When we got the official word that the Tiny Penguin was aspirating and that all of his fluids would need to be thickened, I was first angry and then totally overwhelmed. How was this going to work? How was daycare going to deal with it? How was I going to keep him from drinking thin liquids?
Over the last 1.5 years I’ve accumulated a fair amount of experience with thickening for a toddler. Here’s what I’ve learned.
Choosing a Thickener
We were given samples of a few thickeners to experiment with, including SimplyThick and Thick It. Since then I’ve also tried Resource Thicken Up and some other powders. SimplyThick is hands down the easiest thickener to use.
First, here are the reasons not to use SimplyThick: it’s not the cheapest and it’s not widely available. You can’t buy it at the drugstore (unlike Thick It). Some babies can’t use it (see below).
However, there are a lot of reasons why we went with SimplyThick.
SimplyThick is stable. It doesn’t keep thickening. You can warm it up or cool it down and it stays the same consistency. This is not the case with every thickener! I have made bricks out of milk with Thick It, and I couldn’t figure out why the Tiny Penguin wasn’t drinking the milk I was sending to school (hint: sludge).
SimplyThick is thickens instantly, as you shake it. Resource Thicken Up says instant, but it also says it thickens in five minutes, which is significantly different than instant.
SimplyThick is convenient. The red ‘nectar’ packet is 15 grams. The yellow ‘honey’ packet is 30 grams. Two nectars equals one honey. I like math!
(I know I sound like a testimonial, but I was not compensating in any way for this quasi-endorsement! It just makes this chore of thickening every single fluid so much less cumbersome.)
After tearing open many many packets (and realizing my son’s dysphagia was not going away), I opted for a six-pack of pump bottles. The pump dispenses 15 grams per pump stroke. It works well for about 2/3 of the bottle and then the pump has a hard time getting what’s left. Banging it can help the gel collect at the bottom again. After a day or so of that, I switch to a new bottle. After wishing I could screw together two bottles to get the leftovers out of the old bottle and into the new (and trying to rope a friend into 3D printing that part for me), I ended up finding the perfect funnel for accomplishing the task.
Because SimplyThick was associated with cases of necrotizing enterocolitis (NEC) in premature babies, if your kiddo was a preemie or has or had certain medical conditions, SimplyThick won’t be recommended. You actually need to attest that you are not ordering for a person under 12 months in order to order from their website. However, our hospital does use SimplyThick for kids under 12 months as long as they were not premature and don’t have other risk factors for NEC. Ask your doctor/dietician/occupational therapist.
I use a baby bottle to thicken his fluids. Our hospital gave us a ratio of 5 oz to 1 packet for nectar thick, 5 oz to 2 packets for honey thick, which is different than the SimplyThick instructions which say 4 ounces.
A lot of parents get recipes like “add two tablespoons rice cereal per 4 ounces breastmilk or formula” but then struggle with translating that to other thickeners or other fluids. There is an objective way to measure thickness! The International Dysphagia Diet Standardisation Initiative has come up with this method (full details in this PDF):
- Take a 10 mL slip tip syringe
- Put 10 mL of your fluid into the syringe
- Let it run through for 10 seconds (I use my Google Home timer for this)
- Stop it and see how many mL are left in the syringe. For level 2, for example, there should be 4-8 mL left. Then whenever you are thickening something new, you can test it and make sure it matches that thickness. For example, I made a smoothie with frozen fruit that I thought was thick enough, but the Tiny Penguin was coughing on it. When I tested it, it ran through the syringe way too quickly, so I added thickener and tested again.
Check with your dysphagia medical team before changing consistencies, and check which IDDSI level they would consider appropriate. One challenge is that there is no mapping provided between the conventional US levels (nectar, honey, pudding) and the levels defined by the IDDSI, so I would press your team to define the level they are recommending so that you can use this test to make sure the liquids you’re preparing are appropriate.
On the Go
I keep a plastic baby bottle and cap, and a mix of nectar and honey packets in a Ziploc bag in my backpack. That way, wherever we are, I can thicken water, juice, etc, and he can drink whatever everyone else is drinking. I’ve found I can even thicken carbonated drinks, if I’m careful when I open the bottle!
When we fly, I bring at least two empty baby bottles. If he wants apple juice from the drink cart, for example, I ask the flight attendant for the whole can, pour 5 ounces into each bottle, and then can either thicken that, or water it down and thicken 7.5 ounces.
Going from honey thick to chilled honey thick was a more difficult transition than I anticipated. The Tiny Penguin was in daycare full time, and though you’d think it would be easy enough to put his water back in the fridge like they put milk back in the fridge, it didn’t happen. Kids would helpfully put his water back on the shelf with all the other water bottles. Or the teachers would take all the kids’ water bottles up to the playground in the 80-degree heat.
Remember, if you need thickened liquid, you can’t use regular ice. Regular ice is made of thin water, so it’ll melt to thin and dilute your intended consistency.
My first attempt to keep his fluids cold was to thicken water and milk and freeze them in the little ice cube trays I’d used in his pureed baby food days. While these cubes were very cute, they seemed to melt pretty quickly. I figured if I could reduce the exposed surface area, they might stay solid longer, so I found these silicone popsicle molds. Now I thicken water, pour it into the molds, and stick the molds upright in the freezer. A few minutes before we leave, I pull one or two out of the freezer. If they warm up for 5-ish minutes, it’s easier to get the ice out. With two ice-pops in his 20 ounce insulated water bottle, there is still some solid ice at the end of the day. I still ask his teachers to keep his water in the fridge, but I’m not too worried about lapses, because I know it can stay cold all on its own.
This was a huge problem for the first year or so. The Tiny Penguin was diagnosed with aspiration at 15 months old. At that point, there was not a lot of discussion, and he was not very opinionated, so I thickened his drinks, and that was that. It was at the park that it first came up in actual discussion — he wanted to use the drinking fountain, and so I explained that that water was thin water, and he drinks thick water. He adopted the nomenclature pretty quickly (though it was ‘fin’ and ‘fick’ for him). He was pretty good about only drinking from his own cups (though his teachers reported that sometimes other kids drank his and were quite surprised by the texture they found). The real challenge was in the bathtub and at the sink. He would sneak off and fill tiny cups with water and drink it. He would ‘pretend’ to drink and then drink for real. He would skim water in the bathtub. When he would cough cough cough after that, I tried to reinforce that he was coughing and uncomfortable because he had drunk thin water. I took all the cups out of the bathtub. I took all the cups out of the bathroom. I took all the toys with concave surfaces out of the bathtub! But in a water world there’s little to do but wait until the Penguin matures enough to not drink the water. At 2.5y he’s now pretty decent at following the rules. Rules about drinking, anyway.
What tricks do you have to manage thickening?