Dysphagia for Pediatrics

Introduction

• The International Dysphagia Diet Standardisation Initiative (IDDSI) is a global standard with terminology and definitions to describe texture-modified foods and thickened liquids used for individuals with dysphagia of all ages, in all care settings, and for all cultures.
• The IDDSI framework consists of a continuum of 8 levels (0-7).
• Drinks are measured from Levels 0 – 4, while foods are measured from Levels 3 – 7.
• For the NBCOT Exam, you probably don’t need to be as concerned with the numbered levels themselves as much as the specific food and liquid consistencies and their sequence and progression.
• Levels are identified by text labels, numbers, and colour codes to improve safety and identification.
• Levels for pediatrics and adults are exactly the same, but this lesson will focus on pediatrics.

 0 – Thin Liquids

• Thin beverages flow like water.
• Can flow through a straw or teat/nipple.
• Child without a swallowing problem for liquids.
• Examples: expressed breast milk, water, infant formula, no-pulp juice, soft drinks
• Can be taken through nipple/teat, spout cup, or standard up.

1 – Slightly Thick Liquids

• Thicker than water, but still thin enough to flow through teat/nipple.
• Can flow through straw, teat/nipple.
• For children with swallowing problems with thin liquids.
• Examples: milks, fruit nectars, slightly thickened breast milk or infant formula.
• Can be taken using spout cup or standard cup.

2 – Mildly Thick Liquids

• Sippable
• Pours quickly from. spoon but slower than slightly thick drinks.
• Needs effort using a straw.
• For children with difficulty with level 1 liquids.
• Examples: milkshakes, vegetable juices

3 – Moderately Thick Liquids

• Can be drunk from cup or taken by spoon.
• Needs some effort to drink through a wider straw.
• Cannot be sucked through an infant teat/nipple.
• Have smooth textures with no lumps, fibers, or seeds.
• For children whose tongue control cannot manage previous levels fluids.
• Example: honey

4 – Extremely Thick Liquids

• Best by spoon.
• Cannot drink from cup or sucked through straw or infant teat/nipple.
• Do not require chewing.
• Have smooth texture with no lumps.
• Hold shape on a spoon, but fall off in a single spoonful when tilted.
• Not sticky.
• For children who cannot manage previous level of fluids.
• Important that they are not too sticky as it can get stuck to checks, teeth, roof of mouth, or throat.
• Example: pudding

Level	Liquid Type (Normal to Highest Dysphagia)	Examples
0	Thin	Water, clear broths, consommé
1	Slightly Thick	Milk, thickened formula
2	Mildly Thick	Fruit nectar, thickened soup
3	Moderately Thick	Smoothies
4	Extremely Thick	Pudding, custard, thick shakes

3 – Liquidised Food

• Starts from level 3 (but this is not important to memorize).
• Can be eaten with a spoon or drunk from a cup.
• Cannot be eaten with a fork.
• Has smooth texture but no lumps or particles, e.g., fibers, husk, shell, skin.
• For children with difficulty moving their tongue; allows more time for the tongue to hold and move the liquidized food.
• Example: chicken and vegetable thin puree

4 – Pureed Food

• Usually eaten with a spoon.
• Do not require chewing.
• Have a smooth texture with no lumps.
• Hold shape on spoon, but fall off when tilted.
• Not sticky – can get stuck to checks, teeth, roof of mouth, or throat.
• For children not able to bite or chew food; reduced tongue control.
• Requires tongue be able to move forward and back to bring food to back of the mouth for swallowing.
• Example: pureed fruits & vegetables, mashed potatoes

