20Q: In the Thick of It - The International Dysphagia Diet Standardization Initiative (IDDSI)

From the Desk of Ann Kummer

Dysphagia is a serious medical condition that can cause malnutrition, dehydration, aspiration, and risk of death. To reduce the impact of dysphagia on health, speech-language pathologists and other healthcare providers work with affected patients to provide a diet that consists of modified textures and liquid consistencies. Unfortunately, there has been great variation among health care facilities regarding the use of terminology and definitions of dietary levels and textures. This causes inconsistencies in treatment protocols and, in some cases, reduced the effectiveness of treatment. To resolve this issue, an international team of professionals developed the International Dysphagia Diet Standardization Initiative (IDDSI) based on research and testing of protocols.

This course will describe the International Dysphagia Diet Standardization Initiative (IDDSI) and discuss the importance of using standardized language regarding texture modification. The authors will highlight the IDDSI that is specific to pediatric patients. Finally, potential barriers, solutions, and frequently asked questions during the transition to implementation of IDDSI will be described.

Here is some information about the authors of this 20Q:

Jen Raminick graduated from California State University, Long Beach and has been a speech-language pathologist at CHOC Children’s for 8+ years. She has earned her Board-Certified Specialist accreditation in Swallowing and has multiple leadership roles in the hospital, including a chair of the Clinical Practice Committee to guide patient care.  She has mentored graduate students and fellow therapists, with an emphasis on MBSS and acute inpatient competency.  At CHOC, she has led a committee to implement the International Dysphagia Diet Standardization Initiative, providing guidance and education to multiple departments throughout the hospital.  She has also worked on a team to write a grant for Fiberoptic Endoscopic Evaluation of Swallowing equipment and is working to develop a comprehensive FEES program.  She has been both a national and regional speaker, presenting at the California and American Speech-Language-Hearing Association’s annual conventions covering topics such as feeding on High Flow Nasal Cannula and implementing the IDDSI.

Danielle Ward graduated from California State University, Long Beach and has been a pediatric speech language pathologist for more than six years. She has spent most of her career working at a pediatric acute care hospital where she has experience working with infants and children with a variety of feeding, swallowing, and communication disorders. Danielle has experience as a member of the clinical practice council to promote quality patient care and has been a clinical instructor and mentor to graduate students and guest lecturer to undergraduate students. Danielle has presented both regionally and nationally on topics such as curriculum-based language intervention, word-retrieval in individuals with aphasia, and the International Dysphagia Diet Standardization Initiative (IDDSI). Danielle co-led her hospital in the implementation of the newly established IDDSI. Under Danielle’s guidance, her hospital was proud to be one of Under Danielle’s guidance, her hospital was proud to be one of the pioneer children’s hospitals to successfully implement the IDDSI framework.

Now…read on, learn, and enjoy!

Ann W. Kummer, PhD, CCC-SLP, FASHA, 2017 ASHA Honors
Contributing Editor 

Browse the complete collection of 20Q with Ann Kummer CEU articles at www.speechpathology.com/20Q

20Q: In the Thick of It -
The International Dysphagia Diet Standardization Initiative (IDDSI)

Learning Outcomes

After this course, readers will be able to: 

• Describe the importance of using consistent and standardized language when discussing texture-modified dysphagia diets.
• Identify similarities and differences between IDDSI and the NDD.
• List potential barriers and identify solutions to issues posed during the transition to implementing the IDDSI framework.
• Describe the main differences in IDDSI for pediatric patients and adult patients. 

Jennifer Raminick 

Danielle Ward 

1. Why is consistent language important when discussing diet modification?

Simply put, “Multiple labels increase the risk to patient safety” (Cichero et al., 2013, p. 280). The two main areas this impacts are (1) patient care and (2) research. Standardized terminology exists to reduce misunderstanding and ambiguity, as well as improve the quality of care, safety, and communication efficiency among healthcare professionals. In addition, for researchers to accurately identify which texture-modified diets provide the greatest therapeutic benefit, it is critical to use identical terms, definitions, and measurable characteristics so that research can be replicated.

The previously endorsed NDD utilizes ambiguous descriptions and testing methods that are not easily known or accessible. This creates patient safety concerns, as the consistency of food or liquid can vary depending on the provider that defines and prepares that food.

