In the Thick of It - OSHA...In the Thick of It – Thickening in Dysphagia Abstract: In this...

In The Thick of It

Jennifer Meyer M.A. CCC-SLP Feeding and Dysphagia Resources, PC

In the Thick of It – Thickening in Dysphagia Abstract: In this 90-minute advanced presentation we explore the use and appropriateness of different options and alternatives for thickening in dysphagia across the lifespan. We will learn the different types of thickeners, the importance of their ingredients and pros/cons of each. We review research on use of thickeners in dysphagia treatment, unintended negative side effects, and alternatives or adjuncts to use of thickeners to reduce aspiration. Course Description: Thickening is NOT an exact science. In fact, it is much less exact than we have believed. There are also important, though rarely discussed ramifications of thickening beyond its effects on the actual swallow, including the respiratory and gastrointestinal systems and hydration. We will examine the pros and cons of various thickeners, their ingredients (and why that is important), research on the variables that can affect the viscosity achieved, and the reliability of the VFSS results in predicting the amount of thickening that might be helpful. Information from actual discussions with the FDA and thickener manufacturers regarding use of Simply Thick®, Gelmix®, Carobel® and rice cereal will also be presented. Participants will be taught alternatives to thickening such as various feeding positions, use of different feeding equipment/utensils and when these should be considered. Come away able to integrate this very important information into an evidence-based decision-making process for the best ways to help reduce aspiration in your patients with dysphagia. Objectives: As a result of this course participants will be able to… 1. Explain possible complications of using thickeners. 2. Discuss the pros and cons of various thickeners available. 3. List the benefits of positioning techniques as an alternative to thickening. Take-Aways: Following this session, attendees will be able to…

1. Make the best choice among available thickeners for individual patients. 2. Know what side effects to watch for when using thickeners. 3. Try different positions and equipment to help reduce aspiration, even without thickeners.

Agenda: 0:00 – 0:30 History, Use, and Types of Thickeners 0:30 – 1:00 Issues and Unintended Side Effects of Thickeners 1:00 – 1:30 Alternatives to Thickeners Presenter: Jennifer Meyer, M.A. CCC-SLP Pediatric Feeding Specialist, Developmental Therapist Jennifer Meyer, M.A.CCC-SLP is a Feeding Specialist, Developmental Therapist and popular international speaker in the areas of Pediatric Dysphagia and Neonatal Therapy, receiving exceptional ratings for her courses across the U.S. and in China. She has almost 30 years’ experience specializing in pediatric feeding disorders, working in Neonatal Intensive Care Units, developing inpatient dysphagia, neonatal and outpatient hospital-based feeding programs, Early Childhood Intervention programs, and serving as Assistant Clinical Professor at Texas Woman’s University and the developer and Clinical Coordinator of the

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Copyright © Jenifer S Meyer M. A. CCC-SLP 2019 1

Center for Assisting Families with Feeding and Eating (CAFFE). She has served as a paid consultant to several Home Health companies in the Dallas-Ft., Worth area, including mentoring more than 150 therapists and assisting in the development of a home-based High-Risk Infant program. Through her private practice, Feeding and Dysphagia Resources, she continues to provide consultation and program development for dysphagia services in a wide variety of settings. Through all of her endeavors, Jennifer continues to serve as consultant and mentor in her mission to teach therapists to see themselves as facilitators in treating the child, supporting the family, and bringing back the fun, joy and family connection in eating.

Disclosures: Presenter Disclosure:

Financial: Jennifer Meyer is a co-owner of CEU-Espresso, Inc. and was paid an honorarium for this presentation. She owns a private practice, Feeding and Dysphagia Resources, P. C. in Denton, TX Non-financial: Jennifer is a personal friend and colleague of the inventor of the Res-Q Wedge, discussed in this presentation.

Content Disclosure: This learning event does not focus exclusively on any specific product or service.

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In the Thick of It2.0

Thickening in Dysphagia

Disclosure StatementI have the following relevant relationships in the products or services described, reviewed, evaluated or compared in this presentation.• CEU Espresso, Inc.

• Ownership interest, employee, speaker fee

• Feeding and Dysphagia Resources• Ownership interest, employee, speaker fee

• Res-Q Wedge, Inc.• Friend and colleague of the developer

© 2014 Jennifer S. Meyer, M.A. CCC-SLP All Rights Reserved

Content Disclosure

A number of different thickening products will be discussed in this presentation. The speaker does not have a preference or bias for or against any of the products discussed and for the good of the individuals we serve, endeavors to present objective information about all products discussed.

