This is a little different area of dysphagia for me. I decided to look into Food Chaining with a cancer patient with whom I was consulting. Also, writing a course for pediatric dysphagia prompted me into the article I am reviewing this month (after a couple of months of hiatus from the research blogging.) I am blaming lack of time and maybe a little lack of motivation.
My article is Treatment of Selective Eating and Dysphagia Using Pre-Chaining and Food Chaining Therapy Programs. This article is by Cheri Fraker and Laura Walbert. It is available through Perspectives on Swallowing and Swallowing Disorders (Dysphagia)
Food Chaining is method to treat aversive feeding and pediatric dysphagia. This is a great method for preventing aversion and continuing swallowing with patients, both pediatric and adult, that are NPO. This can also work with cancer patients.
When working with infants, pre-chaining may be necessary to develop skills that are necessary for feeding and swallowing in infants that start out or become NPO.
26% of preterm infants are reported to have dysphagia. Infants that are not eating/swallowing need that exposure to flavors and taste. Research also finds that when a patient is NPO, they have decreased secretions with decreased opportunities for dry swallows.
Aspiration can result in significant health issues such as bronchiectasis and pneumonia. Naspharyngeal reflux has been associated with apnea, choking and pneumonia in infants.
When treating the child, treatment goals are for: rehabilitation of the swallow, providing consistent taste and texture stimulation, improvement of oral-motor function, development of feeding skills and prevention or reduction of the risk of developing feeding aversions. Feeding aversion has been found in 25-35% of typically developing children.
Pre-Chaining is working with the infant that is not ready for oral intake. This to some degree, could be adapted for adults as well. Soothie pacifiers are used, as they help to facilitate the lingual groove required for eating and swallowing. Pressure can be provided by the therapist. The pacifier can also be dipped in formula or breast milk to provide taste/sensory stimulation to the infant.
Once able, the infant is given small amounts of liquid to swallow. A Bionix bottle or the Hazelbaker finger feeder may be used to control amount of liquids given at one time. Always ensure that respiratory function, endurance, strength and respiratory skills are intact.
At 5-6 months, it is time to start pre-spoon/cup and a mouthing program is introduced. Textures can be introduced at this time. A Duospoon or Trichew may be use for the mouthing/texture introduction. Flavor can be added to any tool or texture to enhance sensory stimulation.
Food Chaining involves 6 steps for the evaluation: medical evaluation, nutrition assessment, oral-motor/swallowing assessment, nutrition assessment, sensory and fine/gross motor assessment, behavior analysis, food chaining assessment. The evaluation is completed by multiple individuals including the SLP, OT, PT, dietician, physician, etc.
The child is evaluated for food preferences and a food log is kept by the family to determine the child’s diet. This also determines the starting point for the food chaining as you want the child to begin with a pleasurable flavor. Selection of starting consistency will depend on the child’s oral motor function including pattern of mastication and ability to masticate certain textures/consistencies.
The sample food chain given for a child with core diet of animal crackers:
1. Animal Crackers to Teddy Grahams to Graham crackers to shortbread cookies.
2. Add club and Ritz crackers, oyster crackers, saltines, croutons, peanut butter cookies, Nutter Butter
3. Add Ritz Bits (peanut butter and cheese), quesadilla, toasted cheese sandwich
4. Peanut butter sandwich to peanut butter and jelly sandwich, nuts, dried fruit and granola
5. Expand breads to peanut butter on bagels, etc, explore peanut butter on new foods (banana, celery, apple).
Flavor masking is used to improve the acceptance of a new food, by pairing a new food with a dip or combination of a food they already eat and enjoy. Dips, condiments or dry masks (cinnamon, sugar, etc) may be used when necessary.
Both the child and the parent are educated on the food, especially the properties of new foods to increase their ability for sensory exploration. Theme-based meals are used to teach children routines.
This article is definitely worth a look if you are interested in Food Chaining or Pre-Chaining. There is also a book written by the authors of this article and a Facebook group for Food Chaining or a blog.
Consider the implications of Food Chaining with adults, particularly those s/p resection/chemo/radiation for head/neck cancer (or any cancer), s/p CVA. Those patients that have been NPO and have had their tastes altered by some means.
In addition to this post, my experience with using food chaining with a patient s/p chemo/radiation therapy.
I was called in by a colleague to see a patient. She had no idea what else to do with this patient. She was NPO and had to actually use TPN because she was unable to tolerate the tube feeding. She was NPO by choice, so she was still offered po food, just refused it every meal because the smell was nauseating.
We tried some different flavors but nothing worked with this patient. Finally, another SLP came in and asked about trying food chaining. We thought it was worth a shot. We finally found a flavor that tasted good to the patient, melon!
After working on different melon flavors and different fruits, which were hit and miss, the patient actually started trying more and more foods. She still wasn’t eating overwhelming amounts, but it was a start!