Rehabilitation. Feeding and Nutritional Advice for People with Swallowing Difficulties. s of Health

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1 Rehabilitation Feeding and Nutritional Advice for People with Swallowing Difficulties The s of Health CGH swallowing indd 2 11/4/09 5:44:56 PM

2 Feeding and Nutritional Advice for People with Swallowing Difficulties Dear Carer, Your friend or family member may have some swallowing difficulties or special nutritional needs. The guidelines detailed in this booklet have been designed to provide you with nutrition advice and safe swallowing strategies to help your friend or family member. Swallowing Difficulties Persons with swallowing difficulties (also known as dysphagia) are not able to swallow safely. When they swallow, food and liquids are at risk of entering their airway and lungs instead of going into the food pipe (esophagus) and stomach. As a result, they can suffer from lung infections, malnutrition, dehydration and other medical complications. Nose Tongue Food pipe which leads to stomach Airway which leads to lungs To prevent this, there are several feeding strategies that may reduce the risk of food and liquids entering their lungs. It is essential for you to be familiar with these strategies, as outlined in this booklet. Your family member or friend s swallowing difficulty is characterised by: Weak tongue Delayed swallowing Poor attention Breathing difficulties Weak throat muscles Others : 1 CGH swallowing indd 3 11/4/09 5:45:05 PM

3 As a result of these swallowing difficulties, they may not be able to take normal liquids (i.e. water/tea) or solids (i.e. rice/meat). Your family member of friend requires either: Tube Feeding (Please refer to page 2 ) OR Oral feeding: Modified foods and liquids (Please refer to page 3) Tube feeding Your friend or family member may require tube feeding because he or she is unable to swallow safely or unable to take sufficient food and liquids orally to meet his or her nutritional needs. He or she may be on: Nasogastric tube feeding (NGT) Percutaneous endoscopic gastrostomy feeding (PEG) End of nasogastric tube Nasal cavity Nasogastric tube Gullet (oesophagus) Gullet (oesophagus) PEG tube Stomach Stomach Bung at end of tube 2 CGH swallowing indd 4 11/4/09 5:45:10 PM

4 Oral hygiene While on tube feeding, it is essential that the person s mouth remains clean. Any bacteria in the mouth may mix with saliva and subsequently fall backwards into the throat and lungs. This may increase the risk of lung infection. It is important to note that most people with swallowing difficulties will not be able to brush their teeth and gargle as they may choke when large amounts of water are placed in their mouth. It is best to wipe their mouths with a damp cloth, sponge, oral swab stick or Toothettes, which may be dipped into mouth wash liquids. These may be obtained at the Changi General Hospital pharmacy. Toothettes Pleasure feeds Even though the main source of nutrition enters the body via these tubes, your friend or family member may still be able to take small amounts of food and fluids by mouth. This may improve their quality of life, or/and enable them to practise swallowing. The patient s speech therapist will advise you if pleasure feeding is suitable for the person and the quantity and type of pleasure feeds that the person may require. Please refer below for more guidelines on preparing the correct consistencies. Naso-gastric Tube Oral feeding: Modified Foods and Fluids Even though your family member or friend has a swallowing difficulty, he or she may still be able to consume food and fluids by mouth. However, these foods and fluids must be modified in order for him or her to be able to swallow safely. The following modified foods and liquids are the most suitable for your family member or friend. 3 CGH swallowing indd 5 11/4/09 5:45:16 PM

5 What kind of FOOD to feed? Normal solid food (such as rice, meat and vegetables) can be difficult to chew and control when there is loss of teeth, loose dentures, or weak tongue and lip muscles. Your friend or family member may need softer foods. Blended food (i.e. pureed and mashed as these do not require chewing) Finely minced food (i.e. soft cooked food diced into less that 0.5 cm/0.2 inch cubes). Minimal chewing is required. Coarsely minced food (i.e. soft cooked food chopped into 1 2 cm/ inch cubes.) Soft food (i.e. food without hard and crispy skins) Diet of choice (i.e. all varieties of food) For feeding, use a Tablespoon Teaspoon Please refer to the following pages for examples of different types of food and sample meal plans. Comparison of Coarsely Minced and Finely Minced diets 4 CGH swallowing indd 6 11/4/09 5:45:26 PM

