Nutrition Guide: How to prepare level 2 fluid?

According to the International Dysphagia Diet Standardisation Initiative (IDDSI), a level 2 or mildly thick fluid is essential for those with swallowing difficulties, or dysphagia. Knowing how to prepare level 2 fluid? correctly is crucial for patient safety, preventing aspiration pneumonia, and ensuring proper hydration.

Quick Summary

A comprehensive guide on creating Level 2 mildly thick liquids using both commercial powders and common household alternatives. Detailed steps and best practices are covered to ensure the proper, safe consistency for individuals with swallowing difficulties.

Key Points

• Mildly Thick Consistency: Level 2 fluids pour quickly but more slowly than thin liquids, like runny honey or pouring cream.

• Dysphagia Management: The purpose of thickening is to slow the liquid, giving the individual more control over their swallow and preventing aspiration.

• Use Commercial Thickeners: For best results and consistency, use prescribed commercial thickening powders, following manufacturer instructions carefully.

• Household Options: Ingredients like cornstarch can thicken hot soups and sauces, but commercial products are generally more reliable for all liquid types.

• Safety Precautions: Always measure accurately, test the consistency, and avoid foods that melt into thin liquids, such as ice cream and jelly.

• Nutritional Focus: Monitor fluid intake, as thickened liquids can decrease consumption. Consult a dietitian for advice on fortified drinks or supplements.

Understanding the Level 2 Mildly Thick Fluid

A Level 2 fluid, also known as "mildly thick," is a crucial part of a dysphagia diet, designed for individuals who struggle to swallow thin liquids like water safely. These fluids are sippable from a cup and pour quickly from a spoon, but with less speed than thin liquids. This modified consistency allows for better control during the swallowing process, reducing the risk of aspiration, where liquids enter the airway instead of the esophagus. The consistency is often described as similar to runny honey or pouring cream. A qualified Speech and Language Therapist (SLT) typically recommends this specific thickness based on a swallowing assessment.

Why a Level 2 Fluid is Prescribed

Dysphagia, or difficulty swallowing, can be caused by various medical conditions, including neurological disorders, stroke, or head and neck surgery. For affected individuals, consuming thin liquids can lead to coughing, choking, and a high risk of developing aspiration pneumonia. By slowing the liquid's flow, a mildly thick fluid provides the swallowing muscles more time to coordinate, making drinking safer. It is important to follow the recommendations of an SLT, as the required thickness can vary depending on the individual's specific swallowing difficulty.

How to Prepare Level 2 Fluid with Commercial Thickeners

Commercial thickening powders are the most reliable method for achieving the correct Level 2 consistency. They are tasteless and stable, meaning the liquid's thickness won't change over time.

Method using powder:

1. Start with a clean, dry cup or shaker.
2. Add the recommended number of scoops of thickener to the empty cup, typically 2 level scoops per 200ml of liquid for Level 2, though this can vary by brand.
3. Pour the thin liquid (e.g., water, juice, or tea) directly onto the powder.
4. Stir vigorously with a fork or whisk for approximately 30 seconds, ensuring no lumps remain. A shaker bottle can also work well, especially for milky drinks that can become lumpy when stirred.
5. Let the mixture stand for 1 to 5 minutes to allow the thickener to activate and reach the correct consistency.
6. Tip for fizzy drinks: Stir the drink to remove the carbonation before adding the thickener.

DIY: Thickening Fluids with Household Ingredients

For certain applications, household thickeners can be used, but with caution and careful preparation. These are best suited for hot liquids that will be cooked.

• Cornstarch or cornflour: A common thickener for gravies and sauces, it can be used for soups or hot beverages. It must be mixed with a cold liquid first to create a slurry before being added to the hot liquid to prevent clumping. The thickened fluid should still be smooth.
• Instant potato flakes: Can be added to thicken creamy soups, gravy, or other savory items.
• Pureed baby food: Smooth, pureed vegetables or fruits can be used to thicken fruit juices or other drinks, especially for added nutrients.

Maintaining Nutrition on a Level 2 Fluid Diet

Achieving adequate hydration is a primary concern for individuals on a thickened fluid diet. Because thickened fluids can make a person feel full more quickly, fluid intake might decrease.