How This Will Flow

• History & Uses• Ingredients• Starch-Based • Gum-based• Problems with all Thickeners• Answers & Alternatives

Why? – History & Uses

Dysphagia• Better oral control; gives more time to initiate

and organize oral phases ( including s/s/b and/or bolus formation)

• Slowed pharyngeal transit; reduces frequencyof aspiration


• 1960’s: Using naturally thicker foods (Morris, 2013)

• 1980’s Starch-based Commercial Thickeners – (e.g., Thick-It ®)

• 2000’s: Gum-based Commercial Thickeners– (e.g., Simply Thick ®)

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Reflux• Increasing weight of liquid in stomach reduces

frequency and degree of reflux(?)– Adding Rice cereal (1TBS/1 - 4oz. Formula)

(1960’s)– Adding Starch-based thickeners (1990’s)– Adding Gum-based (2000’s)

It’s what’s IN it that matters!

• Starches• Gums• Maltodextrin

Modified Food Starch

• Starch: Corn, Potato, Tapioca, Rice, Wheat

• Treated with acid, heat, or enzymes

Altered for • So that it dissolves

more easily in hot/cold liquids without having to boil the liquid first

• Better performance at different temperatures

• Improve thickening time• Different viscosity

Maltodextrin/Dextrin

• VERY easily digestible carbohydrate derived from starch (corn, rice, potato, wheat)

• Acts like a simple sugar because is broken down into glucose very quickly.

Gums

• Carob /Locust bean gum – Carob bean (legume)

• Carneegan -red seaweed or algae• Cellulose -plant fiber; insoluble• Guar/ Guaran/ Gellan – guar bean (legume)• Xanthan/ Corn sugar gum – fermentation of a

starch/sugar from corn, soy, dairy, wheat with Xanthomonas campistris

Commercial Thickeners

Starch -based Gum-based

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And the hybrids… Starch-basedPros

• Readily available• Low-cost

Cons• Calories (e.g., 14cal/TBS in rice

cereal, 13 kcal/scoop in Altrix, 15 kcal/TBS Thick It)

• Broken down by Amylase in breast milk, saliva

• Additives such as Iron• Constipation• Lumpy• Will separate over time• Can’t use with PEG laxatives

(Carlisle, et. al., 2016)

• Arsenic levels in Rice Cereal?

Arsenic in Nine Brands of Infant CerealA new study finds six times more arsenic in infant rice cereal than in other infant cereals. - December, 2017

Sounding the Alarm“Arsenic in Baby Rice Cereal Higher Than FDA Recommendation, Advocacy Group Finds”

“Should You Be Worried About the Arsenic in Your Baby Food?”

Arsenic in Rice Cereal

• Federal limit for arsenic in drinking water is 10ppb. (In NJ it is 5ppb as originally proposed by EPA). None for foods.

• No long-term studies in U.S. yet • International Agency for Research on Cancer

links it to lung, bladder, skin cancer

The Event That Started It All

• Chile (high exposure x 12 yrs) :• Lung and bladder cancer (Smith, et al, 2013)• Kidney cancer (Ferreccio, et al, 2013)• Higher mortality rate in young adults (Smith, et al,

2012)• Risk continues up to 40yrs after exposure is stopped

(Steinmaus, et al, 2013)

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• Small study linking rice consumption (1/2c per day) to higher arsenic levels in humans (Davis,et.al. 2012)

• Sources of dietary arsenic: Vegetables (24%), Fruit/Fruit juices (18%), Rice (17%)


• 5x more inorganic arsenic than other cereals (e.g., oatmeal)

• 76% domestic rice from AK, LA, MO, TX (highest levels of arsenic in the soil); Gerber now sourcing rice from CA only

• Higher in brown rice than white because of husk

Consumer Reports (2012) recommended no more than 1 serving of infant rice cereal per day.

