HELPING PATIENTS THROUGH THICK & THIN (LIQUIDS)

HELPING PATIENTS THROUGH THICK & THIN (LIQUIDS)

Presented By Hillary Cooper, M.A., CCC-SLP

ABOUT ME

• President & Co-Founder of the Dysphagia Outreach Project

• Owner of North Louisiana Swallow Solutions, a mobile FEES company

• Owner of SLPstuff.com

• Mentor of The Medical SLP Collective

• Mom of 2 boys (age 18 and 4)

• Wife of a Really Lucky Man

• Never bored

A SPECIAL THANK YOU

I’d like to extend a very special thank you to Rebecca Brown and Kristen West for helping

me gather this (and more) information as part of this lecture and to help further the

mission of The Dysphagia Outreach Project.

Rebecca Brown Kristen West

COMPENSATION VS REHABILITATION

Dysphagia Intervention

Compensation Techniques

Rehabilitation Techniques

COMPENSATION VS. REHABILITATION

• Breath Hold

• 3 second Prep

• Sour Bolus

• Dry Swallow

• Alternate Liquids/Solids

• Carbonated Liquids

• Super/Supraglottic Swallow

• Compensation Techniques*:

• Thickening liquids

• Chin Tuck/Chin Down

• Head Rotation to the Weak Side

• Head Tilt to the Strong Side

• Posterior Head Tilt

• Bolus size restriction

• Texture modification

*Not a comprehensive list….

WE MUST ALWAYS TEST COMPENSATION DURING INSTRUMENTATION!

COMPENSATION VS. REHABILITATION

• Dysphagia Rehabilitation Techniques*:

• Strengthening Exercises

• MDTP

• Swallow Optimization Therapy

• Swallowing Boot Camp Approaches

• MD Anderson Swallowing Boot Camp

• Intensive Dysphagia Rehabilitation (Malandraki, 2018)

• Oromyofunctional Therapy

• Trismus Management


COMPENSATION VS REHABILITATION

• Additional Dysphagia Rehabilitation Tools/Techniques*:

• Respiratory Muscle Strength Training (RMST)

• IOPI or Tongueometer

• Neuromuscular Electrical Stimulation (NMES)

• sEMG Biofeedback

• Endoscopic Biofeedback

• Manual Therapy/Myofascial Release

• Lymphedema Management


AND BACK TO THE ORIGINAL TOPIC…

TO THICKEN OR NOT TO THICKEN

According to Dysphagia Following Stroke (Daniels & Huckabee, 2014), a few key points to consider when deciding to recommend thickened liquids include:

1. Patient Satisfaction/Quality of Life:

• Your patient’s lack of compliance with a recommended diet (puree, thickened) is directly related to the dissatisfaction of the food/liquid preparation (Colony, 2005)

Used with Permission from Theresa Richard, M.A., CCC-SLP, BCS-Swww.mobiledysphagiadiagnostics.com/blog


2. The Risk/Benefit ratio:

• Aspiration

• There is an INCREASED incidence of pneumonia in patients receiving honey-thick liquid compared to nectar-thick or thin with a chin tuck. (Robbins et al., 2008)

• Dependency for feeding and oral care, the number of decayed teeth, and tube feedings are more predictive of aspiration pneumonia (Langmore et al., 1998) <--- (This "Predictors of Aspiration" paper is a must-read for anyone working in SNFs and struggling with the ultimatum to thicken or not to thicken)



2. The Risk/Benefit ratio:

• Dehydration

• The issue is not with the actual thickening agent causing dehydration, rather it is a palatability issue with the patient drinking less than they would if it weren't thickened.

• The free water protocol may be your best bet if dehydration is a concern.


SO WHY DO WE USE THICKENERS?

• Thickened liquids serve to slow down the movement of the bolus from the oral cavity into the pharynx.

• In SOME patients with dysphagia, the slowed transit into the pharynx MAY result in a safer swallow.



THICKENING & EBP*

• Miles et al (2018) tells us that patients may be more likely to silently aspirate thickened liquids than thin liquids.

• This is why getting that instrumental assessment is so important!

• Nativ-Zeltzer (2018) tells us that:

• (1) aspiration of thickener can lead to pulmonary injury

• (2) aspiration of modified cornstarch thickener is worse on lung tissues than aspiration of xanthan gum thickener and aspiration of xanthan gum is worse than aspiration of plain water

• Robbins (2008) tells us that there is an increased risk of aspiration pneumonia development with use of honey thickened liquids.


