When we talk about dysphagia, so much of our clinical attention gravitates toward airway protection, aspiration pneumonia, what exercises to give, and diet textures. But one area that consistently flies under the radar—and directly affects patient outcomes—is hydration.

Dehydration is common in individuals with dysphagia. When liquids are thickened, restricted, or avoided, patients often experience decreased fluid intake, leading to fatigue, confusion, increased fall risk, constipation, UTIs, and overall poorer rehabilitation potential.

And yet, hydration is also one of the easiest areas to support… when we think beyond thickened liquids and consider all the evidence-based tools available to us.

This post explores:
✔ Why hydration matters in dysphagia
✔ The science behind hydration (including insights inspired by Quench)
✔ How free water protocols and ice chips can safely support hydration
✔ Practical strategies SLPs can use to help patients meet hydration needs
✔ Evidence-based considerations for clinical decision-making

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Why Hydration Is a Clinical Priority in Dysphagia

Patients with dysphagia are at high risk for dehydration due to:

• Reduced oral intake
• Fear of choking
• Fatigue when eating/drinking
• Thickened liquids decreasing palatability
• Inadequate assistance with meals
• Over-restriction of water “just in case”

Dehydration can lead to:

• Increased confusion/cognitive decline
• Headaches and dizziness
• Constipation
• Poor wound healing
• Thickened secretions
• Urinary tract infections
• Increased hospitalizations
• Reduced functional progress in therapy

It affects every system, and yet we rarely screen for it as aggressively as we screen for aspiration.

Hydration can be an important part to add to your Clinical Swallow Evaluation. Asking about normal fluid intake, amount of plant foods consumed (fruits and vegetables). You can also assess skin turgor through a quick check. (Pinch the skin on the top of the hand. If it goes back down immediately, hydration is probably adequate. If the skin stays tented or is very slow to go back down, the person is dehydrated or needs more hydration).

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What Quench Teaches Us About Hydration

The book Quench: Beat Fatigue, Drop Weight, and Heal Your Body Through the New Science of Optimum Hydration highlights a concept that is incredibly relevant for dysphagia management:

“Not all hydration comes from plain water.“

Gina Bria and Dr. Dana Cohen discuss:

• Hydro-bound water—water stored inside plants (think cucumbers, melons, berries), which absorbs more slowly and stays in the body longer
• The importance of electrolytes, fiber, and cellular fluid movement
• How small, frequent sips can be more effective than large boluses
• How dehydration is often the result of poor absorption, not just inadequate intake

For our patients with dysphagia, this reinforces that hydration must be viewed functionally and holistically, not just as “minimum mL of fluid/day.”

This is where strategies like ice chips, water protocols, moist foods, and oral care come into play.

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Free Water Protocols: What the Evidence Says

The Frazier Free Water Protocol (FWP) and variations of it have been well studied.
Common findings across the literature include:

• Patients do not have increased incidence of aspiration pneumonia when protocols are followed
• They often show improved hydration markers
• Quality of life increases
• Patient satisfaction improves
• Oral intake of other foods and liquids increases when water access is allowed
• Thickened liquids remain the prescribed liquid for meals, but water is available between meals with oral care

Why does it work?
Aspiration of clean, thin water is less problematic than aspiration of other substances—especially if the oral cavity is clean.

Key Components of Safe Water Protocol Use

• Strict oral care before water access
• No water during meals (to avoid mixing water with residue)
• Water allowed:
  • Between meals
  • With medications when appropriate
  • During therapy to promote swallow practice
• Careful exclusion criteria (patient-specific):
  • Poor oral hygiene
  • Active pneumonia
  • Severely reduced cognition preventing adherence
  • Uncontrolled coughing or respiratory compromise

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Ice Chips: A Low-Risk, High-Reward Strategy

Ice chips provide:

• Minimal liquid volume per piece
• Slow, controlled melt
• Sensory stimulation for swallow initiation
• Another avenue for comfort and hydration
• A bridge to increased liquid intake

In addition, ice chips can:

• Reduce xerostomia
• Support secretion management
• Increase patient willingness to engage in therapy

Ice chips are often safer for patients who cannot yet manage thin water, and they remain a hydration tool even within water protocol frameworks.

