This document provides information about dysphagia (difficulty swallowing), including how to spot signs of aspiration, appropriate precautions, and management strategies. It outlines choking and aspiration precautions like food consistencies and positioning. Visuals show examples of soft, minced and moist, and smooth pureed diets and how to thicken liquids to a mildly thick consistency. The goal is to safely manage dysphagia and prevent choking and aspiration.

1. What is dysphagia?
In simple terms,dysphagiaisdifficultychewingand/orswallowing. Mostof us swallow 1000 or more timesa
day withoutthinkingaboutit, however, the swallowingprocessisquite complicated. Itinvolvescoordinatingthe
openingandclosingof the mouthand lips,chewingwhilein- andexhaling,mixingfoodwithsaliva,movingitto
the back of the tongue andswallowuntil itreachesthe stomach.Manythingscan go wrongwiththese
activities, causingpeoplewith neurological disabilitiestochoke,aspirate orsuffocate. Infact,chokingand
aspirationpneumoniaare amongthe leadingcausesof deathinadultswith these disabilities.
Previous trainingfocusedmuchonthisprocess.The purpose of thistrainingistofocus onhow to spot
aspiration,chokingprecautions,howtomanage the problemof dysphagiawithclients(includingcompensatory
or rehabilitationtechniques,whichwillnotbe includedinthistraining). Compensatorytechniquesforthis
trainingwill onlyinclude dealingwithfoodanddrinkconsistenciesaswell aspositioningof the client.
How to spot aspiration
While youare feedingwatchforthese signs:
 More than one episode of gagging,coughing,orchokingduringoraftereating/drinking
 Change of Colour(greyness)
 Soundsof RespiratoryDifficulty –wheezing,gurgling,shortnessof breath,gasping
 Loss of Voice or Gurgly/WetSoundingVoice
 RapidheartRate
Overtime watchout for these signs:
 Loss of Weight
 Hunger
 ExcessOral Secretions
 RespiratoryProblems/ChestInfections
 CoughingandChoking
 RefusingtoEat
 More than one episode of gagging,coughing,orchokingduringoraftereating/drinking
 Swallowingfoodwhole
 Frequentupperrespiratoryinfectionsand/orpneumonia.
Precautions
Many individualsdiagnosedwithDysphagiaandotherswallowingdifficultieshave “choking/aspiration
precautions”aspart of theircare/supportplan. Precautionsmayinclude:
- consistencies of food andwhatto avoid(alsosee attachedpicture)
- thickeningof liquids(honey,nectar,etc.) (alsosee attachedpicture)
- properpositioningduringmeal times(see attachedaddendum)
All precautionsare designedspecificallytomeetthe needsof the individualwhohasswallowingproblems.
Whateverthe precautionsare,theyshouldbe followedand communicatedby all staff,especiallywhenmoving
to anotherhome or residential agency. Historicalincidentshave highlightedthe importanceof communicating
thislife-threateninginformation. Whenapersonhas such choking/aspirationprecautions,make sure theyare
part of his/hercare plananddistributedtoall staff membersinthe new home. Youmayevenwantto postor
keepchoking/aspirationprecautionsinthe kitchenareaforall staff tosee and follow. Itiseveryone’s
responsibilitytoensure safetyaroundmealtime.

2. How to manage the problem
Schedule mealtimesforwhenthe individual ismostalertandremove distractions
Positioning- ideal isthe hips,knees,andfeettobe at 90 degrees,andthe headupand centredonthe midline
Texture changes- soft,mincedandmoist,smoothpureed
Modifyamountof food(smallerbites) andlengthentimebetweenbites
Don’ttalk to or ask questionsof the clientwhiletheyare eating
Thickenedliquids- thin/regular,nectar/mildlythickened,honey/moderatelythickened,puddingthickened
Compensatoryand rehabilitationstrategies
Lingual sweep(usingtongue toclearresidue)
Cyclicingestion(liquid,solids,liquid,solids)
Chintuck,headto shoulder
Exercisestostrengthenweakmuscles (e.g. EMST)
THE FOLLOWING WILL BE USED ONLY WHEN A PROTOCOL IS PUT IN PLACE:
Effortful swallow
Double swallow
3 second prep (Count to three then swallow)
Supraglottic swallow (Take food into mouth, breath, hold breath, swallow, cough)
Remaining seated after a meal (allow time for food to settle)
REFER TO ATTACHEDINFORMATION FORVISUALSREGARDING THE FOLLOWING:
SOFT DIET
Foods may be naturally soft or may be cooked or cut to make sure they are soft enough. These foods can be chewed easily
and require no mashing,mincing,or blending. Hard,dry or crumblyfoods should be avoided.