POP QUIZ TIME!!!

How many major TYPES (not brands) of products are currently used for thickening liquids for individuals with dysphagia across settings?

A. Two

B. Three

C. Four

D. Five

E. Six

F. Seven

G. Eight

THE ANSWER IS G. EIGHT!

TYPES OF THICKENERS

Types of Thickeners

Modified Food Starch/Cornstarch Gelmix (tapioca starch & carob bean gum)

Xanthan Gum Gel Infant Rice Cereal

Xanthan Gum Powder Infant Oatmeal

Purathick (tapioca starch & tara gum) Food Puree/Baby Food/Yogurt

Note: Although individuals with dysphagia and family members may get *creative* with their thickeningproducts, these are the types that are most currently used in medical settings across the lifespan. Items I’veheard used include regular all purpose flour, potato flakes, agar agar, regular cornstarch, regular tapiocaflour, and regular xanthan gum powder.

MODIFIED FOOD STARCH/CORNSTARCH

Typical Ingredients Modified food starch; Modified Cornstarch, Maltodextrin (varies by brand)

Common Brands Thick-It Original; Concentrated Thick-It2; Resource ThickenUp; Walgreens Thick Now Powder; Hormel Thick&Easy; CVS Instant Food Thickener

Age Range for Safe Use Age 1+

Hot/Cold Liquids Can be used with both hot & cold liquids. Does not work well with carbonated liquids.

Palatability Often mixes up with clumps in it. Can taste “grainy” or “bitter”Liquids become cloudyContinues to thicken over time as it sits

Cost $10-$20 per package

Shelf Life 2.5 years or more (unopened)

Special Diet Considerations Kosher Pareve, Vegetarian

Contraindications/Allergies Gluten free (typically)Avoid if sensitive to cornstarch or corn derivatives

Other Considerations May increase pulmonary injury if aspirated (Nativ-Zeltzer, 2019); Diabetic individuals need to account for the thickener in their diet because it metabolizes like sugar.

XANTHAN GUM GEL

Typical Ingredients Xanthan Gum, Water, Soluble Fiber, Glucono Delta-lactone, Gellan Gum, Potassium Sorbate, Calcium Chloride, Citric Acid, Sodium Citrate, Guar Gum, Pectin

Common Brands SimplyThick EasyMix

Age Range for Safe Use >12 years old (packet says “do not use in infants or children under the age of 12 without consulting a healthcare professional)*some pediatric medical teams may consider off label usage

Hot/Cold Liquids Works with both hot and cold & carbonated liquids. Can be frozen into ice. Does not continue to thicken over time.

Palatability Smooth, gel consistency with no lumps or graininess. Consistency is stable over time.

Cost $40-$70 per package

Shelf Life 12 months after manufacture date

Special Diet Considerations Certified Kosher

Contraindications/Allergies Not for use in individuals at high risk of necrotizing enterocolitis (NEC)Free of major known allergens

Other Considerations Contains 1g soluble fiber per 4oz serving (nectar thick)Contains no more than 1g carbs per 4oz serving (nectar thick)Contains 20mg sodium per 4 oz serving (nectar thick)

XANTHAN GUM POWDER

Typical Ingredients Maltodextrin, Xanthan gum, Erythritol, Carageenan, Ascorbic Acid (varies by brand)

Common Brands Clear DysphagiaAide, Thick-It Clear, Resource ThickenUp Clear, Hormel Thick & Easy Clear

Age Range for Safe Use Recommended for children over age 3

Hot/Cold Liquids Works with both hot & cold and carbonated liquids. Can be frozen into ice. Does not continue to thicken over time.

Palatability More difficult to mix appropriately, but if done properly mixes into a smooth gel consistency. If not mixed appropriately, consistency may contain some small clumps of powder.

Cost $10-$30 per container

Shelf Life 18 months - 3 years (varies by manufacturer)

Special Diet Considerations Kosher

Contraindications/Allergies Gluten Free, Lactose Free, Corn Free

Other Considerations Contains no more than 1g carbs per 4oz serving (nectar thick)

PURATHICK

Typical Ingredients Organic Tapioca Maltodextrin, Organic Tara Gum, Calcium Carbonate

Common Brands Purathick

Age Range for Safe Use Not for use with infants under 1 year old.

