Consistency Modifications for Special Diets at School

1. 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

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

3. 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

4. 504 vs. IEP

5. 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

6. 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

7. 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

8. 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.

9. 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

10. 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

11. 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

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

13. 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=1sFNMk87558

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

16. The Modified Diet Process

17. 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.

18. 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

19. 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

20. 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

21. 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

22. 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

24. 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).

25. 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

26. 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

27. 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

28. Pureed Hamburger

29. Pureed Carrots

30. Pureed Green Beans

31. Pureed Lasagna

32. Puree Broccoli

33. Puree Chicken Nuggets

34. Mashed Potatoes *No modification needed

35. Pureed Pinto Beans

36. Pureed Pizza Dippers

37. Pureed Vegetable Medley

38. 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.

39. Mashed Potatoes VS. Potato Wedges Puree Regular

40. 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.

41. 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.

42. Mechanical Soft Hamburger

43. Mechanical Soft Carrots

44. Mechanical Soft Green beans

45. Mechanical Soft Lasagna

46. Mechanical Soft Chicken Nuggets

47. Mechanical Soft Pizza Dippers

48. Mechanical Soft Vegetable Medley

49. The Food Processors

50. 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 Check consistency