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Consistency Modifications for Special Diets at School
Cord Gentry, CF-SLPSpeech-Language Pathologist
Wake Forest Baptist Health
Perry Flynn, CCC-SLPConsultant to the NCDPI in Speech-Language Pathology
Website: www.uncg.edu/csd/faculty/perryflynn.html
Doris Sargent Ed.D RD LDNSMI Nutrition Consultant
Clear Mandate
• Schools must make substitutions in the reimbursable meal for students who are disabled and whose disability restricts their diet.
Physician’s StatementMust identify:
• student's disability• explanation of why/how the disability restricts the student’s diet• major life activity affected by the disability• food or foods to be omitted from the child's diet• food or choice of foods that must be substituted
504 Eligibility:
•Disability •Negative impact on academic achievement or functional performance
IEP Eligibility:
•Disability •Negative impact on academic achievement or functional performance•Need of specially designed instruction
504 vs. IEP
HACCP Plan
Hazard Analysis
Critical ControlPoints
• An internal check system specific to each kitchen and classroom• A method of identifying critical points (CCP’s) for preventing food-borne illness
Responsibilities of CN Director
• Contact medical staff if the Medical Statement is not complete or does not provide clear instructions.
• Review the medical statement with manager.
• Determine how students will be identified.• Participate in IEPs with nutrition concerns.• Contact other disciplines for advice if
needed
Review Medical Statement with CN Director or supervisor.
File and keep a copy on site Make staff aware of the dietary needs of
individual students Ask for expertise from other disciplines. Train staff to follow food safety practices
especially when working with Children with Special Needs
Responsiblities of CN Manager
To help ensure proper consistency in the modification of food or liquid to help achieve or maintain optimal nutrition intake while reducing the risks of complications for students with disabilities.
To optimally serve students with modified dietary needs, it is essential that team members collaborate with instructional staff, child nutrition workers, school nurses, therapists, community providers, school administrators, and the student’s family and peers.
To facilitate a multidisciplinary approach that creates adequate accommodations while meeting the child’s nutritional and emotional needs.
Goals of this initiative:
Swallowing disorders
◦ Oral phase -sucking, chewing, and moving food or liquid into the throat
◦ Pharyngeal phase -starting the swallowing reflex, squeezing food down the throat, and closing off the airway to prevent food or liquid from entering the airway ( aspiration ) or to prevent choking
◦ Esophageal phase -relaxing and tightening the openings at the top and bottom of the feeding tube in the throat (esophagus ) and squeezing food through the esophagus into the stomach
Dysphagia (dis-fay-juh)
Arching or stiffening of the body during feeding
Irritability or lack of alertness during feeding Refusing food or liquid Failure to accept different textures of food
(e.g., only pureed foods or crunchy cereals) Long feeding times (e.g., more than 30
minutes) Difficulty chewing
Signs and Symptoms of Dysphagia
difficulty breast feeding coughing or gagging during meals excessive drooling or food/liquid coming out of
the mouth or nose difficulty coordinating breathing with eating and
drinking increased stuffiness during meals gurgly, hoarse, or breathy voice quality frequent spitting up or vomiting recurring pneumonia or respiratory infections less than normal weight gain or growth
Signs and Symptoms cont’d…
Modified Barium Swallow Fiberoptic Endoscopic Evaluation of
Swallowing (FEES)
Definitive Diagnosis of Dysphagia
Child eats or drinks food or liquid with barium in it, and then the swallowing process is viewed on an X-ray.
See ASPIRATION for yourself… http://www.youtube.com/watch?v=1sFNMk8
7558
Modified Barium Swallow
a lighted flexible scope is inserted through the nose, and the swallow can be observed on a screen.
Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
The Modified Diet Process
Child Nutrition School Nurse Instructional Staff Occupational Therapist Speech-Language Pathologist Peers Child’s Family
*All of these professionals play an important role in the formation of a proper IEP which should include specifications for the child’s modified diet.
Who is involved in the modified diet process?
Access needed equipment and training� Maintain consistency in preparation� Adhere to and teach safe food handling �
procedures Match modified meals to regular menu�
Child Nutrition
Monitors student’s health, weight, and overall nutrition status
Coordinates acquisition of physician statement �for food adaptations
Troubleshoots issues related to tracheostomies, �feeding tubes, ventilators, etc.
