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FAQ - Drinks (Levels 0-4)

Q: How do I know which level to recommend for a patient?” also “Is it okay to include X food or drink for a patient who is on diet Y?”     
A: These are common questions we regularly receive. It t is important to understand that: 
The IDDSI framework is “descriptive” not “prescriptive” meaning it does not match a particular diagnosis or condition to any particular IDDSI level. The decision regarding which IDDSI Level of foods and drinks to recommend should only be made once the patient/individual has been assessed by a clinician trained in dysphagia assessment and management.  
Q: How do I know a particular food or drink is OK to offer?    
A: Food/drinks vary in consistency depending on temperature, moisture, freshness/ripeness, method of cooking, etc. The BEST and RECOMMENDED way to ensure a food is appropriate for any particular IDDSI level is to  use the recommended testing methods. 

Q:  My facility only uses two levels of drink thickness. Do we have to use all of the IDDSI drink thickness levels?
A:  No, although the IDDSI framework includes five different levels of increasing drink thickness, there is no expectation that every facility will use all five levels. For example, some aged care facilities may only use Level 0 -Thin, Level 3- Moderately Thick/Liquidised and Level 4 – Extremely Thick/Pureed. By labeling the drinks in this way, when a patient/client moves from a facility with fewer drink levels to a hospital with more drink levels, it will be faster, safer and more accurate for health professionals and care staff to provide the appropriate drink thickness level.

Q:  I’ve not heard of Level 1 – Slightly Thick before, what is this level?
A:  Level 1 – Slightly Thick is predominantly used by paediatric clinicians and refers to the thickness level similar to commercially prepared anti-regurgitation infant formula. It is noticeably thicker than regular Level 0 – thin drinks, but thinner than Level 2 – Mildly Thick drinks. Level 1- Slightly Thick slows the flow of the liquid but can be sucked through a nipple/teat without significant effort. Level 2 Mildly Thick fluids also flow more slowly, but due to their thickness require much more effort to suck through a nipple/teat. Clinicians working with adult caseloads may find that some products that they have previously described as “naturally thick” fall in this Level 1 – Slightly Thick category.

  • Cichero JAY, Nicholson T, Dodrill PM. Barium liquid is not representative of infant formula: Characterisation of rheological and material properties.  Dysphagia. 2011; 26(3): 264-271.
  • de Almeida MB, de Almeida JA, Moreira ME, Novak FR. Adequacy of human milk viscosity to respond to infants with dysphagia: experimental study. J Appl Oral Sci. 2011;19(6):554–9.
  • Stuart S, Motz JM. Viscosity in infant dysphagia management: comparison of viscosity of thickened liquids used in assessment and thickened liquids used in treatment. Dysphagia. 2009;24(4):412–22.
  • September C, Nicholson TM, Cichero JAY. Implications of changing the amount of thickener in thickened infant formula for infants with dysphagia. Dysphagia. 2014; 29(4): 432-437.

Q:  My facility has used the terms ‘nectar’ and ‘honey’ for decades; why weren’t these terms used in the IDDSI framework?
A:  Two international stakeholder surveys were conducted regarding texture terminology, and received more than 5000 responses. Although the terms ‘nectar’ and ‘honey’ were widely understood in some parts of the world, they were not understood in other parts of the world, particularly Asia. Other considerations included the natural variability of ‘honey’ in its crystalline and liquid states, and that the food honey is a botulism risk for infants under the age of 12 months. As an international framework suitable for use across the age spectrum, it was decided that terms that described variations of drink thickness would be most appropriate.

Q:  Why do Level 3 ‘Liquidised’ foods and ‘Moderately thick’ drinks share the same number and why do Level 4 ‘Pureed’ foods and ‘Extremely thick’ drinks share the same number?
A:  During the testing phase of IDDSI framework development, the committee came to the realization that at Level 3 liquidised foods and moderately thick drinks share the same flow characteristics and descriptions.  The same is also true for Level 4 pureed foods and extremely thick drinks.  By using the same number and colour to identify both foods and drinks at each of these levels, the IDDSI framework demonstrates this equivalence in texture. We decided to retain separate text labels for foods and drinks at each of these levels based on feedback from food service professionals who told us that they need to be able to label an item as a food or a drink, in addition to its texture characteristics. We are able to differentiate between foods and drinks using the inverted triangle for foods and the upright triangle for drinks.

