Thickened Liquids: Love Them or Hate Them?

Thickened liquids have been a major player in dysphagia management for decades and, depending on the setting, sometimes get recommended more often than other compensatory or management techniques.

As Steele and Miller (2010) put it, “Texture modification has become one of the most common forms of intervention for dysphagia and is widely considered important for promoting safe and efficient swallowing.”

Thickened liquids were never meant to be the first line of defense when assessing a patient with dysphagia rather than trialing compensations and maneuvers first.  Understand though, not every patient can follow directions to try compensations or maneuvers and may need to skip straight to the thickened liquids.

But here’s the thing—while thickened liquids might be commonly prescribed, there’s increasing focus on alternatives. Tools like the Provale® Cup are designed to limit the amount of liquid delivered (usually 5–10 mL per sip), which can help reduce risk with thin or nectar-thick liquids. Depending on the patient, that small volume may be all they need to swallow safely—without jumping to thickening.

Let’s Talk Cost

There’s a lot to consider when recommending thickened liquids, and cost is a big one. Thickener is not cheap.

My friend Vince Clark broke it down on Facebook:

• Per day: 9 x $0.34 = $3.06
• Per week: $21.42
• Per month: $85.68
• Per year: $1,116.90

And that’s for an organization purchasing in bulk. For an individual paying out of pocket? Easily double.  Now remember, prices change and these costs have probably drastically increased.

How Thick Is Thick Enough?

More and more research suggests that we might be overdoing it. Dr. Steven Leder and colleagues (2013) found that patients who aspirated thin liquids had 100% successful swallows with both nectar and honey thick liquids—suggesting that nectar-thick may be enough to promote safe swallowing.

But it’s not always so clear-cut. One of the most well-known studies, Protocol 201 by Robbins and colleagues (2004), found that honey-thick liquids were the most effective in eliminating aspiration—but when patients did aspirate honey-thick, the consequences were more severe: increased risk of pneumonia, longer hospital stays, even death.

So what’s the answer?

It’s not all or nothing. It’s not always thickened vs. thin. It’s the whole patient that matters.

Because let’s be honest—we’ve all done an MBSS where the patient aspirates thin and nectar, so honey-thick it is. But then we discharge them, and they go right back to drinking thin liquids at home—and they don’t keel over from aspiration pneumonia. Imagine that.

Clinical Application

In real life, here’s how I interpret the research: some patients just need thickened liquids. They’re not going anywhere. And that’s OK.

In fact, thickened liquids can even be therapeutic. Dr. Bonnie Martin-Harris, in her work on the Modified Barium Swallow Impairment Profile (MBSImP), found that nectar consistency can increase pharyngeal movement during the swallow. Other research has shown that increasing bolus viscosity or “weight” can be an effective part of a therapeutic strategy.

So don’t toss out your thickener just yet.

(Yes—I actually wrote in 2016: “Just because an article came out that says not to use thickened liquids at all, don’t go and throw out all your thickener.”)

The Real Cost: Health and Quality of Life

Cost isn’t just about dollars—it’s also about our patient’s health, hydration, and satisfaction.

We all know that one patient who doesn’t mind thickened liquids. Maybe they’re not doing backflips, but they tolerate it. They understand it’s temporary. They’re doing the exercises. They want to get back to thin, but for now—they’re fine.

Then we have those patients who absolutely refuse. They hate the texture. They say things like:

“I know I need them… but they taste like snot.”
— A real patient, circa 2011.

These are often the patients who either stop drinking altogether or toss your recommendations in the trash.

Finding the Balance

There has to be a balance. Hydration. Respiratory health. Quality of life.

I’m not talking about that post-discharge survey where the patient rates you from 1 to 10. I’m talking about the real, everyday “am I satisfied with my life?” kind of quality of life.

You have to look at the whole picture:

• Respiratory status
• Medical history
• Cognition
• Patient preferences
• Goals of care

And when possible, make the decision with the patient.

I’ve completed a lot of MBSSs over the years. And when the radiologist is panicking because the patient aspirated on thin, I often say:

“Remember, the person is here because they’ve been having difficulty swallowing. I’m guessing this isn’t the first—or last—time they’ve aspirated.”
— Me. Every time.

And don’t forget the folks in SNFs, sipping honey-thick liquids for years—who you catch sneaking sips from the water fountain, swiping drinks in the dining room, or chugging from the bathroom sink.

Yep. Been there.

Are you ready for a deeper dive with even more resources available? Join the Dysphagia Skills Accelerator today. You will get so many great tools with new tools being added all the time! Click here to join now!

Have you ever wanted a way to create a more standardized protocol for your Clinical Swallow Evaluation?   Do you often forget or leave out parts of the CSE, you know, the parts that are important for your Plan of Care?  You probably need the Clinical Dysphagia Assessment Toolkit if you answered yes.   You can get your copy here.  

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References
Steele, C. M., & Miller, A. J. (2010). Sensory input pathways and mechanisms in swallowing: a review. Dysphagia, 25(4), 323–333.

Robbins, J., Hind, J., & Logemann, J. (2004). An ongoing randomized clinical trial in dysphagia. Journal of Communication Disorders, 37(5), 425–435.

Leder, S. B., Judson, B. L., Sliwinski, E., & Madson, L. (2013). Promoting safe swallowing when puree is swallowed without aspiration but thin liquid is aspirated: nectar is enough. Dysphagia, 28(1), 58–62.