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Thickened fluids position paper

frequently asked questions

The following questions were generated by RCSLT members who attended the thickened fluids

listening event on 30 November 2023. The questions have been split into the sections below.

Alternatives ........................................................................................................................................ 7

Resources ............................................................................................................................................ 8

Evidence .............................................................................................................................................. 9

Other ................................................................................................................................................. 10

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Use of the guidance

How should we use this guidance within our own practice?

a tool to use within the way that you reflect on your own practice already.

Can we use this body of work in Ireland?

Yes, SLTs can use this to influence their work and the people they work with in Ireland. The paper

mentions consent/informed consent and the processes within the UK. It is recommended that a

clinician would need to look at these within the context of the Irish legal system. Everything

within this paper is focused on the principles of evidence-based practice and person-centred care

and, no matter where you work in the world, those principles are still key.

How should SLTs deal with differing clinical viewpoints on the rationale of recommending

safe space to do so.

Has anyone (or a team) managed to go thickener-free in their practice? Do you think that

is the direction of travel?

RCSLT are not advocating for thickener free services, what we are advocating for is person

centred care where the use of thickener is still considered within the toolkit alongside the

potential the risk and burdens associated with it. There are still some service users where using

thickened fluids is the most appropriate intervention. It is vital to recognise the autonomy service

users have in their decisions to use thickener.

framework is to have an awareness of the interventions around EDS, of which thickened fluids is

an intervention. As part of this project consultation, the RCSLT have had representation from

HEIs and researchers. The RCSLT also regularly update CREST, who will have full access to this

paper once it is published.

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Is dysphagia training adequate for SLTs to be questioning more about aspiration

pneumonia diagnosis?

We are undergoing a period of change for pre and post dysphagia training and we hope this

change will improve dysphagia training. Our training is currently inadequate, and our

undergraduate training does not prepare us for understanding respiratory physiology/disease

Associated Pneumonia, Non-Dysphagia Related Aspiration Pneumonia and DAP have overlapping

risk factors, pathophysiology and signs and symptoms. Knowledge of pulmonary physiology and

diseases is not covered well enough in training, but we must embrace it to assess the risk that

dysphagia poses to service users.

What key pieces of evidence would you use to help disseminate change of thickener

practice to a clinical team?

This position paper can be used to disseminate to teams. Hansen et al (2022) and Werden-

Abrams et al (2023) are two systematic reviews that can be used to consider for all clinical

populations. It is also useful to consider pieces of evidence that are relevant to your own clinical

population area, take time to read it and scrutinise it using your own clinical judgement through

might disseminate information. Each service will need to do this individually as there will be

different variables/context to consider.

Please could the panel talk through the process of reducing reliance of thickened fluids in

their services and what alternatives they now offer instead of thickened fluids.

It is important that service users have a swallow assessment before thickened fluids is

recommended. Sometimes other professionals may have introduced thickened fluids without a

swallow assessment with the hope that it will prevent aspiration pneumonia. There may not

always be a need to offer an alternative intervention. It is suggested that clinicians reflect on their

own practice using a person-centred approach following a swallow assessment.

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information leaflet and a non-SLT summary; all of which are open access to the public so

information can be accessible in different ways. External service user organisations and external

professional organisations were invited to be involved in this project. These organisations will be

able to access all resources which can then be shared with their members/service users. The

position paper aims to get people reflecting on thickened fluids and the potential risks and

and sufficient information. SLTs have a crucial role in delving into the medical history, looking at

the circumstances surrounding the possible aspiration event that led to a person's

hospitalisation/diagnosis. It is useful to highlight this in notes – e.g. that it isn’t likely a pneumonia

but rather a pneumonitis because of a reflux event or regurgitation event rather than an

aspiration pneumonia caused by oropharyngeal dysphagia. There are many factors that increase

about the reasons for pneumonia. It is important to share the information to come to a joint

decision on the most likely reason for the aspiration pneumonia to have taken place.

Should care homes / GPs / SLTs still be advising thickener without a clinical dysphagia

assessment and if not, how do we undo that from current practice / service delivery

models?

RCSLT is trying to influence the major conditions strategy and how we can get dysphagia

assessments happening sooner and reduce waiting lists (e.g. having SLTs as first contact

practitioners in GP surgeries). SLTs are currently not on the recognised payable list of first contact

practitioners, and we are lobbying against this. GP surgeries often put service users on thickened

What about using thickened fluids in an acute setting with stroke survivors?

