Medical Home Portal - Thickened Liquids & Modified Foods (2024)

Other Names

• Dysphagia diet
• Feeding children with dysphagia
• Mechanical soft diet
• Modified texture foods
• Pureed food diets

• Check for new safety concerns before prescribing a thickener. Many thickeners are not approved for infants.
• Children with dysphagia should work with a feeding therapist to improve swallowing skills, help manage liquid thickening and food texture modifications, and safely wean off thickening liquids as swallowing skills improve.
• Use standardized terms and instructions from the International Dysphagia Diet Standardisation Initiative Framework (IDDSI) ( 2.3 MB) to reduce variability.
• Thickeners are typically well-tolerated and have few side effects, but they can contribute to dehydration and increase the caloric density of the liquid.
• Regular follow-up is needed to adjust total fluid intake, monitor growth, ensure thickeners are tolerated, and evaluate symptom improvement. [Duncan: 2019] [Cichero: 2013] Also, monitor for silent aspiration - often indicted by choking, gagging, vomiting, and recurrent pneumonitis or lower respiratory tract infections.
• Some thickened medications can lead to sub-therapeutic medication levels; Class III BCS drugs are particularly vulnerable. [Cichero: 2013] Consult a pharmacist for guidance if needed.
• High-quality evidence is lacking about thickeners for infants with reflux; however, expert opinion is that thickened feeds improve visible regurgitation but do not alter acid reflux assessed by pH probe. [Rosen: 2018]

Determining Level of Thickness

An instrumental evaluation is conducted when further information is needed to determine the nature of the swallowing disorder. Instrumental assessments can help provide specific information about anatomy and physiology. Instrumental evaluations also help determine if swallow safety can be improved by modifying food textures, liquid consistencies, and positioning or implementing strategies.

During an instrumental feeding evaluation, the therapist determines the liquid thickness and food texture modification needed by observing a patient swallowing different liquid thickness and solid food textures during a modified barium swallow study (MBS) or fiberoptic endoscopic evaluation of swallowing (FEES). An MBS is a fluoroscopy procedure in which serial X-rays visualize the pathway and the mechanics of swallowing during the oral and pharyngeal phase of swallowing. An FEES allows visualization of the larynx, pharynx, and trachea to evaluate anatomy and assess swallow capability and coordination. Trials of thickened liquids during an MBS can show improvement in swallowing during the study as well.

International Dysphagia Diet Standardisation Initiative (IDDSI) Framework

In the past, liquid thickness and food texture modification was prescribed with vague labels, such as “thin,” “nectar-like,” “honey-like,” and “spoon-thick.” [American: 2002] Caregivers preparing the thickened liquids or food texture modification for children with dysphagia would rely on product labels or subjective impressions, leading to poor control of liquid consistency.

The International Dysphagia Diet Standardisation Initiative Framework (IDDSI) ( 2.3 MB) (left) standardized the terminology describing food textures and liquid thicknesses to improve safety for children with dysphagia. It consists of 8 levels (0 - 7), where drinks are measured from Levels 0 – 4, and foods are measured from Levels 3 – 7. A gravity flow test is used to find the liquid’s flow category, which uses a 10 mL slip tip syringe and monitors the time it takes for the fluid to pass through. Simple charts with images for each food texture and liquid thickness are available on their website. It also includes descriptions and images for the syringe drip test, fork spoon tilt, chopstick, and finger tests.

Types of Thickeners

A range of starches, gums, and food-based products has historically been used to thicken liquids. [Cichero: 2013] Often, the feeding therapist will help guide the family to use the most appropriate thickener.

Information on various thickeners is provided below as a reference; however, research is ongoing, and companies frequently change their products and recommendations. Check for any new safety concerns before prescribing a thickener.