(1/4 cup= 4 TBS=12 tsp)


• 2016 FDA PROPOSED limit:– of 100mcg/kg or 100ppb for inorganic arsenic in

infant rice cereal– 10mcg/kg or 10ppb for apple juice– 2014 sample showed 47% of Infant Rice Cereals

already met the proposed limit. (Varies per box –Gerber 59-112)

Gum-based Thickeners

Examples:• Simply Thick ® - Xanthan gum; gel• Altrix® – Xanthan gum and Potato starch• Gelmix® - Carob Bean Gum; powdered• Thick It Up ® - Locust Bean, Guar, and Xanthan

gums; powdered• Thicken Up Clear ® - Corn starch and Xanthan

gum; powdered• Thik & Clear ® - Cellulose gum (wood pulp +

cotton) with Maltodextrin; insoluble

Gum-based

Pros• Thickens breast milk

(Not broken down by Amylase)

• More stable over time• Less Lumpy• No change in taste• Do not increase

pharyngeal residue (Xanthan gum)

Cons• NEC?• Stimulates GI Motility• Allergy to

galactomannans or legumes?

• Issues with unhydratedgums?

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Simply Thick ®

• Originally marketed for Adult Dysphagia patients.

• Using it for Pediatric GER is an off-label use!• Linked to NEC in preemies?

Necrotizing Enterocolitis(NEC)

Tissue death in the intestines• Abdominal distention• Bloody stools• Lethargy• Irritability

Simply Thick ® & the FDA

• Onset of NEC usually happens due infection or beginning of enteral feeding.

• May, 2011 FDA posted warning that had become aware of 15 cases of NEC following introduction of Simply Thick ® with 2 deaths.

• Conducted Case Series study (pub’d Aug, 2012) of 22 infants with NEC following ingestion of Simply Thick as reported to the FDA, 2008-2011 showed:– 19 developed NEC after 37 weeks gestational age– 50% developed NEC after going home– 7 died

Simply Thick ®

Why? • Accumulation of short-chain fatty acids

produced by bacterial metabolism of the xanthan gum (Silverman, 2012)

• Overstimulation of a premature gut (Woods, et. Al., 2012)

Current FDA Warnings

• Cautioned against use for all infants under 1 year regardless of age at birth. (April, 2013)

• Simply Thick, themselves caution against use with children under 12yrs with history of NEC.

• Per Dr. Silverman, the FDA is NOT going to change the recommendations and warnings

• No new cases of NEC in older babies since warning came out.

Gelmix®Carob bean (Locust bean) gum and Tapioca Maltodextrin with Calcium Lactate• Carob bean gum used in

Europe for pediatric thickening since 1950’s

• Liquid must be warmed to 100 - 120 degrees before thickener is added. (DO NOT MICROWAVE!!)

• SHAKE• Gets thicker as mixture

cools. (Goes from Nectar to a Thin Honey over 20min.)

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How HOT is that?

100°F = 38°C120°F = 49°C• Boiling = 212°F/100° C• Water from the Instant

Hot Tap = 178°F/81°C• Coffee/Tea are usually

SERVED at 160°F /71°C• Hot tap = 108°F/42°F

Gelmix• Must be at least 6 lbs. (“Medical Advisory Committee”?)

– Update now on website: “Not for use with infants under 42 weeks gestation or under 6 pounds.”

• “Gelmix consultants deemed 6 pounds as the minimum weight to ensure infants have met their term-by date to avoid the development of NEC.” (Melissa, Gelmix; email correspondence, July 24, 2013)

• “The main problem with Simply Thick is the large amount of product needed to thicken to nectar consistency.” Dr. Enrique Hernandez-Sanchez, Pediatric Gastroenterology Consultant, Gelmix (email correspondence, July 24, 2013)

Gelmix

• Starts out nectar consistency; thickens to a Thin Honey within 20 min.

• “Gelmix is dietary supplement for thickening, not a treatment for reflux or dysphagia. While thickening feeds is often recommended for dysphagia/aspiration, GERD, spit-up, etc. GelmixThickener is not intended to diagnose, treat, cure, or prevent any disease.” (Melissa, Gelmix; email correspondence, Feb24, 2014)

Thik & Clear

• Cellulose Gum with Maltodextrin

• No Potassium• Manufacturer will not

give age recommendations

• Mixed at Room Temp. • No further thickening

after 5 min.• 5g for 4oz to nectar

Hydrated vs. Unhydrated Gums

• If powders not mixed correctly, fully, and with enough liquid, may cause esophageal obstruction in patients with swallowing difficulty or esophageal narrowing or dysfunction.

• Put product in first, then liquid

Pre-Thickened Products

Starches and gums

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Pureed Foods

• Pre packaged or homemade.