6 Diet Consistencies Texture Description Rice and alternatives Vegetables Blended Blended and smooth. Without lumps. No chewing needed. Blended porridge. Blended oats. Potato, sweet potato or yams, very well cooked and well mashed. Blended or pureed vegetables (e.g. carrots) Remove seeds and skin e.g. in tomatoes. Avoid fibrous vegetables e.g. celery and long beans Finely minced Soft solid food diced into very small pieces (less than 0.5 cm/0.2 inches). Minimal chewing required. Normal porridge and oats. Potato, sweet potato or yam, very well cooked. Soup noodles cut up into very small pieces. Very small pieces of bread. Vegetables cooked (boiled or steamed) till soft and diced into very small pieces. Remove skin and seeds. Coarsely minced Solid food cut up into small pieces (1 2 cm/ inches). Requires some chewing. Soft rice. Dry and soup noodles cut. Small pieces of bread. Softer vegetables chopped into 1-2 cm/ inch cubes. Cook hard vegetables for longer period of time carrots, celery, broccoli. Soft Diet of Choice Any food that is soft. Does not need to be cut up. Soft rice. Dry and soup noodles. Bread. Soft vegetables. Cook hard vegetables for longer period of time carrots, celery, broccoli. Diet of choice Solid food. All types. All types. 5 CGH swallowing indd 7 11/4/09 5:45:27 PM

7 Meat and alternatives Fruit and dessert Avoid s Blended meat, fish and chicken. Remove all bones and skin. Blended bean curd, steam egg, dhal or chickpeas. Blended fruits (e.g. papaya, banana) Remove skin and seeds. Smooth yoghurt without bits of fruit. Smooth puddings e.g. custards and sesame paste. No bread or biscuits. No nuts or seeds (e.g. peanuts, sunflower seeds). d es. Meat cooked till soft and tender and diced into very small pieces. Add thick gravy if dry. Soft fruits cut up. Papaya, banana, kiwi, grapes, peach, mango, durian. Remove seeds and skin. No biscuits. No nuts or seeds. Avoid apples. ed Softer meat cut into 1-2 cm/ inch cubes. Add thick gravy if dry. Avoid meats with hard skins (deep fried or breaded). Avoid tough meat. Soft meat. Avoid meats with hard skins (deep fried or breaded). Avoid tough meat. All types. Normal fruits chopped into 1-2 cm/ inch cubes. Soft desserts. Avoid glutinous cakes (e.g. ang ku kueh) All types. No nuts or seeds. Avoid hard or crispy foods e.g. crackers, fried foods, curry puff skin. Refer to pg for sample meals plan. 6 CGH swallowing indd 8 11/4/09 5:45:27 PM

8 Food Preparation A blender is recommended for the blending of food. A food processor works well, but you need to ensure that the food is blended to a very fine puree. A hand-held electric multi mixer is another useful gadget that reduces washing up by allowing you to blend the food in the serving bowl. Ensure that the food is cooked to be as soft or moist as possible. (You should use a slow cooker or crock pot). Chop food into small pieces before putting into blender / food processor. Add some liquid and blend to reach the desired consistency. Blend food while it is still hot or warm. Avoid food with nuts, seeds, stringy foods (e.g. celery, orange) or foods with skins as they do not blend well. If the food is still watery after blending, you should add thickener: pharmaceutical thickener (e.g. Valens Thixer, Thick & Easy and ThickenUp ) or natural food thickeners (e.g. baby cereal or potato starch). Food Handling and Hygiene Always wash your hands before handling food or feeding/processing equipment Separate cooked and raw food before any processing. Once cooked, cover the food with a lid or plate and transfer it to the fridge as soon as possible (if it is not mealtime yet). Food should not be left outside longer than 1.5 hours at room temperature 7 CGH swallowing indd 9 11/4/09 5:45:27 PM

9 Difficult foods There are certain foods and fluids that are particularly difficult for people with swallowing difficulties. These include: 1. Mixed consistencies Mixed consistencies are types of foods where solids and liquids are mixed together. For example, watery porridge is an example of solids (soft rice) floating in liquid (water). These are particularly difficult as the person has to concentrate on chewing the solids and holding the liquids in the mouth at the same time. Other examples include oats, rice in Food with mixed consistencies soup, cornflakes, bubur cha cha, cheng teng, watermelon, orange, and noodle soup. 2. Glutinous textures These textures are particularly difficult to chew and tend to stick to the teeth or sides of the mouth. What kind of LIQUIDS to feed? Liquids like water can be difficult to swallow because they tend to move at a fast pace, and can easily flow into the airway before the person is able to start swallowing. Thickening these liquids may serve to slow the flow and allow more time for swallowing. There are two main ways to thicken fluids. You may: 1. Add thickener to liquids Thickener is a kind of powder (like starch) that is used to thicken liquids. It thickens the liquids to make it flow more slowly, giving the person more time to swallow. You have to add the correct amount of thickener into all kinds of liquids (coffee, tea, water, soup, cheng teng) AT ALL TIMES. When liquid is consumed without thickener or too little thickener, it can go into the lungs. Some liquids are naturally thick (e.g. milkshake) and may not require as much thickener to be added. Saliva can dilute thickened liquids. You must always check the consistency before feeding. You should only stop using thickener when advised by the Speech Therapist. 8 CGH swallowing indd 10 11/4/09 5:45:30 PM

