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Cord Gentry, CF-SLP Speech-Language Pathologist Wake Forest Baptist Health Perry Flynn, CCC-SLP Consultant to the NCDPI in Speech-Language Pathology Website:

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Presentation on theme: "Cord Gentry, CF-SLP Speech-Language Pathologist Wake Forest Baptist Health Perry Flynn, CCC-SLP Consultant to the NCDPI in Speech-Language Pathology Website:"— Presentation transcript:

1 Cord Gentry, CF-SLP Speech-Language Pathologist Wake Forest Baptist Health Perry Flynn, CCC-SLP Consultant to the NCDPI in Speech-Language Pathology Website: Doris Sargent Ed.D RD LDN SMI Nutrition Consultant

2 Schools must make substitutions in the reimbursable meal for students who are disabled and whose disability restricts their diet.

3 Must identify: student's disability explanation of why/how the disability restricts the students 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

4 504 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

5 Hazard Analysis Critical Control Points An internal check system specific to each kitchen and classroom A method of identifying critical points (CCPs) for preventing food-borne illness

6 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

7 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

8 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 students family and peers. To facilitate a multidisciplinary approach that creates adequate accommodations while meeting the childs nutritional and emotional needs.

9 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

10 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

11 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

12 Modified Barium Swallow Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

13 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…

14 a lighted flexible scope is inserted through the nose, and the swallow can be observed on a screen.

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17 Child Nutrition School Nurse Instructional Staff Occupational Therapist Speech-Language Pathologist Peers Childs Family *All of these professionals play an important role in the formation of a proper IEP which should include specifications for the childs modified diet.

18 † Access needed equipment and training † Maintain consistency in preparation † Adhere to and teach safe food handling procedures † Match modified meals to regular menu

19 Monitors students 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

20 Implements mealtime plan …Documents and communicates student status …Coordinates personnel needed for mealtime …Ensures safe mealtime environment …Request training and assistance …Creates mealtime routines

21 †Coordinates big picture approach to mealtime †Assesses and designs mealtime routines †Selects adaptive equipment †Modifies environment †Addresses mechanics of platetomouth feeding †Addresses sensory deficits limiting mealtime participation

22 Provides screening and modification …Suggests helpful medical studies (e.g., MBSS) …Works with community providers and family to monitor student's mealtime plan …Trains schoolbased 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 schoolbased hub of team activities

23 Student Family Instructional Staff Child Nutrition Program Staff School NurseTherapists School Administrators Community Providers Peers

24 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).

25 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

26 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

27 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

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34 *No modification needed

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38 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.

39 PureeRegular

40 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.

41 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.

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50 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

51 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!!

52 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.

53 Add one pack (6.5g) to 4 fl. oz of liquid and stir for 15 seconds. Allow 1-4 minutes to reach optimal thickness

54 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.

55 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

56 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.

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61 1. Wash 2. Rinse 3. Sanitize 4. Air dry

62 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 ( degrees) Wash and sanitize equipment and utensils when changing products to avoid cross contamination Sanitize blender and all equipment after each use

63 Typical meal experience Comfortable setting With non-disabled peers Not secluded

64 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

65 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 its not the appropriate consistency you would like? Thickening agents such as: Thick-It, Thick and Easy, or potato flakes

66 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? ????

67 The Complete Experience

68 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 Instant Food Thickening Agents for Liquids & Purees, Thick-It®. (2010).Food Thickener for Swallowing Problems & Dysphagia – Thick-It®. Retrieved February 16, 2012, from _id=162http://www.hormelhealthlabs.com/2colTemplate_product.aspx?page=CO_TE_Beverages&cond_id=117&cat _id=162 NCDPI. Accommodating Students with Special Dietary Needs Wake Forest Baptist Health Medical Center Boulevard Winston-Salem, NC Gateway Education Center 3205 E. Wendover Aveenue Greensboro, NC National Dysphagia Diet: What to Swallow?. (2003). American Speech-Language-Hearing Association | ASHA. Retrieved March 18, 2012, from Feeding and Swallowing Disorders (Dysphagia) in Children. (n.d.).American Speech-Language-Hearing Association | ASHA. Retrieved May 30, 2012, from

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