• Simply Thick EasyMix

Follow the Product Instructions for Preparation

Shaken, Stirred, Whisked,Swirled,…

Thickener Interaction with Foods/Liquids

Literature Review by Chichero, 2013:• Do not bind with water• DO retard drug release• Increase satiety and decrease flavor,

which may decrease food intake• Increase thirst

Interaction with Foods/Liquids(McCallum, 2011)

• Starch thickeners– have calories (due to

carbs); if reducing the volume to compensate, will have less liquid available to obtain other nutrients, including fluids

• Gel Gum thickeners– “Gel thickeners displace

liquid ounce for ounce”• Sharon Lemons, MS, RDN, CSLP, LD

– have little to no calories, but can take up volume, increasing the amount required to obtain adequate calories and all the other nutrients.

– Simply Thick EasyMix® is now down to 6g per nectar packet rather than 15g

Other Types• Protein-based

– Knox Gelatin – collagen from animal by-products– Egg whites– Yogurt – Tofu

• Sugar-based– Agar – from algae– Arrowroot– Potato Flakes– Tapioca

• 2X formula

• Powdered Milk

Flow versus Thickness?

• Viscosity of the bolus – “Thickness”• Density• Yield stress – when begins to break apart• Temperature• Propulsion Pressure• Fat Content

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Temperature

• Temp of liquid at time of mixing?

• Maintaining temp?• Temp in mouth?• Can you freeze and thaw?• Above 170 degrees, no

thickener will maintain thickness

Time

• How long is needed to come to target thickness?

• How long will they maintain that thickness?

• Implications for how quickly you serve the drink and how far ahead you can prepare

• With starch-based thickener, formula gets thicker; Breast milk gets thinner (Almeida, et.al., 2011)

• Rice cereal gets thicker over 30 min; Corn-based gets thinner over 1-4 hrs(Dewar & Joyce, 2006)

Difficulties with all Thickeners

– Saliva: (contains Amylase which breaks down starch)• 90% reduction in viscosity within 10 sec.• 100% reduction after 20 min• “Somewhat less” when gum-base added. (Hansen,

et.al., 2012) – but don’t know what that means


• Different liquids/formulas require different amounts of thickener to come to nectar/honey consistencies (Cook Children’s Hospital)

• Apparent viscosity is also very dependent on how fast the swallow is. (O’Leary, et.al., 2011; Pona, et. al., 2013)


• Thickened barium does not necessarily replicate thickened formula or thickened foods (Stuart & Moltz, 2009; Chichero, et al, 2011)

• Pre-thickened liquids consistently test thicker than those with thickener added (Adeleye, et al, 2007)

Aspirating Thickened Liquids

• Thicker substances are harder to clear

• AR formulas thicken at body temperature and are potentially worse if they thicken in the airways.

• Breast milk in the lungs is still a foreign substance in the lungs.

• Rat study: 100% survival with xanthan gum; 10% survival with starch-based (Domer, 2014)

• If there is viral inflammation, there will be breakdown of the mucosal barriers. If a non-human protein or polysaccharide (gel) is aspirated that could lead to allergic reaction ((Richard Rembecki, M.D., Ph.D., Pediatric Pulmonologist with PhD in Immunology)

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Difficulties with all Thickeners • Higher incidence pneumonia,

dehydration, UTI in group using thickened liquids vs. Chin Tuck (Robbins, et al, 2008)

• May reduce bioavailability of calcium, iron, and zinc (Bosscher, et al2000)

• How do research???

Homemade Thickener??

• Video on YouTube using Xanthan Gum

• Do NOT recommend to your patients

Then What CAN we do?? Answers & Alternatives for Slowing the Flow

1. Positioning2. Pacing3. Equipment4. Appropriate, Careful Thickening

PositioningInfant: elevated side-lying

• Better O2 (Clark, et al, 2007)

Positioning

• Chin Tuck (Robbins, et al, 2008)

• Anterior – Neutral Pelvic Tilt

• Trunk and Head support– 90-90-90 (-ish)– Feet supported

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Pacing

Tipping the bottle down every 3-5 sucks without breaking the seal.

• Supervision• Limiting “bites”

available at any given time

• Calm environment to encourage slowed pace

• Conversation between bites*

*Use Care

Equipment

• Slowing the Flow– Nipples

– Chart by Kelli Jackman, (2013)

Cups

• WOW• Munchkin 360• Purple

Alternatives

• Slowing or Controlling the Flow– Cip Tip– Bionix SafeStraw®– Provale

• Pre-thickened beverages

Frazier Free Water Protocol• A protocol developed at the

Frazier Rehab Institute in 1984 in response to concern over patient and family non-compliance with thin liquid restrictions.

