Addressing Nutrient Density in the Context of the Use of Thickened Liquids in Dysphagia Treatment

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1 vol. 3 no. 6 ICAN: Infant, Child, & Adolescent Nutrition Evidence-Based Practice Reports Addressing Nutrient Density in the Context of the Use of Thickened Liquids in Dysphagia Treatment Shirley McCallum, MS, RD, CD, FADA Abstract: Thickening liquids has become a standard of practice for managing children with oropharyngeal dysphagia. A variety of commercial products have been developed from guar gum, xanthan gums, and modified corn starch. Practitioners and families are also trying to thicken liquids with available foods, such as infant rice cereal, yogurt, strained baby foods, and instant potato flakes. Throughout this process little consideration is given to the impact of the use of different thickeners on the nutrient density of human milk, formula, or other beverages. Various fluids were thickened by the author using different products to achieve National Dysphagia Diet nectar-like, or honey-like consistencies. Nutrient analysis of the calorie effect of the thickeners was calculated using the USDA Agriculture Research Service Nutrient database, manufacturer information, and displacement factors to evaluate the effects on calories per ounce of the thickened fluids. Considerations of thickener choice on other nutrients are discussed, including potential for toxicity of nutrient loads with specific thickeners. No one thickener is appropriate for all patients, but the characteristics of the various thickeners need to be understood. The assessment of the individual patient by an interdisciplinary team, including a registered dietitian should determine the patient s specific needs before recommending a thickener. Keywords: dysphagia; thickened liquids; nutrient density; viscosity Introduction Thickening liquids for patients with dysphagia 1 has become a common standard of practice based on small studies primarily on adults implying that increased viscosity might theoretically improve swallowing by increasing oropharyngeal transit times. 2-6 There is very limited high-quality research in either children or adults to support the use of thickeners to reduce aspiration and aspiration pneumonia. 7,8 Questions have arisen in new, large studies in adults showing increased complications with aspiration of honey-thick liquids (see the appendix for definitions). 9 This research demonstrates that using... the health care team must make a careful assessment of readiness for oral feeding and nutritional status and also evaluate the use of different dysphagia treatment modalities, such as positioning and changing the viscosity of liquids. thicker liquids does not necessarily make swallowing safer for all patients. In addition, research shows that the viscosities of barium products used for testing are not comparable with the viscosity of thickened human milk or infant formula using any product. 10 DOI: / From the UW Health American Family Children s Hospital, University of Wisconsin, Madison, WI. Address correspondence to Shirley McCallum, MS, RD, CD, FADA, UW Health American Family Children s Hospital, University of Wisconsin, 1675 Highland Ave, Madison, WI 53711; smccallum@ uwhealth.org. For reprints and permissions queries, please visit SAGE s Web site at Copyright 2011 The Author(s) 351

2 ICAN: Infant, Child, & Adolescent Nutrition December 2011 These inconsistencies make developing a swallow treatment plan for infants more challenging. The etiology of swallowing dysfunction is likely multifactorial, with prematurity and neurological and genetic factors all playing large roles in addition to trauma, ingestion of foreign objects, reflux, and/or eosinophilic esophagitis. The underlying condition causing the dysphagia must be evaluated and treated. For example, a child with dysphagia and symptoms of allergies may have eosinophilic esophagitis. To make the diagnosis, biopsies from an esophagogastroduodenoscopy (EGD) would be required. The dysphagia treatment plan may not be so focused on thickened liquids but on the elimination of allergens with the possible provision of an elemental and/or elimination diet to treat the underlying cause of the dysphagia. In contrast, children with cerebral palsy have a significantly higher rate of postswallow inspiration than controls when consuming thin liquids. However, no difference was found when ingesting thick liquids or foods of pudding consistency, so a careful videofluoroscopic swallow evaluation would help determine the risks and effectiveness of interventions to guide the treatment plan. 4 Each nutrition care plan for dysphagia or swallowing difficulties must be individualized. For a successful treatment plan, the health care team must make a careful assessment of readiness for oral feeding and nutritional status and also evaluate the use of different dysphagia treatment modalities, such as positioning and changing the viscosity of liquids. 