Foods Recommended Foods to be avoided
Bread, cereals, rice, pasta, noodles
 Soft sandwiches with very moistfillings e.g.egg and
mayonnaise,hummus
 Breakfastcereals well moistened
 Soft pasta and noodles
 Rice (well cooked, sticky)
 Soft pastry, e.g. quiche with a pastry base
 Couscous
 Dry or crusty breads (remove crusts) breads with hard
seeds or grains,hard pastry,pizza.
 Sandwiches thatare not thoroughlymoiste.g. sandwiches
with thick cuts of cold meat,salad.
 Coarse or hard breakfastcereals thatdo not moisten easily
e.g. toasted muesli,bran cereals
 Cereals with nuts, seeds and dried fruit
 Filo and puff pastry e.g. sausage rolls.
Vegetables
 Well cooked vegetables served in small pieces and
soft enough to be mashed or broken up with a fork.
 Soft, canned or frozen cooked vegetables.
 All raw vegetables (including chopped and shredded)
 Hard to chew or stringy vegetables e.g.sweetcorn,
broccoli stalks,asparagus, puhu/watercress
Fruit
 Fresh fruit pieces that are naturally soft e.g. banana,
well-ripened pawpaw,ripe melon
 Stewed and canned fruits in small pieces e.g.pears,
peaches,apricots.
 Pureed fruit
 Fruit pieces that pose a choking risk e.g whole grapes,
cherries (remove stones, pips and seeds)
 Large pips
 Dried fruit, seeds and fruitpeel
 Crunchy raw fruit e.g. apple
 Stringy or fibrous fruits,e.g. pineapple,citrus fruit.

3. Dairy
 Yoghurt (may contain soft fruit)
 Soft cheeses e.g.Camembert,Ricotta,cheese
spread
 Yoghurt with seeds,nuts,muesli or hard pieces offruit
 Hard cheeses e.g.cheddar
Foods Recommended Foods to be avoided
Meat fish, poultry, eggs, nuts, legumes
 Casseroles with small pieces oftender meat.
 Moist fish (easilybroken up with the edge of a fork)
e.g. Kina, crayfish, oysters
 Eggs
 Well cooked legumes (the outer skin mustbe soft)
e.g. baked beans,kidney beans,lentils
 Small pieces ofsofttofu
 Dry, tough, chewy or crispy meats e.g.bacon, crackling
 Meat with gristle
 Hard or chewy legumes e.g.lentils,beans,pulses
 Nuts and seeds
Desserts
 Soft puddings e.g.milk or sponge based,trifle,
custard,mousse, bread and butter pudding
 Moist cakes (extra moisture,e.g.custard maybe
required)
 Soft fruit-based desserts withouthard bases
 Creamed rice
 Ice cream (avoid if on thickened fluids)
 Jelly (avoid if on thickened fluids)
 Dry cakes and pastry
 Cakes pastryor desserts containing nuts,seeds,coconut,
dried fruit, pineapple e.g.apple crumble,fruitcake
Extra
 Soup – creamy, thick or blended (maycontain small
soft lumps,e.g.pasta)
 Soft fruit jellies or non-chewylollies
 Soft, smooth chocolate
 Jams and condiments withoutseeds or dried fruit
 Salsa,sauces and dips with small softlumps e.g.
hummus,guacamole
 Soups with large pieces ofmeats or vegetables,corn, or
rice
 Sticky or chewy foods e.g. toffee
 Popcorn,chips,biscuits,crackers,nuts,edible seeds
 Pizza
 Whole fresh or dried herbs e.g. rosemary,basil
MINCED AND MOIST DIET
Food should be able to be easilyminced or mashed with a fork. It may be presented as a thick puree with obvious lumps in it.