Pureed Food Characteristics to Avoid	Examples of Foods to Avoid
Mixed thin + thick textures	Soup with pieces of food, cereal with milk
Hard or dry food	Nuts, raw vegetables (e.g., carrot, cauliflower, broccoli), dry cakes, bread, dry cereal
Tough or fibrous foods	Steak, pineapple
Chewy	Lollies/candies/sweets, cheese chunks, marshmallows, chewing gum, sticky mashed potato, dried fruits, sticky foods
Crispy	Crackling, crisp bacon, cornflakes
Crunchy food	Raw carrot, raw apple, popcorn
Sharp or spiky	Corn chips and crisps
Crumbly bits	Dry cake crumble, dry biscuits
Pips, seeds	Apple seeds, pumpkin seeds, white of an orange
Food with skins or outer shell	Peas, grapes, chicken skin, salmon skin, sausage skin
Foods with husks	Corn, shredded wheat, bran
Bone or gristle	Chicken bones, fish bones, other bones, meat with gristle
Round, long shaped food	Sausage, grape
Sticky or gummy food	Nut butter; overcooked oatmeal/porridge, edible gelatin, konjac containing jelly, sticky rice cakes
Stringy food	Beans, rhubarb
Floppy foods	Lettuce, cucumber, uncooked baby spinach leaves
Crust formed during cooking or heating	Crust or skin that forms on food during cooking or after heating, for example, cheese topping, mashed potato
‘Floppy’ food	Lettuce, cucumber, baby spinach leaves
‘Juicy’ food	Where juice separates from the food piece in the mouth, for example, watermelon
Visible lumps	Lumps in pureed food or yogurt

5 – Minced and Moist Foods

• Soft and moist, but with no liquid leaking/dripping from the food.
• Eaten using a spoon or fork.
• Biting is not required.
• Minimal chewing required.
• Lumps (2mm in size) can be mashed with the tongue.
• Not too sticky.
• Can be easily mashed with just a little pressure from a fork.
• Should be able to scoop food onto a fork, with no liquid dripping and no crumbles falling off the fork.
• For child not able to bite off pieces of food safely but some beginner or basic chewing ability to form a bolus and bring to the back of the mouth for swallowing.
• Examples: finely minced meat, finely mashed fish, finely blended fruit with excess liquid drained, moistened rice.
• No dry bread due to choking risk.

Minced & Moist Food Characteristic to Avoid	Examples of Foods to Avoid
Mixed thin + thick textures	Soup with pieces of food, cereal with milk
Hard or dry food	Nuts, raw vegetables (e.g., carrot, cauliflower, broccoli), dry cakes, bread, dry cereal
Tough or fibrous foods	Steak, pineapple
Chewy	Lollies/candies/sweets, cheese chunks, marshmallows, chewing gum, sticky mashed potato, dried fruits, sticky foods
Crispy	Crackling, crisp bacon, cornflakes
Crunchy food	Raw carrot, raw apple, popcorn
Sharp or spiky	Corn chips and crisps
Crumbly bits	Dry cake crumble, dry biscuits
Pips, seeds	Apple seeds, pumpkin seeds, white of orange
Food with skins or outer shell	Peas, grapes, chicken skin, salmon skin, sausage skin
Foods with husks	Corn, shredded wheat, bran
Bone or gristle	Chicken bones, fish bones, other bones, meat with gristle
Round, long shaped food	Sausage, grape
Sticky or gummy food	Nut butter, overcooked oatmeal/porridge, edible gelatin, konjac containing jelly, sticky rice cakes
Stringy food	Beans, rhubarb
Floppy foods	Lettuce, cucumber, uncooked baby spinach leaves
Crust formed during cooking or heating	Crust or skin that forms on food during cooking or after heating, for example cheese topping, mashed potato
‘Floppy’ food	Lettuce, cucumber, baby spinach leaves
‘Juicy’ food	Where juice separates from the food piece in the mouth, for example watermelon
Large or hard lumps of food	Casserole pieces larger than 2mm x 2mm x 8mm; fruit, vegetable, meat or other food pieces larger than 2mm x 2mm x 8mm

