Creating Caregiver-Friendly Recipes for Thickened Liquids Using Noncommercial Thickening Agents for Older Infants and Young Children

Abstract

The aim of this study was to develop caregiver-friendly recipes for thickened liquids consistent with the International Dysphagia Diet Standardisation Initiative (IDDSI) guidelines using noncommercial thickening agents to reduce variability in preparation. Recipes were tested combining base and thickening agents, where base agents were measured in fluid ounces and thickening agents in weight (ounces). The IDDSI flow test was completed after preparation, 10 min, and 20 min. Step-by-step protocols for slightly thick, mildly thick, and moderately thick recipes of thickened liquids were created. Each recipe resulted in a consistency within the prescribed IDDSI ml range of thickness immediately after preparation and remained stable over 20 min. Given the ease and reliability of preparation, lower costs, and readily available thickening agents, the protocols outlined in this study offer an appealing option for preparing thickened liquids. Additional research is warranted to determine palatability, long-term effects, and caloric value of the recipes.

Keywords

pediatric dysphagia noncommercial thickening agents thickened liquids IDDSI guidelines

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References

Adams

M. S.

Khan

N. Z.

Begum

S. A.

Wirz

S. L.

Hesketh

Pring

T. R.

(2011). Feeding difficulties in children with cerebral palsy: Low-cost caregiver training in Dhaka, Bangladesh. Child: Care, Health, and Development, 38(6), 878–888. https://doi.org/10.1111/j.1365-2214.2011.01327.x

Almeida

M. B.

Almeida

J. A.

Moreira

M. E.

Novak

F. R.

(2011). Adequacy of human milk viscosity to respond to infants with dysphagia: Experimental study. Journal of Applied Oral Science, 19(6), 554–559. https://doi.org/10.1590/s1678-77572011000600003

Beal

Silverman

Bellant

Young

T. E.

Klontz

(2012). Late onset necrotizing enterocolitis in infants following the use of a xanthan gum-containing thickening agent. The Journal of Pediatrics, 161(2), P354–356. https://doi.org/10.1016/j.jpeds.2012.03.054

Brooks

Clayton

Gethers

(2024). Thickening human milk: The effect of time, temperature, and thickener for infants with dysphagia. European Journal of Pediatrics, 183, 1839–1848. https://doi.org/10.1007/s00431-024-05434-5

Brooks

Liao

Ford

Harmon

Breedveld

(2022). Thickened liquids using pureed food for children with dysphagia: IDDSI and rheology measurements. Dysphagia, 37(3), 578–590. https://doi.org/10.1007/s00455-021-10308-1

Budke

Garcia

J. M.

Chambers

IV . (2008). Comparisons of thickened beverages using line spread measurements. Journal of the American Dietetic Association, 108(9), 1532–1535. https://doi.org/10.1016/j.jada.2008.06.434

Cichero

J. A. Y.

Lam

P. T. L.

Chen

Dantas

R. O.

Duivestein

Hanson

Kayashita

Pillay

Riquelme

L. F.

Steele

C. M.

Vanderwegen

(2020). Release of updated International Dysphagia Diet Standardisation Initiative framework (IDDSI 2.0). Journal of Texture Studies, 51(1), 195–196. https://doi.org/10.1111/jtxs.12481

Cichero

J. A. Y.

Lam

P. T. L.

Steele

C. M.

Chen

Dantas

R. O.

Duivestein

Kayashita

Lecko

Murray

Pillay

Riquelme

Stanschus

(2017). Development of international terminology and definitions for texture-modified foods and thickened fluids used in dysphagia management: The IDDSI framework. Dysphagia, 32, 293–314. https://doi.org/10.1007/s00455-016-9758-y

Cichero

J. A. Y.

Nicholson

T. M.

September

. (2013). Thickened milk for the management of feeding and swallowing issues in infants: A call for interdisciplinary professional guidelines. Journal of Human Lactation, 29(2), 132–135. https://doi.org/10.1177/0890334413480561

10.

Dewar

R. J.

Joyce

M. J.

(2006). Time-dependent rheology of starch thickeners and the clinical implications for dysphagia therapy. Dysphagia, 21, 264–269. https://doi.org/10.1007/s00455-006-9050-7

11.

Dion

Duivestein

J. A.

St Pierre

Harris

S. R.

(2015). Use of thickened liquids to manage feeding difficulties in infants: A pilot study of practice patterns in Canadian pediatric centers. Dysphagia, 30, 457–472. https://doi.org/10.1007/s00455-015-9625-2

12.