Food should be moistand should easilyform into a ball in the mouth
Foods Recommended Foods to be avoided
Bread, cereals, rice, pasta, noodles
 Breakfastcereal with small moist lumps e.g.
porridgeor wheat biscuits soaked in milk (unless on
thickened fluids)
 Small,moistpieces of soft pasta e.g. moist macaroni
cheese (some pasta dishes may require blendingor
mashing.)
 Noodles e.g. udon, egg, 2 minute noodles (may
require blendingor mashing
 All breads,sandwiches,pastries,crackersand dry biscuits
 Rice that does not hold together e.g. parboiled,long-
grain,basmati
 Crispy or dry pasta e.g. edges of a pasta bake or lasagne

4. Vegetables
 Tender cooked vegetables that areeasily mashed
with a fork e.g. potato, kumara,pumpkin, taro.
(Pieces should be less that cm)
 Pureed vegetables e.g. peas,corn
 Raw vegetables e.g. salads
 Large vegetable pieces or vegetables too hard or stringy
to be mashed with a fork.
 Vegetable skins e.g. jacketpotato
 Vegetables that have outer shells or requireextensive
chewing e.g. peas,corn
Fruit
 Mashed softfresh fruits e.g. banana,mango,
kiwifruit
 Finely sliced or diced softpieces of canned or
cooked fruit e.g. pears, peaches. (Pieces should be
less than cm)
 Pureed fruit
 Large pieces of fruitor fruitthat is too hard to be mashed
with a fork.
 Dried fruit
 Stringy fruite.g. pineapple
Dairy
 Yoghurt (may have small softfruitpieces)
 Very soft cheeses with small lumps,e.g. cottage or
cream cheese, cheese spread.
 Yoghurt with pips or hard pieces of fruit
 If eating soft cheese e.g. camembert or brie, avoid the
rind
 Hard cheeses
Meat fish, poultry, eggs, nuts, legumes
 Minced, tender, meats with a sauceor gravy.
Sauces should be the same consistency as
recommended fluids.
 Casseroles or boil up dishes may be blended to
reduce the sizeof larger food pieces
 Blended or flaked/minced fish with a sauce
 Very soft and moist egg dishes,e.g. scrambled eggs,
soft quiches
 Well-cooked legumes e.g. beans, lentils,(partially
mashed or blended)
 Small pieces of softtofu
 Casseroleor mince dishes with hard or chewy pieces e.g.
peas, onion
 The crustor pastry of quiches and pies
 Meat with gristle
 Nuts
Desserts
 Smooth puddings e.g. mousse, custard, instant
puddings
 Dairy desserts e.g. custards, yoghurt and icecream
(unless on thickened fluids)
 Soft moistsponge cake desserts with lots of custard,
cream or ice-cream,e.g. trifle,tiramisu
 Soft fruit-based desserts
 Rice puddingor canned creamed rice.
 Desserts with largeor hard fruitpieces e.g. sultanas,
seeds or coconut
 Crumble or flaky pastry
 Hard crumble or bases e.g. applecrumble
 Bread-based puddings
Extra
 Soup, may contain small softlumps,e.g.
pasta/noodles
 Salsa,sauces and dipswith small softlumps e.g.
hummus, guacamole
 Very soft, smooth, chocolatee.g. able to melt in the
mouth
 Jams and condiments without seeds or dried fruit.
 Soups with largepieces of meat or vegetables, corn, or
rice
 Avoid thin watery soups/broths if on thickened fluids
 Lollies includingfruitjellies,hard sweets,toffee and
marshmallow
 Any fastfood that cannot be mashed with a fork e.g.
pizza,sushi,stir-fry

5. SMOOTH PUREED DIET
Pureed foodis thick, smooth andmoist withno lumps. It requires nochewingandshouldbe one single consistency. It shouldnot
separate into a liquidanda solid. It can be preparedwith a blender, foodprocessor or oldfashioned mouli.