10 Preparing the correct thickened consistency is difficult. A fork test has been designed to help you ensure that you are making the correct consistency. Too little or too much thickener can result in liquids entering the lungs when swallowing. Thin fluids (non-thickened) Fork test: They run quickly through the prongs of the fork with little or no coating. Nectar thickened fluids Fork test: They coat the fork and quickly sink through the prongs. Effort is required to drink this level with a standard straw. Honey thickened fluids Fork test: They coat the fork and slowly sink through the prongs. Using a spoon may be the best way to take this fluid level. 9 CGH swallowing indd 11 11/4/09 5:45:38 PM

11 Pudding thickened fluids Fork test: They remain on the fork and hold together well. A spoon is necessary to consume this level. For feeding, use a Tablespoon Teaspoon Straw Cup 2. Make naturally thickened liquids While thickener is beneficial in many ways, some people may develop a strong aversion to thickener. There are some ways to prepare naturally thickened liquids without using thickener. It is still essential to use the fork test to ensure that you have prepared the correct consistency. a) Nectar Fluids - thick barley water, mildly thick smooth fruit juices (papaya juice, banana juice etc), mildly thick milkshake b) Honey Fluids - thick milkshake, thick smooth fruit juices (papaya juice, banana juice etc), thick western soups c) Pudding Fluids - agar agar, jelly, pudding 10 CGH swallowing indd 12 11/4/09 5:45:41 PM

12 Prepare the person before feeding: Ensure he or she is fully alert. If the person is asleep, wait until he or she wakes up. Seat him or her in an upright position, preferably in a chair. Stabilise head/neck position if necessary. Minimise distracting objects and/or sounds, e.g. switch off the television. During feeding: Who should feed? Allow the person to feed himself or herself. Allow the person to feed himself or herself, but be there to supervise him or her to make sure correct feeding methods are used. Feed the person. To check if the patient has swallowed the food or liquids: Put your fingers gently on the front of the person s neck. Feel for the up-and-down movement of the Adam s apple to know that the person has swallowed the food or liquid. 11 CGH swallowing indd 13 11/4/09 5:45:46 PM

13 Chin Tuck Hold the cup Take some water and hold in the mouth Tuck the chin down when swallowing Use these techniques when swallowing: Ask the person to tuck his or her chin down when swallowing Ask the person to swallow times per spoonful Ask the person to eat and drink slowly. Ask the person to cough after every few spoonfuls Ask the person to alternate between solids and liquids. If the person chokes or coughs: Stop the person from eating and drinking Ask the person to cough with all his strength Ask the patient to swallow his or her saliva after coughing Check if the correct consistency of food and fluids was served or if the feeding technique was correct. Make appropriate changes if necessary. Resume eating and drinking with the correct consistencies and techniques when the bout of coughing has come to a complete stop. If coughing and choking still persists, contact your Speech Therapist immediately. 12 CGH swallowing indd 14 11/4/09 5:45:56 PM

14 After feeding: Allow the person to remain seated for at least one hour Clean the person s mouth thoroughly Signs of foods and liquids entering the airway: Choking and coughing Throat clearing Difficulty breathing Wet voice Signs of chest infection: Fever Increased coughing Increased phlegm Difficulty breathing Swallowing difficulties may or may not resolve over time. For some, recovery will take place over time. There may be suitable swallowing exercises which can help your friend or family member to regain normal swallowing. Please ask your Speech Therapist for advice on swallowing therapy. As his/ her swallowing progresses, you may be able to slowly wean off him/ her feeding tube, or upgrade to a more normal diet, or a thinner liquid. Your speech therapist will advise you when it is the correct time to advance to the next step. As you can see, there are numerous feeding rules and regulations for people with swallowing difficulties. These rules, along with modified and often less appetizing diets and fluids often result in a loss in appetite and subsequently, loss in weight. Consequently, many people with swallowing difficulties suffer from malnutrition and dehydration. It is vital to monitor the amount of foods and fluids they consume. If there is inadequate intake, your dietitian may suggest certain supplements to improve the nutrition and hydration of your friend or family member. 13 CGH swallowing indd 15 11/4/09 5:45:56 PM

15 Additional Nutritional Supplements Your friend or family member will need the following supplements ml/can(s)/scoop(s) per day in feedings at the following time via Orally (Please thicken the supplement to Nectar Honey Pudding thick) Nasogastric tube Percutaneous endoscopic gastrostomy (PEG) tube Feeding jejunostomy tube (or J-tube) 14 CGH swallowing indd 16 11/4/09 5:45:58 PM