1. Variety is key: Offer a range of thickened liquids throughout the day to encourage interest and intake. This can include thickened juices, tea, coffee, and savory soups.
2. Fortified drinks: For individuals needing to gain weight or boost nutrition, incorporating thickened milkshakes, smoothies, or fortified milky drinks can be beneficial.
3. Monitor intake: Keep track of the number of cups or glasses consumed to ensure the daily target is met, typically 6 to 8 cups for an adult.
4. Professional advice: Do not thicken commercial nutritional supplements, as this may alter their effectiveness. Always consult a dietitian or SLT for advice on nutritional supplements.

Comparison of Thickening Agents

Feature	Commercial Thickeners	Household Thickeners (e.g., cornstarch)
Consistency	Highly consistent and stable; works in hot and cold liquids.	Consistency can vary; works best in hot liquids; may become thicker or thinner over time.
Taste/Texture	Neutral flavor and smooth texture; less likely to alter the taste of the beverage.	Can alter the taste and texture (e.g., starchy flavor or texture).
Cost	Typically more expensive than household alternatives, but often prescribed.	Very affordable and readily available.
Convenience	Simple to use; powder is added directly and stirred.	May require extra steps like making a slurry or cooking.
Application	Suitable for all fluids, hot and cold, sweet and savory.	Best for hot soups, sauces, and gravies; less effective for cold drinks.

Safety and Best Practices

• Measure accurately: Always use the scoop provided by the manufacturer and adhere to the specified liquid-to-powder ratio to achieve the correct consistency. Never guess.
• Check consistency: After preparation, use a spoon to check that the fluid pours more slowly than water. For a more precise test, the IDDSI Flow Test is recommended, where a specified amount of liquid remains in a 10ml syringe after 10 seconds.
• Safe storage: Store thickened liquids covered in the refrigerator. Use them within 24 hours to maintain the correct consistency and ensure hygiene.
• Food to avoid: Do not serve items that melt into a thin liquid in the mouth, such as ice cream, jelly, or sorbet. Avoid watery foods like watermelon.
• Positioning: Ensure the individual is sitting upright and alert while drinking to further minimize the risk of aspiration.

Conclusion

Properly preparing a Level 2 fluid is an essential skill for managing dysphagia safely. While commercial thickeners offer the most consistent and reliable results, household methods can be useful for certain applications, provided they are prepared carefully. By following the correct steps, observing safety protocols, and consulting with healthcare professionals, you can ensure proper hydration and nutrition for those with swallowing difficulties. For further information on standardized testing methods, refer to the IDDSI Standards.

Frequently Asked Questions

What is the difference between Level 1 and Level 2 fluids?

Level 1 is 'slightly thick' and is only slightly thicker than water, while Level 2 is 'mildly thick' and is considerably thicker, with a consistency similar to pouring cream.

Can I use household ingredients to thicken liquids?

Yes, household ingredients like cornstarch, instant potato flakes, and pureed baby food can be used, particularly for thickening hot soups and sauces. However, commercial thickeners are more stable and reliable, especially for cold drinks.

Is it safe to drink thickened liquids with a straw?

This depends on the individual's swallowing ability. While mildly thick fluids can be sipped through a straw with some effort, it is critical to consult a Speech and Language Therapist (SLT) to confirm if a straw is safe for the patient.

Why do fizzy drinks need to be stirred before adding thickener?

Fizzy drinks should be stirred to release the carbonation. Adding thickener to carbonated drinks will cause them to bubble up excessively, making the preparation difficult and messy.

How long do prepared thickened fluids last?

Thickened drinks should be covered and stored in the refrigerator and consumed within 24 hours. They may need a quick stir before serving to ensure the consistency is uniform.

What foods should be avoided on a Level 2 fluid diet?

Foods that melt from a solid to a thin liquid in the mouth should be avoided, such as ice cream, jelly, and sorbet. Foods with thin juices, like watermelon, and chunky soups are also not recommended.

What if the thickened liquid is too thick or too thin?

If the liquid is too thick, add more of the unthickened liquid and stir. If it is too thin, add a small amount of extra thickener, stir, and wait for it to reach the correct consistency. Always test with a spoon to check before serving.

Do I thicken all fluids, including milk for cereal and medicine?

Yes, all liquids consumed, including milk for cereals and liquid medication, should be thickened to the correct level unless a healthcare provider advises otherwise. Always check with a pharmacist about thickening medication.