Clinical care of children and adolescents who require thickened liquids and/or modified food texture diets often due to dysphagia, aspiration, or aspiration risk

Dysphagia (difficulty swallowing) can lead to aspiration, malnutrition, dehydration, prolonged feeding disorders, and/or altered childhood development. Thickened liquids help prevent aspiration because they flow slower than thin liquids, which provides extra time for a child with dysphagia to achieve airway protection during swallowing. [Barbon: 2018] They can also decrease regurgitation and risk for aspiration of gastric contents. Effective liquid thickening can prevent the need for tube feedings in many children. Modified food texture diets can facilitate swallowing in children with impaired swallowing. In collaboration with feeding specialists, the medical home team may see many patients make gradual improvements or a full recovery, depending on the underlying cause.

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]

Once a need for thickened fluids or a modified-texture diet has been identified (see Feeding & Swallowing Problems in Children), the primary care clinician will typically rely on a feeding therapist, often a speech-language pathologist, to develop recommendations for managing the child’s dysphagia. Recommendations may include position changes, external pacing strategies, bottle nipple or cup modifications, liquid thickening, and/or food texture modifications.

While thickeners are typically well-tolerated and have few side effects, close follow-up is needed to ensure patients tolerate thickeners and have adequate symptom improvement. [Duncan: 2019] Children are monitored for choking, gagging, vomiting, and recurrent pneumonitis or lower respiratory tract infections since these would be red flags for silent aspiration. Children are also closely monitored for oral aversion or feeding disorders, which can develop over time. It is important that a feeding therapist works with patients to improve swallowing skills and help manage liquid thickening and food texture modification.

After initiating or altering liquid thickener or feeding modifications, the feeding therapist can help the child safely wean off thickening liquids as swallowing skills improve. [Wolter: 2018] The primary care clinician and feeding therapist can collaborate regarding the timing of repeat modified barium swallow studies if needed. Clinicians are encouraged to prescribe the minimum thickness needed for swallowing safety and help the patient safely wean off thickeners when swallowing skills improve. [Wolter: 2018] [Cichero: 2013] The primary care clinician or subspecialist should also provide basic guidance for families who need a modified diet for their child as well as monitor for appropriate growth and medical problems, such as inadequate fluid volume intake, constipation, reflux, and delayed gastric emptying.

Determining Level of Thickness

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

• 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

Safety Concerns for Thickeners

Some children with dysphagia and/or other pediatric feeding disorders may need modified-food texture diets, as they can have difficulty tolerating certain textures. Tongue thrusting, gagging, regurgitation, pocketing in the cheeks, and/or vomiting may indicate that the child is not tolerating their feeding and may have a feeding disorder requiring modified food texture.

Determining Level of Texture

Types of Thickened Foods

Safety Concerns for Modified Foods

Speech - Language Pathologists (see RI providers [33]) and Occupational Therapy (see RI providers [21])
Refer to a feeding therapist, speech-language pathologist, or occupational therapist with pediatric feeding and swallowing experience, education, and training to evaluate and help treat dysphagia and pediatric feeding disorders and guide thickened liquids and modified-food texture diets.

Pediatric Gastroenterology (see RI providers [18]), Pediatric Pulmonology (see RI providers [6]), and Pediatric Otolaryngology (ENT) (see RI providers [7])
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 RI providers [3])
Refer to a dietitian/nutritionist to help adjust dietary intake for proper nutrition.