Writes the IHP� Serves as liaison between family, community �
health providers, and school Provides training for school staff, student, and �
peers
School Nurse
Implements mealtime plan Documents and communicates student �
status Coordinates personnel needed for mealtime� Ensures safe mealtime environment� Request training and assistance� Creates mealtime routines�
Instructional Staff
Coordinates “big picture” approach to �mealtime
Assesses and designs mealtime routines� Selects adaptive equipment� Modifies environment� Addresses mechanics of plate‐to‐mouth �
feeding Addresses sensory deficits limiting �
mealtime participation
Occupational Therapist
Provides screening and modification Suggests helpful medical studies (e.g., MBSS)� Works with community providers and family to �
monitor student's mealtime plan Trains school‐based personnel and �
parent/guardian May serve as liaison between school and �
community providers Encourages communication and helps design as �
“normal” a mealtime environment as possible May act as school‐based hub of team activities�
Speech-Language Pathologist
Student
Family
Instructional Staff
Child Nutrition Program Staff
School NurseTherapistsSchool Administrator
sCommunity Providers
Peers
Published in 2002 by the American Dietetic Association, aims to establish standard terminology and practice applications of dietary texture modification in dysphagia management.◦ NDD Level 1: Dysphagia-Pureed (homogenous,
very cohesive, pudding-like, requiring very little chewing ability).
◦ NDD Level 2: Dysphagia-Mechanical Altered (cohesive, moist, semisolid foods, requiring some chewing).
National Dysphagia Diet
Collaborate with the Modified Diets Task Force
Observe and interact with professionals who serve children with modified diets
Research modified diets Identify the role of the SLP in this process Help determine the most appropriate
modified diet process Create a resource manual for other
professionals to reference as needed
My Master’s Project Experience
Prepare and serve consistent and reliably texture-modified foods and thickened beverages
Produce and serve acceptable and aesthetically appealing texture-modified foods and thickened liquids
Produce and serve texture-modified beverages and foods with adequate nutritional content
And the goals of modified food service…
Foods should be pureed into a smooth form or “mashed potato-like” consistency.
No chunks of food present Homogenous in color and texture Requires no chewing or bolus control Food should pass through a 1 mm mesh
screen No water separation
Pureed Diet (Level 1)
Pureed Hamburger
Pureed Carrots
Pureed Green Beans
Pureed Lasagna
Puree Broccoli
Puree Chicken Nuggets
Mashed Potatoes
*No modification needed
Pureed Pinto Beans
Pureed Pizza Dippers
Pureed Vegetable Medley
Puree vs. Regular
Children with modified diets are served applesauce- this is the pureed version of the apple cobbler dessert.
Apple cobbler preparation: Students on regular diets are served this for dessert.
Mashed Potatoes VS. Potato Wedges
Puree Regular
Foods are moist and soft and formed easily into a bolus
Meats are minced/ground to no larger than ¼ inch pieces
Moist and cohesive with no water separation
Food should pass through a 6 mm mesh screen
Closely resemble minced/ground food texture.
Mechanically Altered Diet (Level 2)
For those with difficulty chewing and/or swallowing.
The mechanical soft diet is for persons who can tolerate more texture in foods than the pureed diet offers, while minimizing the amount of chewing needed to ingest food.
It offers foods that are modified in texture, but not always in flavor. Meats are chopped or ground, often with moisture added to make swallowing easier.
Raw and dried fruits and vegetables, nuts and seeds are not allowed.
Mechanical Soft foods:
Mechanical Soft Hamburger
Mechanical Soft Carrots
Mechanical Soft Green beans
Mechanical Soft Lasagna
Mechanical Soft Chicken Nuggets
Mechanical Soft Pizza Dippers
Mechanical Soft Vegetable Medley
The Food Processors
Food Processor Steps
1. Add meat to food processor
2. Fill water to top of food
3. Pulse (mechanical soft); Run on high (puree)
4. Check consistency 5. Finish cooking 6. Check consistency
Foods purchased from different vendors Large versus small production amounts Different additives (chicken broth versus
water versus ketchup) Standardization of terminology
◦ Collaborate with nurse and medical personnel
Picture Recipes!!
Problems with having a recipe:
No worries…
You can add a thickening agent such as: Thick & Easy Thick It Potato Flakes
These agents will help in achieving the proper consistency without starting over.
Not the proper consistency?
Example:Thick & Easy: Instant Food Thickener
Add one pack (6.5g) to 4 fl. oz of liquid and stir for 15 seconds. Allow 1-4 minutes to reach optimal thickness
Pureed Meats◦ The mixing of “Thick-It” Original
or Concentrated Thick-It 2 with pureed beef and chicken will vary depending on the fluidity of the puree. We suggest adding 2 ½ teaspoons to 1 tablespoon of “Thick-It” Original or 1 ¼ - 1 ½ teaspoons of Extra Strength “Thick-It” 2 to 4 oz. of beef or chicken puree. Enhance the flavor with beef, chicken or vegetable dry seasonings if desired.
