Tom, a fourth grade student with cerebral palsy, is only able to chew foods that are very soft. Most textures are difficult for him to chew. His private feeding therapist has him on a minced and moist diet for safety. He receives his breakfast and lunch through the school cafeteria meal plan.
What Should a School-based SLP Do?
Most professionals think about dysphagia in terms of adults and babies, but there are many children with dysphagia attending public schools and eating 2 meals per day at school. Like dysphagia patients in the hospital settings, these clients often eat meals prepared in cafeterias. This article will share with readers how students with dysphagia can eat modified, safe, nutritious, meals at school and the school-based SLP’s role with providing this service.
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What Should Happen in the Cafeteria?
All children, including those with dysphagia, should be able to eat safely and efficiently in the school cafeteria. Federal laws and regulations protect children with disabilities from discrimination and ensure appropriate accommodations related to school activities and nutrition services are made available (Castillo et al, 2010). The school cafeteria manager is responsible for making sure that students with special diets receive the foods that follow their diet requirements.
For example: a student with a milk protein allergy will have foods on their tray that do not contain any milk protein.
In the United States, the school cafeteria program is a federal program that has specific regulations that must be followed for the health and safety of children. When a student requires a special diet, a Meal Modification Form must be completed and signed by the student’s physician annually. This form should specify the student’s diet restrictions and alterations and is only required when changes are necessary before the student picks up his tray (Department of Agriculture, 2012). Once the cafeteria manager knows the student’s recommended diet, they can then individualize the student’s tray.
How Does the Cafeteria Manager Know Which Foods to Include for the Child with Dysphagia?
Students with dysphagia often have specialized feeding recommendations. A cafeteria manager will not know how to prepare the student’s tray unless a trained, school-based SLP establishes a safe swallowing and feeding plan for the classroom and cafeteria staff to follow. The student’s tray needs to be adapted in the cafeteria when the school team determines that he/she needs to have a diet modification that falls between soft and bite-sized to mildly thick liquids, according to the International Diet Framework (ASHA Leader, 2016)
All children, including those with dysphagia, should be able to eat safely and efficiently in the school cafeteria. Federal laws and regulations protect children with disabilities from discrimination and ensure appropriate accommodations related to school activities and nutrition services…
How is a Safe Swallowing and Feeding Plan Established?
The school swallowing and feeding team (SLP, OT, nurse) work collaboratively to establish a safe feeding plan. This is done by:
- Interviewing the parents to determine the student’s medical history, feeding history, feeding habits, cultural considerations, and parental concerns. When there are questions regarding the student’s medical conditions the SLP gets a Release of Information form signed by the parents to share and receive information from the physician(s).
- Conducting an interdisciplinary team clinical evaluation documenting the student’s reactions to different foods, textures, and liquid consistency, and noting sensory and behavioral observations (Lefton-Greif, M. & Arvedson, J., 2016).
- Recommending an instrumental evaluation (Video fluoroscopic Swallow Study (VFSS) or Fiberoptic Endoscopic Examination of Swallowing (FEES)). When indicated, the school SLP will work with the parents to obtain a physician script and attend the study with their student.
- Writing a swallowing and feeding plan. This plan should include the following information:
- Identifying information such as student’s name, school, date of birth, swallowing and feeding team, and date of plan.
- Brief case history including significant medical and feeding history.
- Feeding recommendations: positioning, equipment, diet/food preparation (food and liquid consistency), and precautions (foods to avoid, amount of food per bite)
Note: If an VFSS is recommended the team will establish a safe feeding plan based on the clinical evaluation and parent interview which may need to be revised once the results of the study are received.
Back to the cafeteria, how do they know what foods to put on a student’s tray?
The SLP meets with the cafeteria manager:
- Reviews the monthly menu (which repeats every month) to design a special monthly menu that complies with the student’s swallowing and feeding plan.
- Substitutes foods which do not meet the requirements of the student’s plan with nutritionally similar foods on the monthly menu. This process gives the cafeteria staff the information they need to prepare the student’s tray for the school year.
How Does the Classroom or Cafeteria Staff Know How to Prepare the Recommended Diet?
The classroom or cafeteria staff need to be trained on preparing the food according to the recommendations on the swallowing and feeding plan (Bailey & Lugg, 2009). The SLP provides “hands on” training on the different textures such as minced and moist or pureed, so that the staff can consistently modify the foods on the student’s tray.
How is the food altered?
The trained classroom or cafeteria staff modify the food based on the student’s plan at a blending station set up in the kitchen. Equipment needed for food preparation is assessable to the staff and the food on the tray is modified. Cafeteria staff are responsible for washing and sterilizing the equipment.
Students Eat Safely and Efficiently with Their Peers!
The cafeteria procedure and training should be done immediately and put in place as soon as possible to facilitate the student eating safely at school (Homer, 2016). The results of the school-based team efforts are that students with swallowing and feeding disorders are able to do the following:
- Eat in the cafeteria with their peers
- Eat a cafeteria prepared meal that is safe and nutritious
- Eat within the typical lunch period
This article shared how a school-based SLP can work with other school personnel and parents to establish a safe feeding plan for children in the schools with swallowing and feeding concerns. So what about Tom? In his new school district, his swallowing and feeding skills were quickly assessed, a safe feeding plan was established, the cafeteria plan was put in place and he is now eating safely in the school cafeteria with his classmates!
Links of Interest
Emily’s New Book: Management of Swallowing and Feeding Disorders in Schools
System-approved Swallowing and Feeding Procedure- Flowchart
ASHA Leader (2016). ASHA Supports International Dysphagia Framework. The ASHA Leader, March, Vol. 22, 60. doi:10.1044/leader.AN1.22032017.60
Bailey, R. & Lugg, E. (2009). Avoiding disputes in school-based management of students with dysphagia: five key strategies. SIG 13 Perspectives on Swallowing and Swallowing Disorders (Dysphagia), Vol. 18, 97-102. doi:10.1044/sasd18.3.97
Castillo, A., Carr, D., & Nettles, M.F. (2010). Best practices for serving students with special
food and/or nutrition needs in school nutrition programs. School nutrition association, 34.
Department of Agriculture Food and Nutrition Service: Nutrition Standards in the National School Lunch and School Breakfast Programs, 77 Fed. Reg. (January 26, 2012) (to be codified at 7, C.F. R. pts. 210 & 220.
Homer, E. (2016). A time-tested procedure for addressing swallowing and feeding in the school setting. In E. Homer (Ed), Management of swallowing and feeding disorders in schools. (69 – 106). SanDiego: Plural.
Lefton-Greif, M. & Arvedson, J. (2016). Pediatric feeding /swallowing: yesterday, today, and tomorrow. Seminars in Speech and Language. Vol. 37, No. 4., 298 – 309.