Dodrill

Gosa

M. M.

(2015). Pediatric dysphagia: Physiology, assessment, and management. Annals of Nutrition and Metabolism, 66(Suppl. 5), 24–31. https://doi.org/10.1159/000381372

13.

Duncan

D. R.

Larson

Rosen

R. L.

(2019). Clinical aspects of thickeners for pediatric gastroesophageal reflux and oropharyngeal dysphagia. Current Gastroenterology Reports, 21(30), 21–30. https://doi.org/10.1007/s11894-019-0697-2

14.

Eichenwald

E. C.

, & the AAP Committee on Fetus and Newborn. (2018). Diagnosis and management of gastroesophageal reflux in preterm infants. Pediatrics, 142(1), e20181061. https://doi.org/10.1542/peds.2018-1061

15.

Follent

A. M.

Rumbach

A. F.

Ward

E. C.

Marshall

Dodrill

Lewindon

(2017). Dysphagia and feeding difficulties post-pediatric ingestion injury: Perspectives of the primary caregiver. International Journal of Pediatric Otorhinolaryngology, 103, 20–28. https://doi.org/10.1016/j.ijporl.2017.09.013

16.

Garand

K. L.

McCullough

Crary

Arvedson

J. C.

Dodrill

(2020). Assessment across the lifespan: The clinical swallow function. American Journal of Speech-Language Pathology, 29(2S), 919–933. https://doi.org/10.1044/2020_AJSLP-19-00063

17.

Garcia

J. M.

Chambers

IV. Matta

Clark

(2008). Serving temperature viscosity measurements of nectar- and honey-thick liquids. Dysphagia, 23, 65–75. https://doi.org/10.1007/s00455-007-9098-z

18.

Garcia

J. M.

Chamber

IV. Molander

(2005). Thickened liquids: Practice patterns of speech-language pathologists. American Journal of Speech-Language Pathology, 14(1), 4–13. https://doi.org/10.1044/1058-0360(2005/003)

19.

Gonzalez Ayerbe

J. I.

Hauser

Salvatore

Vandenplas

. (2019). Diagnosis and management of gastroesophageal reflux disease in infants and children: From guidelines to clinical practice. Pediatric Gastroenterology, Hepatology, & Nutrition, 22(2), 107–121. https://doi.org/10.5223/pghn.2019.22.2.107

20.

Gosa

M. M.

(2012). Videoflouroscopic analysis to determine the effects of thickened liquids on oropharyngeal swallowing function in infants with respiratory compromise [Doctoral dissertation, University of Memphis]. University of Memphis Digital Commons. https://digitalcommons.memphis.edu/etd/542/

21.

Gosa

M. M.

Choquette

C. K.

(2021). Effect of commercially available thickening agents on ready-to-feed infant formulas. Journal of Texture Studies, 52(5–6), 612–622. https://doi.org/10.1111/jtxs.12600

22.

Gosa

M. M.

Corkins

M. R.

(2015). Necrotizing enterocolitis and the use of thickened liquids for infants with dysphagia. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 24(2), 44–49. https://doi.org/10.1044/sasd24.2.44

23.

Gosa

M. M.

Dodrill

(2017a, January 1). Pediatric dysphagia rehabilitation: Considering the evidence to support common strategies. Swallowing and Swallowing Disorders (Dysphagia), 2(13), 27–35. https://doi.org/10.1044/persp2.SIG13.27

24.

Gosa

M. M.

Dodrill

(2017b, April). Effect of time and temperature on thickened infant formula. Nutrition in Clinical Practice, 32(2), 238–244. https://doi.org/10.1177/088453361666299

25.

Gosa

M. M.

Dodrill

Robbins

(2020). Frontline interventions: Considerations for modifying fluids and foods for management of feeding and swallowing disorders across the life span. American Journal of Speech-Language Pathology, 29(2S), 934–944. https://doi.org/10.1044/2020_AJSLP-19-00065

26.

Gosa

M. M.

Schooling

Coleman

(2011). Thickened liquids as a treatment for children with dysphagia and associated adverse effects: A systematic review. Infant, Child, and Adolescent Nutrition, 3(6), 344–350. https://doi.org/10.1177/1941406411407664

27.

Hadde

E. K.

Chen

(2021). Texture and texture assessment of thickened fluids and texture-modified food for dysphagia management. Journal of Texture Studies, 52, 4–15. https://doi.org/10.1111/jtxs.12567

28.

Hojsak

Braegger

Bronsky

Campoy

Colomb

Decsi

Domellöf

Fewtrell

Fidler Mis

Mihatsch

Molgaard

van Goudoever

(2015). Arsenic in rice: A cause for concern. Journal of Pediatric Gastroenterology and Nutrition, 60(1), 142–145. https://doi.org/10.1097/MPG.0000000000000502

29.