• Premise: aspirating small amounts of uncontaminated water is not harmful.

• After screening, many patients are allowed thin water between meals.

• Must have excellent oral hygeine.

• Use compensatory strategies.

Frazier Free Water Protocol

• Has shown that individuals with good mobility and cognitive status show improved hydration and quality of life and no increase in aspiration pneumonia (Karagiannis & Karagiannis,2014)

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IDDSI

International Dysphagia Diet StandardisationInitiative

1. Standardize terminology an definitions

1. Objective Measurement for thickness

Resources

Take Away

• Thickening is an inexact “science”• So much we don’t know• Go carefully• Recognize that we are never able to

completely eliminate aspiration• Look at the Big Picture

Jennifer S. Meyer, M.A. CCC-SLP

Feeding and Dysphagia Resourceswww.Feeding-And-Dysphagia-Resources.com

FeeDR Pediatric Dysphagia Group on Facebook214-538-7328

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http://www.Feeding-And-Dysphagia-Resources.com

“In the Thick of It – Thickening in Dysphagia” Jennifer Meyer, MA CCC-‐SLP

Bibliography

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characterisation of rheological and material properties. Dysphagia. 2011 Sep;26(3):264-‐71 Clark, L., Kennedy, G., Pring, T., & Hird, M. (2007). Improving bottle feeding in preterm infants: investigating the elevated side-‐lying position. Infant, 3, 154–158. Consumer Reports Magazine November,2012 Arsenic in your food http://www.consumerreports.org/cro/magazine/2012/11/arsenic-‐in-‐your-‐food/index.htm Davis MA, Mackenzie TA, Cottingham KL, Gilbert-‐Diamond D, Punshon T, Karagas MR. (2012) Rice consumption and urinary arsenic concentrations in U.S. children. Environ Health Perspect. 2012 Oct;120(10):1418-‐24. Dewar RJ & Joyce MJ (2006) Time-‐dependent rheology of starch thickeners and the clinical implications for dysphagia therapy. Dysphagia. 2006 Oct;21(4):264-‐9.

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Domer, Amanda et al. “The Effects of Aspirated Thickened Water on Survival of Pulmonary Status in a Lagomorph Model.” UC Davis Study, 2014. Drenckpohl D, Knaub L, Schneider C, McConell C, Want H, Macwan K (2010). Risk factors that may predispose premature infants to increased incidence of necrotiing enterocolitis. Infant Child Adolesc Nutr 2. 37-‐44. Evans-‐Morris, S (2012) in a post on the Dysphagia Listserv From: sem at new-‐vis.com > Date: Thu, 20 Dec 2012 11:24:17 -‐0500 > To: kskrings at gmail.com; dysphagia at dysphagia.com > Subject: Re: [Dysphagia] History of Thickened Liquids Ferreccio C, Smith AH, Durán V, Barlaro T, Benítez H, Valdés R, Aguirre JJ, Moore LE, Acevedo J, Vásquez MI, Pérez L, Yuan Y, Liaw J, Cantor KP, Steinmaus C. (2013). Case-‐Control Study of Arsenic in Drinking Water and Kidney Cancer in Uniquely Exposed Northern Chile. Am J Epidemiol. 2013 Jun 13. Hanson B, O'Leary MT, Smith CH.(2012) The effect of saliva on the viscosity of thickened drinks. Dysphagia. 2012 Mar;27(1):10-‐9.

