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Infant dysphagia is commonly managed using thickened formulas. Substantial research investigates thickening of a variety of beverages for adults and children, yet few studies address the unique considerations of thickened formula for infants. Understanding the consistency and behaviour of thickened formula will guide clinicians and parents to make informed decisions to minimise risk of aspiration. To investigate the effect of time and storage temperature on the flow properties of thickened formula, four formulas and two thickeners currently utilised at a major metropolitan children’s hospital in Australia were tested in combinations, at refrigerated and room temperatures. Their flow properties were measured at three time-points (baseline, 1 h, 24 h) using the International Dysphagia Diet Standardisation Initiative (IDDSI) Flow Test, the current clinical standard for classifying drinks based on flow properties. A combination of paired t tests, Wilcoxon Signed-Rank tests, repeated measures analysis of variance (ANOVA) and Cohen’s d was used to statistically compare flow properties and determine the significance of the observed data. At baseline, 98% (n = 48) of the thickened formula bottles were measured as thinner than the “mildly thick” IDDSI category to which they were prepared. Conversely, at 24 h, 17% were measured thicker than “mildly thick” whilst 10% measured too thin for the category “mildly thick”. Refrigerated samples increased in thickness more significantly over time compared to those stored at room temperature. Two of the formulas, when thickened, resulted in a foamy mixture non-compatible with IDDSI Flow Test measurement. As a result, these two formulas were not subjected to further testing. All the tested commercial products behaved differently to each other and were unstable over varying times and temperatures. This finding indicates the need for improved guidelines regarding preparation and storage of thickened fluids. Further investigation is recommended into the chemical processes underlying the observed deviations.

Ensuring inpatients with dysphagia receive and consume the correct texture-modified diet and thickened fluid prescriptions is challenging, and errors can result in significant complications for patients and increased costs to hospitals. The aim of this study was to investigate underlying factors that help or hinder receipt and consumption of correct dietary prescriptions for people with dysphagia in the hospital setting then implement and evaluate a range of strategies to address identified issues. A mixed-methods study design, using an integrated knowledge translation approach, was conducted in three phases. In Phase 1, clinical incident data (i.e., documented incidents of diet/fluid errors, with errors defined as the provision or consumption of any food/fluid not appropriate for a patient's dietary prescription) were analyzed, and staff, patients, and family members were interviewed using the Theoretical Domains Framework to identify factors contributing to errors. In Phase 2, health professionals assisted with the development and implementation of interventions targeted at micro (patient/family), meso (staff), and macro (organizational) levels to address factors identified in Phase 1. In Phase 3, outcomes including the change in number of dietary clinical incidents pre- to post-intervention, meal accuracy error rates from mealtime audits post-intervention, and follow-up interviews were evaluated using quantitative and qualitative measures. Post-intervention, there was a 50% reduction in clinical incidents, and a 2.3% meal accuracy error rate was observed. Staff reported most interventions were acceptable and feasible within their workload, although some interventions were not well embedded in everyday practice. This study highlights the value in using an integrated knowledge translation approach to inform tailored interventions targeting improved dietary accuracy in the hospital setting.

Background: Thickened fluids are a recognised intervention strategy in use for people with dysphagia. However, their bacterial profile has not previously been examined. Aims: To identify bacteria and changes in bacterial profiles in a range of water sources and thickener preparations over a 5-day period. Methods: Nine experiments were performed using a range of preparations of water (sterile, drinking, non-drinking tap water) and a thickening agent (sterile sachet and a used tin). Findings: No bacteria were grown on serial subcultures of sterile water, both with and without thickener. Drinking, tap and thickened water left at room temperature for 24 hours may become contaminated with environmental organisms. Conclusions: The growth of bacteria in preparations of thickening agent appears to be dependent upon water quality, while the proliferation of bacteria is dependent upon the length of time the preparation is allowed to stand at room temperature.

