“How can you recommend soft solids if you did not see how the patient does with it?”

I think this can be a burning question for many clinicians. Often followed by, “well what would they say to you in court?”

It may be one of those clinical judgments we are “afraid” to make, but as one of my mentors once said to me, “As long as you have rationale for the clinical decisions you make, you will be fine.”

Have you ever seen a patient at bedside who consumed thin liquids without difficulty, consumed 1-2 tsp of applesauce without issue and then he said, “Get out, I’m full!” Well, I hate to recommend this patient a puree diet, but sadly, this may often happen. Sheesh, I feel like this may be punishing and now I have a patient on caseload who I am trying to trick to eat something soft in my presence, so I can “upgrade” his diet. Like many of my blogs, there is a tone of sarcasm and of course exaggeration and we are making a lot of assumptions on my make-pretend patient, but it’s to serve a point. I say, we, as swallowing experts, have the tools and rationale to say, “Let him eat regular!” Let the following hypothetical “fishy” example aid to illustrate a point.

In reality, there are a wide variety of protocols for consistencies used during a clinical swallow evaluation and during a diagnostic evaluation. During a diagnostic exam, one may use thin barium, nectar barium, pudding paste, and a cookie. One day, Mrs. SLP received an order from Dr. Who requesting: “Please do an MBS with a tuna sandwich as patient complains of dysphagia with tuna sandwich only.” After the mad dash to the cafeteria to gather a tuna on rye, Mrs. SLP returns to fluoro . After administering all consistencies + a well prepared tuna sandwich, the clinician and radiologist noted a Zenker’s Diverticulum which becomes even more problematic with a tuna sandwich. Mrs. SLP says to the patient, “yep, I can see the problem you are having with the tuna sandwich.”

Would this have been an incomplete study without testing barium laced tuna on rye? I say an emphatic “86 the tuna on rye” (86, for all you former food servers out there).  Don’t forget, it is an RN swallow screen in many facilities that suggests, if a patient can consume 3oz of water they may be safely placed on a regular diet.

What are your thoughts on the following familiar scenarios?

  1. He doesn’t have teeth, so I can not recommend anything more than Puree
  2. She is refusing to eat a graham cracker, so I am unable to advance him to regular
  3. How do we truly make sound recommendations for how a patient can swallow a pill? Thank God for pill crushers, huh?
  4. Do you need to test honey thick liquids to recommend honey thick liquids?

While, I am yet to meet a shy SLP, when it comes to these scenarios, I hope it may promote thoughtful discussion. While thinking about 1-4, perhaps, focus on #4. There is an excellent article by Leder et. al 2013 that may help to dissect #4 and springboard into further discussion. The article is:

Leder, S.B., et al. 2013. Promoting safe swallowing when puree is swallowed without aspiration but thin liquid is aspirated: Nectar is enough. Dysphagia, 28, 58-62.


  1. if this is a neuro pt or a head and neck cancer, I recommend looking into McNeill dysphagia protocol and taking the course… it will clear up many food modification misconceptions… in case with the diverticulum – well that would have to be addressed medically first, before an SLP touches the pt, AND, to do a good job in establishing it, an AP view is a must (and must be part of protocol for radiologists, so you don’t have to beg and explain every time that you are NOT performing an esophagram and not trying to dx GI issues)

    • Love McNeil concepts, definitely want to make it to a course when able. Diverticulum was purely used as illustration, but agree with your recs for management. Thanks for contributing!

    • Thanks for contributing. I’ve heard everything from a) Rookie mistake not to recommend solids when appropriate with edentulous patient to b) if they choke it is on you. I go case by case for sure. Thanks for contributing!

  2. Grappling with #3 right now. Typically I recommend meds crushed in puree, however, it’s very difficult when pts remain with a g-tube (despite getting good oral nutrition/hydration) because medications are only safe this way. Patients and their families want that g-tube out and who can blame them. I’ve heard that trialing a tic-tac is one option for assessing smaller pills, though I’ve never tried it with any of my patients. Any other ideas out there?


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