• Thickened formulas are commercially available. Benefits include a set viscosity; they may have improved digestibility and nutritional balance. They can be helpful for reflux; however, they tend to be only slightly thick, and often for dysphagia, an additional thickener is needed. [Salvatore: 2018]
• Food-based thickeners can displace formula volume and are typically recommended for thickening purees or solid foods rather than formula or breast milk. Banana, yogurt, pudding, blended foods, bread crumbs, crushed crackers, and infant cereal (see below) are examples of food-based thickeners.
• Infant cereal can be added to infant formula to reduce regurgitation. Breastmilk can break down infant cereal, and it does not stay thickened. If cereal is used to thicken feeds, an oat-based cereal is generally preferred over rice cereal due to concerns about the contamination of rice with arsenic. Thickening with infant cereal may lead to excessive weight gain and constipation.
• Carob bean (e.g., Gelmix) is not approved for preterm infants until they have reached a minimum weight of 6 pounds and at least 42 weeks post-menstrual (gestational) age.
• Corn starch (e.g., Thick-It, Thick & Easy, Resource Thickenup) is not approved for infants. It seems to take more powder to get desired thickness.
• Xanthan gum (e.g., Simply Thick, Nestle ThickenUp, Thick & Easy Clear) is not approved for preterm infants or infants <12 months of age due to concerns about necrotizing enterocolitis (NEC). [Beal: 2012] [Woods: 2012] Caution should be used for any child over age 1 with a history of necrotizing enterocolitis or altered bowel anatomy.
• Tapioca flour/starch is an effective thickening agent for recipes, such as homemade pudding, cookie dough, sauces, and gravies.
• Gelatin thickens as it cools and is more difficult to regulate for liquid swallowing.
• Pectin is commonly used to thicken jams, jellies, and preserves. It may cause constipation and increased gas production/distension because it is an undigested fiber.

Paying for Thickeners

Some insurance companies cover thickeners, but the types covered are usually limited. The medical home clinician can consider writing a prescription for thickeners – even for over-the-counter ones. Affording Formula has some suggestions that could help with paying for thickeners.

Safety Concerns for Thickeners

The long-term effects of using thickeners are unknown. Many thickeners cannot be used for infants (such as Thick-It, Thick Easy, SimplyThick)—see “Types of Thickener” above for details. Thickeners may cause intestinal gas production, changes in the stool ranging from diarrhea to constipation, and dehydration if the child is not taking in enough liquid or the thickener viscosity is at a high level (IDDSI 3 and above). The thickness can be variable based on the temperature of the liquid. Some liquids, including breastmilk and some infant formulas, do not thicken well and become foamy. [Duncan: 2019] Working closely with a feeding therapist can help support the proper use of thickeners.

Determining Level of Texture

Pureed foods do not require chewing, while other IDSSI categories (minced & moist, soft & bite-sized, etc.) require less chewing than a regular diet but include foods with different textures and thicknesses. Many soft table foods can be served as pureed foods without much modification, including puddings and gelatins, mashed potatoes, oatmeal, yogurt, and applesauce.

Soft and bite-sized foods (IDDSI level 6) include foods that are soft, tender, and moist throughout. Adult "bite-sized" food pieces are 0.5 inches wide and 0.5 inches in length or less; child "bite-sized" pieces are half that size (0.25 inches). These foods do not have separate thin liquids (i.e., sauces/juices do not leak or drip from food), are not sticky, and can be mashed or broken down with pressure from a fork or spoon. They can be eaten with a fork or spoon; a knife is not required to cut and eat the food. And they do require chewing before swallowing food.

Types of Thickened Foods

Small, portable blenders are available for “on-the-go” meals; pureed containers or pouches of single-serve foods and protein goo may also be helpful. Almost any table food can be blenderized or pureed in a food processor to an appropriate consistency by adding water, milk, or juice; some require additional cooking to puree (such as carrots). Extra servings can be frozen in small containers for later use. Pectin or other thickeners may be used to help achieve a uniform consistency.

Blenderized or smoothie diets contain foods blended with liquids but usually do not specify a thickness. Be aware that the consistency can change as the smoothie sits over time, separating liquids and pureed elements. If a child with dysphagia drinks smoothies, encourage the family to have them drink them right after blending and monitor for liquid separation. Purees and smoothies can vary in consistency – avoid runny, watery purees for children at risk for aspiration. Smoothie and blenderized diets for dysphagia should be managed with input from a feeding therapist and dietician to ensure adequate calories and nutrition.

