Most people swallow without thinking about how it is done. This is because swallowing involves a series of complex actions that coordinates automatically and precisely with breathing.

That automatic response can go out of sync for someone who has swallowing difficulties (dysphagia), such as chewing or controlling the foods or liquids in their mouths. When that happens, choking can result, and the foods or liquids then go into the airways or lungs — instead of the stomach — which can lead to aspiration pneumonia, a form of lung infection.

“Severe pneumonia and choking can be fatal,” said Ms Lee Yan Shan, Principal Speech Therapist, Speech Therapy Department, Singapore General Hospital (SGH). In Singapore, pneumonia is the second leading cause of death after cancer. This count includes all sorts of pneumonia, including aspiration pneumonia.

Fear of choking or having food stuck in their throats often leads people with swallowing difficulties to restrict what they eat or drink. However, this can put them at risk of dehydration and malnutrition. At the same time, they may also avoid eating with family and friends, leading to social isolation and depression, Ms Lee added.

Swallowing rehabilitation is one way of managing swallowing difficulties. This involves teaching patients to chew and swallow more slowly, swallow more often to ensure food and liquids go down the throat safely, use different spoon sizes to eat different amounts, and to cough periodically to expel potential aspiration, said Ms Lee.

Not all dysphagia patients display coughing or other signs indicating that food or liquid is going into the lungs. “No coughing does not mean that there is no problem because for some people, their cough response is very delayed or poor,” she said, pointing out that some patients, such as those with advanced Parkinson’s disease or dementia, can experience what is known as silent aspiration.

To make eating and drinking safer and easier, food can be modified by cutting into smaller pieces or softened by cooking longer. To slow the passage of liquids down the mouth and throat, thickening powders can be added to liquids.

What causes swallowing difficulties?

Dysphagia is often a symptom of an underlying medical issue:

• Neurological diseases, such as stroke, Parkinson’s disease, dementia and multiple sclerosis, may affect how the brain controls swallowing reflexes and muscle movements.
• Congenital and developmental issues, such as cerebral palsy, cleft lip and palate, can affect the anatomy, cognition and feeding posture of the person.
• Muscular disorders, such as muscular dystrophy and myasthenia gravis.
• Reduced respiratory function, such as chronic obstructive pulmonary disease (COPD), can affect the coordination between breathing and swallowing.
• Some medications can cause dry mouth, changes in muscle coordination and other side effects. 
• Cancer in the head, neck or digestive tract can cause anatomical changes, especially after surgery or treatment.
• Ageing weakens muscles or impairs muscle coordination.

What exactly is finely minced?

Finely minced can mean a smooth puree at one hospital, and small, finely chopped pieces of food at another. A standard definition is important, as patients with varying degrees of dysphagia need different food consistencies to eat safely and easily.

To avoid confusion, a Ministry of Health workgroup consisting of healthcare professionals from various institutions worked on adopting a standard set of diet and fluid terminologies under the International Dysphagia Diet Standardisation Initiative (IDDSI) framework.

As the IDDSI framework is progressively being adopted across Singapore, food companies catering to healthcare institutions and companies producing and selling dysphagia-friendly foods will have to adhere to the same standards, said Ms Lee Yan Shan, Principal Speech Therapist, Speech Therapy Department, Singapore General Hospital.

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