Speech and Language Therapy - Swallowing advice for a Puree Diet (Level 4)

Contact Numbers:

Please ONLY contact your local community team

Salford Speech and Language Therapy Department
Ladywell Building
Community: 0161 206 2333
Hospital: 0161 206 5450
Email: adult.salfordslt@nca.nhs.uk

Oldham Speech and Language Therapy Team
Integrated Therapy Hub
Telephone: 0161 770 2300 (Option 5)
Email: saltoldhamadults@nca.nhs.uk

Bury Speech and Language Therapy Team
Bury Living Well Centre
Telephone: 0161 206 0576
Email: buryadultsalt@nca.nhs.uk

Why is it important to follow the Speech and Language Therapy recommendation?

Following your assessment with the Speech and Language Therapist you will be given specific advice regarding suitable food types.

It is important to follow these recommendations as you may be at risk of the food ‘going down the wrong way’ which is known as aspiration. This may lead to coughing after eating and may cause a chest infection.

If you experience any difficulty with your swallow such as coughing when eating or drinking, frequent chest infections, or feel your swallow deteriorating please contact your Speech and Language Therapist for further advice or assessment.

What is a puree diet?

A puree diet:

• Should be smooth throughout and have no bits, lumps, skins or shells
• Should be a thick puree
• Should be moist
• Can fall off a spoon slowly and hold its shape on the plate or when scooped
• Can usually be eaten with a spoon, but can be eaten with a fork because it does NOT fall through the prongs
• It can be piped, layered or moulded

A puree diet should NOT:

• Require chewing
• POUR off a spoon
• Be drunk from a cup or sucked through a straw
• Be mixed all together either – each item must be presented separately to encourage appetite
• Have sticky texture in the mouth
• Have hard pieces, crust, or skin
• Ice cream is not suitable for people having thickened fluids
• Have any loose liquid e.g. milk, gravy, custard. (e.g. Weetabix should be well combined together with milk)

This advice is written for adults. If under 16 years old, please refer to separate paediatric guidelines.

How to prepare pureed food

• Food can be pureed using a blender, liquidiser, food processor or a masher. Food can also be sieved to get a smooth texture

• Cook food as per cooking instructions and cut into small pieces before blending
• Pureed food often needs to be blended with a liquid, especially dry foods such as meats. Liquids to use can be gravy, milk, or stock – water should not be used as it is not nutritious
• If the food becomes too thin, thickener can be added to gain the correct texture e.g. cornflour or instant mashed potato, breadcrumbs, or thickener
• Use flavourings to add to the taste e.g. curry powder, herbs
• Avoid all nuts or seeds, stringy food such as celery or onions and foods with a tough skin such as dried beans, peas or corn as these foods do not puree well

If you are on thickened drinks, puree should not be thinner than your drinks.

How to present pureed food

• Pureed food must be presented attractively to make it more appealing and appetising
• Food should be pureed separately so there are individual portions of each food on the plate
• This retains the individual taste and colour of each item and also makes it more appealing to eat
• Puree food can be scooped onto the plate using an ice cream scoop or piped using piping bags with different nozzles

How is food tested to make sure it is Level 4 Puree?

It is safest to test Level 4 puree foods using the Fork Drip Test and the Spoon Tilt Test (see below diagram).

The food should be thick enough not to drip continuously through the prongs of a fork and thin enough to fall fairly easily off a tilted spoon.

Extremely thick liquids sit in a mound or pile above the fork. A small amount may flow through and form a tail below the fork.

IDDSI Fork drip test - Liquid does not dollop, or drip continuously through the fork prongs.

IDDSI Spoon tilt test - Sample holds its shape and falls off fairly easily if the spoon is tilted or lightly flicked. The sample should not be firm or sticky.

Pureed food must pass both tests!

Specific food groups

Meat

• Place 100g of cooked meat into a blender. Chop the meat to a fine texture
• Pour over 100ml of liquid (stock, gravy)
• Blend to a smooth paste
• Reheat in a conventional oven or microwave and save as required

All types of fruit and vegetables can be pureed fresh/frozen, canned, or dried. Some may be better if cooked or stewed before liquidising. Extra stock or sauce can be used to blend.