Q:  Won’t fruit smoothies and liquidised soups clog up the syringe?
A:  The official IDDSI recommendation is that products in Levels 0-4 should be smooth and homogeneous, without particles or lumps.  If you are blending a smoothie or a soup, then you must take care to ensure there are no lumps or seeds. If particles clog the syringe during the IDDSI Flow Test, then additional blending or passing through a sieve is recommended. The IDDI Flow test has been successfully used to measure the thickness of soup and smoothies. It is also sensitive enough to show changes in consistency with a change in temperature. It should be noted that the IDDSI Flow Test is designed to confirm the flow characteristics of levels 0-3.  Level 4 Extremely thick fluids will not flow through the syringe or may pass only 1-2 droplets. At this level, the Spoon Tilt Test and Fork Drip test are recommended to confirm sample characteristics.

Q:  What does a 10 mL Slip Tip syringe look like and can I be sure it is the same around the world? 
  A 10 mL ‘slip tip’ syringe is shown in the photo below. It is sold as a plastic sterile hypodermic syringe for single use. It is also known as a ‘Luer slip tip’ syringe. The tip of the syringe is smooth and without a locking system.  It does not matter if the tip is situated to be central or eccentric (positioned off to one side). Although 10 mL syringes were initially thought to be identical throughout the world based on reference to an ISO standard (ISO 7886-1), it has subsequently been determined that the ISO document refers only to the nozzle of the syringe and that variability in barrel length and dimensions may exist between brands. The IDDSI Flow test uses a specific reference syringe with a measured length of 61.5 mm from the zero line to the 10 mL line (BDTM syringes were used for the development of the tests – manufacturer code 301604). IDDSI is aware that there are some syringes that are labeled as 10 mL, but in fact have a 12 mL capacity.  Results using a 12 mL syringe will be different to those from a true 10 mL syringe.

  • ISO-7886-1: 1993 (E) Sterile hypodermic syringes for single use: Part 1: syringes for manual use. International Standards Organisation www.iso.org 

Q:  When I test the sample using the IDDSI Flow test I have exactly 8mL left in the syringe – is this Level 2 or Level 3? 
The sample is neither Level 2 nor Level 3. A sample that tests at exactly the IDDSI cut-off point of 8 mL is exactly between levels 2 and 3.  It needs to be adjusted to meet either the Level 2 Mildly Thick of Level 3 Liquidised or Moderately Thick requirements. 
 The same is true of a sample that tests at exactly 4 mL. It is neither a Level 1 nor a Level 2, but between levels.  Likewise it would need recipe adjustment to allow it to test at either Level 1 Slightly thick or Level 2 Mildly Thick as desired.

Q:  If there is no flow (or 1 or 2 drips) through the syringe after 10 seconds, does that automatically make the sample a Level 4 – Pureed or Extremely Thick? 
  No. If there is no flow (or only 1 or 2 drips) through the syringe after 10 seconds, then the sample is thicker than Level 3 – Liquidised or Moderately thick. The sample should then be tested using the Spoon Tilt test and the Fork Drip test to see if it meets the requirements for Level 4 Pureed or Extremely Thick.   Follow the descriptors for Level 4 Pureed or Extremely thick. 

It is possible that a sample will be too thick to flow through the syringe, but NOT meet the requirements for Level 4. Some common problems include slumping, the sample leaving a sticky residue on the spoon, and the sample having a long tail under the fork when assessed using the Fork Drip test.  In these cases the sample is neither a Level 3 nor a Level 4. It is between levels. The sample needs to be adjusted to meet either the Level 3 or Level 4 requirements.