Hot/Cold Liquids Works with hot and cold liquidsLiquids will continue to thicken over time. Cold liquids thicken slower over time than hot liquids. Not recommended for carbonated beverages.

Palatability More difficult to mix appropriately, but if done properly with a shaker cup it mixes into a smooth gel consistency. If not mixed appropriately, consistency may contain some small clumps of powder.

Cost $20 per container

Shelf Life 2 years after manufacturing date (unopened)30 days after opening

Special Diet Considerations Kosher Pareve, Vegan

Contraindications/Allergies Do not use if patient has galactosemia (rare) or allergy to galactomannans is suspected.

Other Considerations Non-GMO, Organic

GELMIX

Typical Ingredients Organic Tapioca Maltodextrin, Organic Carob Bean Gum, Calcium Carbonate

Common Brands Gelmix

Age Range for Safe Use For infants >6 pounds and/or born preterm and currently under a corrected age of 2 weeks

Hot/Cold Liquids Heat activated. Does not work well with cold liquids. Viscosity may change as the mixture cools over time.

Palatability Despite it’s name, it is a powder, not a gel.More difficult to mix appropriately, but if done properly with a shaker cup it mixes into a smooth gel consistency. If not mixed appropriately, consistency may contain some small clumps of powder.

Cost $25 per container

Shelf Life 2 years after manufacturing date (unopened)30 days after opening

Special Diet Considerations Kosher Pareve, Vegan, Non-GMO, Organic

Contraindications/Allergies Do not use if patient has galactosemia (rare) or allergy to galactomannans is suspected.

Other Considerations May cause transient gassiness or loose stools in the first two weeks of use which typically resolves on its own or with decreased use.

INFANT RICE CEREAL

Typical Ingredients

Common Brands Gerber, beechnut, earth’s best, variety of “store brands”

Age Range for Safe Use Term-1 year + (most common use, medical team decisions vary)

Hot/Cold Liquids Thickening and then reheating liquids results is significantly different flow rates indicating impact of temperature on liquid consistency andcereal thickening (Gosa and Dodrill 2017)

Palatability Can have gritty texture may decrease palatability or change taste

Cost Approximately $3-5 dollars per container

Shelf Life About 2-3 months after opening

Special Diet Considerations -Macronutrient shift from protein and fat to carbs which may lead to excessive weight gain (Horvath et at., 2008)-Introduction of solids prior to 4 months-Associated with obesity (x6) by age 3 (Grummer-Strawn et al, 2008) -Increased risk of diabetes, eczema, and celiac disease (Norris et al., 2005; Tarini et al., 2006)-Additional iron and inorganic Arsenic introduced into diet-Cannot use in breastmilk due to amalyse-Grain cut/size may impact consistency of thickening

Contraindications/Allergies May not be recommended for infants with complex GI histories or constipation due to side effects

Other Considerations Can thicken over timeResearch has found that Formula thickened with rice cereal separates over time into thin liquid and solid residue (Gosa and Dodrill 2016)Can cause constipationDifferent “cuts” and particle sizes result in different thicknessesMay clog nipple

INFANT OATMEAL

Typical Ingredients

Common Brands Gerber, beechnut, earth’s best, variety of “store brands”

Age Range for Safe Use Term-1 year + (most common use, medical team decisions vary)

Hot/Cold Liquids Thickening and then reheating liquids results is significantly different flow rates indicating impact of temperature on liquid consistency andcereal thickening (Gosa and Dodrill 2017)

Palatability Can have gritty texture may decrease palatability or change taste

Cost Approximately $3-5 dollars per container

Shelf Life About 2-3 months after opening

Special Diet Considerations Macronutrient shift from protein and fat to carbs which may lead to excessive weight gain (Horvath et at., 2008)Introduction of solids prior to 4 months-Associated with obesity (x6) by age 3 (Grummer-Strawn et al, 2008) -Increased risk of diabetes, eczema, and celiac disease (Norris et al., 2005; Tarini et al., 2006)-Additional iron and inorganic Arsenic introduced into diet (less so with oatmeal)-Cannot use in breastmilk due to amalyse-Grain size/cut may impact thickening

Contraindications/Allergies May not be recommended for infants with complex GI histories or constipation due to side effects

Other Considerations Formula thickened with oatmeal may over-thicken and/or separate over time into thin liquid and solid residue (Gosa and Dodrill 2016)Can cause constipationDifferent “cuts” and particle sizes result in different thicknesses American Academy of Pediatrics (AAP) now recommends parents of children with reflux and/or dysphagia use oatmeal instead of rice cereal.