11 When recommending a change in viscosity of feeding liquids, the team must also consider the specific properties of thickeners and their impact on the nutrient density of human milk, formula, and foods. Issues With Thickened Liquids There are multiple issues with thickened liquids that affect the outcome of their use: consistency, reliability, stability, effectiveness, patient acceptance, and costs for both individuals and facilities. Research has not identified how and if thickening liquids can stimulate or improve the swallow reflex, and if so, what is the minimum measurable viscosity needed to achieve that goal. 12 Food scientists generally do viscosity research at room temperature, but in the United States, beverages are consumed either hot or chilled and served directly from the refrigerator. The temperature of the beverage can affect the final viscosity of the thickened liquid. 13 Commercial thickeners for beverages are generally available in the form of gums, such as xanthan and cellulose, or modified corn starch. These products have different properties, which have been evaluated for ease of use, consistency achieved, and stability of thickness over time. 14 Gel thickeners tend to be more stable over time, but mixing requires carefully following directions. The parents or hospital staff cannot take a spoon and mix it into a beverage. It must be mixed with a fork or whisk or aggressively agitated to evenly disperse the gel. If these directions are not carefully followed, the infant will receive a mixed consistency of thick gel globules interspersed in thin liquid. Gums are stabile in human milk, but the FDA is warning that xanthan gum should not be used for infants born at less than 37 weeks of gestation. 15 Starch thickeners tend to continue to thicken over time, and most are thicker at colder temperatures. The amylase enzyme in human milk quickly breaks down the thickening action of starches, including rice cereal. Also, there is a need to ensure, with all thickeners, that the final product is not lumpy or unevenly mixed. Research and observation in adult dysphagia treatment programs consistently show that patients are not happy with any of the thickened liquids currently available. 16 Patients object to the taste, texture, and lack of thirst quenching satisfaction of thickened liquids. 17,18 Studies have clearly shown that adult patients on thickened liquids consume less fluid than their calculated needs. 19 Infants and children cannot always express their dislike verbally; they make their displeasure known through behaviors that can lead to a decrease in consumption. In adults, there is an indirect correlation with the degree of thickness of beverages and the amount of fluid consumed (Table 1) Since the use of thickened liquids became a common treatment for patients with dysphagia, clinicians have been concerned about the absorption of the fluid to achieve adequate hydration. Hydration research has not been done on infants and children using various thickeners. There are no studies on the safety of allowing children with dysphagia to have plain unthickened water. 7 In limited studies done on animal models and adults, no significant differences were found in the availability of fluid for hydration between thickened liquid and water. Also, no differences in fluid absorption were found with different viscosities. Water absorption exceeded 95% of the fluid dose consumed. 23 This means that hydration achieved using thickened or unthickened liquids should be essentially the same, with both reflecting the adequacy of the intake volume. Because consuming adequate fluids is such an issue in these patients, parents need to be educated in the physical symptoms of dehydration. Dehydration will worsen signs of dysphagia by weakening muscle strength and contributing to the formation of sticky saliva, interfering with consumption, so it needs to be corrected quickly. 24 More research is needed regarding the impact of all thickened fluids on the immature guts of infants and children. 25 Concerns were raised in the case of 2 English patients with necrotizing enterocolitis (NEC); they were treated with carob bean gum, which is not used in any of the thickeners currently used in the United States. On May 20, 2011, the FDA issued a press release announcing a warning that SimplyThick (xanthan gum) should not be used in infants born at less than 37 weeks of gestation because of reports of associated NEC. At the time of the announcement, 15 cases of NEC with 2 deaths had been reported in premature infants. On June 4, 2011, the company voluntarily recalled the product produced 352