Safety Concerns for Modified Foods

It may be difficult to get adequate calories, fluid, and/or fiber with the above diets. Working with a feeding therapist and dietician is helpful to navigate this and work toward increasing chewing and swallowing skills and acceptance of regular food textures.

Pediatric Gastroenterology (see NW providers [0]), Pediatric Pulmonology (see NW providers [0]), and Pediatric Otolaryngology (ENT) (see NW providers [1])
Consult a pediatric gastroenterologist to assess a child's need for nutritional evaluation and possible tube feeding, malabsorption concerns, esophageal disorders, and other related medical issues. Pediatric pulmonology and ENT specialists may offer further diagnostic tests (such as endoscopy) and treatment.

Dieticians and Nutritionists (see NW providers [1])
Refer to a dietitian/nutritionist to help adjust dietary intake for proper nutrition.

Information & Support

Lock J, La Via MC.
Practice parameter for the assessment and treatment of children and adolescents with eating disorders.
J Am Acad Child Adolesc Psychiatry. 2015;54(5):412-25. PubMed abstract
This practice parameter from the American Academy of Child and Adolescent Psychiatry reviews evidence-based practices for the evaluation and treatment of eating disorders in children and adolescents.

Rosen DS.
Identification and management of eating disorders in children and adolescents.
Pediatrics. 2010;126(6):1240-53. PubMed abstract
This AAP clinical report includes a discussion of diagnostic criteria and outlines the initial evaluation, treatment including pharmacotherapy, and monitoring of the patient with disordered eating. Reaffirmed Feb 2018

Rosen R, Vandenplas Y, Singendonk M, Cabana M, DiLorenzo C, Gottrand F, Gupta S, Langendam M, Staiano A, Thapar N, Tipnis N, Tabbers M.
Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition.
J Pediatr Gastroenterol Nutr. 2018;66(3):516-554. PubMed abstract / Full Text

Patient Education

Let's Talk About... Dysphagia (Spanish & English)
Printable, 2-page, patient education about diagnosis and management of dysphagia in children; Intermountain Healthcare.

Thickening Liquids and Pureeing Foods (IDDSI) ( 784 KB)
Two-page patient handouts about food characteristics to embrace and avoid when striving to achieve consistent food texture level; International Dysphagia Diet Standardisation Initiative.

Tools

International Dysphagia Diet Standardisation Initiative Framework (IDDSI) ( 2.3 MB)
A continuum of 8 levels (0-7) of food levels of thickness; International Dysphagia Diet Standardisation Initiative.

Services for Patients & Families Nationwide (NW)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Helpful Articles

Brooks L, Liao J, Ford J, Harmon S, Breedveld V.
Thickened Liquids Using Pureed Foods for Children with Dysphagia: IDDSI and Rheology Measurements.
Dysphagia. 2021. PubMed abstract
Preparing thickened liquids with commercially available thickeners can result in poor compliance due to concerns regarding taste, texture, accessibility, cost, thickness variability, and potential negative impact of these substances on a child's immature digestive tract. The purpose of this study was to determine if liquids could be successfully thickened with widely available, commercial pureed foods, and to assess how these mixtures compare to starch and gum-based thickening agents.

Duncan DR, Larson K, Rosen RL.
Clinical Aspects of Thickeners for Pediatric Gastroesophageal Reflux and Oropharyngeal Dysphagia.
Curr Gastroenterol Rep. 2019;21(7):30. PubMed abstract
The purpose of this review is to discuss current knowledge and recent findings regarding clinical aspects of thickeners for pediatric gastroesophageal reflux and oropharyngeal dysphagia. We review evidence for thickener efficacy, discuss types of thickeners, practical considerations when using various thickeners, and risks and benefits of thickener use in pediatrics.

Oparaji JA, Sferra T, Sankararaman S.
Basics of Blenderized Tube Feeds: A Primer for Pediatric Primary Care Clinicians.
Gastroenterology Res. 2019;12(3):111-114. PubMed abstract / Full Text