A FEW POINTS ABOUT THICKENING WITH CEREALS

• There is currently SOME research regarding use of cereals as thickeners, but we need more.

• Oatmeal can sometimes be less consistent than rice cereal, but it’s variable based on whether it’spulverized vs flake size vs brand (Gosa, 2011).

• Cereal creates more of a suspension which may contain inconsistent pockets of thin and thick.

• Temperatures can affect thickening efficacy (Gosa et al., 2020)..

• Intraoral dwell time and pressure exerted on the bolus can impact its consistent thickening (Suiter, et al., 2013).

FOOD PUREES/BABY FOOD

Typical Ingredients

Common Brands Commercial vs homemade, wide variety of choices AND different foods to utilize including baby yogurt

Age Range for Safe Use 6 months + generally (remember to consider AA)

Hot/Cold Liquids ???

Palatability Will vary based on what is used can change texture/grit and alter flavor

Cost Varies.Relatively inexpensive depends on brand, organic, homemade etc.

Shelf Life 1-2 years for commercial baby foods depending on brand/type

Special Diet Considerations Potential to introduce flavor variety to child

Contraindications/Allergies Have to be cautious for potential developing allergy based on what puree you choose

Other Considerations Adds nutritional value (vs empty calories)Potential for nutrient displacementReflux considerations when picking a food type to use as a thickenerMonitor GI health for stooling patterns (constipation vs loose)Lower acid baby foods include: Gerber Squash and Sweet Potatoes, Beech Nut Mixed Veggies, Corn and Sweet Potatoes, Earth’s Best Organic corn and butternut squash, organic garden vegetables

IMPORTANT TO NOTE

• It is currently difficult to thicken barium in a way that mimics thickened formula or breastmilk (Gosa, 2013).

• This is one reason why FEES may be preferable in small infants.The actual thickenedformula or breast milk may be tested with FEES, decreasing the likelihood of falsenegatives/positives from aVFSS.

FINAL THOUGHTS

• Remember, choosing a thickener should NOT be a one size fits all situation. Not everyone with high blood pressure responds well to one medication. Therefore there are many medications on the market to meet individual patients’ needs.

• Use this information to advocate for access to a variety of different products to serve each individual patient’s unique needs.

CASE HISTORY

• 61 year old male admitted to acute care hospital due to a severe lower GI bleed requiring multiple units of blood and surgical intervention.

• PMHX includes ETOH abuse, COPD, Type 2 Diabetes, Hypertension, Hyperlipidemia, Gout, Congestive Heart Failure, Toxic Metabolic Encephalopathy, Respiratory Failure with Hypoxia

• Pt referred to SLP due to failing the RN dysphagia screen post-surgery.

• FEES revealed frank aspiration with thins (level 0) and minced and moist (level 5) and deep penetration with nectar thick liquid (level 2) and puree consistency (level 4).

• SLP recommendation is for Nectar Thick Liquids (level 2) and Puree Solids (level 4).

• Based on this case history, what thickener product would you recommend? (assuming you have access to all of the previously mentioned thickeners)

REFERENCES

• Colodny, N. (2005). Dysphagic independent feeders' justifications for noncompliance with recommendations by a speech-language pathologist. American Journal of Speech-Language Pathology, 14(1), 61–70.

• Corbin-Lewis, K, Liss, J.M., & Sciortino, K.L., 2005, Clinical Anatomy & Physiology of the Swallow Mechanism, Thomson Delmar Learning, Clifton Park, NY.

• Daniels, S. K., & Huckabee, M. L. (2008). Dysphagia following stroke. San Diego: Plural Pub. Langmore, S. E., Terpenning, M. S., Schork, A., Chen, Y., Murray, J. T., Lopatin, D., & Loesche, W. J.(1998). Predictors of aspiration pneumonia: How important is dysphagia? Dysphagia, 13(2), 69–81.

