Keeping up with the literature. Together.
As both a speech language pathologist (CF) and a lactation counselor, I get an excuse to nerd out on research “for my job” :) I am always helped to write out my thoughts on what I read, and hope this can be a benefit to other practitioners who also need to keep abreast of the literature. My plan is to post synopses here in plain language of what I’m reading. I’ll always link to articles so you can read the full text.
If you are also a bit nerdy and want to join the Nurture Appalachia team in this effort, let me know! I don’t pay anything, but I’ll dialogue with you about ideas and implications of the current research for practice :)
Banana Puree Thickener
If thickened feeds are indicated by an instrumental swallow evaluation, banana puree can be used to reliably thicken a variety of human milk and cow-based formulas to IDDSI levels 1-3. Caution is indicated to manage potassium intake levels such that banana puree is kept at or below 15% of total feeding volume.
Brinker K, Winn L, Woodbury AE, et al. The nutrition profile and utility of banana puree as a liquid thickener for medically complex infants with dysphagia. Nutr Clin Pract. 2025;40:227‐238. doi:10.1002/ncp.11240
Type: Clinical research in vitro experiment
Research question: Is banana puree a feasible thickening agent for hospitalized infants with dysphagia?
Results: “Banana puree effectively achieved IDDSI Levels 1–3, with varying volumes required based on milk types and caloric concentrations. The nutrition analysis revealed the importance of restricting banana puree to 15% of feeding volumes to avoid exceeding recommended potassium levels while promoting appropriate nutrition.”
Quick Summary
If thickened feeds are indicated by an instrumental swallow evaluation, banana puree can be used to reliably thicken a variety of human milk and cow-based formulas to IDDSI levels 1-3. Caution is indicated to manage potassium intake levels such that banana puree is kept at or below 15% of total feeding volume. Infants at risk of renal failure may not be appropriate for banana puree and should be monitored for electrolyte levels. Banana puree should not be introduced <39 PMA.
Benefits of banana puree as thickener include reduced cost and ease of access, avoidance of NEC risk from gel-based thickeners, avoidance of arsenic intake from rice cereal, and more consistent thickness over time compared to oatmeal.
Recipes should be modified for specific milk used via the IDDSI test. General guidelines for each level provided in article.
Longer Summary
Dysphagia prevalence among preterm infants is estimated between 40% and 60%. Therapeutic strategies include positioning, bolus manipulation, pacing, and altering liquid thickness. Thickening has been shown to enhance oral-pharyngeal coordination and sensory feedback, potentially reducing risk of aspiration. Current thickeners all have limitations and include: 1) carob bean gum-based products that are inappropriate for preterm infants and infants younger than 41 weeks PCA given risk of necrotizing enterocolitis, 2) rice cereals that contain arsenic and displace calories, and 3) oatmeal that changes in consistency over time.
This study hypothesized that “banana puree mixed with infant formulas or human milk can achieve desired thickness levels according to IDDSI standards, providing a safe and effective alternative for infants with dysphagia while maintaining appropriate neonatal nutrition standards.”
The researchers tested Gerber Sitter 2nd Food Banana Baby Food as thickener of unfortified unpasteurized donor human milk, fortified human milk, and prepared cow-based formula to achieve IDDSI levels 1-3 using mixing methods similar to typical feeding preparations by bedside nurses in a temperature-controlled patient room in the NICU. Results were analyzed using student t test. Note that use of IDDSI test allows for human error.
They were able to produce reliable IDDSI levels using the puree. Different formula fortifiers required different amounts of banana puree. Recipes are provided, but should be modified and tested for specific milk used.
Excess potassium (hyperkalemia) increases risk of fatal arrhythmias, so volume of banana puree added should be restricted to <=15% proportion of total feeding volume. Infants with renal dysfunction or a higher risk of hyperkalemia may need lower proportion and should be monitored for electrolyte balance. Banana puree does not contain the vitamins, protein, or minerals necessary for bone mineral density, lean muscle mass gain, or optimal brain and eye development. “Introduction of solid foods prior to four months of age has been associated heightened risks of obesity, diabetes, eczema, and celiac disease.”
Banana puree should not be introduced earlier than 39 weeks postmenstrual age and only after instrumental swallowing assessment has been conducted to determine thickness level. Thickened feeds should never be pushed through tubes.
Long-term impacts of banana puree as thickener need to be assessed.
Full text link
Accessed 2/20/25
https://aspenjournals.onlinelibrary.wiley.com/doi/abs/10.1002/ncp.11240