NeuroNICU 5 Minute Friday:
Using Thickened Liquids to
Improve Swallowing Safety
Kelly Andrasik OTR/L, MOT
Friday April 8th, 2016
Thickener Background Information
•  Dysphagia
•  Difficulty or inability to swallow
•  Impacts 25-55% of premature infants
•  (Mercado-Dean, et al. 2001)
•  60% of infants with developmental issues
•  (Giudice, et al. 1999)
•  Texture and viscosity modifications are considered a
cornerstone of dysphagia management
•  Slows flow of liquid
•  Improves cohesiveness of the bolus
•  Improves sensation/feedback
History of Thickeners
•  Pre- 2011
•  no regulations on thickeners with NICU population
•  Post- 2011
•  FDA puts out warning against Simply Thick for
preemies (May 2011)
•  Vague guidelines expanded to other thickening
agents, especially for ex-preterm infants
•  FDA expands warning to term infants (May 2012)
•  LPCH Policy Update 2014
Thickeners for Formula
Rice Cereal
(NO breast milk)
Pa#ent Age
Recommended Use
Premature infants (no h/o NEC) FT infants 0-­‐4 months
4 months and older
Limited, recrea,onal feedings up to 10 mL BID, if cleared by primary MD once baby is 44 weeks PMA or older Limited, recrea,onal feedings up to 10 mL BID, if cleared by primary MD
Full thickened oral feeds, if deemed appropriate by feeding therapist and primary MD
Thick-It
(NO breast milk)
Pa#ent Age
Recommended Use
Premature infants (no May be used for full oral feeds, if deemed appropriate by feeding h/o NEC)
therapist and primary MD once baby is 44 weeks FT Infants 0 months
Full thickened oral feeds, if deemed appropriate by feeding therapist and primary MD
Thickeners for Breast Milk
Simply Thick
Pa#ent Age
Any infant 0-­‐12 months
12 months & older, including premature infants (no h/o NEC)
Infant with h/o NEC
Recommended Use
May not be used Full thickened oral feeds, if deemed appropriate by feeding therapist and primary MD May be only used once child is greater than 12 years of age
Gelmix
Pa#ent Age
Premature infants (no h/o NEC)
All other infants and older children
Recommended Use
May be used for full oral feeds, once baby is 44 weeks PMA and 6 pounds May be used for full oral feeds, once baby is 44 weeks PMA and 6 pounds Why We Love Thickeners
•  Can facilitate safer feeding for our patients with
dysphagia and swallowing difficulties
•  Keeps oral feeding as an infant occupation
•  Faster transition to full oral feedings
•  Decreased incidence of oral aversion
•  Baby and parent bonding opportunities via feeding
Why We Love to Hate Thickeners
•  No perfect thickening options
• 
• 
• 
• 
•  Limited use in MBM
Added cost
Infection risks from additives
Difficult family carry over
Increases demands on baby
•  Can be difficult to meet nutrition & hydration orally
•  Taxing endurance-wise
•  Changes nutritional value of feeding
Kelly Andrasik, OTR/L, MOT, SWC [email protected] References
Abrams, S. A., (2011). Be cautious in using thickening agents for preemies. AAP News. Downloaded from http://aapnews.aappublications.org
American Academy of Pediatrics (2012), “Arsenic in Food Products.” For Immediate Release: September 19, 2012.
Beal, Silverman, Bellant, Young, Klontz. Late Onset Necrotizing Enterolcolitis in Infants following Use of Xantham Gum-Containing Thickening
Agent. The Journal of Pediatrics, August 2012.
Cichero, J. & La, P. (2014). Thickening Liquids for Children and Adults with Oropharyngeal Dysphagia: the Complexity of Rheological
Considerations. Journal of Gastroenterology and Hepatology Resarch. Vol 3 (5).
Clinical tube weaning supported by hunger provocation in fully-tube-feed children; J Pediatric Gastroenterol Nutrition; April 2015; 60(4); Page
538-43.
FDA expands caution of use to all infants, September 18, 2012:http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm256250.htm
Giudice ED, Staiano A, Capono G, Romano A, Florimonte L, Miele E, Ciarla C, Campanozzi A, Crisanto AF. Gastrointstinal manifestations in
children with cerebral palsy. Brain & Development 1999; 21: 307-311
Initial FDA warning June 5, 2011:http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm256253
Khoshoo, V., Ross, G., Kelly, B., Edell, D., & Brown, S. Benefits of Thickened Feeds in Previously Healthy Infants with Respiratory Syncytial
Viral Bronchiolitis. Pediatric Pulmonology 31:301-302 (2001).
Late Onset Necrotizing Enterocolitis in Infants following Use of Xanthan Gum-Containing Thickening Agent; The Journal of Pediatrics; 11 May
2012; pgs 354-356.
Law, W.S. et al. Rapid characterization of complex viscous liquids at the molecular level. Angew. Chem. Int. Ed. 48, 8277–8280 (2009).
Mercado-Deane M-G, Burton EM, Harlow SA, Glover AS, Deane DA, Guill MF, Hudson V. Swallowing dysfunction in infants less than 1 year of
age. Pediatric Radiology 2001; 31: 423-428
References
Meunier, L., Garthoff, J., Schaafsma, A., Krul, L., Schrijver, J., van Goudoever, J., Speijers, G., & Vandenplas, Y., Locust bean gum safety in
neonates and young infants: An integrated review of the toxicological database and clinical evidence. Regulatory Toxicology and Pharmacology
70 (2014) 155-169.
NEC with thickened feeds; The Journal of Pediatrics; August 2012; Volume 161, Issue 2, Page A4.
Parapharma Tech, LLC. (2015). Gelmix: Harnessing the Power of Carob Bean Gum.
Parapharma Tech, LLC. (2015). Gelmix: Gelmix Fact Sheet.
Prevention of Invasive Cronobater Infections in Young Infants Fed Powdered Infant Formula; American Academy of Pediatrics; 8 October,
2012:http://pediatrics.aappublications.org/content/130/5/e1076.full.html
September, C., Nicholson, T., & Cichero, J. Implications of Changing the Amount of Thickener in Thickened Infant Formula for Infants with
Dysphagia. Dysphagia, August 29, 2014, p 432-437.
Simply Thick-Our Thickener. (2016, March 6). Retrieved from http://www.simplythick.com/Our-Thickener
Swallowing Function and Medical Diagnoses in Infants Suspected of Dysphagia, American Academy of Pediatrics; 2001:http://
pediatrics.aappublivations.org/content/108/6/e106.full.html
Thick It: About us. (2016, March 6). Retrieved from http://thickit.com/about-us/
U.S. Food and Drug Administration. (2012). FDA Expands Caution About Simply Thick. U.S. Department of Health and Human Services.
Warning Too Late for Some Babies, February 4, 2013:well.blogs.nytimes.com/2013/02/04/warning-too-late-for-some-babies/