This information sheet is for speech pathologists to help them provide patient care/education for families. It is not written for/intended for providing directly to families – please seek other written education materials for family education.

Infants who have difficulty feeding and swallowing may benefit from thickened fluids. Thickened fluids can reduce flow rate and help some infants coordinate their suck-swallow-breathe cycle while feeding.

What to consider before thickening fluid for infants

There are 2 thickening products suitable for infants under one year of age in Australia:

• Aptamil® Feed Thickener.
• Supercol® Food and Liquid Thickener.

Aptamil® Feed Thickener is made of carob bean gum and may contain allergens such as milk or soy.

Supercol® Food and Liquid Thickener is made from guar-gum and contains no reported allergens.

Thickeners are contraindicated in premature infants, and health professionals are recommended to try alternative feeding strategies to reduce flow rate before offering thickener.

When considering thickeners for infants, it is important to consider:

• if the infant has poor pharyngeal clearance
• if there is a history of necrotising enterocolitis
• if the infant is on a ketogenic diet
• if the infant has poor oesophageal motility
• if the infant has monosaccharide intolerance or food allergies/intolerances.

This should involve consultation with the infant’s medical team if you are unsure.

‘Slightly thick’ formula recipes (Level 1)

Fluid thicknesses are defined by the International Dysphagia Diet Standardisation Initiative (IDDSI). For infants, a Level 1 (slightly thick) fluid is often recommended as infants are generally still able to extract it from the teat.

Achieving ideal fluid thickness can be challenging as thickness may be influenced by:

• time
• temperature
• base fluid
• how the formula/thickener combination was mixed
• the type of thickener used.

Through rigorous methodology by clinician-researchers at the Queensland Children’s Hospital, there are recipes available for consistent thickened formulas for infants at a Level 1 (‘slightly thick’) level.

There is still potential for individual variability. If there is any doubt in the suitability of a thickened formula combination for an infant, consider conducting an IDDSI flow test at bedside (see https://www.iddsi.org/framework/drink-testing-methods/) .

Recipes mixed with Aptamil® Feed Thickener

Instructions:

1. Before adding thickener, ensure the milk is room temperature (23-25°C).
2. Measure the recommended volume of thickener and put it into the bottle.
3. Shake the formula and thickener for 30 seconds before feeding the infant.
4. Gently re-shake the bottle when the infant pauses for burp breaks. This is also an opportunity to check that the teat is not blocked.

RTF=ready-to-feed
*timeframes rounded to the nearest minute
**please note this is a metric teaspoon (5ml)

Recipes mixed with Supercol® Food and Liquid Thickener

Instructions:

1. Ensure milk is room temperature (23-25°C).
2. Measure recommended volume of thickener and sprinkle thickener into fluid.
3. Whisk formula and thickener for 30 seconds and pour into bottle before feeding the infant.
4. Gently re-shake the bottle when the infant pauses for burp breaks. This is also an opportunity to check that the teat is not blocked.

RTF=ready-to-feed
*timeframes rounded to the nearest minute
**please note this is a metric teaspoon (5ml). 1/8 teaspoon is very similar to the scoop provided by Supercol®.

A rule of thumb for both types of thickener is to wait at least 10 minutes after mixing before feeding. Thickened formula was typically found to be more stable after this time. From a food safety perspective, thickened formula should only be given to infants within an hour of being made. For infants that have a preference for heated formula, thickener should be added after heating, the waiting period should be applied, and an IDDSI flow test should be conducted to ensure correct thickness, being aware that thickness may increase as the formula cools.

References

1. Beal, J., Silverman, B., Bellant, J., Young, T. E., & Klontz, K. (2012). Late onset necrotizing enterocolitis in infants following use of a xanthan gum-containing thickening agent. The Journal of Pediatrics, 161(2), 354-356.
2. Centers for Disease Control and Prevention. Infant Formula Preparation and Storage. 2022 [cited 2022, 24th April, 2023]; Available from https://www.cdc.gov/nutrition/InfantandToddlerNutrition/formula-feeding/infant-formula-preparation-and-storage.html
3. Cichero, J. A., Nicholson, T. M., & September, C. (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
4. Cichero, J. A., Lam, P., Steele, C. M., Hanson, B., Chen, J., Dantas, R. O., Duivestein, J., Kayashita, J., Lecko, C., Murray, J., Pillay, M., Riquelme, L., & Stanschus, S. (2017). Development of international terminology and definitions for texture-modified foods and thickened fluids used in dysphagia management: The IDDSI framework. Dysphagia, 32(2), 293–314. https://doi.org/10.1007/s00455-016-9758-y
5. 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
6. Marshall, J., Buttsworth, J., Grandt, H. D. S., Raatz, M., Signorini, A., Fernando, S., & Clarke, S. (2023). Testing and development of slightly thick infant formula recipes for dysphagia management: An Australian perspective. Dysphagia, 10.1007/s00455-022-10550-1. Advance online publication. https://doi.org/10.1007/s00455-022-10550-1
7. Martínez, O., Vicente, M.S. & Salmeron, J. (2019). Sensory perception and flow properties of dysphagia thickening formulas with different composition. Food Hydrocolloids, 90, 508-514. https://doi.org/10.1016/j.foodhyd.2018.12.045
8. Ng, V., Bogaardt, H., Tzannes, G., Collins, S., & Docking, K. (2022). Thickened formulas used for infants with dysphagia: Influence of time and temperature. Dysphagia, 37(4), 923–932. https://doi.org/10.1007/s00455-021-10353-w
9. Nutricia. Aptamil Feed Thickener 2022. Available from: https://nutricia.com.au/paediatrics/product/aptamil-feed-thickener/#.
10. Rush, O. M., Bolland, A. C., & Gosa, M. M. (2021). 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
11. Supercol Australia. Supercol Food and Liquid Thickener 2022. Available from: https://supercol.com.au/.

Developed by the Speech Pathology department, Children’s Health Queensland’s Child Health Service. We acknowledge the input of consumers and carers.

Resource No: FS400. Reviewed: June 2024

Disclaimer: This information has been produced by healthcare professionals as a guideline only and is intended to support, not replace, discussion with your child’s doctor or healthcare professionals. Information is updated regularly, so please check you are referring to the most recent version. Seek medical advice, as appropriate, for concerns regarding your child’s health.