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Jane, M. G., Chambers, E.,IV, & Molander, M. (2005). Thickened liquids: Practice patterns of speech-language pathologists. American Journal of Speech – Language Pathology, 14(1), 4-13. Retrieved from http://jerome.stjohns.edu:81/login?url=http://search.proquest.com.jerome.stjohns.edu:81/docview/204277532?accountid=14068 May, Angela (2017). Arsenic in Baby Rice Cereal Higher Than FDA Recommendation, Advocacy Group Finds. December 8, 2017. Retrieved January 29, 2018 at: https://www.usatoday.com/story/news/nation-‐now/2017/12/08/arsenic-‐baby-‐rice-‐cereal-‐higher-‐than-‐fda-‐recommendation-‐advocacy-‐group-‐finds/935725001/ McCallum, S (2011) Addressing Nutrient Density in the Context of the Use of Thickened Liquids in Dysphagia Treatment. ICAN: Infant, Child, & Adolescent Nutrition 2011 3: 351 O’Leary M, Hanson B, Smith CH (2011) Variation of the apparent viscosity of thickened drinks. Int J Lang Commun Disord. 2011 Jan-‐Feb;46(1):17-‐29. Park, J., Thoyre, S., Knafl, G., & Nix, B. (2012). Bottle-‐feeding outcomes in very preterm infants: preliminary effects of positioning. Advances in Neonatal Care, 12(4), 242–243. Popa Nita S, Murith M, Chisholm H, Engmann J. (2013) Matching the Rheological Properties of Videofluoroscopic Contrast Agents and Thickened Liquid Prescriptions. Dysphagia. 2013 Feb 14. Questions & Answers: Arsenic in Rice and Rice Products. U.S. Food and Drug Administration. 2017.. Accessed January 29, 2018 at: https://www.fda.gov/food/foodborneillnesscontaminants/metals/ucm319948.htm

Rabin, Roni (2017). Should You Be Worried About the Arsenic in Your Baby Food? December 7, 2017. Retrieved January 29, 2018 at:

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https://www.nytimes.com/2017/12/07/well/eat/should-‐you-‐be-‐worried-‐about-‐the-‐arsenic-‐in-‐your-‐baby-‐food.html Robbins J, Gensler G, Hind J, Logemann JA, Lindblad AS, Brandt D, Baum H, Lilienfeld D, Kosek S, Lundy D, Dikeman K, Kazandjian M, Gramigna GD,McGarvey-‐Toler S, Miller Gardner PJ. (2008) Comparison of 2 interventions for liquid aspiration on pneumonia incidence: a randomized trial. Ann Intern Med. 2008 Apr 1;148(7):509-‐18. Saint Lous, Catherine (2013) Warning Too Late for Some Babies. February 4, 2014 Retrieved 7/25/2013 http://well.blogs.nytimes.com/2013/02/04/warning-‐too-‐late-‐for-‐some-‐babies/

Shaker, C (2011) Post on the Dysphagia Listserv re: Rationale for Sidelying. Subject: [Dysphagia] Sidelying: From: Catherine.Shaker at flhosp.org (Shaker, Catherine) Wed, 20 Apr 2011 21:32:01 -‐0400

Smith AH, Marshall G, Liaw J, Yuan Y, Ferreccio C, Steinmaus C. (2012) Mortality in young adults following in utero and childhood exposure to arsenic in drinking water. Environ Health Perspect. 2012 Nov;120(11):1527-‐31 Steele, C. M., Alsanei, W. A., Ayanikalath, S., Barbon, C. E., A., Chen, J., .Wang, H. (2015). The influence of food texture and liquid consistency modification on swallowing physiology and function: A systematic review. Dysphagia, 30(1), 2-26.doi:http://dx.doi.org.jerome.stjohns.edu:81/10.1007/s00455-014-9578 Steinmaus CM, Ferreccio C, Romo JA, Yuan Y, Cortes S, Marshall G, Moore LE, Balmes JR, Liaw J, Golden T, Smith AH. (2013) Drinking water arsenic in northern chile: high cancer risks 40 years after exposure cessation. Cancer Epidemiol Biomarkers Prev. 2013 Apr;22(4):623-‐30. Stuart,S & Motz, J (2009) Viscosity in Infant Dysphagia Management: Comparison of Viscosity of Thickened Liquids Used in Assessment and Thickened Liquids Used in Treatment. Dysphagia (2009) 24:412-‐422. Total Diet Study. U.S. Food and Drug Administration. 2010. Accessed September 17, 2012 at: http://www.fda.gov/Food/FoodSafety/FoodContaminantsAdulteration/TotalDietStudy/defau Vilardell, N., Rofes, L., Arreola, V., Speyer, R., & Clavé, P. (2016). A comparative study between modified starch and xanthan gum thickeners in post-stroke oropharyngeal dysphagia. Dysphagia, 31(2), 169-179.

Sources:

http://www.dysphagia-‐diet.com/Images/ThickenerComparison_2013.pdf (Thickener Comparison Chart) https://www.fda.gov/Food/FoodborneIllnessContaminants/Metals/ucm319870.htm

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