Texture modified food

People with cerebral palsy and their families and carers need clear information on why modified foods and thickened drinks are important and how food and drinks should be prepared. Regular review by a speech pathologist and a dietitian is vital to ensure modified foods and thickened drinks continue to meet the needs of the person with cerebral palsy.

Cerebral Palsy Alliance offers a specialised service to children and adults with eating and drinking difficulties. Speech pathologists will provide a comprehensive assessment to identify whether changing food textures, adding thickener to drinks, or other strategies will be helpful.

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Fees may apply for speech pathology assessment and intervention, and will depend on the provider and number of sessions needed. Check with the provider whether fees will also apply for development of a home program, report writing or therapist travel.

Additional costs may be associated with food preparation.

Ask the therapist if you are eligible for funding to assist with fees. People with a disability living in Australia may be eligible for a health care rebate through Medicare or funding under the National Disability Insurance Scheme.

If modification of food or fluids is required, then additional time for planning and preparing food and drink for outings may be required.

Cerebral palsy can affect the muscles that open and close the mouth, move the lips and tongue, and control swallowing. As a result, many children and adults with cerebral palsy can experience eating and drinking difficulties, also called dysphagia. These difficulties include minor to very severe problems with sucking, chewing, keeping food in the mouth, swallowing food and drinking safely, as well as taking a long time to complete a meal.

Dysphagia can have a significant impact on development, growth, nutrition, respiratory health, digestion, social interaction and behaviour. For example, mealtimes and meal preparation may be time consuming, people may avoid eating with others, and may eat and drink less. Reduced safety of swallowing and risk of poor nutrition may also cause anxiety. These factors can impact significantly on quality of life for the person, their family and carers.

People with cerebral palsy are more likely to have difficulties eating and drinking if they have an intellectual difficulty, epilepsy, are unable to walk or have a dyskinetic form of cerebral palsy (which causes involuntary movements).

Speech pathologists often recommend changing the consistency of drinks, food texture or the size of food pieces. These are some of the ways that may help people with cerebral palsy to eat and drink more safely, as well as consume enough food and fluids to maintain adequate nutrition and hydration.

Some eating and drinking difficulties can result in food or drink going down the wrong way and into the lungs. This can lead to infection and, in turn, pneumonia. Some swallowing difficulties can lead to choking which may become a life-threatening medical emergency. A speech pathologist should be consulted urgently if you or your family member are experiencing these problems.

An example of modifying foods is to soften or mash meals so that they require less chewing and are easier to swallow. This can reduce the risk of choking. A thickener can be added to drinks to achieve a thicker fluid that moves more slowly in the mouth. This allows better control of swallowing and may help to reduce the risk of the drink going down the wrong way into the airway and lungs.

Food and drink can be thickened with natural products, although a commercial thickening agent is often recommended. Ready-made thickened drinks are also available, but can be expensive. Blenders and hand mixers are usually required to prepare modified food and drinks.

• People requiring any form of modified food or thickened drink may have difficulty swallowing medications.
• Modified food and thickened drinks are widely used as they are considered to assist people with dysphagia to have adequate nutrition and hydration, and to minimise risk of aspiration. One of the alternative solutions is gastrostomy feeding, which is where liquid food is fed through a tube surgically implanted into the stomach. Modified foods and thickened drinks may be trialled before considering gastrostomy feeding.
• Thickened drinks are often called thickened fluids.

Before modified foods and drinks are introduced, the person should receive a comprehensive assessment by a speech pathologist experienced in cerebral palsy and dysphagia. The speech pathologist can help identify what is contributing to difficulties with eating and drinking and advise on the most appropriate intervention for a person with cerebral palsy. The assessment may also include input from a multi-disciplinary team that may include a doctor, dietitian, nurse and occupational therapist.

This team might recommend additional medical assessments of a person’s ability to swallow safely and effectively. Examples of these assessments are fibre optic endoscopic evaluations of swallowing (FEES) and videofluoroscopic swallowing studies, also known as modified barium swallow studies.

It is important to measure the outcome of modified foods or drinks to ensure they are meeting the individual’s needs. A speech pathologist, together with the person with cerebral palsy and their family and carers, will determine the most suitable measure. One option is Goal Attainment Scaling (GAS goals) (GAS goals), which measures how well a person’s goals are achieved.

We searched the medical, allied health and education literature, published after 1994, to find studies evaluating the outcomes of modified foods and thickened drinks for children and adults with dysphagia due to cerebral palsy.

The search aimed to find the best available evidence about texture modified food and thickened drinks used in everyday life. Outcomes of interest were weight, growth, nutrition and quality of life. We also wanted to understand the impact of texture modified food and thickened drinks on aspiration pneumonia.