Texture-modified foods (TMFs) and thickened fluids have been used as a therapeutic strategy in the management of food intake in the elderly and people with dysphagia. Despite recent advances in describing rheological features of TMFs for dysphagia management, there is still paucity of research regarding the sensory attributes, therapeutic thickness levels and swallowing safety of these foods. Additionally, the relationship between mechanical and structural properties of TMFs throughout the oral processing is not yet fully understood. The present review discusses several properties of food boluses that are important during oral processing to allow for safe swallowing. Dynamic changes that occur during oral processing of TMFs will be reviewed. The use of hydrocolloids to improve the cohesiveness of TMFs and how this impacts the sensory properties of TMFs will be also discussed. Additionally, this review will suggest potential new research directions to improve textural and sensory properties of TMFs.

Thickened fluids are commonly used as a therapeutic intervention for various swallowing impairments (dysphagia). However, there is little understanding around rheological properties of thickened fluids that are relevant to dysphagia. This study compared shear rheology of thickened fluids with sensory properties during oral preparation and swallowing. Fluids were thickened with different concentrations of three hydrocolloids (xanthan gum, starch, carboxymethylcellulose gum) to provide a range of viscosities at different shear rates, and yield stresses. Perceived oral cohesiveness, propulsion effort, stickiness, and oral residue were quantitatively assessed by a specially trained sensory panel, and data correlated with rheological measurements. Very strong correlations were found between fluid viscosities at shear rates of 10 s −1 for oral cohesiveness (r = 0.97), and 50 s −1 for propulsion effort (r = 0.97). Strong positive correlations were found between viscosities at 100 s −1 and perceived stickiness and oral residue (r = 0.78 and 0.80, respectively). Yield stress was not a direct indicator of any sensory attribute studied. Measurements of fluid viscosity at representative shear rates 10, 50 and 100 s −1 provide a sound basis for investigating the impact of a 2.5 mL bolus size on sensory performance of thickened fluids during oral preparation and propulsion. Different hydrocolloids produce differing sensory profiles, providing important consideration for selecting thickeners for dysphagia.

Oropharyngeal dysphagia can cause chronic aspiration leading to significant respiratory symptoms. When dysphagia is diagnosed, an underlying cause is sought. We present a case series of 15 children diagnosed aged 6 months to 5 years (mean 2y 5mo; 11 males, four females) over a 6-year period, who were found to have an isolated bulbar palsy on genioglossus electromyography, with no accompanying neurological or neurodevelopmental disorder. Eight children had dysphagia but a normal EMG. In those with isolated bulbar palsy, management included thickened fluids (n=13), cooled boiled water (n=1), and nasogastric tube feeding (n=1). Follow-up over 1 to 8 years (mean 5y) showed complete resolution in six children, improvement in four children, and no improvement in five children (including two requiring fluids via a gastrostomy). Eight children no longer had any respiratory symptoms. Isolated bulbar palsy is under-recognized and has not been reported previously as a cause of significant dysphagia in children.

Thickened fluids are used in the medical management of individuals who suffer from swallowing difficulties (known as dysphagia). Recent studies show that understanding the rheological properties of thickened fluids is advantageous in designing better-controlled fluids. Whilst the rheological behavior of thickened fluids in shear deformation has been studied by several authors, studies on their extensional behavior are limited, despite their critical importance in influencing bolus flow and swallowing. Our aim in this work was to rheologically characterize extensional deformation of dysphagia fluids thickened with different types of commercial thickeners at varying concentrations using a filament stretching and break-up device. It was observed that the extensional viscosity increased and became more cohesive as the thickener concentration was increased. Additionally, it was observed that for similar shear viscosity at 50 s−1, the extensional viscosity of the fluid was dependent on the type of thickener. This study confirms that by thickening fluid with different types of thickeners, the cohesiveness of the fluid may be very different even at the same shear viscosity. Therefore, both shear and extensional rheology of thickened fluids should be considered for the management of dysphagia.