Foods Recommended Foods to be avoided
Bread, cereals, rice, pasta, noodles
 Smooth lump-free breakfast cereals, e.g. Semolina, pureed
porridge, cremoata, babyrice
 Pureed pasta or noodles
 Pureed rice, pureed congee
 Cereals withlumps or large pieces
 All drycereals
 All bread
 Crackers
Vegetables
 Cooked, peeledpureedvegetables
 Smooth, lumpfree mashedpotato
 Pureed vegetables withvisible lumps
 All vegetable skins or pips, seeds (remove before blending)
Fruit
 Cooked, peeled, pureedfruits  Pureed fruit withvisible lumps
 All skins or pips, seeds (remove before blending)
Dairy
 Yoghurt (lump-free)e.g. plainor dairyfood, Greek
 Smooth milk-basedsauces e.g. cheese sauce (thickenedto
correct consistency
 Yoghurt withlumps, pips or piecesof fruit.
All solidandsemi-solidcheese including cottage cheese
Meat fish, poultry, eggs, nuts, legumes
 Pureed meat, chickenor fish;remove all skin, rindandfat
prior to blending (use sauce/gravyto achieveda thick
moist texture – discuss with your SLT if you are on
thickened fluids)
 Soufflésandmousses, e.g. lumpfree salmonmousse.
 Pureed legumes e.g. bakedbeans, lentils, chickpeas (make
sure there are nohusks infinal puree)
 Soft silken tofu
 Pureed scrambled/poachedegg
 Minced or partiallypureedmeats.
 Scrambled eggs (NB:is not pureed consistency)
 Stickyfoods e.g. pate or peanut butter
Desserts
 Dairydesserts e.g. custards, mousse, instant puddings, ice-
cream (avoidif onthickenedfluids)
 Desserts withfruit pieces,seeds, crumble, pastryor non-pureed
garnishes
 NO JELLY OR ICE CREAM (regular consistencywhenit melts in
the mouth)
Extra
 Soups that have been blendedor strainedto remove
lumps
 Smooth jams, condiments andsauces
 Smooth savourydips
 Soup withlumps
 Avoid thinwaterysoups/broths if onthickened fluids
 Jams andcondiments with seeds, pips, pulps or lumps.

6. MILDLY THICK (NECTAR) FLUIDS
Thickened fluids are recommended for people who have difficulty swallowing normal drinks because:
 They move more slowly and are easier to control, giving you more time to swallow
 They may be less likely to go down the wrong way
Mildly thick fluid has the following features:
 It can be sipped from a cup
 It runs fast through the prongs of a fork, and leaves a mild coating on the prongs
Thickening fluids to a mildly thick consistency using a thickening powder
 Thickening powders can be purchased from your local pharmacy. There are also some online ordering options.
Please discuss with your Speech Language Therapist
 Examples of thickening powders are: Nestle: “Resource Thicken Up”, Nutricia: “Nutilis”, and Flavour Creations:
“Easy Thick”
 If you are an inpatient, thickened drinks and thickening powder will be provided during your hospital admission
Method
Pleaserefer to the instructions on the back of the package.Pleasefollowstrictly to ensure the appropriateconsistency is
achieved.
Other tips you may finduseful
 Add the powder very gradually to the drink,whilestirringquickly with a fork or a small hand whisk
 Hand held blenders or food processers arealso useful when preparingthickened drinks in bulk
 Hot drinks need to be made usingvery hot water, so that the powder can be easily dissolved,butbe careful to cool
off before givingit to the client,who might not be ableto discern hot/cold
 For cold milky drinks,shakethe milk drink,add the thickener, then shakeagain very hard, to dissolvethe
thickeningpowder
 If the drink stands for longer than 10 minutes, the thickener may settle on the bottom of the cup. Stir thoroughly
again before drinking.Take care that the drink does not thicken too much when it stands.In this case,add fluid to
get the rightconsistency.
Please ensure that sufficientquantities of fluid aretaken throughout the day. If unsureof how much is enough, please
discusswith Nurse. Some clients don’t want to drink, becausethey distastethickened drinks.
MODERATELY THICK (HONEY) FLUIDS
Thickened fluids are recommended for people who have difficulty swallowing normal drinks because:
 They move more slowly and are easier to control, giving you more time to swallow
 They may be less likely to go down the wrong way
Moderately thick fluid has the following features:
 It can be sipped from a cup
 Fluid slowly drips in dollops through the prongs of a fork
Thickening fluids to a moderately thick consistency using a thickening powder
 Thickening powders can be purchased from your local pharmacy. There are also some online ordering options.