• Eney, A. Changes in pediatric hospital wide thickening protocol in response to events and evidence. [PDF Format]. http://depts.washington.edu/nutr/wordpress/wp-content/uploads/2015/08/Eney_MNT-Poster_FINAL-DRAFT.pdf

• Gosa, M., Schooling, T., & Coleman, J. (2011). Thickened Liquids as a treatment for children with dysphagia and associated adverse effect: A systematic review Infant Child and Adolescent Nutrition, 3(6): 344-350.

• Gosa, M. & Dodrill, P. (2017). Effect of time and temperature on thickened liquid formula. Nutrition in Clinical Practice, 32;2.

http://depts.washington.edu/nutr/wordpress/wp-content/uploads/2015/08/Eney_MNT-Poster_FINAL-DRAFT.pdf

REFERENCES

• Gosa, M., Dodrill, P., & Robbins, J. (Accepted, January 2020). Front line interventions: Considerations for modifying fluids and foods for management of feeding and swallowing disorders across the lifespan. American Journal of Speech-Language Pathology.

• Horvath A, Dziechciarz P, Szajewska H. (2008). The effect of thickened-feed interventions on gastroesophageal reflux in infants: systematic review and meta-analysis of randomized, controlled trials. Pediatrics,122:e1268–e1277.

• Logemann, J. A. (1993). The dysphagia diagnostic procedure as a treatment efficacy trial. Clinics in Communication Disorders, 3(4), 1-10.

• Logemann, J. A., Gensler, G., Robbins, J., Lindblad, A., Brandt, D., Hind, J. A., . . . Miller Gardner, P. J. (2008). A randomized studyof three interventions for aspiration of thin liquids in patients with dementia and Parkinson's disease. Journal of Speech, Language, and Hearing Research, 51(1), 173–183.

• Miles, A., McFarlane, M., Scott, S., & Hunting, A. (2018). Cough response to aspiration in thin and thick fluids during FEES in hospitalized inpatients. International Journal of Language & Communication Disorders. https://doi.org/10.1111/1460-6984.12401

• Miller, M. (2019). Thickener is not the answer in the NICU. The ASHA Leader, June 1. https://doi.org/10.1044/leader.FMP.24062019.8

https://doi.org/10.1044/leader.FMP.24062019.8

REFERENCES

• Neocate. (2019). Baby formula and food thickeners: What are the options? Retrieved From: https://www.neocate.com/living-with-food-allergies-blog/baby-formula-food-thickeners-options/\

• ParapharmaTech. Gelmix Product Specifications. [PDF File]. https://www.healthierthickening.com/wp-content/uploads/2018/11/Gelmix-Product-Spec-Sheet_012019.pdf

• ParapharmaTech. Purathick Product Specifications. [PDF File]. https://www.healthierthickening.com/wp-content/uploads/2018/11/Purathick-Product-Spec-Sheet-012019.pdf

• Robbins, J., Gensler, G., Hind, J., Logemann, J. A., Lindblad, A. S., & Brandt, D. (2008). Comparison of 2 interventions for liquid aspiration on pneumonia incidence: A randomized trial. Annals of Internal Medicine, 148(7), 509–518.

• Seattle Children’s Hospital. Choosing Thickeners for Your Child. [PDF File]. June 2019. https://www.seattlechildrens.org/globalassets/documents/for-patients-and-families/pfe/pe2166.pdf

• Suiter, D., Gosa, M., & Leder, S. (2013). Intra oral dwell time results in increased bolus temperature and decreased bolus viscosity for thickened liquids Topics in Clinical Nutrition, 28(1): 3-7.

• Zur, K., & Welc, J. (2020). Hidden acidity and the use of natural thickeners to manage pediatric dysphagia. Retrieved from: https://www.chop.edu/news/hidden-acidity-and-use-natural-thickeners-manage-pediatric-dysphagia

https://www.neocate.com/living-with-food-allergies-blog/baby-formula-food-thickeners-options/

https://www.healthierthickening.com/wp-content/uploads/2018/11/Gelmix-Product-Spec-Sheet_012019.pdf

https://www.healthierthickening.com/wp-content/uploads/2018/11/Purathick-Product-Spec-Sheet-012019.pdf

https://www.seattlechildrens.org/globalassets/documents/for-patients-and-families/pfe/pe2166.pdf

https://www.chop.edu/news/hidden-acidity-and-use-natural-thickeners-manage-pediatric-dysphagia

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HELPING PATIENTS THROUGH THICK & THIN (LIQUIDS)