an informed decision-making process. Ask for further clarifications and testing as needed. You may need to seek out someone to act as your advocate, as many medical decisions are very complex. Sometimes, a doctor or other healthcare person may recommend what they think is best for you. You may need to advocate for your own goals of care, preferences, wishes, and for what quality of life means to you.

For example, if you do not want food that is pureed, you can discuss your wishes. The team can help you craft solutions that work best for you, such as a Soft & Bite-Sized, Level 6 with making sure all foods are soft with a Fork Pressure Test and very moist with extra sauce/gravy, which having a particle size that is small (1.5 cm or less than ½ inch) to reduce your choking risks further.

Our USIRG Person-Centered Care statement is as follows:

The IDDSI Framework cannot change, but the diet order can be individualized. Person-centered diet orders specify an individual’s needs within and outside the IDDSI Framework. The medical team works in collaboration with the person’s wishes, preferences, goals of care, and individual abilities. Risks and benefits may be addressed in the informed consent process. Clear orders, communication, and documentation are key to person-centered care.

https://www.iddsi.org/images/AroundTheWorld/UnitedStates/faq/USIRGFAQExceptionsBreadsMixedConsistencyJan2025.pdf

Exceptions can be made to a person’s diet order in a healthcare facility.

Exceptions, within a person-centered care approach, are based on an individualized-comprehensive clinical swallowing assessment. This is a full evaluation by a speech pathologist who specializes in swallowing and is in collaboration with the rest of the medical team. Don’t forget, that team includes you (and/or your appointed healthcare proxy).

Take-home point: IDDSI Framework cannot change, but the diet order can be written on a case-by-case basis. This may include simple statements to describe the exceptions outside the IDDSI framework.

https://www.iddsi.org/images/AroundTheWorld/UnitedStates/faq/USIRGFAQExceptionsBreadsMixedConsistencyJan2025.pdf

So many people love bread, but bread is a challenging regular texture that commonly causes choking. Therefore, it is defined as a Regular, Level 7 food item only.

Bread (Part 1):

• Regular bread is only included in Regular, Level 7.
• According to The IDDSI Framework, bread is not on the diet levels of Soft & Bite-Sized, Level 6 or Minced & Moist, Level 5, even when cut-up.
  • The use of bread on these levels would be an exception written into the diet order.
  • Clear diet orders and exceptions are needed to avoid confusion when creating exceptions to the IDDSI Framework.
  • The diet order by the ordering healthcare professional (i.e., MD, PA, or NP) may be following a clinical recommendation by the SLP or be based on decision-making by the person with dysphagia (or healthcare proxy). The medical team works in collaboration with the person’s wishes, preferences, goals of care, and individual abilities to manage bread products (or any exception) and/or to accept risks. Communication and documentation are keys to patient care.
• The diet level of “Easy to Chew, Level 7” may include soft breads, analyzed with the assistance of your speech pathologist after a clinical swallowing evaluation. You can make sure these bread items are softer by using the side of a fork/spoon to see if you can cut or break them apart easily. You may need to avoid breads that are hard, dry, seeded, crusty, or crumbly.

For More Information:

• The IDDSI.org FAQ page addresses several bread questions. Just go to this link, and type “bread” into the search bar.
• Use the Minced & Moist, Level 5 Sandwich Recipe YouTube video. Soft and moist fillings can be added that meet your diet level needs (e.g., small moist particles for Minced & Moist or soft-moist bite-sized chunks for Soft & Bite-Sized diets). https://www.youtube.com/watch?v=W7bOufqmz18

Mixed consistencies are also common in our foods such as dry cereal with milk or a chicken noodle soup. Why are these hard for someone with difficulty swallowing (dysphagia)?

Mixed Consistencies (Part 2):

• A mixed consistency or dual consistency is a food that either:
  • Contains both solids and liquids within the same bite (e.g., cold cereal in thin liquid milk or a soup with chunks of solids in a thin liquid broth), or
  • Appears to be a single consistency on a plate but may quickly separate into two consistencies in the mouth (e.g., watermelon or any juicy fruit).