While the association between dysphagia and malnutrition is well established, there is a lack of clarity regarding the nutritional status and mealtime satisfaction of those consuming texture-modified diets (TMDs). This systematic review summarises and critically appraises the nutritional status and mealtime satisfaction of adults consuming TMDs. A systematic database search following PICO criteria was conducted using Cochrane Central (via Ovid), MEDLINE, CINAHL, EMBASE and Scopus. Nutritional status, mealtime satisfaction and costs were identified as primary outcomes. Eligible studies were grouped according to outcome measurement. In total, 26 studies met the inclusion criteria. Twenty studies evaluated the nutritional status by weight change or using malnutrition screening tools and found the consumption of TMDs correlated with weight loss or malnutrition. Nine studies evaluated mealtime satisfaction, with two reporting poor satisfaction for people on thickened fluids (TFs). Nutrition intervention through adjusting texture and consistency and nutrition enrichment showed positive effects on weight and mealtime satisfaction. The majority of the studies were rated as ‘neutral’ quality due to the limited number of experiments. TMD consumers had compromised nutritional status and poor mealtime satisfaction. More research input is required to identify promising strategies for improving the nutritional status and mealtime satisfaction of this population. Food services need to consider texture, consistency and fortification in designing menus for people on TMDs to avoid weight loss and malnutrition, and to enhance mealtime enjoyment.

Purpose of review Use of thickened fluids has long been a cornerstone of dysphagia management. However, clinicians and researchers are increasingly questioning their effectiveness and highlighting potential harms. This review aims to present the current state of the evidence for use of thickened fluids in children. Recent findings The relationship between aspiration and respiratory infection is complex. The role of thickened fluids in improving respiratory health is limited and contradictory. A high level of variability exists in all aspects of thickened fluid use. Little is known about patient and family perspectives on meaningful endpoints for intervention. Summary Clinicians should be open and transparent in their decision making with patients and families, acknowledging the limited evidence and the need for individualised care. Further research is needed to establish the efficacy of thickened fluid use in children with regard to improvements in respiratory health, fluid intake and child and family wellbeing.

Dysphagia is the difficulty during the progression of the bolus from the mouth to the stomach. Modifying the texture of the food is a fundamental factor for safe swallowing in patients with dysphagia since inadequate consistency can result in complications. To personalize and develop diets for dysphagia, understanding, and controlling the rheological and sensory properties of thickeners is useful. This review examines the different types of thickeners used to modify the texture of foods, as well as their influence on rheological properties and sensory attributes to efficiently manage the diet in dysphagia. The study discusses characteristics such as: hardness, viscosity, viscoelasticity, as well as sensory attributes related to rheology. The thickeners xanthan gum, methylcellulose, carboxymethylcellulose, guar gum, linseed, and chia, carboxymethylated curdlan, and konjac glucomannan were reviewed in this work. Sensory evaluations of different foods have already been carried out on some products such as: meats, carrots, soups, pates, and timbales with their modified textures. The sensory attributes measured among hydrocolloids are strongly correlated with rheological parameters. Dysphagic diets should have less hardness and adherence, but with adequate cohesiveness to facilitate chewing, swallowing to protect from aspiration and reduction of residues in the oropharynx. The use of a single type of thickener may not be ideal, their mixtures and synergistic effect can improve the viscous and elastic characteristics of foods, to obtain safe food to swallow and to improve the sensory interest of dysphagic patients. Personalized recommendations with follow-up on swallowing approaches, respecting patient's individuality, explaining thickening agents' differences would be pertinent.

The flow behavior of the administrated fluid matrices demands careful assessments for stability when consumed by individuals with dysphagia. In the present study, we incorporated tapioca starch (TS), hydroxypropyl distarch phosphate (HDP), and xanthan gum (XG) as thickeners into different nectars (300 &plusmn, 20 mPa.s) undergoing thermal processing and evaluated their stability. The thickened nectars presented better water holding and oil binding capacities at 25 &deg, C than 4 &deg, C, and the nectars with TS provided the best results for both capacities as well as the highest solubility index and swelling power (p &lt, 0.05). All prepared nectars appeared to be shear-thinning fluids with yield stress closely fitting the power law and Casson models. XG-containing nectars presented a higher yield stress and consistency index. Matrices thickened by HDP exhibited a higher viscoelastic property compared to those thickened by TS during thermal processing. TS nectars presented viscous behavior, whereas HDP and XG nectars presented elastic behavior at 80 &deg, C processing. The 3 min thermal processing HDP nectars remained stable and met dysphagia-friendly requirements under 4 &deg, C storage for 28 days, regardless of the type of fluid base (distilled water, sport drink, or orange juice). The employed thickeners present adequate physicochemical properties to be potentially utilized for producing dysphagia-friendly formulations.

