I don't have the time or energy to dig through my references at the moment BUT I wanted to weigh in on this conversation.

Sarah is right, there is no great solution for thickening liquids for infants and small children. (But then again should any of us -even adults- really be consuming xantham gum or maltodextrin every time we take a drink? Or even at all???)

"Thick It" and other powder based thickeners have been avoided for preterm infants in *most* NICUs for some time due to their potential links to increased incidence of NEC, forgive me I don't have the references for those studies right off hand. The "Simply Thick" reps were really marketing their product to NICUs 3+ years ago. As a speech pathologist working on an NICU I was contacted many times by Simply Thick reps and sent lots of free samples. I repeatedly asked for studies, clinical trials, anything to show me that this was safe to use with this very vulnerable population. They had none. They could only give me the names and contact info of other swallowing specialists who were using this thickener on their NICUs. That wasn't enough for me...

Rice cereal has been the baby milk thickener of choice for years for BOTH dysphagia and reflux. Yes there is no real evidence either way on whether it helps with reflux or not but it is definitely still used routinely in many NICUs in the US for this purpose. I don't think there is any real rationale for using rice cereal over anything else other than it is a product marketed for babies??? (Anyone with any additional insight into that please chime in.) It is a pretty terrible thickener as far as thickeners go. It is extra clumpy, it gets stuck in bottle nipples which compels well meaning nurses to cut large holes in nipples to feed infants who inevitably already have major flow rate control issues. (This was the main selling point of "Simply Thick", it is a gel and gives a consistent viscosity.) I can't imagine it is a pleasant sensory experience for the infant to have the clumps in their milk. And yes, breastmilk does "digest" rice cereal somewhat. The longer it sits the thinner the liquid gets generally. Some mom's breastmilk breaks it down faster than others. If we had to do a videoflouroscopic swallow study/VFSS (or modified barium swallow study/MBSS or oral pharyngeal motility study/OPMS or whatever you call them at your facility) on a baby that was getting breastmilk we would always do a trial mix of the rice cereal with the mom's milk to make sure that it could maintain the viscosity that we wanted for at least the length of a feeding (a magical 30 minutes in my hospital) with a minimal amount of rice cereal. Rice cereal won't work adequately to thicken breastmilk to the desired consistency in all circumstances. Thickening, in my opinion, is an absolute last resort. I personally try EVERYTHING else before going to thickening. We thicken, as Sarah mentioned, only to preserve oral feeding when other measures have failed to prevent or minimize aspiration. But I am not sure what the *cost* of that thickener is on the overall system, and particularly the digestive tract, of the infant. I'm afraid it's greater than we perceive.

So what do we do? I'm not sure. My bias, of course, is towards breastfeeding and breastmilk. I *wonder* if a version of the Frazier Water Protocol (http://nursing.advanceweb.com/article/frazier-water-protocol.aspx) might work for infants? I'm just theorizing here so bear with me. But basically Frazier Water Protocol for adults allows known aspirators to have as much regular thin liquid water as they want (between meals and with a clean mouth) based on the fact that water is pH neutral and we know that aspiration of "clean" (low bacterial load), pH neutral water is a relatively benign event. Breastmilk is relatively pH neutral and I would certainly think the infant's body would be just as able to readily assimilate/absorb breastmilk as the adult's body does water. Many NICU speech pathologists also suspect that most infants probably have fewer/less severe aspiration episodes at breast than they do with a bottle anyway. Sooo do we really need to thicken at all? Particularly since thickening forces bottle feeding. Susan Langmore's studies on the causes of pneumonia in adult geriatric population found that the top cause was not dysphagia but dependence for feeding. I'm not sure we can really generalize that to infants but it certainly makes you stop and think, doesn't it? 

Obviously this is a very complicated matter without easy answers. I suppose any intervention requires a careful analysis of potential risks versus potential benefits. 

Laura Wasielewski MS, CCC-SLP, IBCLC
Los Angeles, CA
Somewhat thankful I am at home with MY baby right now and not having to wrestle with the thickening problem in real life on a daily basis anymore...

   

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