Thickened Liquids & Modified Foods

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

Other Names

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

Key Points

  • Check for any 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 with managing 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) (PDF Document 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]

Overview

Dysphagia is a feeding disorder characterized by impaired oral, pharyngeal, and/or esophageal phases of swallowing. Complications of dysphagia can include 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 use of liquid thickening can prevent the need for tube feedings in many children. Modified food texture diets can facilitate swallowing in children with impaired oral phase of 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.

Role of the Medical Home

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 for children with dysphagia to work with a feeding therapist to improve their swallowing skills and help with managing liquid thickening and food texture modifications.
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 minimal level of 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.

Thickening Liquids

Determining Level of Thickness

During a Clinical Feeding Evaluation, the therapist will determine 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.
IDDSI Framework - 7 levels of thickness for liquids and foods ranging from "thin" to "regular."
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) (PDF Document 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, and 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.

Modified Foods

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.
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.

Determining Level of Texture

To obtain foods that are minced and moist (IDDSI level 5), foods will be the following:
  • Soft and moist throughout
  • Can be scooped or shaped on a plate
  • Not sticky
  • No separate thin liquids (i.e., sauces/juices do not leak or drip from food)
  • Require minimal chewing; biting is not required
  • Minced-sized pieces of food: No larger than 4mm in width and 15mm in length (adults); no larger than 2mm in width and 8mm in length (children)
  • Small lumps may be visible, which can be easily mashed with the tongue
  • Food can be easily mashed with a small amount of pressure from a fork
  • Can be eaten with a fork or spoon
  • Can be scooped onto a fork without liquid dripping or crumbles falling off
Soft and bite-sized foods (IDDSI level 6) include foods that are soft, tender, and moist throughout. Bite-sized food pieces are defined as 0.5 inches (15mm or 1.5cm) wide and 0.5 inches (15mm or 1.5cm) in length or less in size for adults. For children, ‘bite-sized’ pieces are half that size which is 0.25 inches (8mm). 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

For “on-the-go” meals, there are small, portable blenders available; 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 calorie intake, fluid intake, and/or fiber intake 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.

Specialty Collaborations & Other Services

Speech - Language Pathologists (see UT providers [71]) and Occupational Therapy (see UT providers [38])
Refer to a feeding therapist, a speech-language pathologist, or an occupational therapist with additional training in feeding and swallowing to evaluate and treat dysphagia and pediatric feeding disorders. They provide guidance in thickening liquids, modified-food texture diets, and improving mealtimes.
Pediatric Gastroenterology (see UT providers [4]), Pediatric Pulmonology (see UT providers [4]), and Pediatric Otolaryngology (see UT providers [9])
Consult a pediatric gastroenterologist for assessing a child for nutritional evaluation, possible tube feeding intervention, malabsorption concerns, esophageal disorders, and other related medical issues. Pediatric pulmonology and ENT specialists may offer further diagnostic tests such as endoscopy and treatment as well.
Nutrition Assessment Services (see UT providers [7])
Refer to a dietitian/nutritionist to help adjust dietary intake for proper nutrition.

Resources

Information & Support

For Parents and Patients

How and Why to Thicken Liquids (Nationwide Children's)
How to thicken liquids with Similac, Gerber, Elecare, Enfamil, Neocate, Bright Beginnings, Boost, Pediasure, and other formulas.

Practice Guidelines

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

Services for Patients & Families in Utah (UT)

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

Authors & Reviewers

Initial publication: April 2022; last update/revision: April 2022
Current Authors and Reviewers:
Authors: Kathryn Murray, MD
Kimberly P. Hirte, MA CCC-SLP
Contributing Author: Anna Ermarth, MD, MS

Page Bibliography

American Dietetic Association.
National dysphagia diet: Standardization for optimal care.
National Dysphagia Diet Task Force, and American Dietetic Association; 2002.

Barbon CEA, Steele CM.
Thickened Liquids for Dysphagia Management: a Current Review of the Measurement of Liquid Flow.
Curr Phys Med Rehabil Rep. 2018;6(4):220-226. PubMed abstract / Full Text

Beal J, Silverman B, Bellant J, Young TE, Klontz K.
Late onset necrotizing enterocolitis in infants following use of a xanthan gum-containing thickening agent.
J Pediatr. 2012;161(2):354-6. PubMed abstract

Cichero JA.
Thickening agents used for dysphagia management: effect on bioavailability of water, medication and feelings of satiety.
Nutr J. 2013;12:54. PubMed abstract / Full Text

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.

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

Salvatore S, Savino F, Singendonk M, Tabbers M, Benninga MA, Staiano A, Vandenplas Y.
Thickened infant formula: What to know.
Nutrition. 2018;49:51-56. PubMed abstract
This study aimed to provide an overview of the characteristics of thickened formulas to aid health care providers manage infants with regurgitations.

Wolter NE, Hernandez K, Irace AL, Davidson K, Perez JA, Larson K, Rahbar R.
A Systematic Process for Weaning Children With Aspiration From Thickened Fluids.
JAMA Otolaryngol Head Neck Surg. 2018;144(1):51-56. PubMed abstract / Full Text

Woods CW, Oliver T, Lewis K, Yang Q.
Development of necrotizing enterocolitis in premature infants receiving thickened feeds using SimplyThick®.
J Perinatol. 2012;32(2):150-2. PubMed abstract