Three commercial thickened fluids were rheologically characterized before and after addition of unstimulated human saliva to improve the further development of better products in dysphagia management by taking into account the dynamic process of bolus flow and the effect of saliva. Instant purées (vegetables and beef (VB), vegetables and codfish (VC) and chicken with rice and carrots (CR)) were prepared and mixed with water or unstimulated saliva from five healthy individuals. Steady and dynamic rheological properties were evaluated, and composition of saliva from five donors was determined. Control purées had shear-thinning behaviour and showed a liquid-structured character with different viscoelastic parameters. All the water samples showed significant differences in the steady and viscoelastic parameters although not so notable as those produced by saliva addition. Thereby, addition of saliva produced a remarkable change in: viscosity (at 0.1, 1, 10 and 50 s−1), consistency index (K) and flow behaviour (n), and, in the conformational structure (decrease of maximum stress amplitude (σmax) and maximum complex modulus (G*) and increase in loss factor (tan δ) of all the three purées, especially in CR. VC and CR purées showed an increase in degree of structural deformability (higher γmax). High variability was found in the saliva composition, specifically in α-amylase activity, which might affect the rheological behaviour of these commercial products. Therefore, structural changes produced by saliva addition should take into account to design safer dysphagia products although this inter-individual effect should be studied with a larger number of individuals to obtain more relevant conclusions.

Texture-modified diets (TMDs) play an important role in ensuring safety for those with dysphagia but come with risks to nutrition and quality of life. The use of TMDs has been addressed with the increasing prevalence of dysphagia in previous decades. However, there is limited literature that investigates the nutrition perspectives of TMD consumers. This review summarises the nutrition outcomes of adults consuming TMDs and thickened fluids (TFs) and identifies the limitations of TMD and TF productions. A systematic database search following PICO criteria was conducted using Cochrane Central (via Ovid), MEDLINE, CINAHL, EMBASE, and Scopus databases. Nutrition intake, meal consumption, adequacy, and meal composition were identified as relevant outcomes. 35 studies were included for analysis. Consumption of TMDs demonstrated a poorer intake compared to regular diets, in particular significant in energy and calcium. Meta-analysis of mean differences showed favourable effects of shaped TMDs on both energy (−273.8 kJ/d; 95%CI: −419.1 to −128.6, p = 0.0002) and protein (−12.4 g/d; 95%CI: −17.9 to −6.8, p < 0.0001) intake compared to traditional cook-fresh TMDs. Nutrition intake was compromised in TMD consumers. Optimisation of nutrition intake was achievable through enrichment and adjusting meal texture and consistency. However, the heterogeneity of studies and the missing verification of the consistencies lead to difficulty in drawing conclusions regarding particular texture or intervention.