The scope of this position paper does not allow for coverage of different clinical populations and

settings. Instead, it is important that the clinician goes back and considers their own setting in

line with key principles such as:

• Is the service user involved in the informed consent process?

harms and benefits of using thickened fluids.

• Is there an ability to review and monitor the use of thickened fluids?

SLTs may wish to consider referring to research by Maggie Lee Huckabee and Arlene Mccurtain

within stroke service users.

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Non evidence based / anecdotally offered symptom and quality of life management in end-

of-life care - what's the position?

There may be a role in end-of-life care, but clinicians need to consider situations on an individual

basis and look at the evidence in that area. Clinicians may need to consider what their main aim

is i.e. is it to keep someone medically stable, is it to increase their hydration or is it to consider

small adults, they are very different. As SLTs we extrapolate evidence from available research and

apply it to the populations we work with, acknowledging what evidence is appropriate to apply

and what other considerations need to be made. One very important point about the paediatric

population is that they are developing and changing. This must be considered when

recommending thickener, monitoring its impact (positive or negative) and weaning off, as well as

potentially lung changes or persistent / recurring respiratory symptoms. It is vital that

considerations of the risks and benefits should be done in collaboration with the MDT (including

the respiratory team and the paediatrician). These decisions are made as a team and not in

isolation.

Relevance to the paediatric and neonatal population?

The scope of this position paper does not allow coverage of different clinical populations and

settings. It's important to consider that thickened fluids are not used as much with the neonatal

population. This paper would not necessarily change views but more reinforces what we already

know within the neonatal population.

what are the alternatives and what would happen if the service user decided not to engage with

treatment. If the service user is unable to give informed consent, then you need to follow the

path of the best interest decision. When working in a busy environment, and where it is not

possible to present this information, then there is still opportunity to reflect on the treatment.

In terms of monitoring service users on thickened fluids - do you feel those who are on

thickener in the community should be automatically reviewed and monitored by acute

services should they be admitted to hospital - even if they are not showing signs of

deterioration?

Acute services can only see service users if it is related to their admission reason or if there is a

deterioration or change to their swallow. If a service user is on long term intervention, they

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should be routinely reviewed by the team they are under in the community. If a service user is

readmitted into acute care, the SLT needs to investigate the reasons for this and if it is related to

the burden of the use of thickened fluids. If a community service is not commissioned or set up

to monitor service users on long term use of thickener, then they need to consider the risks this

may pose and highlight this to commissioners and senior management teams. We recognise the

beneficial for the individuals? We are thinking to recommend small sips of water with

good positioning and alertness until SLT can assess. Is this a suitable approach?

Anyone who has prescribing rights is an autonomous practitioner and it is their responsibility to

be up to date and understand the benefits and potential burdens of what they are prescribing.

More questions need to be asked during clinical triage e.g. how distressing is the coughing, how

blanket approach for all nursing homes, the advice would not be individualised to each service

user. It is worth considering the benefits of educating the nursing home staff on what to look out

for so that they can monitor a service users’ symptoms and return if they have any concerns.

Is thickener helpful for paediatrics who show overt signs of aspiration on thin fluids but

appears stable and environmental adaptations have already been trialled)? Is there a need

for VF prior to using thickener as intervention in such cases (in the context of very long

wait times for VF)?

It is important to consider why the child is on your caseload. If there are no chest health concerns

Rationale

Do you think thickener is justified for people who struggle to register or hold thin liquid in

their mouth?

It may have a role to play, as may positioning, sensory modification, dispensing devices, and the

environment. Our rationale is ultimately going to be based on what the clinical benefit is for that

difficult because we are dealing with a treatment that has not yet been comprehensively

evaluated by clinical trials. There are three factors we must consider, the first of which is the

biological plausibility of that treatment and how can we confidently reason that there is a cause-

and-effect relationship between thickened fluids and clinical benefit? Secondly, what is the risk

versus benefit profile, including the direct risk to the service user? Finally, what is the cost versus

benefit profile? This includes the investment for both the service user and the clinician to apply a

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therapy.

Could you discuss the rationale for grouping naturally thickened fluids with commercially

thickened fluids?

A consensus agreement was achieved within the working group to include both naturally

fluids and this can be impacted when using both naturally and commercially thickened fluids.

Oral hygiene is important to consider for both naturally and commercially thickened fluids. The

bioavailability of medication is impacted by semi liquid or semi solid foods (this includes both

naturally thickened and commercially thickened fluids). There are studies also that report on the

effect of the electrical charge created by the interaction between commercially thickened

Do the lead authors have a view on recommending thickened fluids from a bedside

swallow assessment vs instrumental assessment within the scope of this paper?