3 vol. 3 no. 6 ICAN: Infant, Child, & Adolescent Nutrition Table 1. Thickening Agents Product Manufacturer Comments Calories added Availability NutraBalance Instant Thickener NutraBalance Modified corn starch 2 tsp (3.4g) = 10 cal NutraBalance fortified version NutraBalance w/ 100 mg Ca+ and 6 mg vitamin C 2 tsp (3.4g) = 10 cal Ready Care Lyon Magnus Modified corn starch 1 Packet (6.5g) = 25 cal; 1 tablespoon (3.9 g) = 15 cal html Resource Thicken Up Nestle Modified corn starch 1 Tablespoon = 15 cal; add 1 tablespoon and 1 teaspoon to 4oz H 2 O = 20 cal www. cvs.com; Thicken Up on some pharmacy shelves Simply Thick Simply Thick Gel thickener xanthan gum Nectar (15 ml) = 0 cal; honey (30 ml) = 5 cal (FDA investigating NEC in premies <37 weeks) check Web site for local pharmacy availability or call (FDA warning 5/20/2011;voluntary recall 6/4/11) Thik & Clear NutraBalance products Cellulose gum standardized with maltodextrin 1½ tsp (3 g) = 12 cal Thick & Easy Modified corn starch and maltodextrin 1 packet; nectar = 15 cal; honey = 25 cal www. cvs.com; Thick & Easy Plus Modified corn starch & maltodextrin; contains Vitamin A 300 IU, 6 mg C, 1.8 mg iron, 1.5 mg zinc, 20 mg phosphorus 1 Tablespoon (5 g) = 20 cal www. brucemedical.com Thick-It Milani/Precision Foods Modified corn starch and maltodextrin 2 Tablespoons (8 g) = 30 cal www. walgreens.com; Thick-It on some pharmacy shelves Thick-It 2 Precision Foods Modified Cornstarch 1 Tablespoon (4.8 g) = 20 cal www. walgreens.com; Thixx Bernard Foods Modified corn starch and maltodextrin 2 Tablespoons (9 g) = 35 cal foodservice/dietspecdietandsupp/ thickeners.htm; Ultra Thixx Bernard Foods Modified corn starch 1 Tablespoons (4.5 g) = 20 cal; 1 packet (6.75 g) = 25 cal foodservice/dietspecdietandsupp/ thickeners.htm; Note: Data in tables is current as of June 20, 2011 based on listed manufacturer and government websites. 11,15,32 353

4 ICAN: Infant, Child, & Adolescent Nutrition December 2011 Table 2. Foods Used to Change Consistencies Product Manufacturer Comments Calories Added Availability Instant pudding Varies 204 mg Na+ 1/2 oz (1 Tablespoon/14 g) = 53 cal Grocery stores Mashed potato flakes Varies 0.38 g Protein 1 Tablespoon (4g) = 15 cal Grocery stores Baby food strained Varies Applesauce/Banana 1/2 oz (1 Tablespoon) = 6-8 cal Grocery stores Baby rice cereal Varies 0.2 g Protein; 1.2 mg Fe+ 1 Tablespoon (2.5 g) = 10 cal Grocery stores Gravy Heinz/Campbell 68 mg Na+ 1/2 oz (1 Tablespoon) = 6 cal Grocery stores Sauces: White/Cheese Homemade 55-58/74 mg Na+ 1 Tablespoon (15 g) = 23-29/30 cal Homemade Unflavored gelatin Knox 2 g Protein ¼ Envelope(1.8 g) = 5 cal Grocery Stores Yogurt Varies g Protein 1 oz (2 Tablespoons/28.3 g)=17-27 cal Grocery Stores in their Georgia plant because of a lack of documentation that harmful bacteria were destroyed. 15 For infants who consume all or most of their nutrients through fluids in the form of human milk or infant formula, the impact of thickener selection can be great. Yet little research has been done that investigates the effects of thickeners on nutrient density. Human milk has enzymes that dissolve starch thickeners, so gum-based gel thickeners have been used because they are stable in human milk. However, the gel thickeners add volume without calories or the other nutrients the infant needs. These young infants become challenged to consume greater volumes to achieve the same calorie/nutrient intake. Starch-based thickeners add calories to the formula without the full range of nutrients, so the infant can be satisfied by the caloric intake, typically decreasing volume and thereby limiting the intake of other nutrients. The energy effect of thickeners can dilute micronutrient density in relation to the increased calories. Thickeners are recommended and purchased to provide a safe consistency, but they also add cost to the food or beverage, which is rarely covered by insurance. Although ordering in bulk can be more cost-effective, families usually avoid bulk purchases because of the initial monetary outlay; also, they are hopeful that their child will have significant improvement, so that the thickener will no longer be needed. Food service operations may order in bulk to decrease