The purpose of this investigation was to compare two assessment techniques, the Clinical Feeding Evaluation (CFE) and the Videofluoroscopic Swallow Study (VFSS), in their ability to document the nature of swallowing impairment, identify aspiration, determine level of feeding activity limitation and make feeding recommendations for children in the transitional feeding stage.Design. A prospective case series.Participants. Data was collected on 20 consecutive infants and children, aged from three months to three years of age, who presented for evaluation at the Videofluoroscopic Swallow Clinic at a tertiary hospital.Procedure. Participants were scheduled for CFE prior to their radiological evaluation. The CFE was conducted by the primary clinician and included a case history and parent interview, a pre-feeding evaluation, oral sensorimotor assessment and clinical feeding trial. Participants then underwent a VFSS conducted by a second clinician, blinded to the results of the CFE. The participants then attended an appointment with the primary clinician, who had results of both the CFE and VFSS, to determine a management plan. The nature of the information from both the CFE and VFSS was analysed.A penetration-aspiration rating was assigned at two points, following the CFE and following the VFSS. Measures of swallowing impairment, feeding limitation and feeding recommendations were made at three points, following the CFE ('CFE only' condition), following the VFSS ('VFSS only' condition) and following information from both assessments ('Combined' condition). The individual assessments (CFE and VFSS) were compared with the Combined condition to determine which individual assessment most influenced the final outcome for the swallowing impairment and feeding limitation measures and feeding recommendations.Results. The CFE provided the most information regarding medical complexity of the children. Analysis of medical information revealed this population of infants to be medically complex with an average of 2.9 medical conditions. Children on non-oral or combined feeding methods generally had a higher number of conditions (Mean = 3.5) than those on full oral intake (Mean = 2.1). The VFSS demonstrated superior ability to detect laryngeal penetration and aspiration, particularly with fluid textures. The CFE and VFSS showed good agreement in determining a rating for presence or absence of penetration/aspiration on puree (k= 1.000), semisolid (92%) and solid (100%) textures, but poor agreement on thin fluid (zc = . 118) and thick fluids (k= -.132). The CFE had the highest agreement with the Combined condition when determining the level of severity for oral phase impairment (r= 0.925) and feeding limitation (r= 0.803), while the VFSS had the highest agreement with the Combined condition (t=0.948) for pharyngeal phase impairment. When making feeding recommendations, the CFE had the highest agreement with final recommendations for semisolid (zc = 0.700) and chewable solid (k = 1.000) textures, while the VFSS influenced final recommendations regarding thin (zc = 0.800) and thickened fluid (zc = 0.900) textures. Both assessments were similar in determining recommendations for feeding method (oral, combined oral and tube feeding, or non-oral) (zc =0.500 respectively) and puree textures (95%).Conclusions. Feeding and swallowing difficulties in medically complex infants and children during the transitional feeding period require comprehensive evaluation. The nature of information about feeding and swallowing dysfunction from both assessments was complementary and not redundant. An optimal assessment battery should include both the clinical feeding evaluation and video fluoroscopic swallow study to adequately determine swallowing impairments and feeding limitation and to make appropriate feeding recommendations. The use of only one assessment for the young, medically complex child presenting with dysphagia could lead to inaccurate diagnosis and subsequent management recommendations.

Thickened fluids and texture-modified foods are commonly used in the medical management of individuals who suffer from swallowing difficulty (known as dysphagia). However, how to reliably assess texture properties of such food systems is still a big challenge both to industry and to academic researchers. This article aims to identify key physical parameters that are important for objective assessment of such properties by reviewing the significance of rheological or textural properties of thickened fluids and texture-modified foods for swallowing. Literature reviews have identified that dominating textural properties in relation to swallowing could be very different for thickened fluids and for texture-modified foods. Important parameters of thickened fluids are generally related with the flow of the bolus in the pharyngeal stage, while important parameters of texture-modified foods are generally related with the bolus preparation in the oral stage as well as the bolus flow in the pharyngeal stage. This review helps to identify key textural parameters of thickened fluids and texture-modified foods in relation to eating and swallowing and to develop objective measuring techniques for quality control of thickened fluids and texture-modified foods for dysphagia management.

Texture modification of foods by using thickening agents is a routine practice for assessing and treating dysphagic patients. However, a powder-thickened fluid's viscosity might change over time, and little has been proposed to overcome this inconsistency. This study aimed to evaluate variations in the thickness of a fluid thickened with a common xanthan gum–based powder and to explore the feasibility of a simple advanced preparation method for thickened liquids to improve thickness stability. Thickened fluids with concentrations of 1.0 g/100 mL, 0.7 g/100 mL, and 0.5 g/100 mL were prepared from both freshly opened and previously opened thickening powders. Fluid thickness was measured every 10 min in a series of International Dysphagia Diet Standardization Initiative flow tests. A significant time-dependent decline in thickness was observed for all three concentrations in both groups, namely those prepared with freshly opened and previously opened thickening powders, and the shortest periods to achieve a stable viscosity after liquid preparation for the two groups were 80 and 70 min, respectively. On diluting the thickened liquids from the base liquid, which was prepared at a concentration of 1.0 g/100 mL and stored at room temperature for 90 min, no significant time-dependent thickness changes were observed over the following 60 min. The simple protocol of preparing the thickest "base" liquid in advance and then diluting it to the desired thickness resulted in a consistent liquid thickness, with the prepared liquids ready to be clinically applied and consumed, with high stability within 60 min.

