Iona and I went in to see Isobel today at 2pm. Claire, the speech and language therapist arrived soon afterwards. Isobel had missed breakfast today but eaten all her lunch and drunk all her other drinks. Isobel was asleep when we arrived, it took a few minutes to wake her but she was fully awake when Claire arrived. Isobel had been awake for a period at lunchtime and was probably already slightly tired when we started the investigations.

I gave Isobel a test drink of half a beaker of unthickened orange squash. She drank this fairly quickly with no problems while Claire felt her throat in order to judge the efficiency of swallowing. She felt that there was a real risk of drink finding its way into Isobel's lungs as she was not controlling the fluid within the mouth. We thickened the drink to "syrup" thickness and tried again, using the beaker spout again. Then we thickened the drink to "custard" thickness and spooned it in. Claire expressed the view that only the custard thickness was really safe and was being swallowed at the first attempt, the others were taking two or more attempts even when small amounts are given, liquid was slopping around in an uncontrolled fashion within the mouth between swallows. This is slightly disappointing as it will make giving drinks much slower. The ban on jelly and ice cream was confirmed - as these tend to liquify in the mouth and Isobel cannot cope with the free unthickened liquid. Isobel was clearly becoming too tired to swallow properly before the custard thickness drink was finished.

We all agreed that muscle fatigue while eating was now a significant factor which would prevent Isobel finishing some meals. Yogurt seemed to be the optimal thickness and never posed a problem as eating could be suspended while Isobel regained her strength, maybe fifteen or thirty minutes later. Claire is not really happy with anything except liquidised food, regarding even mashed potato as potentially dangerous. Grapes are completely out of the question, other fruit including banana must be liquidised. Chocolate is also ruled out, apart of course from chocolate mousse and yogurt. We agreed than given Isobel's sedentary lifestyle, one incompletely eaten or missed meal each day did not pose a problem to her overall level of nutrition. There might tend to be a move to smaller amounts being fed more frequently. Iona stressed that her mother was not a fussy eater and was always happy to eat what was put in front of her.

The present position is not stable and the strategies discussed today will very likely not last for more than a couple of weeks given the rapid rate of change in Isobel's condition. I confirmed I was aware that we were approaching a position where conventional eating may no longer be possible. Claire will meet with the GP to discuss this. She will also discuss with the Ellenor nurse a collar that will help to hold Isobel's head in position for swallowing. At present her head tends to fall to the left, a position which makes swallowing less efficient than if she was facing straight ahead - at present I get round this by holding her head in place with the right hand while feeding her with the left hand but it is far from satisfactory.

We made a further attempt to give Isobel some more of the custard thickness drink, but after three spoon loads she was too tired to continue. Claire left at about twenty past three, she will come back next Tuesday just before noon to observe Isobel have her lunch. I will come in at 2pm to see the doctor and discuss medium term strategies.

During these discussions Isobel was not able to contribute much apart from slurred single word responses. She was very tired and fell asleep within a few minutes of Claire leaving. During the investigations I had flexed her right arm at the elbow a few times but did not attempt much more, it was not badly swollen. Iona and I did some re-organisation in the room before leaving at about 3.40pm. I took home the fruit bowl with grapes and bananas, very depressing to think Isobel will not be able to eat whole fruit again. Iona and I went on to Bluewater where we equipped her with a pair of maternity jeans, her bump is starting to show now.