Transcript Modified-diets-presentation-with-changes1x

Cord Gentry, CF-SLP
Speech-Language Pathologist
Wake Forest Baptist Health
Perry Flynn, CCC-SLP
Consultant to the NCDPI in Speech-Language Pathology
Website: www.uncg.edu/csd/faculty/perryflynn.html
Doris Sargent Ed.D RD LDN
SMI Nutrition Consultant
• Schools must make substitutions in
the reimbursable meal for students
who are disabled and whose
disability restricts their diet.
Must 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:
IEP Eligibility:
•Disability
•Negative impact on
academic achievement or
functional performance
•Disability
•Negative impact on
academic achievement or
functional performance
•Need of specially
designed instruction
Hazard
Analysis
Critical
Control
Points
• An internal check system specific to each kitchen
and classroom
• A method of identifying critical points (CCP’s) for
preventing food-borne illness
• 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
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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
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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.
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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
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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
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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
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Modified Barium Swallow
Fiberoptic Endoscopic Evaluation of
Swallowing (FEES)
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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
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a lighted flexible scope is inserted through the nose, and the
swallow can be observed on a screen.
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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.
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†Access needed equipment and training
†Maintain consistency in preparation
†Adhere to and teach safe food handling
procedures
†Match modified meals to regular menu
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Monitors student’s health, weight, and overall
nutrition status
Coordinates acquisition of physician statement
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for food adaptations
Troubleshoots issues related to tracheostomies,
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feeding tubes, ventilators, etc.
Writes the IHP
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Serves as liaison between family, community
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health providers, and school
Provides training for school staff, student, and
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peers
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Implements mealtime plan
Documents and communicates student status
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Coordinates personnel needed for mealtime
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Ensures safe mealtime environment
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Request training and assistance
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Creates mealtime routines
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†oordinates “big picture” approach to
C
mealtime
Assesses and designs mealtime routines
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Selects adaptive equipment
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Modifies environment
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Addresses mechanics of plate‐to‐mouth
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feeding
Addresses sensory deficits limiting mealtime
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participation
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Provides screening and modification
Suggests helpful medical studies (e.g., MBSS)
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Works with community providers and family to
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monitor student's mealtime plan
Trains school‐based personnel and
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parent/guardian
May serve as liaison between school and
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community providers
Encourages communication and helps design
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as “normal” a mealtime environment as
possible
May act as school‐based hub of team activities
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School Nurse
Therapists
Child Nutrition
Program Staff
School
Administrators
Instructional
Staff
Family
Community
Providers
Student
Peers
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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).
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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
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Prepare and serve consistent and reliably texturemodified 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
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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
*No modification needed
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.
Puree
Regular
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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.
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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.
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
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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
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Picture Recipes!!
No worries…
You can add a thickening agent such as:
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Thick & Easy
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Thick It
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Potato Flakes
These agents will help in achieving the proper
consistency without starting over.
Add one pack (6.5g) to 4 fl. oz of
liquid and stir for 15 seconds.
Allow 1-4 minutes to reach optimal
thickness
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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.
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Pureed Fruits
◦ Pureed Fruits: Mix 1 tablespoon of “Thick-It”
Original or ½ tablespoon of Concentrated “ThickIt” 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
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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.
1
2
2. Rinse
1. Wash
3. Sanitize
4. Air dry
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Safety and sanitation are extremely
important.
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Prepare as close to service as possible and avoid holding
the foods, since they lose quality quickly
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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.)
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Avoid the temperature danger zone (40-135 degrees)
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Wash and sanitize equipment and utensils when changing
products to avoid cross contamination
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Sanitize blender and all equipment after each use
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Typical meal experience
Comfortable setting
With non-disabled peers
Not secluded
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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.
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2. What is dysphagia?
◦ A big word for “swallowing disorder”
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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
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4. What is a puree consistency?
◦ Mashed potato-like consistency
◦ No chunks of food
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5. What is a mechanical soft consistency?
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6. Who is involved in the modified diet process in the
schools?
◦ Moist and cohesive with no water separation, soft foods that are
easily formed into a bolus
◦ EVERYONE!! CN, Nurse, OT, SLP, Instructional Staff, Peers and
family members
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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 texturemodified foods and thickened liquids
• Produce and serve texture-modified beverages and foods with adequate
nutritional content
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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
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9. What are the 4 steps in proper sanitation?
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Wash
Rinse
Sanitize
Air dry
10. How will you help ensure the proper
modified diet process in your school?
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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 Boulevard
Winston-Salem, NC 27157
Gateway Education Center
3205 E. Wendover Aveenue
Greensboro, 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