“Thick-It” Mixing directions for Puree
Pureed Fruits◦ Pureed Fruits: Mix 1 tablespoon of “Thick-It”
Original or ½ tablespoon of Concentrated “Thick-It” 2 with 4 oz. pureed fruit like applesauce, apricots, peaches or pears for a firm consistency. To enhance the flavor, add a dash of cinnamon or allspice in combination with either 1/8 teaspoon lemon juice or ½-1 teaspoon sugar or sweetener
“Thick-It”
Pureed Vegetables◦ 4 ounces of pureed carrots, green beans, wax
beans, peas, tomatoes and winter squash can achieve the desired consistency with 1 tablespoon of “Thick-It” Original or ½ tablespoon Concentrated Thick-It 2. Flavor with your favorite seasonings to make them taste more like the comfort foods you enjoy.
“Thick-It”
Regular and Modified Foods Ready to Serve
Puree vs. Mechanical Soft FoodsWhich one is which?
1 2
The Serving Process
Sanitation
1. Wash
2. Rinse
3. Sanitize 4. Air dry
Safety and sanitation are extremely important.
Prepare as close to service as possible and avoid holding the foods, since they lose quality quickly
Consider color, flavor, smells - all the sensory triggers here to
encourage consumption of nutrient dense, healthy food items (It is very important that food does not end up looking like white mush.)
Avoid the temperature danger zone (40-135 degrees)
Wash and sanitize equipment and utensils when changing products to avoid cross contamination
Sanitize blender and all equipment after each use
Typical meal experience Comfortable setting With non-disabled peers Not secluded
Least Restrictive Environment:
1. What is a modified diet in the school system?◦ To help ensure proper consistency in the modification of food or liquid to
help achieve or maintain optimal nutrition intake while reducing the risks of complications for students with disabilities.
2. What is dysphagia?◦ A big word for “swallowing disorder”
3. What are 3 signs and symptoms of dysphagia?◦ Irritability or lack of alertness during feeding, coughing or gagging during
meals, excessive drooling or food/liquid coming out of the mouth or nose
4. What is a puree consistency?◦ Mashed potato-like consistency◦ No chunks of food
Cord’s Top 10 POP QUIZ!!!
5. What is a mechanical soft consistency?◦ Moist and cohesive with no water separation, soft foods that are
easily formed into a bolus
6. Who is involved in the modified diet process in the schools?◦ EVERYONE!! CN, Nurse, OT, SLP, Instructional Staff, Peers and family
members
7. Name 3 goals of the modified food process in the schools.• Prepare and serve consistent and reliably texture-modified foods and
thickened beverages• Produce and serve acceptable and aesthetically appealing texture-modified
foods and thickened liquids • Produce and serve texture-modified beverages and foods with adequate
nutritional content
8. What can you add to a food consistency if it’s not the appropriate consistency you would like? ◦ Thickening agents such as:
“Thick-It”, Thick and Easy, or potato flakes
9. What are the 4 steps in proper sanitation?◦ 1. Wash◦ 2. Rinse◦ 3. Sanitize◦ 4. Air dry
10. How will you help ensure the proper modified diet process in your school? ◦ ????
The Complete Experience
Dahl, .W. J. (2008). Modified Texture Food Production: A Manual for Patient Care Facilities, 2nd Edition. Dietitians of Canada.
Instant Food Thickening Agents for Liquids & Purees, Thick-It®. (2011).Food Thickener for Swallowing Problems & Dysphagia – Thick-It®. Retrieved February 16, 2012, from http://www.thickitretail.com/ForthePublic/Usage.aspx
Instant Food Thickening Agents for Liquids & Purees, Thick-It®. (2010).Food Thickener for Swallowing Problems & Dysphagia – Thick-It®. Retrieved February 16, 2012, from http://www.hormelhealthlabs.com/2colTemplate_product.aspx?page=CO_TE_Beverages&cond_id=117&cat_id=162
NCDPI. “Accommodating Students with Special Dietary Needs.” 2011.
Wake Forest Baptist Health Medical Center BoulevardWinston-Salem, NC 27157
Gateway Education Center3205 E. Wendover AveenueGreensboro, NC 27405
National Dysphagia Diet: What to Swallow?. (2003). American Speech-Language-Hearing Association | ASHA. Retrieved March 18, 2012, from http://www.asha.org/Publications/leader/2003/031104/f031104c.htm
Feeding and Swallowing Disorders (Dysphagia) in Children. (n.d.).American Speech-Language-Hearing Association | ASHA. Retrieved May 30, 2012, from http://www.asha.org/public/speech/swallowing/FeedSwallowChildren.htm#what_are_f_and_s_dis
References
THANK YOU FOR YOUR TIME AND PARTICIPATION
Cord Gentry
Perry Flynn
Doris Sargent