Ilgaz

Serel Arslan

Gökmen Özel

Demir

Karaduman

A. A.

(2017). SUN-P132: Thickener use in pediatric dysphagia: Treatment results and family experiences. Clinical Nutrition, 36(Suppl. 1), S103. https://doi.org/10.1016/S0261-5614(17)30495-8

30.

International Dysphagia Diet Standardization Initiative. (n.d.). IDDSI resources. https://iddsi.org/Resources/Videos/Introduction-to-IDDSI

31.

Kennewell

Kokkinakos

(2007). Thick, cheap, and easy: Fortifying texture-modified meals with infant cereal. Nutrition and Dietetics, 64(2), 112–115. https://doi.org/10.1111/j.1747-0080.2007.00101.x

32.

Kim

S.-G.

Yoo

(2015). Viscosity of dysphagia-oriented cold-thickened beverages: Effect of setting time at refrigeration temperature. International Journal of Language and Communication Disorders, 50(3), 397–402. https://doi.org/10.1111/1460-6984.12141

33.

Koo

J. K.

Bode

Kim

J. H.

(2016). Current methods of thickening feeds for preterm infants with gastroesophageal reflux disease is highly variable. The FASEB Journal, 30(S1), 151–155. https://doi.org/10.1096/fasebj.30.1_supplement.151.5

34.

Koperna

Scarnecchia

Pierce

R. S.

(2004). The effects of time and temperature changes on liquids thickened to liquid and honey consistencies. Contemporary Issues in Communication Sciences and Disorders, 31, 200–204. https://doi.org/10.1044/cicsd_31_F_200

35.

Krummrich

Kline

Krival

Rubin

(2017). Parent perception of the impact of using thickened fluids in children with dysphagia. Pediatric Pulmonology, 52(11), 1–9. https://doi.org/10.1002/ppul.23700

36.

Lefton-Greif

M. A.

Okelo

S. O.

Wright

J. M.

Collaco

J. M.

McGrath-Morrow

S. A.

Eakin

M. N.

(2014). Impact of children’s feeding/swallowing problems: Validation of a new caregiver instrument. Dysphagia, 29(6), 671–677. https://doi.org/10.1007/s00455-014-9560-7

37.

Madhoun

L. L.

Siler-Wurst

K. K.

Sitaram

Jadcherla

S. R.

(2015). Feed-thickening practices in NICUs in the current era: Variability in prescription and implementation patterns. Journal of Neonatal Nursing, 21(6), 255–262. https://doi.org/10.1016/j.jnn.2015.07.004

38.

McCallum

(2011). Addressing nutrient density in the context of the use of thickened liquids in dysphagia treatment. Infant, Child, and Adolescent Nutrition, 3(6), 351–360. https://doi.org/10.1177/1941406411427442

39.

Pados

B. F.

Feaster

(2021). Effect of formula type and preparation on international dysphagia diet standardisation initiative thickness level and milk flow rates from bottle teats. American Journal of Speech-Language Pathology, 30(1), 260–265. https://doi.org/10.1044/2020_AJSLP-20-00272

40.

Payne

Methven

Fairfield

Bell

(2011). Consistently inconsistent: Commercially available starch-based dysphagia products. Dysphagia, 26, 27–33. https://doi.org/10.1007/s00455-009-9263-7

41.

Philip

K. E. A.

Greenwood

C. E.

(2000). Nutrient contribution of infant cereals used as fluid thickening agents in diet fed to the elderly. Journal of the American Dietetic Association, 100(5), 549–545. https://doi.org/10.1016/S0002-8223(00)00170-X

42.

Prasse

J. E.

Kikano

G. E.

(2009). An overview of pediatric dysphagia. Clinical Pediatrics, 48(3), 247–251. https://doi.org/10.1177/0009922808327323

43.

Rule

D. W.

Kelchner

Mulkern

Couch

Silbert

Welden

(2020). Implementation strategies for the International Dysphagia Diet Standardisation Initiative (IDDSI), part 1: Quantitative analysis of IDDSI performance among varied participants. American Journal of Speech-Language Pathology, 29(3), 1514–1528. https://doi.org/10.1044/2020_AJSLP-19-00012

44.

Rush

O. M.

Bolland

A. C.

Gosa

M. M.

(2020). Effect of mixing method on resulting thickness of infant formula. Journal of Texture Studies, 52(1), 57–70. https://doi.org/10.1111/jtxs.12566

45.

