What is a Stage 2 Fluid Consistency? (IDDSI Mildly Thick)

According to the International Dysphagia Diet Standardisation Initiative (IDDSI), a stage 2 fluid consistency is defined as 'Mildly Thick' and is prescribed for individuals with dysphagia to improve swallowing safety and prevent aspiration. This modification is a crucial part of managing swallowing disorders, providing a safer, more controlled way to consume liquids.

Quick Summary

A stage 2 fluid consistency, known as IDDSI Level 2 or mildly thick, is a slower-pouring liquid recommended for people with swallowing difficulties. It is typically consumed from a cup, but can be managed with a standard straw with some effort.

Key Points

• Definition: A stage 2 fluid consistency, also known as IDDSI Level 2, is a mildly thick liquid designed for safer swallowing.

• Characteristics: It is easily pourable but flows slower than thin fluids, leaves a thin coating on a spoon, and can be consumed with mild effort via a cup or straw.

• Purpose: It is used for individuals with dysphagia to reduce the risk of choking and aspiration (liquid entering the lungs).

• Preparation: Commercial thickener powders are added to thin liquids according to manufacturer instructions, and the mixture must stand for a specified time.

• 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.

• Safety: Foods that melt into thin liquid (like ice cream) should be avoided, and all liquids, including those for medication, must be thickened.

• Professional Guidance: A healthcare professional, such as a Speech and Language Therapist, should always recommend and monitor the use of thickened fluids.

Understanding the IDDSI Framework

For many years, inconsistent terminology for modified diets created confusion and increased risks for individuals with dysphagia, or swallowing difficulties. The International Dysphagia Diet Standardisation Initiative (IDDSI) was created to provide a universal framework of standardized terms, definitions, and testing methods for texture-modified foods and thickened fluids. This framework is now used by healthcare professionals worldwide to ensure patient safety and consistency in care.

IDDSI describes a range of eight levels, from 0 (Thin) to 7 (Regular). Stage 2 fluid consistency, or IDDSI Level 2, is the second thinnest level of thickened fluid on this scale, providing a safe starting point for many individuals who cannot tolerate thin liquids.

Characteristics of Stage 2 Fluid Consistency (Mildly Thick)

Stage 2 fluids are distinctly different from thin liquids like water, flowing more slowly to allow for better oral and swallowing control. Here are the key characteristics:

• Pourable: While thicker than water, this consistency is still easily pourable, similar to the consistency of a thin syrup or fruit nectar.
• Slower Flow: The liquid moves at a slower rate than thin fluids, which gives individuals with dysphagia more time to react and organize the bolus for a safe swallow.
• Spoon Test: When pouring the liquid off a spoon, it should flow quickly but at a noticeably slower pace than unthickened drinks, leaving a thin coating on the spoon.
• Straw Use: A standard straw can be used to drink this consistency, but it requires a mild increase in effort compared to thin liquids.
• Lump-Free: The fluid must be completely smooth and free of any lumps, chunks, or pulp, which can pose a choking hazard.

The IDDSI Flow Test for Verification

The IDDSI framework provides a simple and effective testing method to ensure the correct consistency is achieved. This process uses a standard 10 mL syringe with a specific nozzle opening, following these steps:

1. Cover the nozzle of the syringe with a finger.
2. Fill the syringe with 10 mL of the prepared fluid.
3. Release your finger and allow the fluid to flow out for exactly 10 seconds.
4. After 10 seconds, place your finger back over the nozzle and measure the amount of fluid remaining in the syringe.

For a true stage 2 fluid consistency (Mildly Thick), the remaining volume should be between 4 mL and 8 mL.

Who Benefits from a Stage 2 Fluid Consistency?

This consistency is typically recommended by a Speech and Language Therapist (SLT) after a swallowing assessment. It is indicated for individuals with dysphagia who have difficulty managing thin or slightly thick liquids due to issues such as:

• Slowed Swallow Reflex: A delayed trigger of the swallowing reflex means that thin liquids may enter the airway before the protective mechanism can engage.
• Poor Oral Control: Individuals with poor tongue or lip strength may struggle to form and control a liquid bolus in their mouth, leading to spills.
• Recurrent Aspiration: For some, thin fluids may repeatedly enter the airway and lungs (aspiration), potentially causing chest infections like pneumonia.

By thickening the fluid, its movement is slowed, giving the individual more time to safely manage the swallow.

How to Prepare Stage 2 Thickened Liquids

To prepare a mildly thick fluid, a commercial thickening powder or gel is typically used, following the manufacturer's specific instructions.