Instrumental assessments such as Videofluoroscopies (VFs) are a useful tool but provide a

snapshot in time of someone’s swallowing. They are not able to solely predict aspiration

pneumonia risk in the future and the impact of what you see on the VF in terms of risk of

aspiration pneumonia survival. It is a useful adjunct to bedside assessment for some people e.g.

to understand the swallow physiology and what interventions may be appropriate. As with all

ways to assess swallowing the results of a VF need to be interpreted within the context of the

individual. We are also aware of the limitations that SLTs have in terms of access to and resource

allocation for instrumental assessments. We are aware that there are large parts of the UK who

assessment to support decision making?

Instrumental assessment is a snapshot and may not predict the rate of aspiration pneumonia

survival. Information gathering is important and will give a lot of answers to the decisions you

need to make. Access to instrumental assessment is not limited to the area of thickened fluids.

Alternatives

What do they see the role of the Frazier free Water Protocol as, at this time of possible

transition?

This position paper is only looking at thickened fluids but several of the referenced studies in the

position paper reference the use of the Frazier free Water Protocol with service users on

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thickened fluids to improve oral intake. The Frazier free Water Protocol already has a role as part

of the speech and language therapy toolkit. Like any treatment, the evidence has a risk of bias,

and we must reflect on what is the risk to the service user of using a Free Water Protocol relative

to thickened fluids, sensory modification, and any of the other treatments that you might use in

your clinical practice.

being ambulatory has an impact on chest health if the service user is on thickened fluids.

If found not to recommend thickener, should we get people off thickener if they have been

on it long term and try new strategies?

It depends on the clinical situation and whether a speech and language therapist feels that there

their quality of life. It is also key to consider whether the person has been placed on thickened

fluids following a robust swallow assessment?

What is our duty of care to children who are on prescribed thickener?

We should not discharge children on thickener because then we would be unable to monitor the

use, the impact, and the outcomes relative to the aims for that child. Children are consistently

developing and changing. Thought therefore needs to go into the practicality of what is the right

time to assess weaning the child off thickener. It is also important to regularly review if the child

still needs thickener.

Resources

More practical guidance for clinicians would be helpful.

Along with the position paper, additional resources such as a podcast, easy read version, a non

SLT summary and practice-based learning scenarios will also be available. There is so much

variation across the UK in terms of service models and individual practices with the use of

thickened fluids it is impossible to be prescriptive about its use. The RCSLT encourage services

and individuals to go back and reflect on their own practice and to consider what they think is

best for their service users.

As clinicians how might we support carers, family members and others involved in a

service user to monitor use of thickener?

your access to support from the MDT. General principles will apply e.g. the use of food and fluid

charts to monitor hydration, and patient leaflets about the potential harms and benefits of using

thickener. Thorough and detailed education as part of the informed consent process will mean

that service users and their carers can then advocate for any changes or concerns. It is key that

the service user and their carers or family members know that they have a choice in the use of

thickened fluids. Involve the service user, carers and family members in decision making, making

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sure they understand risks and benefits, what to monitor, and when and who to contact at any

given time. It is key to help service users and their families understand they are not alone in the

process and that the SLTs have an important role in working and monitoring with them the use

of thickened fluids.

and consider how these can be audited in practice to ensure that consent giving is happening. In

Scotland, clinicians can refer to the Adults with Incapacity Scotland Act. It is important that service

users can express their wishes and are informed about the benefits/risks of using thickened

fluids. Information sharing with service users should be seen more as a teaching opportunity that

can also help the wider MDT understand that we should not just assume that a service user is

Evidence

What are going to be the challenges of addressing some of these gaps in the evidence

base?

As part of the RCSLT research priority setting work, the use of thickened fluids within dysphagia,

Which evidence specifically references the effects of taking medications with thickened

fluids. We have consulted with our pharmacy team about this, and their review concluded

that there was no evidence of a clinical impact of this in service users (apparently a big

mismatch between the in vitro studies and studies in humans). I am just interested to read

the papers you were describing.

The papers referenced in the position paper that are useful to consider are Cichero (2013) and

Marique et al. (2014, 2016). We know that there is an impact on some medication absorption in

patients who have gastroparesis. Some medications also need to be taken on an empty stomach

to enable fast absorption. If you are giving that medication with a thickened fluid, it stands to

itself and not necessarily the commercial chemical properties of a thicker that’s delaying that, if a

medication needs to be taken with a fluid.