Brinker K, Winn L, Woodbury AE, et al. (2025) The nutrition profile and utility of banana puree as a liquid thickener for medically complex infants with dysphagia. Nutr Clin Practice  40:227‐238

There is limited but growing evidence to support using banana puree for infants <12 months of age. Efficacy, nutritional value, and safety are key issues. Among all purees tested, banana puree has achieved the greatest thickness level and maintained that same level of thickness regardless of temperature overtime. (Brooks et al 2024, Brooks et al 2022). Thickening with bananas can allow infants with swallowing difficulties to experience  oral feeding, and can facilitate positive feeding experiences, without direct evidence of compromising safety. Banana puree has an appealing taste,  and may offer a more cost‐effective option for families than commercially branded products.

This paper is unique in that its authors reflect the team—an SLP, PT, MDs and a also a registered dietician. It addresses: Involving the physician (attending or pediatrician) in decisions about thickeners and the role of a dietician; and  the importance of the nutritional impact of banana puree. It informs our problem-solving, with the team,  about whether banana puree is the optimal thickener  for our infant patients who require thickened feedings for dysphagia. The authors also remind us as well about the critical role of  data via a VFSS to objectify swallowing physiology and the impact of thickeners, selected utensils and combine interventions. Enjoy this new addition to our evidence base. We are grateful to our SLP colleagues, co-authors Kristin Brinker and Michelle Taggart!

Here is quoted commentary from the paper. You can find the full text through open access on Google Scholar.

Nutrition is an important consideration when choosing the right thickening agent because

it may disrupt the delivery of nutrients to infants. Thickening agents can displace the

nutrition content in formula and human milk, potentially impacting feeding osmolarity,

gastrointestinal transit time, bowel movement frequency, stool consistency, and nutrient

absorption. Banana contributes carbohydrate calories without the comprehensive nutrition

density, essential vitamins, and minerals inherent in human milk and formula. Improper or

excessive use of banana puree can result in weight gain without the requisite accumulation

of vital vitamins, protein, and minerals necessary for optimal bone mineral density and lean

muscle mass gain. Fruit puree lacks essential fatty acids for optimal brain and eye

development. Introducing solid foods before four months of age  has been associated with

heightened risks of obesity, diabetes, eczema, and celiac disease. Because bananas

have a high potassium content, cautious deliberation is warranted, especially for infants

with renal disease. If renal function or potassium clearance is a concern, banana puree as

a thickening agent may not be suitable. Restricting the total banana volume to 15% of feeds

enables balanced delivery of nutrition, including essential fat and protein, mitigates

the risk of hyperkalemia, and increases likelihood of favorable gastrointestinal tolerance

without significant constipation effects. Although using up to 15% bananas

slightly exceeds potassium recommendations when fortifying formulas in some cases we

continue to recommend this limit unless infants have renal dysfunction or difficulty with

potassium clearance. This allows for optimization of both nutrition and hydration

needs in these infants. Our institution did follow the infants exposed to banana puree as

thickener, and our preliminary findings did not show that infants on banana puree

thickener had more complications than those on Gelmix (Finch et al., manuscript in

preparation). However, growth, laboratory results, and clinical presentation

should guide decision‐making for individual patients.

 

Managing infants with dysphagia requires a multidisciplinary team. As mentioned above, a

pediatric registered dietitian should be involved in nutrient analysis and monitoring growth

over time. Additionally, the SLP should provide ongoing assessment and work towards

safely discontinuing thickening agents as soon as possible. The SLP can guide feeding

position and bottle nipple selection. The flow rate of a bottle nipple contributes to the

infant’s ability to feed by mouth safely and efficiently and must be considered carefully

when using thickened milk. Most studies conducted to measure flow rates of various bottle

nipples have shown average flow rates using unthickened formula. They should not be

generalized with the use of thickened liquids. A recent study by Pados et al conducted flow

rate tests for seven different Dr Brown nipple types using thin (IDDSI Level 0), slightly thick

(IDDSI Level 1), and mildly thick (IDDSI Level 2) infant formula. These bottle nipple flow

rates tested with thickened liquids may be used to guide clinician decisions. However,

when making nipple recommendations, one must also consider other factors

that contribute to the safety and efficiency of oral feeding, including medical complexity,

oral‐motor control, and the infant’s integration of respiratory coordination. The use

and recommendation for thickened liquids should only be made after objective evaluation

via VFSS or fiberoptic endoscopic evaluation of swallowing providing an individualized

assessment of the infant’s response to varying nipple flow rates using various

consistencies. Feeding practice recommendations should be comprehensive,

including the appropriate level of thickened milk, bottle nipple, and all necessary feeding

interventions such as positioning and co-regulated external pacing.  Gastroenterologists

should also monitor gastrointestinal complications and other medical or surgical

interventions if the infant is not progressing as anticipated with thickened feeds.