Understanding the IDDSI Framework
To understand what is level 2 drink, one must first understand the International Dysphagia Diet Standardisation Initiative (IDDSI) framework. The IDDSI provides a standardized, universal system for describing food textures and drink thicknesses, helping healthcare professionals and caregivers communicate clearly and accurately. The framework uses a continuum of 8 levels (0–7), with drinks categorized from levels 0 to 4. This standardized approach helps prevent errors that could be dangerous for individuals with swallowing difficulties (dysphagia).
Why are thickened fluids necessary?
Dysphagia is a condition where a person has difficulty swallowing. Thin fluids, like water, move very quickly in the mouth and throat, making them hard to control for someone with compromised swallowing function. If a thin liquid enters the airway instead of the esophagus, it can lead to aspiration, which increases the risk of serious complications like pneumonia. Thickening agents are added to liquids to slow their flow, giving the person more time to manage the swallow safely. A speech-language therapist will perform an assessment to determine the appropriate fluid thickness for a person's specific needs.
Characteristics of a Level 2 Drink
The IDDSI framework categorizes a Level 2 drink as "Mildly Thick." This consistency is thicker than water and slightly thicker than a Level 1 "Slightly Thick" fluid.
Key characteristics of a Level 2 drink include:
- Consistency: Pours quickly from a spoon, but notably slower than thin liquids like water. It should leave a thin, creamy coating on the back of a spoon.
- Drinkability: Can be consumed from a cup and, with mild effort, through a standard-sized straw.
- Texture: The fluid should be smooth and have no lumps.
- Visual appearance: Often resembles the consistency of a thin shake or some fruit nectars.
How to test a Level 2 drink
For clinical accuracy, IDDSI recommends using the IDDSI Flow Test to ensure the correct thickness. This involves a 10 mL syringe:
- Hold a 10 mL syringe over a cup with your finger blocking the nozzle.
- Fill the syringe to the 10 mL mark with the prepared fluid.
- Release your finger and let the fluid flow for exactly 10 seconds.
- After 10 seconds, place your finger back on the nozzle.
- Measure the amount of liquid remaining in the syringe. For a Level 2 drink, 4-8 mL should remain.
Preparing Level 2 Thickened Fluids
Achieving the correct consistency is critical for safety. It's vital to follow the instructions provided by the healthcare professional and the thickening product manufacturer precisely. Different products and liquids can interact differently.
Here are some best practices for preparation:
- Measure accurately: Use the scoop provided with the thickening agent and follow the liquid-to-powder ratio strictly.
- Mix thoroughly: Stir briskly for the recommended time to dissolve the powder completely and avoid lumps.
- Allow to stand: Many thickeners, especially those based on gums like xanthan gum, need a few minutes to reach their final consistency. Always allow the drink to stand for the time recommended on the packaging before serving.
- Avoid certain foods: Frozen desserts like ice cream and gelatin should generally be avoided unless thickened, as they melt into thin liquids in the mouth.
- Handle different liquids: Beverages with higher fat or acidic content may thicken differently. For example, milk may take longer to thicken, and acidic juices can alter the final texture.
Nutritional Considerations and Challenges
While thickened fluids are a critical safety measure, they can pose nutritional challenges for individuals with dysphagia. Due to altered taste, texture, and the physiological sensation of being full, patients may drink less, putting them at risk of dehydration and malnutrition.
Addressing hydration and nutrition
- Frequent intake: Encourage individuals to sip on thickened fluids frequently throughout the day to ensure adequate fluid intake.
- Hydration monitoring: Caregivers and healthcare providers should monitor hydration levels, for example, by checking urine color, as dark yellow urine can indicate dehydration.
- Nutritional fortification: For those with malnutrition or unintentional weight loss, a dietitian may recommend fortifying drinks with high-protein and high-energy supplements, or using naturally calorie-dense liquids like milky drinks.
- Addressing thirst: Many thickeners can leave a film on the mouth, which doesn't quench thirst. Adding a squeeze of lemon or offering sour-tasting beverages (if safe for the individual) can sometimes stimulate saliva production and provide a more satisfying taste.
Comparison of IDDSI Fluid Levels
| Feature | Level 0 (Thin) | Level 1 (Slightly Thick) | Level 2 (Mildly Thick) | Level 3 (Moderately Thick) |
|---|---|---|---|---|
| Consistency | Water-like | Slightly thicker than water, runs easily off a spoon | Pours quickly but slower than thin liquids, leaves a thin coating on a spoon | Pours slowly off a spoon in a dollop |
| IDDSI Flow Test | Less than 1 mL remaining after 10 sec | 1-4 mL remaining after 10 sec | 4-8 mL remaining after 10 sec | >8 mL remaining after 10 sec |
| Straw Use | Easy | Easy | Requires mild effort | Requires significant effort to impossible |
| Examples | Water, fruit juice | Varies with thickening agent, but thicker than water | Some fruit nectars, thinned shakes | Some commercial supplements, honey-like thickness |
| Who may need it | Healthy individuals | Mild dysphagia | Mild to moderate dysphagia | Moderate dysphagia |
The Role of Healthcare Professionals
A multidisciplinary team approach is essential for managing dysphagia safely and effectively. The speech-language pathologist assesses the swallowing function and determines the correct fluid thickness, while a dietitian helps ensure nutritional needs are met. A pharmacist should also be consulted regarding medication, as thickened liquids can potentially affect drug bioavailability.
In some cases, especially when patients dislike thickened fluids, a "free water protocol" might be considered, allowing un-thickened water intake at specific times with strict oral hygiene protocols. However, this should only be done with the explicit guidance of a healthcare professional. It is a shared decision-making process involving the patient, their family, and the clinical team.
Conclusion
A Level 2 drink is a mildly thick fluid prescribed as part of a nutritional diet for individuals with dysphagia. Its specific consistency, defined by the IDDSI framework, helps to slow down the liquid flow, making swallowing safer and reducing the risk of aspiration. While it is a crucial intervention for safety, careful attention must be paid to preparation, hydration, and overall nutrition to prevent potential complications. A collaborative approach involving a speech-language pathologist, dietitian, and other healthcare professionals is vital for ensuring the individual's safety, nutritional needs, and quality of life are maintained. For more information on the official IDDSI standards and testing methods, you can visit their website.
Resources
- International Dysphagia Diet Standardisation Initiative: The official website provides comprehensive resources and testing methods for all IDDSI levels. [https://www.iddsi.org/standards/framework]
Keypoints
- IDDSI Classification: A Level 2 drink is classified as 'Mildly Thick' by the International Dysphagia Diet Standardisation Initiative (IDDSI).
- Designed for Dysphagia: It is prescribed for individuals with swallowing difficulties (dysphagia) to slow down the flow of liquids for safer swallowing.
- Specific Consistency: This fluid is thicker than water but thinner than honey, pouring quickly from a spoon with a slight coating.
- Clinical Testing: The correct thickness can be verified using the IDDSI Flow Test with a 10 mL syringe, where 4-8 mL should remain after 10 seconds.
- Requires Care: Proper preparation with the correct thickening agent and monitoring of hydration are essential, as some individuals may not drink enough thickened fluids.
- Healthcare Professional Guidance: Prescription and management of thickened fluids should always be overseen by a speech-language pathologist and a dietitian.