costs, or they pay and use prethickened products to have a safe, consistent product quickly available for nursing to give the patient to promote better intake. Most thickeners are packaged to effectively thicken 4-oz volumes. Thickeners also vary greatly in their ability to maintain their consistency over time. This may make managing small volumes and recipes for infants more challenging and less cost-effective. Costs of thickened liquids were calculated by the author based on consumer pricing through the manufacturer and vary by brand, desired consistency, and case size purchased (see Tables 1-4). Shipping, bulk purchases, or contract pricing through wholesale distributors are not included. Thickening a 4-oz beverage using a premeasured gel thickener adds 32 to 45 cents per 4-oz portion. A starch thickener, also in premeasured packages, increases the beverage cost by about 25 to 44 cents. If an 8-oz can of powdered starch thickener is purchased, it can cost from 19 to 25 cents to thicken a 4-oz beverage to nectar consistency. Many hospitals use prethickened juice, milk, and water to ensure a consistent product that is stable over time. Depending on the brand, these products come in 4- or 8-oz containers or larger bulk bottles. Using consumer pricing without shipping or adjusting for the cost of the base juice, the prethickened juices cost approximately 81 cents for 4 oz or $1.33 for 8 oz. Thickened water ranges from about 76 cents for 4 oz to $1.56 for 8 oz. These premeasured waters are stable, so in the older infant, the formula powder can be added to these to simplify getting the right consistency and concentration by giving the family a recipe appropriate for the energy density of the thickened water. To reduce cost and have easy access to thickeners, many parents and clinicians experiment with the use of foods to thicken liquids for infants and children. Adding 1 tablespoon of rice cereal to 4 oz of human milk or formula would only increase the cost by about 2 cents. Although this is a significant savings for the patient and/or the facility, the impact of using foods, like rice cereal, as a thickener for young infants has largely been unstudied. 10,25-27 Recent research has led the American Academy of Pediatrics to work to get parents to avoid the introduction of solids before 6 months of age because of the increased incidence of type 1 diabetes and celiac disease Use of foods as thickeners is cost-effective, but it is important that cost is not the only element considered when deciding on an appropriate thickener (Table 2). 354

5 vol. 3 no. 6 ICAN: Infant, Child, & Adolescent Nutrition Table 3. Thickened Beverage Products for People With Dysphagia Product Manufacturer Comments Calories per Ounce Availability Prethickened Juices (nectar and honey: apple, cranberry, and orange juice) Prethickened prune drink (nectar/honey) Prethickened kiwistrawberry Beverage Prethickened water (nectar/honey) Prethickened milk, 8-oz box (nectar/ honey) Prethickened shake 6 oz (honey only) Prethickened diet cola Prethickened iced tea (4 oz) Thick & Easy 4-oz cup ~ cal/oz Nestle Resource 8-oz carton ~20-24 cal/oz www. cvs.com NutraBalance 4-oz cup ~11 cal/oz (frozen) com AquaCareH2O 8-oz bottle ~14-19 cal/oz precision/home.htm Thick&Easy Thick&Easy Hydrolyte Vitamin C, 138 mg; high fructose corn syrup (HFCS) 60 mg Vitamin C; HFCS sweetened 60 mg Vitamin C; 50 mg Na cal/oz; HFCS sweetened 20 cal/oz cal/oz Nestle Resource 13 mg Na+ ~9-10 cal/oz AquaCareH2O Thick&Easy 35 mg Na+ (nectar); 48 mg Na+ (honey) Thickened Dairy 0 cal precision/home.htm ~24 cal/oz; 1 g protein/oz Nestle Resource Dairy Thick ~21-24 cal/oz; 1 g protein/oz Nestle Resource Thickened shake (low lactose) 45 cal/oz; 1.5 g protein/oz NutraBalance Thickened Nutra/Shake- Frozen 50 cal/oz; 1.5 g protein/oz www. walgreens.com com NutraBalance Nectar thick only 0 cal com/pre-thickened-drinks. htm Thick&Easy 60 mg Vitamin C 17.5 cal/oz Decaf coffee/tea Thickened coffee, dry ~11 cal/oz Ice cream supplement (frozen, melts to pudding consistency) Nestle Resource Thickened Coffee, Dry 9-10 cal/oz AquaCareH2O Liquid Reg/Decaf in 8 or 64 oz 0 cal/oz precision/home.htm Magic Cup Blue Bunny NUTRIplus Chocolate, vanilla, orange crème, and wild berry; contains vitamins A and C, calcium, and iron Vanilla, orange crème; contains Fiber plus 72.5 cal/oz/2.25 g Protein 60 cal/oz/2.25 g Protein Foodservice/Products/Cups/ Nutriplus_Cups 355

