Transitional Solids: The key to getting your patient off puree?
What are the chances that your patient enjoys puree? As in, look forward to eating it for each meal? Not likely, right? Knowing this, our recommendation for such a diet consistency carries a lot of weight. And with great power comes great responsibility (Thanks, Spiderman). But if our patient requires puree, what can we do to ensure we keep her safe and do so responsibly, knowing it’s unlikely she’ll be able to enjoy a fine-dining experience any time soon?
First, understand that every recommendation carries risk. This is even true, and maybe even especially true, when we are trying to avoid risk at all costs. Puree is a good example of that. We are obviously concerned about choking and swallowing efficiency, so we recommend pulverizing everything to the point of no return. But this recommendation misses the fact that puree actually carries well-documented risks: increased risk of malnutrition, reduced sensory-motor experience, and diminished enjoyment of food, to name a few.
Sometimes we do this to patients even when the enjoyment of food (real food) is one of the few things they have left. This situation is like building a castle with walls so high and gates so secure that it does a tremendous job of keeping enemies out, but also trapping the inhabitants inside, cutting them off from the world they love.
Meet Tony
To put some of these concepts in perspective, let’s consider Tony, a 64-year-old post-tracheostomy patient recovering from acute respiratory failure. Following his modified barium swallow study, puree was determined to be the safest diet. But the news to continue a pureed diet, which he was already on for over a week, was met with palpable disappointment: "More mush?" he asked. "I can't face another day of that slop".
So, what are our options for Tony? One option would be to talk around his pleas and tell him, “It is what it is,” and “There’s just no other diet that is acceptable.” This is the equivalent of being the unmovable object. But Tony is an unstoppable force… “Well if there’s nothing you can do, then there’s nothing I can do because I’m not eating that stuff.” Uh oh. You didn’t see that one coming. What are we supposed to do now?
Does this sound familiar? While standing there with our arms crossed, witnessing this poor man’s hunger strike, is certainly an option, I think most would argue it’s not the best option. Thankfully, there’s some new research that might help us break through to Tony and give him a choice that’s both safe, effective, and maybe… just maybe… delicious?
Picture puree running into a phone booth and exiting as a Transitional Food (TF)
TFs, historically used with young children who are just getting used to eating solids, are uniquely defined by their texture transformation: they start as one texture (e.g., a solid) and rapidly convert to another (typically a cohesive bolus or puree). The catalysts are moisture and temperature, which can amazingly take a food from IDDSI 7 all the way to IDDSI 4. Not bad, huh? This property actually distinguishes them entirely from IDDSI 7, as they often don’t even require biting and only necessitate minimal chewing. Many can be broken down with tongue pressure alone once softened by saliva. So, they're sort of in a league of their own.
TFs can be a helpful negotiation tool to use as an in-between-meal treat for patients who truly are unable to tolerate the solids they’ve grown to love and enjoy and must otherwise resort to softer solids. But they go further than that, too. TFs can be implemented to assist in re-teaching chewing skills and for patients trying to functionally progress from a pureed diet to something less restrictive (Quick note: TFs are typically not nutritionally dense enough to be used for caloric intake, so their use must be kept for pleasure and therapeutic purposes at least for now).
Show Me The Evidence!
I must admit, giving a patient something solid to chew on when they have been deemed unsafe for solids does feel a bit… risky? So let’s take a look at the research to see if it can help guide our practice. Thankfully, the clinical utility of transitional foods for adults with dysphagia has been investigated in a study by Bruno, Barewal, and Shune (2025). They examined 31 medically complex inpatients with dysphagia following acute respiratory failure. Using VFSS, the researchers compared a pureed texture against a specific, high-dissolving transitional solid (Savorease cracker).
The key finding was that there was no statistically significant difference in oral or pharyngeal performance between the pureed texture and the transitional solid, as measured by the Modified Barium Swallow Impairment Profile (MBSImP) scores. Crucially, no instances of airway invasion were documented with the transitional solid trials. This evidence suggests that a well-designed transitional food can be introduced without increasing aspiration or residue risk compared with puree, offering a potential bridge for patients to progress toward more advanced textures.
For those of us working clinically, we know how difficult it can be to safely advance a patient off of puree once they’ve been on it (especially if it’s been a while). The task can be akin to moving a mountain (if that mountain were made out of blended burgers). The authors of the aforementioned agree with this sentiment and note that the “textural ‘jump’ from pureed to the next solid is steep, particularly in more complex cases.” TFs can be used as a tool to move that mountain, rock by rock, and to do so safely with close supervision and guidance from an instrumental swallowing evaluation.
The Disclaimers (The Not So Fun Part of Research)
While the initial research is promising, the findings cannot be universally generalized to all commercially available transitional food products. Clinical judgment is essential when recommending a TF. So what should we consider in this clinical determination?
Transitional foods may be appropriate for several patient profiles:
Patients who are non-compliant or resistant to a long-term puree diet.
Patients experiencing fear or anxiety related to progressing to more advanced solid textures.
Patients requiring long-term puree diets who would benefit from sensory variety.
However, TFs are not appropriate for all individuals, particularly those with impaired salivary production or mucosal issues. Research has shown that the dissolution of transitional foods can vary widely depending on oral conditions. The standard IDDSI tabletop testing protocol for TFs—which involves adding water to the sample and waiting one minute—may not accurately reflect a patient's intra-oral preparation due to changes in individual salivary flow and swallowing physiology. For example, some TFs are less dependent on saliva due to their fat or oil content, while others rely heavily on moisture for proper breakdown.
Clinicians must verify that any chosen product meets the IDDSI criteria through appropriate testing and assess its use within the context of the individual patient's oral physiology. All of this is to say that no patient nor TF product is created equal, and the various combinations of each unique mouth and unique TF composition can be endless. So, if you want to test a potential TF, but you’re unsure how it will go: when in doubt, test it out…
Complete a thorough, comprehensive clinical assessment and an instrumental swallowing evaluation to ensure it's safe for that specific patient, and always discuss the risks, benefits, and alternatives of that decision with the patient or representative before moving forward.
Non-Brand Options for TFs
Not sure which brands to start with and want to use what’s lying around as a TF test item first? Test each of the following using the IDDSI TF Fork Pressure Test to ensure it's in line with the standard. Here are some options you might want to consider first:
Wafers
Shortbread
Veggie Stix ™
Potato crisps
Cheeto Puffs ™
Rice Puffs ™
Wait, so what happened to Tony?
The decision was made to include regular TFs in Tony’s diet. During a modified barium swallow study, he successfully consumed a TF without increased residue or risk, validating its safety. This success allowed him to safely transition to a Minced and Moist diet, with the option of incorporating TFs for variety and potential further advancement. Tony immediately felt a boost in morale, stating that having the option to eat solids helped him "feel human again". By appropriately integrating transitional foods, we not only ensured his safety and facilitated his therapeutic progress but also significantly improved his quality of life and diet compliance. Not bad for a cracker.
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