6 – Soft & Bite Sized

• Soft, tender and moist, but with no thin liquid leaking/dripping from the food.
• Ability to ‘bite off’ a piece of food is not required.
• Ability to chew ‘bite-sized’ pieces so that they are safe to swallow is required.
• ‘Bite-sized’ pieces no bigger than 8mm x 8mm in size.
• Food can be mashed/broken down with pressure from fork
• A knife is not required to cut this food.
• For child not able to bite off pieces of food safely but able to chew bite-sized pieces down into little pieces that are safe to swallow.
• Ability to moderately chew and for tongue to collect food into bolus to bring to back of mouth for swallowing.
• Food pieces should be chewed well to reduce choking risk.
• Examples: cooked tender meat chopped, cooked fish soft enough to break and serve in pieces, soft and chopped fruit without fibrous parts or high water content, steamed vegetables to small size, moistened rice but not sticky or gluey and not able to separate into individual grains when served with sauce to hold together.
• No dry bread due to choking risk.

Soft & Bite-Sized Food Characteristics to Avoid	Examples of Foods to Avoid
Mixed thin + thick textures	Soup with pieces of food, cereal with milk
Hard or dry food	Nuts, raw vegetables (e.g. carrot, cauliflower, broccoli); dry cakes, bread, dry cereal
Tough or fibrous foods	Steak; pineapple
Chewy	Lollies/candies/sweets, cheese chunks, marshmallows, chewing gum, sticky mashed potato, dried fruits, sticky foods
Crispy	Crackling, crisp bacon, cornflakes
Crunchy food	Raw carrot, raw apple, popcorn
Sharp or spiky	Corn chips and crisps
Crumbly bits	Dry cake crumble, dry biscuits (add sauce to make these suitable)
Pips, seeds	Apple seeds, pumpkin seeds, white of orange
Food with skins or outer shell	Peas, grapes, chicken skin, salmon skin, sausage skin
Foods with husks	Corn, shredded wheat, bran
Bone or gristle	Chicken bones, fish bones, other bones, meat with gristle
Round, long shaped food	Sausage, grape
Sticky or gummy food	Nut butter, overcooked oatmeal/porridge, edible gelatin, konjac containing jelly, sticky rice cakes
Stringy food	Beans, rhubarb
Floppy foods	Lettuce, cucumber, uncooked baby spinach leaves
Crust formed during cooking or heating	Crust or skin that forms on food during cooking or after heating, for example, cheese topping; mashed potato
‘Floppy’ food	Lettuce, cucumber, baby spinach leaves
‘Juicy’ food	Where juice separates from the food piece in the mouth, for example, watermelon
Large or hard lumps of food	Casserole pieces larger than 8mm x 8mm, fruit, vegetable, meat, pasta, or other food pieces larger than 8mm x 8mm

7 – Regular

• Normal, everyday foods of soft/tender textures that are appropriate to your child’s development.
• Child should have teeth and chewing skills.
• Any method may be used to eat these foods (e.g. fingers, fork, spoon, chopsticks etc.).
• Child should be able to bite off pieces and choose bite sizes that are safe to chew and swallow without tiring easily.
• Tongue should be able to move food for chewing and apply pressure until the food is soft and moist enough to be easily swallowed.
• May include mixed liquids and foods together of different thicknesses and textures.
• Contraindicated behaviors: not chewing very much, putting too much food into the mouth, eating too fast or swallowing large mouthfuls of food.

Under 3 years

• Children under 3 are at a high risk for choking.
• Characteristics to avoid: hard or dry food, round or long-shaped food, stringy food, foods with husks, tough or fibrous foods, floppy foods, and crunchy food.
• Examples: nuts, raw vegetables, celery, beans, rhubarb, corn, bread with grains, shredded wheat, steak, pineapple, lettuce, cucumber, uncooked baby spinach, popcorn, toast, dry cookies, chips.

Sources

IDDSI. (2016). What is IDDSI? Retrieved from https://iddsi.org/IDDSI/media/images/Posters/IDDSI_Poster_What_is_IDDSI_Jan2020.pdf

IDDSI. (2019). Consumer Handouts for babies and children and their careers. Retrieved from https://iddsi.org/IDDSI/media/images/ConsumerHandoutsPaed/Consumer_Handouts_for_Paediatrics_All_Levels.pdf

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