1. Gather Ingredients: Obtain the prescribed thickener and the liquid to be thickened. Common liquids include water, juice, milk, coffee, and tea.
2. Measure Accurately: Measure the liquid precisely, as the ratio of thickener to liquid is crucial for achieving the correct consistency. Use the scoop provided with the thickener for accurate measurement.
3. Mix Thoroughly: Add the thickener to a clean, dry cup and then pour the liquid on top. Stir briskly with a fork or whisk for at least 30 seconds until the powder is fully dissolved and there are no lumps. Stirring with a spoon can sometimes cause lumps.
4. Allow to Stand: Let the mixture stand for the time specified by the manufacturer, typically one to five minutes, to allow the thickening process to complete. Some liquids, like milk-based drinks, may require a longer standing time.
5. Re-Check Consistency: Before serving, perform the IDDSI Flow Test again to confirm the correct consistency has been reached.

Important Considerations and Safety Tips

Properly managing a thickened fluid diet is critical for patient health and safety. Healthcare providers must work with patients and caregivers to address potential challenges and ensure compliance.

• Dehydration Risk: Some individuals may find the taste or texture of thickened fluids less palatable, which can lead to reduced fluid intake and dehydration. It is important to encourage consistent fluid consumption and offer a variety of thickened beverages to find preferences.
• Medication: All liquids, including those used to take medication, must be at the prescribed consistency. This may require consulting a pharmacist or doctor about alternative forms of medication, such as a tablet that can be crushed and mixed with a small amount of thickened fluid.
• Foods that Melt: Avoid giving foods that melt from a solid state into a thin liquid, such as ice cream, jelly, and sorbet, as these can pose a significant aspiration risk.
• Cross-Contamination: Leaving spoons in thickened drinks can cause the consistency to break down due to enzymes in saliva. Always serve the drink fresh and use a clean utensil.
• Professional Consultation: Always consult with an SLT or other healthcare professional before making any changes to a patient's thickened fluid level.

Table: IDDSI Liquid Levels at a Glance

IDDSI Level	Name	Characteristics	How to Test (10 mL syringe, 10s)	Example	Drinking Method
0	Thin	Flows like water; no lumps.	Less than 1 mL remains.	Water, juice, coffee.	Cup or straw.
1	Slightly Thick	Thicker than water; flows through a straw.	1-4 mL remains.	Thinner milkshakes, some nectars.	Cup or straw.
2	Mildly Thick	Pours quickly from a spoon; slower than water.	4-8 mL remains.	Fruit nectars, thick milkshakes.	Cup or straw (mild effort).
3	Moderately Thick	Pours slowly; drips off a spoon.	More than 8 mL remains.	Honey, custard.	Cup (with care) or spoon.
4	Extremely Thick	Holds its shape; cannot be poured.	10 mL remains.	Pudding, thick yogurt.	Spoon.

Conclusion

A stage 2 fluid consistency, known as Mildly Thick under the IDDSI framework, is a critical dietary modification for many individuals with dysphagia. By providing a slightly thicker, slower-moving liquid, it significantly reduces the risk of aspiration and promotes safer swallowing. Proper preparation, regular testing, and close supervision by healthcare professionals are essential for ensuring both the safety and hydration of the patient. The use of a standardized system like IDDSI has been pivotal in improving patient care and communication across the healthcare spectrum.

For more information on the IDDSI framework, you can visit the official website: IDDSI Framework.

Frequently Asked Questions

What is the difference between a slightly thick (Level 1) and mildly thick (Level 2) fluid?

A slightly thick fluid (Level 1) is thicker than water but still flows easily, while a mildly thick fluid (Level 2) pours more slowly and requires more effort to drink through a straw.

Can I use household ingredients like cornflour to thicken liquids?

While some household ingredients can thicken liquids, using commercial thickeners is generally safer and more consistent. Always consult a healthcare professional before using alternative methods.

What happens if I don't mix the thickener correctly and lumps form?

If lumps form, you must discard the drink and start over. A lumpy drink is a choking hazard and should never be consumed. Ensure you stir briskly immediately after adding the thickener.

How long can I store pre-thickened liquids?

Storage times can vary depending on the thickener and liquid. Generally, cold drinks can be prepared in advance, but they should be stored in the refrigerator and discarded after 24 hours.

Can I have ice cream or jelly on a stage 2 fluid diet?

No. Ice cream and jelly are considered thin liquids because they melt at body temperature. They should be avoided entirely to prevent aspiration.

What if I don't like the taste or texture of thickened fluids?

Talk to your healthcare team about exploring different types of thickeners and flavors. Proper hydration is essential, so it's important to find acceptable options.

What should I do if my swallowing problem seems to be getting worse?

Contact your Speech and Language Therapist immediately. They can re-assess your swallowing function and determine if a different fluid consistency is necessary.