ORIGINAL ARTICLE Promoting Safe Swallowing When Puree is Swallowed Without Aspiration but Thin Liquid is Aspirated: Nectar is Enough Steven B. Leder • Benjamin L. Judson • Edward Sliwinski • Lindsay Madson Received: 1 February 2012 / Accepted: 5 May 2012 / Published online: 27 June 2012 Ó Springer Science+Business Media, LLC 2012 Abstract The use of thickened liquids is a common compensatory strategy to improve swallow safety. The purpose of this study was to determine the optimal liquid viscosity to use to promote successful swallowing in a specific subset of dysphagic patients who swallow puree without aspiration but thin liquid with aspiration. A refer- ral-based sample of 84 consecutive inpatients from a large, urban, tertiary-care teaching hospital who met the study criteria was analyzed prospectively. Inclusion criteria were no preexisting dysphagia, a successful pharyngeal swallow without aspiration with puree consistency but pharyngeal dysphagia with aspiration of thin liquid consistency, and stable medical, surgical, and neurological status at the time of transnasal fiberoptic swallow testing and up to 24 h after recommendations for oral alimentation with a modified diet consisting of nectar-like and honey-like thickened liquids. Success with ingesting both nectar-like and honey-like thickened liquids and clinically evident aspiration events were recorded. Care providers were blinded to the study’s purpose. All 84 patients were successfully ingesting nectar- like and honey-like thickened liquids at the time of swal- low testing and up to 24 h after testing. A specific subset of dysphagic patients who swallowed puree without aspiration but aspirated thin liquid demonstrated 100 % successful swallowing of both nectar-like and honey-like thickened liquids. Therefore, a nectar-like thickened liquid appears to be adequate to promote safe swallowing in these patients and, because of patient preference for the least thick liquid, may enhance compliance and potentially contribute to maintenance of adequate hydration requirements. Keywords Deglutition Á Deglutition disorders Á Thickened liquid Á Viscosity Á Aspiration Introduction A dysphagia evaluation’s dual objectives are to determine the etiology of dysphagia and to recommend appropriate intervention strategies to promote safe swallowing [1]. To this end, the compensatory strategy of using thickened liquids is common [2–5], but it cannot be assumed that altering food consistency will resolve a given patient’s dysphagia [6]. Rather, empirical evidence is needed to determine what effects different viscosities of food have on swallowing behavior. This is particularly relevant for a specific subset of patients with pharyngeal dysphagia who swallow puree without aspiration but exhibit aspiration with thin liquid consistencies. This pattern of swallowing puree consistency without aspiration but thin liquid with aspiration is often due to age-related sarcopenia, i.e., the gradual loss of muscle bulk and strength [7, 8], and related sequelae, i.e., reduced functional reserve [9], generalized weakness and decondi- tioning [10], and depressed cognitive functioning [5], and is especially prevalent in the acute-care setting. Potential benefits from the compensatory strategy, despite a weak oropharyngeal swallow, derive from prolonged pharyngeal S. B. Leder (&) Á B. L. Judson Section of Otolaryngology, Department of Surgery, Yale University School of Medicine, P.O. Box 208041, New Haven, CT 06520-8041, USA e-mail: steven.leder@yale.edu E. Sliwinski Danone Research Centre for Specialized Nutrition, PO Box 7005, 6700 CA Wageningen, The Netherlands L. Madson Department of Food and Nutrition, Yale-New Haven Hospital, New Haven, CT, USA 123 Dysphagia (2013) 28:58–62 DOI 10.1007/s00455-012-9412-2