6 ICAN: Infant, Child, & Adolescent Nutrition December 2011 Table 4. Food Products for People With Dysphagia Product Manufacturer Comments Calories/Serving Availability Ice cream supplement (frozen, melts to pudding consistency) Magic Cup Blue Bunny NUTRIplus Chocolate, vanilla, orange crème, and wild berry; contains vitamins A and C, calcium and iron Vanilla, orange crème; contains fiber plus 72.5 cal/oz and 2.25 g Protein 60 cal/oz and 2.25 g protein Foodservice/Products/Cups/ Nutriplus_Cups Purees Campbell s TrePuree Complete meal in a dish: 2 oz of meat, 1 serving of vegetable and starch cal/250 g Meal : Cliffdale Farms Varied flavors 150 cal/4-oz Serving Thick&Easy Instanized Rice 50 cal (1 Tablespoon dry; ½ cup prepared) Thick & Easy Instanized Pasta 50 cal (1 Tablespoon dry; ½ cup prepared) Thick-It Purees Portion: 1/3 cup Vegetables, entrees, desserts; small cans, 5 servings/can Varies: Vegetable, cal; entree, cal; dessert: cal www. dysphagia-diet.com/precision/ home.htm; Resource Puree Appeal Nestle Powdered hot puree food thickener 1 Tablespoon = 30 cal/2.5 g protein Resource Puree Solutions Nestle Eggs and Toast, Bread mix 1/3 Cup = 200 cal/10g protein; 2 tablespoons = 80 cal/3 g protein Shaped Purees Thick&Easy Entrees (3 oz meat, poultry, and fish; 2 oz griller;1 oz bacon, sausage); breakfast; vegetables; fruits Varies com; Examples of the Impact of Thickening Fluids With Different Thickeners For the purposes of this review of the impact of thickeners on nutrient density, different thickened liquids were analyzed by the author for the effects of using both commercial and food-based thickening agents. As an example, a small infant was used who needs about 400 cal/d, which would require 20 oz/d of human milk or infant formula mixed to 20 cal/oz. A specific age, gestational age, or weight are purposely not given, so that the reader can think more globally about the impacts and focus on their own specific patient population. The recipes used as examples of nutrient density may not be practical for the very small infant only taking 60 ml at a feeding but are used to demonstrate the effects of thickeners on nutrient density. One should keep in mind as recipes are designed, that the premeasured gels or powdered thickeners are all designed to thicken for 4-oz portions and may not be stable over time. 356

7 vol. 3 no. 6 ICAN: Infant, Child, & Adolescent Nutrition Human Milk/Formula Thickened With Xanthan Gum Gel Thickener Nectar-like consistency: 4 oz + 15 ml gel thickener = 4.5 oz final volume = 17.8 cal/oz. This infant would have to consume 22.5 oz/d to achieve 400 cal. Honey-like consistency: 4 oz+ 30 ml gel thickener = 5 oz final volume = 16 cal/oz. The infant would have to consume 25 oz/d to achieve 400 cal. For infants who have difficulty managing these volumes, an alternative is to increase the caloric density of the human milk by adding infant formula powder and then thickening to the desired consistency. This process keeps the nutrient content more balanced. Here are some examples of recipes using a semielemental formula for an infant with symptoms of cow s milk protein intolerance (note that similar recipes could be developed using other standard or specialized formulas): 8 oz human milk + 1 scoop semielemental infant formula + 30 ml gel thickener = 9.2 final volume of 22 kcal/oz nectar-thick human milk. The infant would need 18.2 oz (546 ml) per day to consume 400 cal. 4 oz human milk + 1 scoop semielemental infant formula + 30 ml gel thickener = 5.2 oz final volume 24 kcal/oz honey-thick human milk. The infant would need 16.7 oz (501 ml) per day to get 400 cal. The fluid needs of the reference infant can still be met in this volume. Infant Formula Thickened With Modified Food Starch We need to consider the points discussed below. First, starch-based thickeners are digested by the amylase found in human milk and so cannot provide a stable, thickened product. Second, for each specific patient requiring thickener, the vitamins and minerals needed for growth should be analyzed in each recipe to ensure adequacy within the reduced volume needed to meet the energy goal. Nectar-like consistency: 4 oz infant formula (20 cal/oz) + 1 tablespoon and 1 teaspoon to 1½ tablespoons food starch thickener (amount needed will vary with the specific brand) = 4.7 to 4.8 oz final volume = ~21 ( ) cal/oz nectar-thick infant formula. The infant would need approximately 19 oz (570 ml) of formula to get 400 calories. Honey-like consistency: 4 oz infant formula (20 cal/oz) + 1½ to 2½ tablespoons food starch thickener (amount needed will vary with the specific brand) = 4.8 to 5.3 oz final volume = ~21 to 22 ( ) cal/oz honey-thick infant formula. The infant would need approximately 18 to 19 oz ( ml) of formula to get 400 cal. Human Milk/Formula