The IDDSI Framework and Mildly Thick (Level 2) Liquids
The International Dysphagia Diet Standardisation Initiative (IDDSI) was created to establish a universal language for describing food and drink textures for individuals with dysphagia. This standardization helps to improve patient safety and reduces confusion often associated with older, less specific terms like "nectar thick" and "honey thick". Under IDDSI, what is nectar thick in IDDSI is now formally referred to as Level 2, or Mildly Thick.
This level is prescribed by healthcare professionals, such as a Speech-Language Pathologist (SLP), when a person has difficulty swallowing thin liquids, which increases their risk of aspiration (when food or liquid enters the lungs). The mildly thick consistency slows down the liquid's flow, giving the person more time to control the swallow and protect their airway. It is important to note that IDDSI is a continuum, and while mildly thick is a specific category, an individual's needs may vary slightly within that level.
Characteristics of Mildly Thick (Level 2) Liquids
An IDDSI Level 2 liquid has distinct characteristics that differentiate it from other levels. For example, it flows quickly off a spoon but leaves a thin coating. The consistency is thicker than water, similar to a thick fruit nectar, some smoothies, or creamy soups. While it can be sipped from a cup, drinking it through a standard bore straw requires a noticeable amount of effort. This slight resistance helps to give the swallowing muscles more time to coordinate the swallow effectively.
Examples of naturally occurring or modified liquids that can be Level 2 include:
- Fruit nectars (must be tested to ensure correct thickness)
- Some milkshakes and smoothies
- Tomato juice
- Some eggnog varieties
- Thickened water, juice, or milk
How to Prepare Nectar Thick (Mildly Thick) Liquids
Preparing liquids to the correct IDDSI Level 2 consistency is crucial for patient safety. The most reliable method is using a commercial thickener, available in powder or gel form. Always follow the manufacturer's instructions, as the amount of thickener needed will vary based on the brand and the liquid being thickened. Liquids can change consistency over time and with temperature changes, so regular testing is recommended.
Here are some tips for preparation:
- Measure the liquid and the thickener accurately according to the product's directions.
- Add the thickener to the liquid and stir briskly for about 20 seconds.
- Allow the mixture to stand for 1–2 minutes to reach its final thickness.
- Re-check the consistency before serving, especially with hot liquids that tend to thicken further as they cool.
- For carbonated drinks, stirring will cause the drink to lose its fizz but can still be thickened safely.
How to Test for Correct Nectar Thick (Mildly Thick) Consistency
To ensure the liquid is safe for a person with dysphagia, it is best to perform the standardized IDDSI Flow Test. This simple, reliable method uses a 10 mL syringe to measure the liquid's flow rate.
- Remove the plunger from a 10 mL syringe.
- Cover the nozzle with a finger and fill it to the 10 mL line with the prepared liquid.
- Release your finger and start a timer for 10 seconds.
- After 10 seconds, quickly cover the nozzle again and measure the amount of liquid remaining in the syringe.
- For an IDDSI Level 2 (Mildly Thick) liquid, 4-8 mL should remain in the syringe.
This objective test helps to minimize the inconsistencies that were common with the old "nectar thick" terminology. For individuals using a thickener brand for the first time, it is highly recommended to perform this test to ensure the correct consistency is achieved.
The Importance of Correct Consistency
Serving liquids at the incorrect thickness can pose serious risks. If a liquid is too thin, it may be aspirated, leading to respiratory complications like pneumonia. If it is too thick, it can increase the risk of dehydration, reduce quality of life due to an unpleasant texture, or lead to a sensation of early fullness and constipation. An SLP determines the appropriate level for an individual based on a clinical swallow evaluation. It is a critical part of a person's treatment plan to follow this recommendation precisely. Consistency in preparation is key, which is why standardized tools like the IDDSI Flow Test are so important.
Nectar Thick (Mildly Thick) vs. Other IDDSI Liquid Levels
| Feature | Level 0 (Thin) | Level 1 (Slightly Thick) | Level 2 (Mildly Thick) | Level 3 (Moderately Thick) |
|---|---|---|---|---|
| Consistency | Like water; flows quickly | Thicker than water; slower than thin liquids | Thicker than Level 1; comparable to fruit nectar | Like honey; flows slowly |
| Straw Use | Easily drinkable | Flows through a straw | Requires effort to use a standard straw | Requires wide bore straw with effort |
| Flow Test (10s) | < 1 mL remains in syringe | 1-4 mL remains in syringe | 4-8 mL remains in syringe | > 8 mL remains in syringe |
| Spoon Test | Runs freely off a spoon | Runs off a spoon but leaves a slight residue | Runs quickly off a spoon, leaves a thin coating | Drips slowly off a spoon in dollops |
Conclusion: Ensuring Safe and Appropriate Hydration
In conclusion, understanding what is nectar thick in IDDSI means recognizing its place within a standardized, global system designed to protect individuals with swallowing difficulties. Formerly known as nectar thick, this Mildly Thick (Level 2) consistency is thicker than water and requires more effort to swallow, providing crucial time for the person to manage the liquid safely. By utilizing commercial thickeners and performing the reliable IDDSI Flow Test, caregivers and patients can ensure consistency and minimize risks. Always work closely with a healthcare team, especially a Speech-Language Pathologist, to determine the appropriate liquid thickness for specific needs and to ensure proper preparation and monitoring. This proactive approach is key to promoting safe hydration and a better quality of life for those with dysphagia. For more information, the IDDSI website provides detailed resources and testing instructions.
