cord gentry, cf-slp speech-language pathologist wake forest baptist health perry flynn, ccc-slp...

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

clgentry@wakehealth.edu

Perry Flynn

pfflynn@uncg.edu

Doris Sargent

Doris.Sargent@dpi.nc.gov