Powder thickeners are used to modify liquid consistency in dysphagia management. These thickeners may contain starches, gums or their mixtures. Since the salivary α-amylase enzyme favours starch hydrolysis, this might affect the overall rheology of thickened fluids. This study provides a first insight into the impact of salivary α-amylase on the elongational properties of different types of thickened fluids, differentiating between gum-based and starch-based fluids, when considering the axial force developed during uniaxial elongation. The experimental results obtained in this study showed a dramatic decrease in the axial force as a result of salivary α-amylase addition to a pudding-like starch-based thickened fluid, while no significant change was observed after addition to a pudding-like gum-based thickened fluid. Monitoring axial forces during the stretching phase of CaBER was found to be a quick alternative method to identify structural changes of pudding-like thickened fluids in the presence of saliva, for which the conventional CaBER experiments are technically limited.

Use of thickener is a widely-known intervention in the management of oropharyngeal dysphagia, aiming to reduce the incidence of aspiration pneumonia. Thickener can benefit some patients with dysphagia, but does not reduce aspiration pneumonia in all patients and can pose other risks for physical health and psychological well-being. This article draws together current research to explore the benefits and risks of thickener and a range of less well-known interventions, many of which are delivered by nurses. It highlights an individualised approach to dysphagia management and case studies provide a context for management decisions. It concludes that thickener is one of a range of interventions carefully assessed by a speech and language therapist on an individual basis. Nursing observations and interventions are also essential in dysphagia management, with joint working recommended, especially for oral hygiene, fluid intake monitoring and support with feeding. All interventions recommended by speech and language therapists that are delivered by nurses are equally important in providing holistic, individualised treatment for patients with dysphagia.

This paper describes the implementation and evaluation of an accessory designed and manufactured to be adapted to a 3D printer to allow the in situ and continuous mixing of powder and liquid feeds. In particular, the capacity of this accessory to correctly mix a dysphagia-oriented commercial powder thickener with several conventional fluids (i.e. water, juice, and milk) was studied. Target thickener concentrations were defined in order to achieve mixtures with viscosities corresponding to the textures established by the National Dysphagia Diet Task Force (NDD)—nectar-like, honey-like, and spoon-thick—for thickened fluids. Both the accuracy of the solid content and the rheological response of the obtained mixtures were evaluated. Although fluctuations were observed in the concentrations of the mixtures obtained by continuous mixing with respect to the target values, the viscosities obtained were within the limits established for each of the desired textures. The thickened fluids processed using the 3D printing mixing accessory showed viscosities very similar to their hand-mixed counterparts and a higher degree of structuration, especially when printed at low mass flow rates, as well as a lower amount of entrapped air. This method of preparation allows the production of thickened fluids with more appealing shapes and colours for the long-term dysphagia management, improving the quality of life of patients with dysphagia, and promoting treatment compliance.

Dysphagia is a medical condition that affects normal swallowing. To prevent the risk of aspiration or choking, thickened fluids and texture-modified foods have been used for dysphagia management with the goal of slowing down the flow of liquids and protecting the airway. This article summarizes the available information about the rheological and textural parameters, the characterization of the most-used thickeners and the application of alternative texture modification technologies that are crucial to developing safe dishes for people who suffer from swallowing difficulties. Regarding rheological and textural measurements, fundamental and empirical methods are described.

Purpose To investigate differences in the acceptability between thickened and naturally viscous beverages. Design This was an exploratory, cross-sectional study. Methods One hundred and twenty-eight healthy volunteers rated overall liking/disliking of a selection of each of three thickened drinks and three beverages of natural viscosity pre- and post consumption. Mean ratings were subjected to statistical analysis done with t tests. Findings While all naturally thick beverages evoked good expectations, there were significant differences in expected acceptance of thickened fluids concerning the kind of beverage. Post consumption naturally thick beverages were rated significantly better than thickened. Conclusions The findings suggest an alternative offer of naturally thick drinks and waiver of thickening water when viscosity adaption is needed. Clinical Relevance The sufficient and safe oral fluid intake in dysphagia requires compliance to dietetic recommendations. Naturally thick beverages can contribute to increase the appeal of texture-modified diet.