No high level studies including people with cerebral palsy were found so the search was expanded to include the highest level of evidence (systematic reviews or randomised controlled trials) of modified foods and thickened drinks used with children or adults who had dysphagia from other neurological causes. We also extended the search to include systematic reviews of studies which looked at swallowing modified food and thickened drinks in experimental conditions rather than everyday life.

Modified foods and thickened drinks used in experimental conditions.

We found two detailed reviews of studies which used special tests such as videofluoroscopic swallowing studies to see what happens to food and drink when it is swallowed^{1, 2}. The reviews concluded:

• There are very few studies which look at texture modified food and therefore there is little information to guide practice
• Drinks of increasing thickness are less likely to enter the airway
• Thicker drinks can sometimes leave a residue in the throat after a swallow and this can also place a person at risk of aspiration
• Mouthfuls which are larger are harder to manage and there is increased risk of food going into the airway
• More material is likely to go in the airway when drunk from a cup than a spoon

Modified foods and thickened drinks used in real-life environments.

The best available evidence was a systematic review³ and three randomised controlled trials (RCTs)^4-6. The systematic review investigated the effect of modified food and drinks on health related quality of life. The RCTs compared outcomes of drinking thin versus thickened drinks for five days or more in adults with dysphagia. No high level studies of children were found.

Quality of life. Quality of life appears better for people who have food and drinks which are modified to a lesser extent, and those who are able to drink regular water, rather than thickened drinks only³. This conclusion is based on very low quality evidence from one systematic review³ which included studies of people with dysphagia with a range of non-neurological diagnoses (e.g., head and neck cancers) and neurological diagnoses (e.g., stroke). The review included several studies where participants who were more physically disabled were allocated more significantly modified food and drinks. This may have contributed to a lower quality of life, regardless of the type of food and drink they had.

Aspiration pneumonia. Pneumonia can be caused by aspiration, that is, food and drink entering the lungs when swallowing is impaired. The incidence of pneumonia was measured in all three RCTs^4-6. The three studies had different findings.

There was no difference in the incidence of aspiration pneumonia in a large study (515 participants, Level II, good quality) comparing three different groups of adults who were asked to drink fluids thickened to honey consistency or nectar consistency, or to drink normal thin fluids with the chin tucked in⁴. This chin tucked posture is considered to be one of the safer ways of drinking for people with dysphagia. In another study⁵ (85 participants, Level II, good quality), no participants (out of 34) in a group drinking thickened drinks were diagnosed with aspiration pneumonia. In contrast, 14% (6 out of 42) of those drinking thin fluids under strict conditions were found to have aspiration pneumonia. In the third study of just 14 people6, no participant in either group developed aspiration pneumonia.

The evidence for aspiration pneumonia is considered to be of low quality. Although there is high level evidence from RCTs, and two of the studies are considered to be good quality^4-5, the results are inconsistent. That is, it is not clear from these studies whether drinking thin fluids in everyday life results in aspiration pneumonia for people with swallowing difficulties. Furthermore, none of the research was completed with people with cerebral palsy.

Preferences of people with dysphagia. Participants in the studies tended to prefer thinner drinks. This conclusion is based on low quality evidence^{5, 7}.

Other outcomes. Very low quality evidence from one RCT⁶ concluded that there was a higher incidence of urinary tract infection, but no difference in the incidence of constipation, in participants who had thickened fluids compared to participants who had thin fluids. No studies were found that looked into the effects of modified foods and thickened drinks on nutrition or growth and development.

Overall, no research evaluated the effects of texture modified foods and we located no research involving people with cerebral palsy. The results from studies in everyday life are inconclusive as to whether having thickened drinks results in reduced risk of aspiration pneumonia^4-6. Practices in everyday life seem to be informed by the studies carried out under experimental conditions and by the experiences of clinicians. Studies under experimental conditions show that drinking thickened drinks reduces the risk of aspiration^1-2. It is not clear though, from the evidence, whether this aspiration leads onto the serious complication of aspiration pneumonia. Results also showed that very thick drinks may leave a residue in the throat after a swallow. Although the residue was not aspirated during the course of the experiment, there may have been a heightened risk of aspiration later. Based on the lower incidence of aspiration of thicker liquids reported in the experimental conditions, clinical practice is generally to recommend thickened drinks for people with dysphagia.

The evidence suggests that people with dysphagia do not prefer thickened drinks. Also, quality of life is lower for those having more significantly modified food and thickened drinks as compared with those who have thin or less modified food and drinks.

Research is just one piece of evidence that should inform the use of interventions. The preferences of the person with cerebral palsy and their family and carers are important when deciding whether to use modified foods and thickened drinks. People with cerebral palsy, their families, caregivers and specialist speech pathologists should carefully consider the unique goals and needs of each person with cerebral palsy to determine whether texture modified food and thickened drinks should be introduced.