Our hospital rehabilitation staff encountered this firsthand. We had a new clinician join our team during an SLP rounding discussion and asked what consistency Pediasure (a pediatric nutritional supplement) was. She received three different answers – thin liquid, half-nectar, and nectar. We attempted to test the liquid, but without a viscometer, we were not able to identify its consistency. We recognized that we were not all on the same page and we needed a more accessible and standardized dysphagia diet. At the same time, we began to see more information on the development of IDDSI and recognized that the ease of testing and consistent terminology was the answer we were looking for.

2.  I have been using NDD for ages, why do I need to transition to IDDSI?

IDDSI was created in 2013 to provide more consistent terminology and easily accessible testing methods. The world first heard about IDDSI in 2015 when it was published, providing clear guidelines for testing methods and texture modification of foods and liquids. The goal was to create globally standardized terminology and descriptions for diet modification across all ages, care settings, and cultures, providing clear consistency guidelines and simple carry-over with easily accessible testing tools. As illustrated in the example above, the NDD does not have easily accessible testing methods and results in ambiguity about what consistency you are providing your patients. With IDDSI, you can test any food or liquid in 10 seconds or less using items most individuals have on hand in their kitchens.

3. Is IDDSI implementation mandatory?

While there is no mandatory rule that you MUST implement IDDSI, it is strongly recommended and has also been endorsed by ASHA. It is becoming best practice to use IDDSI terminology in your assessment and treatment. Additionally, across disciplines, IDDSI is becoming widely used. The Academy of Nutrition and Dietetics announced in October 2021 that IDDSI will be used by the Nutrition Care Manual (NCM) as the only recognized texture-modified diet, and the National Dysphagia Diet will no longer be used. Consumer products are also becoming labeled using IDDSI terminology and color schemes. Our patients and providers are becoming more comfortable with using IDDSI, and as such, we should be too! While the implementation process can seem overwhelming, actually using IDDSI in your practice is very easy. Additionally, knowing you are providing and teaching families diet modification that is accurate and reproducible is worth it.

4. What are the differences specific to pediatric patients when utilizing IDDSI?**

The main differences specific to pediatric patients involve the solid consistencies: minced and moist and soft and bite-sized. For minced and moist, the pediatric particle size should be equal to or less than 2mm in width and no longer than 8mm in length, whereas the adult particle size is equal to or less than 4mm in width and no more than 15mm in length (for reference, 4mm is about the gap between the prongs of a standard dinner fork). For soft and bite-sized, the bite size should be no larger than 8mm for pediatric patients and 15mm or 1.5 cm for adult patients. The size of the food pieces was selected in relation to the size of the airway to help reduce the risk of a piece of food fully blocking the airway and causing choking.

5. When do we transition from pediatric particle/bite size to the adult size?

The pediatric particle size for Level 5 – minced and moist and Level 6 – soft and bite-sized is based on the size of the pediatric airway. The smaller particle size is used to prevent choking. You can transition from the pediatric particle size to the adult size as the airway grows to that of an adult. This is usually around the time a child reaches puberty, but IDDSI resources recommend discussing with the child’s pediatrician before transitioning to adult particle size.

6. Can you use IDDSI to help patients transition and learn oral motor skills for chewing?

Yes! IDDSI provides a progressive approach to increasing texture according to oral motor skill level. This can be beneficial for children with emerging oral motor skills as well as oral sensory differences. A basic texture progression can be done by starting with Level 3 liquidized consistency, which is a thin, smooth consistency. Then you can gradually work up to Level 4 – puree, which is a bit thicker and more dense but still has a uniform, smooth consistency. Once you want to introduce a more textured consistency, you can offer Level 5 – minced and moist. There are many advantages to using IDDSI to progress oral motor skills. For example, the gradual progression in particle size helps to prevent choking while introducing solid food. IDDSI has so many great resources and is so easy to carry over, you can easily offer parents easy-to-follow guidelines about how to recreate the textures at home that you have been working on in therapy. 

7. What IDDSI consistency do you start with in a child that has never eaten by mouth before? Why?

In working with a child that has never tried solid food before, it might be best to start with Level 4 – puree. This consistency will be the easiest for children that have minimal oral motor skills, as it moves slowly and is the most cohesive. Additionally, no chewing or bolus manipulation (outside of AP transit) is required. Level 4 – puree also does not include texturized particles or crumbs that break off, so it may be easier for children that have oral-sensory difficulties. 