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Practical Hydration Strategies for Patients With Dysphagia

1. Offer Ice Chips Throughout the Day

A low-volume, sensory-rich option that supports both hydration and swallow practice.

2. Use Free Water Protocols When Appropriate

Follow evidence-based guidelines and interdisciplinary collaboration.

3. Increase Moisture Through Food (“Hydro-Bound Water”)

Ideas inspired by Quench and supported by nutrition literature:

• Water-rich fruits (melons, berries, grapes, citrus)-many of these can be mixed into a smoothie
• High-moisture vegetables (cucumbers, tomatoes, zucchini)
• Broths and soups (texture modified as needed)
• Yogurt
• Gelatin
• Applesauce
• Cottage cheese
• Encourage smoothies, that may already be thicker but can provide maximum hydration

These foods provide water that is absorbed more effectively at a cellular level.

4. Encourage Small, Frequent Sips

Large boluses can overwhelm the swallow; micro-sips maximize safety and absorption.

5. Optimize Oral Moisture

• Regular oral care
• Lip moisturizers
• Mouth sprays
• Humidifiers
• Avoiding alcohol-based mouthwashes

Moisture matters for comfort, swallowing, and secretion management.

6. Address Barriers to Hydration

Common issues include:

• Fear
• Fatigue
• Poor assistance
• Unpalatable liquid textures
• Environmental factors

SLPs can collaborate with nursing, dietitians, and caregivers to identify and fix these barriers.

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Clinical Decision-Making: When to Be Cautious

Hydration strategies should always be individualized.
Use caution with:

• Active pulmonary infection
• Poor oral hygiene or xerostomia with thick secretions
• Severe cognitive impairment
• Poor airway protection
• Patients who cannot follow water protocol rules
• Cases of extreme fluid restrictions (CHF, ESRD—coordinate with the medical team)

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Our Role as SLPs

SLPs are uniquely positioned to:

• Advocate for hydration
• Prevent dehydration-related complications
• Recommend individualized hydration plans
• Educate caregivers and facilities
• Integrate therapy with hydration strategies
• Reduce unnecessary dietary restriction

Hydration isn’t just a nutrition issue—it’s a swallowing safety, quality of life, and recovery issue.

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Conclusion

Dehydration is preventable.

With evidence-based strategies—free water protocols, ice chips, hydro-bound foods, oral care, and patient-centered planning—we can help patients hydrate safely while maintaining dysphagia precautions.

Hydration is more than water.
It’s comfort.
It’s recovery.
It’s quality of life.
And our interventions make a measurable difference.

References:

Cohen, D., & Bria, G. (2024). Quench: Beat Fatigue, Drop Weight, and Heal Your Body Through the New Science of Optimum Hydration. Hachette+ ORM.

Panther, K. (2005). The Frazier free water protocol. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 14(1), 4-9.

Gillman, A., Winkler, R., & Taylor, N. F. (2017). Implementing the free water protocol does not result in aspiration pneumonia in carefully selected patients with dysphagia: a systematic review. Dysphagia, 32(3), 345-361.

Gaidos, S., Hrdlicka, H. C., & Corbett, J. (2023). Implementation of a free water protocol at a long term acute care hospital. Scientific Reports, 13(1), 2626.

Pisegna, J. M., & Langmore, S. E. (2018). The ice chip protocol: A description of the protocol and case reports. Perspectives of the ASHA Special Interest Groups, 3(13), 28-46.

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Have you ever wanted a way to create a more standardized protocol for your Clinical Swallow Evaluation?   Do you often forget or leave out parts of the CSE, you know, the parts that are important for your Plan of Care?  You probably need the Clinical Dysphagia Assessment Toolkit if you answered yes.   You can get your copy here.