Background Oropharyngeal dysphagia occurs in children without known neurological disorders, increasing their risk for respiratory problems and inadequate intake. Clinicians may recommend thickening nutritive fluids; however, there is little research regarding the impact of thickening nutritive fluids on clinical outcomes in children. Methods We used a parental reporting tool to determine whether parents identified changes in signs of dysphagia or volume of intake when thickened fluids were incorporated into an individualized feeding program for dysphagic children without known neurological problems. Fifty-five children diagnosed with dysphagia, for whom thickened fluids had been recommended per radiographic and clinical exam, qualified for the study. Parents of 44 children (24 females, 20 males) aged 2 weeks to 14 months completed baseline and post-thickening (within 90 days) rating scales. Results Compared to baseline, parents reported significant decreases in the frequency of apnea (W = −219, P

Dysphagia is estimated to affect ~8% of the world's population (~590 million people). Texture-modified foods and thickened drinks are commonly used to reduce the risks of choking and aspiration. The International Dysphagia Diet Standardisation Initiative (IDDSI) was founded with the goal of developing globally standardized terminology and definitions for texture-modified foods and liquids applicable to individuals with dysphagia of all ages, in all care settings, and all cultures. A multi-professional volunteer committee developed a dysphagia diet framework through systematic review and stakeholder consultation. First, a survey of existing national terminologies and current practice was conducted, receiving 2050 responses from 33 countries. Respondents included individuals with dysphagia; their caregivers; organizations supporting individuals with dysphagia; healthcare professionals; food service providers; researchers; and industry. The results revealed common use of 3-4 levels of food texture (54 different names) and ≥3 levels of liquid thickness (27 different names). Substantial support was expressed for international standardization. Next, a systematic review regarding the impact of food texture and liquid consistency on swallowing was completed. A meeting was then convened to review data from previous phases, and develop a draft framework. A further international stakeholder survey sought feedback to guide framework refinement; 3190 responses were received from 57 countries. The IDDSI Framework (released in November, 2015) involves a continuum of 8 levels (0-7) identified by numbers, text labels, color codes, definitions, and measurement methods. The IDDSI Framework is recommended for implementation throughout the world.

Thickened fluids are commonly used in the medical management of individuals who suffer swallowing difficulty (known as dysphagia). Previous studies have shown that the rheological properties of a liquid affect the flow behavior of the bolus in swallowing, such as pharyngeal transit time. While there is no doubt that shear rheology is a highly important factor for bolus flow, it is suspected that extensional properties of a liquid bolus also plays an important role in swallowing, due to elongation of the bolus as it flows through the oropharynx. Our aim in this work was to observe the effect of extensional viscosity on pharyngeal transit time and elongation of the bolus during swallowing. Eight samples of thickened liquid barium that were shear-controlled, but varied in extensional viscosity and two samples that were extensional-controlled, but varied in shear viscosity were swallowed by eight healthy individuals. Data were collected under lateral view of videofluoroscopy swallow study (VFSS); measures of pharyngeal transit time and the ratio of the length to the width of the bolus on the frame of Upper Esophageal Sphincter (UES) opening were taken from the VFSS recordings. It was observed that the pharyngeal transit time generally increases when the fluids are thickened to higher IDDSI consistency. Additionally, higher extensional viscosity fluids reduced the elongation of the bolus during swallowing, thus potentially reducing the risk of post-swallow residue due to bolus breakage. This study confirmed the relevance of the extensional viscosity of the bolus in swallowing.

Purpose: To identify perceived enablers and barriers that may influence the implementation of water protocols (WPs) as an intervention for dysphagia in acute stroke settings. Method: Semi-structured interviews were conducted with nine nurses, eight speech-language pathologists (SLPs), five doctors and four dietitians working in acute stroke units in a major city in Australia. Data were thematically analysed and themes were mapped to the Theoretical Domains Framework. Result: Ten barriers and nine enablers were identified. Key barriers were: nurses lack oral care skills and agency nurses lack stroke-specific skills; only SLPs are perceived to be involved with WPs; WP rules will not get followed and may lead to adverse patient outcomes; WPs increase nursing workload; transient workforce impacts efficiency of implementation; and established culture of using thickened fluids. Key enablers were: patients would benefit from WPs; communication and education systems are already in place; acute hospital brings unique benefits; and peer support and modelling support implementation. Conclusion: The perceptions of barriers and enablers to implementation of WPs can be used to inform future studies designed to evaluate the safety and efficacy of WPs and subsequently facilitate their uptake in acute stroke as an alternate dysphagia management strategy.