How to Use Purees in Feeding Therapy

Why do we use purees in feeding therapy? 

• To improve intake of food with an easy texture.
• To stimulate midline and lateral tongue movement (pre-exercise for chewing)
• To introduce new textures and flavors in an easy to manipulate form.

This post is inspired by my latest trainee who said one of her take home messages after spending this past week with our feeding team was the benefits of using purees in feeding intervention. So I thought I would write a little more about that.

We know that oral motor skill development is often dependent on practice and typically as a child’s diet transitions to textured and more solid foods, we see chewing skills emerge and develop. This is not always the case for our young feeding clients who often present to us with an oral motor delay. This may be due to underlying medical issues making the transition to chewable foods more difficult, tube feeding dependence making oral practice limited,  or refusal to accept these types of foods making practice difficult.

I often look developmentally at progression of feeding skills rather than at what would be expected chronologically. That means if a child comes to us with reduced oral intake or a less than optimal diet, we would start therapy with puree acceptance. In many cases, it is easier to teach a child to take purees while allowing for modification in texture and flavor to expand the diet. This allows the child to start receiving a higher quality more nutrient dense diet in an easy to manipulate form.

Then there is the matter of the oral motor delay. If a child has emerging chewing skills or is a new chewer, it may be difficult for them to complete an entire meal of chewable foods. We often see this with children coming for an evaluation. We request that parents bring their children hungry and bring foods from home for observation. When a child who has an oral motor delay is presented with a meal of chewable foods, the result may be poor intake, sucking on solids, swallowing foods whole, expelling food, choking on solids, and sometimes grazing behavior throughout the day. Last week, we had a new evaluation where the child was accepting only a few bites of food per meal and receiving liquids for nutrition. By returning to puree, the child accepted 10 ounces of 3 different flavors and food groups during the evaluation. Parents were thrilled.

Some caregivers may interpret returning to puree as regression or going backwards to give their toddler “baby food”. Educate parents as to why you are making the recommendation for purees. We always prefer a home made puree over a store bought baby food.

Keep a blender in clinic. We often demonstrate how to puree solids. When a parents brings solid foods that are too difficult for the child, we throw the food into a Vitamix blender we keep in clinic with added  liquid or puree and demonstrate what it takes to make a “home made puree”. Then we work together to feed the child. In many cases, food that was rejected, swallowed whole, or expelled is accepted after we blend it to a form that matches what the child’s mouth can handle. Keep in mind that some children may need to transition from smooth puree to a thicker more textured puree over time. To make puree smoother or thinner, add more liquid.

Do we take chewable foods away? Not necessarily if a child is safe for them, but nutrition comes first. Our goal is always that the child can accept a balanced diet orally. For some children, it may mean starting with a diet of all puree. Meals might include 3 purees from different food groups. Or it might mean a child receives 2 purees and then a small portion of solids to stimulate chewing in each meal. We often use purees to help us with oral development. If a child is retracting their tongue, we would feed purees with techniques to bring their tongue down into a proper position to accept the spoon. We also use purees as a pre-chewing skill by placing them on the side, we call this lateral placement of puree. We teach parents to feed a certain number of bites this way to stimulate lateral tongue movement as a pre-chewing exercise. If a child has emerging chewing, we would encourage a limited number of chewable bites per meal or at snack time for practice.

Some children may refuse puree. We would then utilize what I call “gentle behavioral” strategies to encourage intake. That might mean caregiver feeds and provides praise and verbal encouragement after each bite. Some children who have strong aversions play while we feed them. We use these techniques to encourage acceptance, we want the child to equate eating with something fun and positive. We always recommend using the least amount of distraction needed and some children do not need any at all except the normal conversation that occurs at meal time. It is important to also note that medical and nutritional strategies  as well as addressing feeding structure and schedules greatly help with comfort at meal time and encouragement of appetite. Of course,  as we move to solids, we remove distractions in the meal.

For children with food refusal and limited acceptance, purees can also be used to expand the diet. Many things can be added to increase texture in puree as well as expanding taste. Home made purees typical have more texture, flavor and nutrient density. Some children do well with mixing a smooth puree with one that has more texture. You can also expand flavor by mixing a preferred flavor into a new one.

There are many ways in which using purees in feeding therapy and at meal can benefit a child’s nutritional intake, oral motor skills, and build caregiver confidence in feeding. Of course, there are always exceptions. Some children will not accept purees or due to their age, we may decide to focus primarily on solids. However, for a great number of our clients, these techniques will benefit oral motor function and improve intake at meal time.