Consistency Modifications for Special Diets at School 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

Clear Mandate Schools must make substitutions in the reimbursable meal for students who are disabled and whose disability restricts their diet. The basic intent of statute and regulations is to ensure that children with disabilities have access to program benefits In the case of the Child Nutrition Programs, this means that substitutions to the reimbursable meal must be made for children who are unable to eat school meals because of their disabilities. (The word “substitution” is used because for the most part, accommodations under the school meal programs will involve replacing one food with another, although this will not always be the case.) Meeting the needs of these children with disabilities presents SFS staff with new challenges and situations. It is important that your SFS Managers and parents be involved at the outset – be proactive instead of reactive! Three federal legislative acts mandate that school food service programs will serve children with special dietary needs because of their disabilities: Section 504 of the Rehabilitation Act of 1973 Individuals with Disabilities Education Act (IDEA) Americans with Disabilities Act (ADA). In We also need to remind you that Children with disabilities are NOT subject to the new meal pattern. In the case of Children with Special Needs you follow the physicians statement and the IEP .

Physician’s Statement 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 School food service staff must follow the instructions that have been prescribed by the licensed physician. Under no circumstances should school food service staff diagnose health conditions, perform a nutritional assessment, prescribe nutritional requirements, or interpret, revise or change a diet order. Make sure your school has a procedure in place for receiving and distributing the medical statement so CN Director and managers are informed when a child needs a modified diet.

504 vs. IEP 504 Eligibility: Disability Negative impact on academic achievement or functional performance IEP Eligibility: Need of specially designed instruction

HACCP Plan 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 Because you are serving a population that may a compromised immune system it is important for you to make sure you are following your HACCP plan. Use your HACCP plan to monitor the food from delivery to service. Follow proper sanitation procedures for sanitizing equipment and food contact surfaces with the correct concentration for the sanitizer. and avoid cross contamination of products especially when you are dealing with allergies. Check temperatures of modified food to keep it in a safe range of 135 or above for hot foods and 41 or below for cold foods. Follow the regulations for personal hygiene by washing hands frequently and changing gloves and most important of all do not report to work if you are sick

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 Accommodating Students with Special Dietary Needs Suggested Procedures for Child Nutrition Administrators can be found on the CN Website

Responsiblities of CN Manager 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

Goals of this initiative: 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.

Dysphagia (dis-fay-juh) 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

Signs and Symptoms of Dysphagia 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 cont’d… 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

Definitive Diagnosis of Dysphagia Modified Barium Swallow Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

Modified Barium Swallow 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

Fiberoptic Endoscopic Evaluation of Swallowing (FEES) a lighted flexible scope is inserted through the nose, and the swallow can be observed on a screen.

The Modified Diet Process

Who is involved in 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.

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

School Nurse 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

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

Occupational Therapist †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

Speech-Language Pathologist 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

Child Nutrition Program Staff School Nurse Therapists Student Family Instructional Staff Child Nutrition Program Staff School Nurse Therapists School Administrators Community Providers Peers

National Dysphagia Diet 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).

My Master’s Project Experience 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

And the goals of modified food service… 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 Child nutrition- attend to the language on this slide (Doris?)

Pureed Diet (Level 1) 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 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

Mechanically Altered Diet (Level 2) 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.

Mechanical Soft foods: 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 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 Add meat to food processor Fill water to top of food Pulse (mechanical soft); Run on high (puree) Check consistency Finish cooking

Problems with having a recipe: 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!!

Not the proper consistency? 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.

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

“Thick-It” Mixing directions for Puree 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” 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.

Regular and Modified Foods Ready to Serve

Puree vs. Mechanical Soft Foods Which one is which? 2 1

The Serving Process Use small individual cups to send to classrooms. Feeding is done primarily by the OT’s.

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

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

Least Restrictive Environment: Typical meal experience Comfortable setting With non-disabled peers Not secluded

Cord’s Top 10 POP QUIZ!!! 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

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

References 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

THANK YOU FOR YOUR TIME AND PARTICIPATION  Cord Gentry clgentry@wakehealth.edu Perry Flynn pfflynn@uncg.edu Doris Sargent Doris.Sargent@dpi.nc.gov