8. We use meltable solids a lot with our pediatric patients. What consistency does IDDSI consider these?

IDDSI refers to meltable solids as “transitional solids.” This is a very common consistency for pediatric patients, especially those learning to chew who have oral motor difficulties. Transitional solids start as a solid/crunchy texture and transition to a different consistency when liquid or heat is applied. Oral skills required for this consistency include bolus control and tongue pressure. We like to use this consistency for pediatric patients because they can experience chewing and work on skills, but the food will eventually turn soft and almost into a puree after a short time in the child’s mouth. If the child isn’t able to chew the food item fully, the food will “melt” and be easier for the child to swallow without becoming a choking hazard. Examples include veggie straws, puffs, graham crackers, or ice chips. We can test this consistency by dropping 1 ml of water or heat on a small piece of food and waiting one minute. Using the fork pressure test, press into the food with the tines of the fork until the thumbnail blanches to white. The food should be totally squished or melted and should not resemble its original form.

9. What is the difference between level 7 “Regular” and level 7 “Easy to Chew”?

Level 7 – Easy to chew was created after feedback was received that there are significant differences between some solid food items, such as a French fry and a steak. Level 7 – easy to chew foods are developmentally appropriate SOFT food items that can be eaten in their typical manner. There is no size limit (as seen in Level 6 – soft and bite-sized), but these foods can still be squished with less effort than a hard food, such as a raw carrot. Examples of pediatric Level 7 – Easy to Chew foods might be cheddar cheese, banana, cooked pasta, and Dino nuggets. 

10.  Is slightly thick (ST1) liquid the equivalent to the NDD “half-nectar” consistency?

Technically, yes. However, in the past, due to a lack of accessibility to valid and easy-to-use testing methods, half-nectar consistencies varied from therapist to therapist. IDDSI now allows us to use the flow test to create a true ST1 liquid, which can be consistently replicated. ST1 liquid is frequently used in pediatrics. Similar to the thickness of most infant AR formulas, it is often used as a thickness level that reduces the speed of liquid flow but is still thin enough to flow through a bottle nipple. ST1 liquid also utilizes less volume of commercial thickener, which can be important when watching caloric intake or carbohydrates (e.g., Keto diet). Liquids thicker than ST1 can be more difficult to draw through a bottle nipple than a thin liquid, which can result in decreased volume intake and dehydration.

Another variable that we try to control when using a thickened liquid with infants is identifying a nipple that the patient can use efficiently with the thickened liquid. We want to avoid the infant refusing the thickened liquid. We also want to make sure that drawing the thickened liquid is not going to overwork the baby, especially if they already have poor endurance observed during feeding. And lastly, we want to avoid caregivers self-modifying nipples as this can result in a larger, potentially less-safe bolus and lack of consistency with feeding vessels.

11. Can I use any 10mL syringe to perform the flow test?

No! You cannot use just any syringe to perform the flow test. The IDDSI flow test uses a 10mL slip-tip hypodermic syringe that must measure 61.5mm from the zero line to the 10mL line. Using a syringe with incorrect dimensions will give unreliable and incorrect results. BD syringes were used for IDDSI development (manufacturer code 303134 North America). Recently, IDDSI created a special funnel that can be used in place of the slip-tip hypodermic syringe. These funnels are available for purchase on the IDDSI website (link here: [IDDSI Funnel Resources](https://iddsi.org/News/Special-Features/IDDSI-Funnel-Resources)). 

12. What are some tips for successful implementation of IDDSI?

The first and most important step in the process is to familiarize yourself, your implementation team, and your key stakeholders with IDDSI. Get to know the IDDSI framework and the terminology well. Practice using the flow test and how to test different solid foods at your facility using IDDSI testing methods. This will help you as you introduce the new framework and also identify gaps with your current dysphagia diet that are not consistent and are ideal for patient care.