Per IDDSI.org: “As a general rule, ‘mixed’ or ‘dual consistency’ foods are more challenging to swallow, because a person must have adequate abilities to handle (control) both the solid and the liquid component of these items, which requires more advanced swallowing coordination abilities.” People who aspirate thin liquids may be at a high risk for having difficulty with mixed consistencies

• Only Regular, Level 7 inherently includes mixed consistencies, as they are a challenging texture.
• Easy to Chew may include them under clinician guidance and/or an informed decision-making process.
• Levels 4, 5, and 6 exclude mixed consistencies unless clearly ordered as an exception.
• Diet orders can be individualized through these “exceptions.” However, collaboration and clear documentation are required to manage risk.

For More Information:

• The IDDSI.org FAQ page addresses mixed consistency questions. Just go to this link, and type “mixed” into the search bar. https://www.iddsi.org/faq
• Go to IDDSI’s News section for this article. https://iddsi.org/news/mixed-dual-consistencies
• See article: Saitoh, E., Shibata, S., Matsuo, K., Baba, M., Fujii, W., Palmer, J.B. (2007). Chewing and food consistency: Effects on bolus transport and swallow initiation. Dysphagia, 22, 100–7.
• Read more about mixed consistencies here at DysphagiaCafe.com.

https://www.iddsi.org/images/AroundTheWorld/UnitedStates/faq/USIRGSaucesGraviesNov2024.pdf

Sauces, gravies, and condiments restore moisture lost during processing/holding and help foods pass IDDSI testing by:

• Adding moisture, flavor, and nutrition
• Binding to foods to make the bolus cohesive and slippery
• Preventing dry or crumbly bites

Framework specifics:

• All levels from Pureed (Level 4) through Easy to Chew (Level 7) can benefit.
• Levels 4 and 5 require smooth, lump-free sauces; Level 6 allows soft lumps (≤1.5 cm adults / 8 mm pediatrics).
• Levels 5–7 solids can be served in thicker sauces with excess drained; no thin liquid separation is allowed.
• Always verify with IDDSI Testing Methods (Spoon Tilt, Fork Drip) to ensure the sauce is properly integrated.

https://www.iddsi.org/images/AroundTheWorld/UnitedStates/faq/USIRGSaucesGraviesNov2024.pdf

Sometimes, but Not always.

The thin, slightly thick or mildly thick gravy or sauce may be just what is needed! When you have a food that is way too thick, sticky, and dry, you will need to add a broth, sauce, or gravy to fix the texture and make it safer.

• For example, a thinner gravy may be just what is needed to turn that sticky mashed potato into a puree that passes a Spoon Tilt Test.
• For more examples, see the Spoon Tilt Test for a Minced & Moist, Level 5 meat here. It cannot be dry and crumbly; rather, it must be moist and cohesive and slide of spoon when tilted.
• See the Spoon Tilt Test for a Puree or Extremely Thick Liquid, Level 4 here.

Add that sauce or gravy until your food is smooth and slippery and easy to swallow through your mouth, throat and esophagus (food tube to the stomach).

Thicken gravy further only if it separates from the food and creates a mixed consistency, which could be unsafe. Adjust thickness so it blends into the food to form a cohesive yet slippery ball in your mouth.

Always use these IDDSI Testing Methods (mainly the Spoon Tilt Test) before serving to make sure your food is easier for your needs. Check out these Audit charts that help you analyze foods.

1. Please also see the FAQs on IDDSI global.
2. Sign up for IDDSI newsletters here.
3. Check out IDDSI’s huge resource section here.
4. Don’t miss the IDDSI YouTube Channel for many instructional videos and webinars.
5. Download the IDDSI App on your smart device by searching “IDDSI” in the App Store.
6. Connect with IDDSI Around the World here.
7. See our contact emails for USIRG at the bottom of our USIRG chart of resources here.
8. Please see my library of resources on SwallowStudy.com here:
   1. IDDSI Resources and list of blogs from 2014 to current. https://swallowstudy.com/iddsi-resources/
   2. 7 IDDSI Updates https://swallowstudy.com/7-iddsi-updates/

Affordability:
Do you need help affording the products for your difficulty swallowing in yourself or a loved one (adult)?
Do you need help affording the products for the feeding and swallowing difficulties in your baby or child?