Please discuss with your Speech Language Therapist
 Examples of thickening powders are: Nestle: “Resource Thicken Up”, Nutricia: “Nutilis”, and Flavour Creations:
“Easy Thick”
 If you are an inpatient, thickened drinks and thickening powder will be provided during your hospital admission

7. EXTREMELY THICK (PUDDING) FLUIDS
Thickened fluids are recommended for people who have difficulty swallowing normal drinks because:
 They move more slowly and are easier to control, giving you more time to swallow
 They may be less likely to go down the wrong way
Extremely thick fluid has the following features:
 It cannot be sipped from a cup – it needs to be taken by teaspoon
 It sits on the prongs of a fork and does not flow through
Thickening fluids to an extremely thick consistency using a thickening powder
 Thickening powders can be purchased from your local pharmacy. There are also some online ordering options.
Please discuss with your SLT
 Examples of thickening powders are: Nestle: “Resource Thicken Up”, Nutricia: “Nutilis”, and Flavour Creations:
“Easy Thick”
 If you are an inpatient, thickened drinks and thickening powder will be provided during your hospital admission
Kitchenstaff:
Things to watch out for:
- Be careful not to mix all foods together justbecause they arethe sameconsistency.Some people liketo have each
flavour independently, some likethem mixed, some likecertain things mixed but not everything. Make sure to
includethe patient in the feeding process and ask them if they want things mixed or not. Remember that he/she
has to compromise consistency.Do not compromise the display on the plate, colour of food or taste.
- Mixed consistencies: this is when a food has more than one consistency i.e. cereal has milk which is a thin liquid
and bits of grains which aresolids. If someone has dysphagia itcan bevery difficultto control swallowingtwo
consistencies atonce. Thin fluids travel faster than the solids so when swallowing,the liquidsmay go down but the
solids getleft behind and stick in the back of the throat and may spill into the airway. Alternatively,the fluids go
down before the person is ready and spill into the airway. Some other things with mixed consistencies arecanned
fruitin syrup, soups,etc
- Dry crumbly foods: this type of food is easy to inhaleprior to getting itall mixed with salivaand ready to swallow
i.e. oat biscuits,dry crackers etc.
- Hard and crunchy foods: this type of food takes a lotof chewing and sometimes biting(i.e. apples and carrots).
Sometimes people may be ableto eat a full diet but avoid this consistency i.e.those with dentures find bitinginto
an apple hard,or those with weak/sore jaws may find this too difficult.
- Bitsy foods (i.e. rice,couscous,etc.): this kind of food does not stick well together, meaning itis harder to control in
the mouth especially with poor tongue function. Food that is bound together is easier to swallow.
- Things that change consistency: things that melt change consistencies as they melt. For example, icecream starts
off as a cohesiveball but itturns into a liquid before itis swallowed. This changein consistency can be hard to
control.On the other hand, sometimes extreme temperatures create a greater swallowresponseso a person with
reduced oral sensation may find iteasier to swallowicecream.Other examples of things that melt arejelly,
chocolate,thickened drinks (can become too thick when left for a period).
Preparation tips
- Never puree a whole meal together. Puree each item of the meal and serve separately.
- Puree and season to taste or add seasonings to enhance flavour e.g. dried powdered spices,finely ground mixed or
fresh herbs,pureed garlic/ginger,chilli / BBQ / Soy / Worcestershire/ Mint / Apricot/ Cranberry sauce/ or jellies
(ensure sauces aresmooth consistency and do not contain bits that could stick to your tongue.
- To savetime prepare an extra four servings of each pureed item and freeze in individual servings. Icecubetrays
are useful for this
- Use liquids such assour cream,gravy,cheese sauce,soups,cream, or fruit juiceto add extra energy and taste when
preparingpureed food.
- Commercially prepared stage one (6 month) baby foods area good option, when travelling or out visiting. You may
want to add extra seasoningor flavour to these. E.g. spices,pepper, salt
- Puree meat raw and then again once cooked to reduce the gritty texture.