Identify key stakeholders within your facility. These are typically members of your rehabilitation leadership, nutrition and food services departments, nursing care, etc. In terms of your key stakeholders, identify compelling reasons for buy-in that pertain to their specific departments (e.g., improved patient safety, improved nutrition reporting). Meet with leadership teams to illustrate why you need to change your current dysphagia diet and why implementing IDDSI would be better. Don’t reinvent the wheel… IDDSI has done a lot of the work for us and created a wealth of resources that are all available free of charge on their website. One aspect that was helpful for our implementation was doing a short in-service for nurses on each unit in the hospital. We demonstrated how to perform the flow tests at the bedside. Seeing how fast and easy the flow test could be completed helped create buy-in from the nursing staff. Additionally, we also presented a short in-service to the kitchen staff that prepares the food. We discussed what dysphagia was and how preparing these meals can help keep patients safe and healthy. This was the first time many of the individuals working in the kitchen had heard of dysphagia. The kitchen staff was happy to implement IDDSI, knowing they have a role in helping prepare safe meals for our pediatric patients. They continue to use IDDSI testing methods for each tray that is prepared for our patients with dysphagia. 

13.  How long does it take to transition to IDDSI?

The transition to IDDSI is a process that requires the cooperation and teamwork of multiple departments (e.g., Rehab, Food Service, Clinical Nutrition, Physicians, Nursing, etc.). Because of this, the full transition relies on a variety of factors. In our acute care pediatric hospital facility, we were able to make the transition over several months. Other facilities may take up to a year or more. When creating your implementation plan, look ahead at which areas might take longer. Be sure to start the process in these areas well in advance to minimize any hold-ups you may have.

Transition tip: It is recommended to use transitional language while in the transition process. What this means is when writing up evaluations and recommendations, you may choose to include both the new language and old language in order to reduce confusion. For example, “Level 2 - Mildly thick liquid/nectar-thick liquid”. This was especially helpful for our hospital as our IT department required extra time to make changes in our electronic charting. We were able to use IDDSI while we awaited the official change from IT as we utilized the transitional language.

14.  What are some challenges you encountered when implementing and transitioning to IDDSI?

One of our initial challenges was establishing the need for change and encouraging all of our key players to get on board with the transition to IDDSI. Specifically, identifying the inconsistent terminology and classification of liquids among fellow therapists. Once we identified a need for change within our department, we created a work group to divide the project into more manageable tasks. Some therapists worked with food services and the nutrition department while other therapists worked with the IT department. There are many facets to this project and this would be a huge undertaking for a single person. Working together with your team will not only help complete the project faster but also create ownership and fresh ideas among your team.

We also encountered some collaboration difficulties due to staffing issues in other departments, which pushed back our initial “go-live” date. Make sure to give yourself plenty of time for unexpected challenges that arise! Lastly, since our implementation, we have found there is also a need for ongoing education of rehab and food service staff to provide “refreshers” and also initial education for new hires.

15. Why is it important to use a kitchen tool to prepare the minced and moist and soft and bite-sized consistencies, rather than chopping/mincing by hand?

We knew it was important to find a kitchen tool that could achieve the correct consistencies rather than utilizing hand chopping/mincing, which carries a higher risk of user error.  We knew we wanted a tool so that the food service staff would not be chopping and mincing the items by hand, as we assumed that preparing the chopped and minced food by hand could lead to inconsistent sizes of the particles and bite-sizes. Finding the right kitchen tool for the job was something that took a lot of time and experimentation! We eventually found a kitchen chopper with the correct grate size for Level 6 - soft and bite-sized. However, the food chopper required additional testing, as some food items would become stuck in the chopper grate. We also had to experiment with Level 5 - minced and moist. We settled on a food processor to create the small particles of soft, solid food items. We found that we needed to use only soft meats or carb/bread-type foods (e.g., crackers, cakes, ground turkey, etc.) because we discovered that if we used fruits or vegetables, or other items with a high moisture content, they quickly became a puree in the food processor. Most of our recipes for Level 5 - minced and moist use soft meats and bread/carb-type foods with some kind of sauce to bind the meal together. For example, for our Level 5 - minced and moist spaghetti bolognese, we used ground turkey (minced in the food processor) and small pieces of acini di pepe pasta mixed with a marinara sauce. 

16. What have you found are the best ways to educate families about IDDSI testing methods?

The best way we have found to educate families is through one-on-one, hands-on teaching of the specific diet that their child requires. Printing out the IDDSI consistency level handouts and using them as a reference during teaching is very helpful, as well as providing demos of flow testing and food preparation and how the final product should look. There are also many helpful videos on the IDDSI YouTube channel. Families can also download the app on their mobile device or tablet to have an easily accessible reference for consistencies and testing methods. 

