A beginner’s guide to what you need to know about transitional foods and dysphagia.
The term “transitional foods” might conjure up images of ice cream or cotton candy, but what exactly are they? And how can they play a role in dysphagia treatment? Karen Sheffler, MS, CCC-SLP, BCS-S is here to help, with a comprehensive guide to what you need to know about using and testing transitional foods.
What are Transitional Foods?
As defined by the IDDSI framework, transitional foods “start as one texture (e.g., a firm solid) and change to another texture specifically when moisture (e.g., water or saliva) is applied or when a change in temperature occurs (e.g., heating or the warmth of your mouth).”
The following are examples of potential transitional foods. The person with dysphagia and/or the caregiver should always test the item to make sure that it is a transitional food (see below and page 10 of IDDSI’s Testing Methods). Some transitional foods may be harder for a person with dysphagia (e.g., gelatin), while other items may be easier. Please follow the guidance of your dysphagia specialist (speech-language pathologist/SLP).
- Ice chips, popsicles
- Gelatin (e.g., Jell-O brand)
- Ice cream
- Some wafers (e.g., religious communion wafers)
- Some baby teething wafers, but all teething wafers need testing prior to giving them to your child. (See Barewal et al., 2021 regarding the poor dissolvability of Baby Mum Mums™ and other products; See Awadalla et al., 2018 regarding analysis of first finger foods)
- Some specific crackers or cookies that are made to dissolve easily in the mouth (See Barewal et al., 2021 and Savorease™)
In short, there are two types of transitional foods; some transitional foods melt down to a thin liquid with the heat of the mouth, while others are a unique food texture that once the solid has been broken down by moisture and temperature, then minimal chewing is required and even tongue pressure alone can break down these items.
Dos and Don’ts of Transitional Foods for Dysphagia Diets
Despite the potential of transitional foods to be a safe option for some on dysphagia diets, there are still some rules to follow to ensure utmost safety while eating:
- Direct supervision to ensure safety.
- Attention to task (not impulsive or trying to eat too much at once).
- Avoid transitional food wafers, crackers, cookies if the person has significant dry mouth, as they will not have sufficient moisture to begin the break-down process.
- Make sure the person can perform:
- Up and down motions of the tongue to mash the item.
- Some front to back tongue stripping to move food from the front of the mouth to the back of the mouth.
Different transitional foods will break down differently, and each food should be properly analyzed and evaluated within a person’s own swallowing structure and function to ensure that the item is safe to consume.
Testing Transitional Foods
IDDSI recommends the following testing regimen for transitional foods:
- Apply 1ml of water to your food sample (this can be done via syringe).
- Wait 1 minute.
- Perform the IDDSI Fork Pressure Test
- Use a standard fork
- Apply pressure to the base of the fork with your thumbnail until your thumbnail blanches white
- The sample should melt, disintegrate, or squash, leaving indentations of the fork. It will not return to its original shape after releasing the pressure.
While transitional foods have shown great promise as a potential bridge between pureed foods and solid foods, there’s still been very little research done on this topic. In fact, IDDSI has only two recommended articles noted in their frequently asked questions section on transitional foods (Gisel, 1991 and Dovey, Aldridge & Martin, 2013). But there’s optimism towards using transitional foods as a way to help develop important chewing and swallowing skills for those challenged by dysphagia, or as a substitute for those with oral sensitivity issues. Drs. Reva Barewal and Samantha Shune and colleagues recently published an article on transitional foods in the Dysphagia Journal. The authors highlighted the key point to expect variability within people and between different products. They cautioned that even when a product states that it is a transitional food or that it is a first finger food, one must consider the following:
- Quality and quantity of saliva to add moisture
- Type and severity of dysphagia (your SLP can perform individualized testing)
- How long will the food be held in the mouth, as people tend to only contain food in the mouth for 12 seconds versus the 1-minute length of time in the IDDSI testing method.
Therefore, in addition to the IDDSI testing methods, it is wise for a caregiver without dysphagia to first test the food by placing it in their own mouth. When you hold the food on your tongue and apply some up and down tongue pumping, the sample should start dissolving into a paste in about 12 seconds (Barewal, et al., 2021).
Barewal and colleagues (2021) emphasized the benefits of transitional foods for improving quality of life and more. For example, providing crunchy transitional food textures for people on pureed diets can satisfy food preferences, increase caloric intake at snack time, retrain chewing motions, and potentially foster diet texture advancements for people with dysphagia. Another example is from Japan, where healthcare professionals use a dysphagia training jelly for safer swallowing retraining during treatment, as this jelly does not thin down to a thin liquid in the mouth like typical American gelatin (Jell-O). Applications like these give hope that transitional foods can help aid in a return to quality of life for those on dysphagia diets.
To learn more about transitional foods and their relationship with dysphagia, check out the full three-part series on transitional foods from Karen Sheffler, MS, CCC-SLP, BCS-S.
*This author, Karen Sheffler, does not have a financial relationship with any of the mentioned products.
References on Transitional Foods
Awadalla, N., Pham, T. & Milanaik, R. (2018). Chew on this: Not all first finger foods are created equal. Clinical Pediatrics, 57(8), 889-894. https://www.ncbi.nlm.nih.gov/pubmed/28990427
Barewal, R., Shune, S., Ball, J. et al. (2021). A Comparison of Behavior of Transitional-State Foods Under Varying Oral Conditions. Dysphagia, 36, 316-324. https://link.springer.com/article/10.1007/s00455-020-10135-w
Dovey, T.M., Aldridge, V.K. & Martin, C.I. (2013). Measuring oral sensitivity in clinical practice: A quick and reliable behavioural method. Dysphagia, 28(4), 501-510. https://doi.org/10.1007/s00455-013-9460-2
Gisel, E.G. (1991). Effect of Food Texture on the Development of Chewing of Children Between Six Months and Two Years of Age. Developmental Medicine & Child Neurology, 33, 69-79. https://doi.org/10.1111/j.1469-8749.1991.tb14786.x