Thickened With Rice Cereal Rice cereal is commonly used when thickening formula for infants. The amylase enzyme in human milk breaks cereal down, so it does not maintain thickness over time. When rice cereal is used to thicken human milk, it must be fed right away before it becomes too thin. The use of rice cereal to thicken liquids can leave an irregular lumpy consistency requiring the use of an X-cut nipple, which can increase aspiration risk and make for hard work in a neonate. Fatigue can lead to further reduction in oral intake. Rice cereal is commonly used with gastroesophageal reflux with recipes easily available on the Internet. Because rice cereal is inexpensive, parents many times change from the recommended treatment thickener plan prescribed by their team and switch to rice cereal, which is available and affordable. The impact of rice cereal is largely unstudied, but the American Academy of Pediatrics recommends delaying the introduction of solids to 6 months. There is an increased risk of type 1 diabetes and celiac disease associated with early introduction of solids Rice cereal adds 15 kcal/tablespoon primarily from carbohydrates and at least 1.19 mg iron/tablespoon 32 ; Using common recipe for reflux: 1 oz breast milk/formula + 3 teaspoons rice cereal = 1.1 oz final volume = ~32 cal/oz 33,34 ; The infant would only take in ~12.5 oz to take in the same 400 cal. Although this would meet the calorie needs of this infant, the fluid provided would only be 375 ml/d. This small volume may not meet the fluid needs of the patient. When using calorically dense thickeners, such as rice cereal, adequacy of fluid intake for hydration must always be assessed. This small volume also provides high levels of iron: 15 mg iron/d in thickened human milk or 19.4 mg iron/d in thickened standard cow s milk formula. Keep in mind that the dietary reference intake for adequate intake of iron from birth to 6 months is just 0.27 mg/d and jumps to 11 mg/d from 6 months to a year. 35 If the infant consumed the original 20 oz/d (600 ml), he or she would take in ~654 cal/d, which is 254 cal more than their goal. Plus they would take in very high levels of iron: 24 mg iron/d in thickened human milk or 31 mg iron/d in thickened, standard cow s milk formula. As the infant grows and takes greater volumes of formula thickened with rice cereal, the infant would reach the 40 mg tolerable upper intake level for iron in 25.8 oz (Figures 1 and 2). 35 Thickened Juices Apple juice without thickener provides approximately 15 cal/oz. Prethickened juices are available and commonly used in health care settings to ensure a standard product. Those using a starch thickener provide about 20 to 24 cal/oz. Prethickened juices using gel thickeners provide about 11 to 15 cal/oz. (See Table 3 for manufacturer Web sites). Apple juice thickened with gel thickener Nectar thick: 13 cal/oz Honey thick: 12 cal/oz Apple juice thickened with strained baby applesauce 357

8 ICAN: Infant, Child, & Adolescent Nutrition December 2011 Figure 1. Impact of thickeners on calories per ounce Calories per Ounce Human Milk/Formula 4-oz Strained baby applesauce + 50 ml apple juice = 150 ml = 17 cal/oz. 32 Conclusions Nectar Xanthan Gum Honey Xanthan Gum Figure 2. Impact of thickeners on iron content mg Iron per 20 Ounces Plain Nectar Xanthan Gum Thickening human milk or formulas can have a great impact on an infant beyond making the consistency more manageable to swallow. The effects of thickeners must be incorporated into the nutrition care process with the assessment of needs in order to determine the right thickener strategy. Start by determining weight and swallowing goals for your patient. Are they underweight or Nectar Modified Starch Thickener Type Honey Xanthan Gum Honey Thicken Modified w/rice Cereal Starch Formula, 31 Human Milk, 24 Thicken w/rice Cereal overweight, and do they need nectar or honey consistency liquids? Are they taking human milk or other products? Think about the wide variation in caloric density and the impact on your patient. Would they benefit from a formula providing 32 kcal/oz with less volume or a dilute formula providing 16 kcal/oz requiring greater intake. Or do they need a more standard dilution closer to 20 kcal/oz. Starch thickeners have calories that increase the energy density by increasing the carbohydrate load, thereby reducing the volume available to obtain all other nutrients, including fluids. Gum thickeners do not have calories, so they reduce the energy and nutrient density, thereby increasing the volume required to obtain adequate calories and all the other nutrients. Although