16 o SAMPLE MEAL PLAN BLENDED DIET Breakfast 1 bowl blended oats with milk powder / nutritional supplement OR 1 bowl blended chicken porridge Morning tea 1 bowl almond / sesame seed paste OR 1 bowl oats with milk powder OR 1 cup high calorie high protein custard / pudding OR 1 serve nutritional supplement Lunch 1 bowl blended porridge 3 heaped tablespoon of blended fish ½ cup blended vegetables (carrot and cauliflower, ¾ cup before blending) 1 blended banana Afternoon tea 1 bowl oats with milk powder OR 1 bowl almond / sesame seed paste OR 1 serve nutritional supplement OR 1 cup high calorie high protein custard / pudding Dinner 1 mashed potato (medium size) with margarine / milk 3 heaped tablespoon of blended chicken ½ cup blended vegetables (spinach, ¾ cup before blending) 1 wedge blended papaya Bedtime snack 1 serve nutritional supplement OR 1 cup plain yoghurt / fruit yoghurt without fruit bits OR 1 bowl oats with milk powder / nutritional supplement OR 1 cup high calorie high protein custard / pudding 15 CGH swallowing indd 17 11/4/09 5:45:58 PM

17 o SAMPLE MEAL PLAN FINELY MINCED DIET Breakfast White bread x 2 (cut into very small pieces) With margarine / jam / smooth peanut butter Tea / Coffee / Milk (thickened to required consistency) Afternoon tea 1 bowl oats with milk powder OR 1 bowl almond / sesame seed paste OR 1 serve nutritional supplement OR 1 cup high calorie high protein custard / pudding Morning tea 1 bowl almond / sesame seed paste OR 1 bowl oats with milk powder OR 1 cup high calorie high protein custard / pudding OR 1 serve nutritional supplement Lunch 1 bowl porridge 3 heaped tablespoon of minced pork ½ cup diced vegetables 1 diced kiwi fruit Dinner 1 bowl soup noodle (cut into very small pieces) 3 heaped tablespoon of minced chicken ½ cup diced vegetables 1 wedge diced papaya Bedtime snack 1 serve nutritional supplement OR 1 bowl almond / sesame seed paste OR 1 bowl oats with milk powder OR 1 cup high calorie high protein custard / pudding 16 CGH swallowing indd 18 11/4/09 5:45:59 PM

18 o SAMPLE MEAL PLAN COARSELY MINCED DIET Breakfast 2 slices bread (cut into small pieces) With margarine / jam / smooth peanut butter Tea / Coffee / Milk (thickened to required consistency) Afternoon tea 1 piece soft cake OR 1 bread with cheese (cut into small pieces) OR 3 pieces cream crackers with margarine / jam OR 1 serve nutritional supplement Morning tea 3 pieces cream crackers with margarine / jam OR 1 soft cake OR 1 bread with cheese (cut into small pieces) OR 1 serve nutritional supplement Lunch 1 bowl soft rice 1 palm size chopped chicken ¾ cup cut-up vegetables 1 cut-up apple Dinner 1 bowl soup noodle (cut up) 1 palm size fish ¾ cup cut-up vegetables 1 cut-up pear Bedtime snack 1 serve nutritional supplement OR 1 bowl almond / sesame seed paste OR 1 bowl oats with milk powder OR 1 cup high calorie high protein custard / pudding 17 CGH swallowing indd 19 11/4/09 5:45:59 PM

19 Monitoring at home: To help ensure that your friend or family member is feeding well, it may be useful to check his/her weight regularly (once a month). Date Weight (kg) Date Weight (kg) It is important to ensure that your family member or friend gets the appropriate nutrition in a safe way. Please contact your speech therapist or dietitian if you have any further enquiries. Speech Therapist: Tel: Dietitian: Tel: Date of next outpatient appointment: Dietitian Clinic on Speech Therapist Clinic on Swallowing and Nutrition Support Clinic on Location: 18 CGH swallowing indd 20 11/4/09 5:45:59 PM

20 For appointments and enquiries, please call the CGH Appointment Centre at Tel: (65) CGH Appointment Centre operating hours: 8.30 am to 8.00 pm (Monday to Friday) 8.30 am to pm (Saturday & Sunday) Closed on Public Holidays For more information, please visit 2 Simei Street 3 Singapore Tel: Fax: Reg No R All information is valid at the time of printing (November 2009) and subject to revision without prior notice. CGH swallowing indd 1 11/4/09 5:44:54 PM

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