Please see The Dysphagia Outreach Project https://www.dysphagiaoutreach.org/.
They have a Food Bank.
You can apply for assistance.

Finding Products: (here are some ideas)

1. Please see Hormel Health Nutrition for ordering foods and liquids to your home: https://www.hhnutrition.com/collections/hormel-health-labs
   (Hormel Health Labs is now known as Lyons Health Labs https://www.lyonshealthlabs.com/). Note: Per Lyons: “Hormel Health Labs joined forces with foodservice leader Lyons Magnus, whom you may already be familiar with as the makers of the Lyons ReadyCare® brand products.”
2. Please see SimplyThick for thickener gel and many dysphagia resources. https://www.simplythick.com/
3. Check out Savorease (https://savorease.com/): makers of dissolvable finger foods for those who love some texture and savory crunch. These foods dissolve in the mouth to a puree and should be easy to swallow. Warning: if you have a very dry mouth, the foods may not dissolve well. Test these out with your swallowing specialist first.

Please see the National Foundation of Swallowing Disorders (NFOSD) and their many resources:

• Patient Stories
• Local Support Groups and other support options under the “Resources” tab.
• Programs, including webinars for people and caregivers.

In addition to the resources provided above, please see:

• American Speech-Language-Hearing Association (ASHA) has a “practice management” page that includes: Ethics, Practice Portal, Evidence Maps, Licensure information, Multicultural Resources, Social Determinants of Health (SDOH), and more. Please also see the Scope of Practice documents for SLPs here.
• American Board of Swallowing and Swallowing Disorders (AB-SSD) who, according to their website: certify “speech–language pathologists (SLPs) who have advanced knowledge, skills and experience are recognized by the designation of BCS-S or Board Certified Specialist in Swallowing and Swallowing Disorders. This certificate is akin to the Board Certification that qualified physicians hold. The American Speech-Language Hearing Association (ASHA) grants basic certification to all SLPs (with the Certificate of Clinical Competence or CCC) as an entry level requirement for practice. However, starting in 1995, ASHA began a program of Specialty Recognition, and that developed into our Specialty Certification that we have had since the early 2000’s. Please see our History tab to read more about AB-SSD’s history. While BCS-S is voluntary, it is becoming the standard for identifying an SLP who is an expert in dysphagia, or swallowing disorders.
• Please also see the Dysphagia Research Society (DRS) whose mission is to advance the science of swallowing and feeding/swallowing disorders. DRS hosts annual meetings, gathering professionals across the disciplines that evaluate and treat all types of difficulties in feeding and swallowing. Their mission statements are:
  • to enhance and encourage research pertinent to normal and disordered swallowing and related functions
  • to attract and encourage new students, investigators and others from diverse backgrounds to the field and foster their development within a collegial, supportive, and inclusive environment
  • to encourage interdisciplinary research
  • to promote the dissemination of knowledge related to normal and disordered swallowing and related functions
  • to provide a multidisciplinary forum for presentation of research into normal and disordered swallowing and related functions
  • to foster research leading to new methodologies and instrumentation for the study of normal and disordered swallowing and its clinical applications
  • to enhance and encourage research, and use of research in evidence-based practice, that improves the lives and function of those with swallowing disorders
  • to enhance and encourage research in the area of normal and disordered swallowing that is inclusive and equitable. We encourage our members to perform and support research that strives to reduce health inequities globally and aims to include diverse voices and perspectives

Great, we at SwallowStudy.com really reinforce digging deeper and asking questions. I have written many blogs with that in mind!

Feel free to use the Contact Us page.