17. What are the best ways to educate related service providers on IDDSI?

We found that multimodal education is key, as different providers may benefit from different educational modalities depending on their level of involvement. Education platforms include online presentations and learning modules, hands-on demos, “hot sheets” that can be hung around units and offices, and lecture-style presentations. Providing the best form of education will help reduce confusion and generate more buy-in along the IDDSI transition process. For example, a GI physician may need a more in-depth overview, whereas a bedside nurse may benefit from more hands-on training. We also try to offer ongoing education for key players such as our kitchen staff, bedside nursing, and our rehab staff. Lastly, we include a link to www.iddsi.org at the bottom of our charting so that physicians know where to reference the IDDSI diet if they are unfamiliar with the consistencies in our reports.

18. What about bread? I know that there is a concern about bread being offered to adults with dysphagia as it presents as a choking risk. Is this still a concern with pediatric patients?

Bread, in most forms, is considered a Level 7 regular food. This is due to the fact that in order to eat bread, you need to bite with sufficient strength and chew. Additionally, due to the fact that bread is typically dry, this can potentially create difficulty with AP transit and bolus clearance. For most patients with dysphagia, bread can be tricky, to say the least. Additionally, the saliva in the oral cavity is quickly absorbed by bread, often before it is fully chewed, and becomes a slimy consistency. Sensory receptors in the oral cavity interpret that the bread is ready to be swallowed when in fact, it is not fully chewed (Sheffler, 2023). Pediatric patients are also at an increased risk as they are more prone to over-stuffing and pocketing food in the buccal cavity and along the hard palate. The good news is that there are many ways to present bread for each IDDSI consistency.  Here are some of our favorite examples:

Level 5 minced and moist: Using a food processor, crumble a pancake to a crumb-line 2mm particle consistency and add a fruit puree or whipped cream to serve as a sauce. This will help create a cohesive bolus that has texture but can also be easier to move through the oral cavity without chewing or biting required.

Level 6 soft and bite-sized: First, start with a pancake, soft piece of bread (no seeds or textured grains) that is lightly toasted. You can even use a soft dinner roll. Then, chop it to the 8mmx8mm consistency. Finally, use a fruit puree, jelly, or syrup to create a moist, soft piece of food. The benefit of this consistency is that the child does not need to bite off the food and the small pieces require only a moderate amount of chewing prior to bolus transport for swallowing.

Level 7 easy to chew: Again, using a pancake, or a soft, slightly toasted piece of bread, add a fruit puree, mashed banana or avocado, or jelly, then slice the item in strips or columns appx. 8mm wide and long enough for the child to hold and self-feed. The strips make biting easier as the food is already somewhat modified for biting and chewing to help promote appropriate bite-size.

19. How does IDDSI aim to be culturally sensitive and inclusive?

All of the IDDSI testing methods can be performed with culturally-specific utensils (e.g., chopsticks, fingers) and don’t require the use of a fork. This makes IDDSI accessible around the globe, as all testing methods utilize household utensils easily found in any home. Additionally, IDDSI educational materials have been translated into 24 different languages and are easily accessible on the IDDSI website. Lastly, the color coding of the framework was designed to reduce challenges for people with color blindness.

20. What is your favorite IDDSI recipe?

There are so many! We made some amazing soups in a Level 4 puree consistency by pureeing our chicken noodle soup and cream of tomato soup. Both of these soups are broth-based soups, which made them very thin when we initially put them through a blender. They were not able to pass the fork test or spoon test IDDSI testing methods. To thicken the soups while maintaining the flavor, we added cooked rice in the blender with the soups, which helped reach the appropriate IDDSI thickness for Level 4 - puree. Our favorite Level 5 - minced and moist IDDSI recipe that we have created for our pediatric patients is something we affectionately refer to as “Nilla Banana Pudding.” This is a Level 5 - minced and moist consistency which includes shortbread wafer crackers that have been pulsed in the food processor to the proper particle size, and then mixed with a Stage 2 banana baby food puree and some vanilla pudding. The patients love this one! 

References 

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Cichero, J. A., Lam, P., Steele, C. M., Hanson, B., Chen, J., Dantas, R. O., Stanschus, S. (2016). Development of international terminology and definitions for texture-modified foods and thickened fluids used in dysphagia management: The IDDSI framework. Dysphagia. 

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