stable in human milk, gum thickeners are not to be used in infants of gestational age less than 37 weeks. Also evaluate thickeners that have extra nutrients beyond calories; determine if those nutrients are appropriate for the specific patient. In particular, if rice cereal is used, monitor iron intake for possible toxic levels. Carefully educate families on how to accurately prepare the thickened human milk or formula recipe. Work with the family to obtain the appropriate product considering availability and finances to provide appropriate thickened fluids to promote adequate intake. Monitor adequacy of the fluid intake volume. Coordinate the timely advancement of prescribed consistency with the speech pathologist. If the patient is also on diet, consider that pureed foods contain on average between 75% and 85% of fluid, which contributes to hydration status. When working with infants and children, better outcomes will be achieved with careful consideration of the nutrient density of various thickeners. Appendix Honey-like thickened liquids: When poured off a spoon, these liquids flow in a continuous stream, like room temperature honey. The National Dysphagia Diet defined the honeylike thickened liquid range as 351 to 1750 cp.¹ Hydration: This refers to the absorption of adequate fluids into the body. Hydration status reflects the maintenance of needed balance between fluid and electrolytes. Nectar-like thickened liquids: Liquids thickened to a nectar-like consistency flow through the prongs of a fork but lightly coat the prongs leaving a residue. The National Dysphagia Diet defined nectar-like thickened liquids as having a viscosity of 51 to 350 cp.¹ 358

9 vol. 3 no. 6 ICAN: Infant, Child, & Adolescent Nutrition Nutrient density: This is a measure of the amount of micronutrients (vitamins, minerals, phytochemicals, and fiber) in relation to the amount of energy (measured as calories). A nutrient-dense food is high in micronutrients in relation to the calories consumed. An example of a nutrient-dense food would be breast milk. It provides the nutrients that an infant needs to grow and thrive. Oropharyngeal dysphagia: This is defined as swallowing/chewing impairments in the mouth and/or pharynx demonstrated by inefficiencies in moving a bolus through the mouth and swallowing through the pharynx with adequate muscle function and pressure. In children consuming thin liquids, research has shown that wet voice, wet breathing, and cough are good clinical markers of oropharyngeal dysphagia. 5 Spoon-thick liquids: These liquids have been thickened to a soft spoonable consistency, like pudding. Spoon-thick liquids do not pour but form a soft mass that can be scooped. This consistency sits on the spoon or drops off the spoon as a soft bolus. The National Dysphagia Diet defines spoon-thick liquids as having a viscosity greater than 1750 cp.¹ Thin liquids: This includes water, juices, milk, coffee, tea, supplement, or any beverage desired. Frozen desserts, like ice cream, sherbet, and sorbet that quickly melt in the mouth are included in this category. The National Dysphagia Diet defined the thin liquid range as 1 to 50 cp.¹ Viscosity: This is thought of as the ease of flow or fluidity. Thin liquids flow easily and quickly, whereas spoonthick liquids sit as a soft mass on a spoon. To measure viscosity, food scientists use the unit called centipoise (cp) at 25 C at a specific shear rate (stress or force). The National Dysphagia Diet defines viscosity as the rate of flow per unit force; the thickness or thinness of a liquid. ¹ References 1. National Dysphagia Diet Task Force. National Dysphagia Diet: Standardization for Optimal Care. Chicago, IL: American Dietetic Association; Bisch E, Logemann J, Rademaker AW, et al. Pharyngeal effects of bolus volume, viscosity and temperature in patients with dysphagia resulting from neurologic impairment and in normal subjects. J Speech Hear Res. 1994;37: Dantos RO, Kern MK, Massey BT, et al. Effect of swallowed bolus variables on oral and pharyngeal phases of swallowing. Am J Physiol. 1990;258(5, pt 1):G675-G Rempel G, Moussavi Z. The effect of viscosity on the breath swallow pattern of young people with cerebral palsy. Dysphagia. 2005;20: Weir K, McMahon S, Barry L, et al. Clinical signs and symptoms of oropharyngeal aspiration and dysphagia in children. Eur Respir J. 2009;33: Kendall KA, Leonard RH, McKenzie SW. Accommodation to changes in bolus viscosity in normal deglutition: a videofluoroscopic study. Ann Otol Rhinol Laryngol. 2001;110: Weir K, McMahon S, Chang AB. 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