Rybak

Pesce

Thapar

Borrelli

(2017). Gastro-esophageal reflux in children. International Journal of Molecular Sciences, 18(8), 1671. https://doi.org/10.3390/ijms18081671

46.

Salvatore

Savino

Singendonk

Tabbers

Benninga

M. A.

Staiano

Vandenplas

(2018). Thickened infant formula: What to know. Nutrition, 49, 51–56. https://doi.org/10.1016/j.nut.2017.10.010

47.

September

Nicholson

T. M.

Cichero

J. A. Y.

(2014). Implications of changing the amount of thickener in thickened infant formula for infants with dysphagia. Dysphagia, 29, 432–437. https://doi.org/10.1007/s00455-014-9523-z

48.

Shibata

Meng

Umoren

West

(2016). Risk assessment of arsenic in rice cereal and other dietary sources for infants and toddlers in the U.S. International Journal of Environmental Research and Public Health, 13(4), 361. https://doi.org/10.3390/ijerph13040361

49.

Simione

Harshman

Cooper-Vince

C. E.

Daigle

Sorbo

Kuhlthau

Fiechtner

(2023). Examining health conditions, impairments, and quality of life for pediatric feeding disorders. Dysphagia, 38, 220–226. https://doi.org/10.1007/s00455-022-10455-z

50.

Stevens

O’Rourke

Coleman Casto

Benedict

Lundine

J. P.

(2022). Clinical focus: Findings and implications for thickening formula with infant cereal using the International Dysphagia Diet Standardisation Initiative flow test. American Journal of Speech-Language Pathology, 31, 1601–1610. https://doi.org/10.1044/2022_AJSLP-21-00298

51.

Stewart

Burr

(2021). Thickened liquids: Do they still have a place in the paediatric dysphagia toolkit? Current Opinion in Otolaryngology & Head and Neck Surgery, 29(3), 194–199. https://doi.org/10.1097/moo.0000000000000707

52.

Swan

Speyer

Heijnen

B. J.

Wagg

Cordier

(2015). Living with oropharyngeal dysphagia: Effects of bolus modification on health-related quality of life—A systematic review. Quality of Life Research, 24, 2447–2456. https://doi.org/10.1007/s11136-015-0990-y

53.

Syahariza

Z. A.

Yong

H. Y.

(2017). Evaluation of rheological and textural properties of texture-modified rice porridge using tapioca starch and sago starch as thickener. Journal of Food Measurement and Characterization, 11, 1586–1591. https://doi.org/10.1007/s11694-017-9538-x

54.

Tan

Cocks

Claessen

(2021). Mothers’ perspectives of support for their child with feeding/swallowing disorders. Speech, Language, and Hearing, 25(1), 17–28. https://doi.org/10.1080/2050571X.2021.1904734

55.

Taylor

Kong

A. C.

Foster

Badawi

Novak

(2022). Caregivers’ feeding experiences and support of their child with cerebral palsy. Journal of Child and Family Studies, 31(3), 819–830. https://doi.org/10.1007/s10826-021-02123-x

56.

Vandenplas

Salvatore

Hauser

(2005). The diagnosis and management of gastro-oesophageal reflux in infants. Early Human Development, 81(12), 1011–1024. https://doi.org/10.1016/j.earlhumdev.2005.10.011

57.

Werden-Abrams

Gandhi

Namasivayam-MacDonald

(2023). The adverse effects and events of thickened liquid use in adults: A systematic review. American Journal of Speech-Language Pathology, 32(5), 2331–2350. https://doi.org/10.1044/2023_AJSLP-22-00380

58.

West

K. M.

(2024). Treating pediatric feeding disorders and dysphagia: Evidence-based interventions for school-based clinicians. Language, Speech, and Hearing Services in Schools, 55(2), 444–457. https://doi.org/10.1044/2023_LSHSS-23-00016

59.

Woods

C. W.

Oliver

Lewis

Yang

(2012). Development of necrotizing enterocolitis in premature infants receiving thickened feeds using SimplyThick. Journal of Perinatology, 32, 150–152. https://doi.org/10.1038/jp.2011.105

60.

Yoon

S.-N.

Yoo

(2017). Rheological behaviors of thickened infant formula prepared with xanthan gum-based food thickeners for dysphagic infants. Dysphagia, 32, 454–462. https://doi.org/10.1007/s00455-017-9786-2

61.

Zuurmond

O’Banion

Gladstone

Carsamar

Kerac

Baltussen

Tann

C. J.

Nyante

G. G.

Polack

(2018). Evaluating the impact of a community-based parent training programme for children with cerebral palsy in Ghana. PLOS ONE, 13(9), 1–17. https://doi.org/10.1371/journal.pone.0202096