Fruit

• Place 100g of drained fruit (e.g. peaches, pears) in a blender and blend until smooth. Use tinned juice, fruit juice or syrup as extra liquid during blending
• Use thickener as necessary to achieve the correct texture
• They can also be made into fruit smoothies with yogurt or ice- cream

Vegetables

• Place 100g of cooked vegetables in a blender and cover with approximately 75ml of nutritious fluid (depending on the vegetables)
• Season and blend until smooth
• Add thickener if required to obtain a creamed potato consistency
• The vegetables can be reheated in a conventional oven or microwave
• The vegetables can be thickened when they are either hot or cold

Potatoes, Pasta and Rice

• All types of potatoes should be pureed to ensure a smooth and non-sticky texture. If you need to add a liquid you can use warm milk, butter, sour cream or cheese
• Puree pasta and rice using warm milk, butter, cheese, or cream when they are either hot or cold

Soup

• Puree tinned soups that contain vegetables, noodles or meat for a smooth texture without lumps

If you are on thickened drinks, all soup should be the same consistency as your drinks.

Desserts

• Many desserts are smooth and do not need to be pureed. This includes custard, semolina, smooth yoghurts, and chocolate mousse
• Strain or blend pudding that contain lumps such as fruit yoghurts, rice pudding and porridge
• Puree cakes with nutritious liquid. For example, chocolate cake with chocolate sauce or ice-cream

Nutritious fluids to use to puree foods

Savoury

Add to beef - Gravy, cranberry sauce, soup, fruit juices. Add to chicken - Gravy, cream sauce, fruit juices.
Add to Ham - Pineapple/fruit juices, white sauce. Add to pork - Gravy, soups, apple juice, apple sauce.
Add to fish - Cheese sauce, white sauce, parsley sauce, tartar sauce, cream cheese.

Sweet

Custard, cream, seedless jams.

Examples of flavourings

Savoury

• Curry powder
• Herbs and spices
• Lemon
• Tomato Puree
• Cheese or Parsley sauce

Sweet

• Coffee
• Cocoa
• Drinking chocolate
• Honey
• Jam
• Syrup
• Lemon
• Blackcurrant cordial
• Cinnamon
• Ginger
• Nutmeg

Suggested puree meal ideas

Breakfast

• Pureed/smooth porridge, ready brek or oatmeal
• Pureed creamy scrambled egg with extra cheese
• Weetabix with milk (blend in pureed banana or other soft fruits)

Main meals

• Pureed minced meat or chicken – add extra flavouring
• Pureed casserole or stews – add lentils or beans prior to blending
• Pureed potato/vegetables – add extra cheese, margarine
• Pureed pasta/rice with sauces such as lentil and vegetable curry

Puddings

• Stewed/pureed fruit with custard/cream/ice cream
• Pureed rice pudding
• Instant whips
• Sorbet
• Mousse
• Fromage frais

Nourishing puree snacks

• Strained porridge/instant hot cereal/Weetabix served with hot milk
• Liquidised soft fruit or tinned fruit
• Liquidised stewed apple with sugar
• Banana blended with milk, cream or custard
• Milk based drink, thick fruit smoothies without lumps, skins or seeds
• Strained yoghurt – thick and creamy varieties, Greek yoghurt
• Custard, mousse, and crème caramel
• Milk pudding with Jam
• Home-made, tinned or packet pudding such as custard and semolina
• Rice pudding and sago may need to be liquidised
• Angel delight or instant whip

What to do if you are losing weight?

• Aim for a ‘little and often’ meal pattern (3 small meals and 3 snacks per day)
• Have nourishing drinks between meals (Milk, Horlicks, Ovaltine, hot chocolate)
• Have high energy drinks (Build Up or Complan) which are available from your chemist in-between meals and not as a meal replacement
• Have nourishing snacks between meals (please see the list of Nourishing puree snacks)
• Use only full fat products (Full fat milk, thick and creamy yoghurts, Full fat cheese)
• Try ‘fortifying’ your food by making foods that are higher in energy and protein without increasing portion size

Food Fortification

• Add skimmed milk powder to foods (Add 2 to 4 tablespoons into a pint of full fat milk or 1 tablespoon into porridge or soup)
• Add double cream, condensed milk or evaporated milk to foods before pureeing (add to porridge, custard, mashed potato, soups, vegetables and milky drinks)
• Add grated cheese to foods before pureeing (mashed potato, scrambled eggs, vegetables, and soups)
• Add margarine or butter to foods before pureeing (mashed potato, vegetables, and milk puddings)
• Add extra sugar, syrup or honey to cereals, drinks and puddings but please take caution if you have diabetes

If you experience weight loss you can ask your GP to refer you to a Dietitian for further advice.

Buying prepared soft or pureed meals

Wiltshire Farm Foods – Soft and puree main meals and puddings
http://www.wiltshirefarmfoods.com

Hermolis – Kosher food specialists
http://www.hermolis.com

Punjab Kitchens – Modified main meals and puree puddings – Halal food specialists
http://www.punjabkitchen.co.uk
 

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As well as providing a confidential advice and support service, PALS will help guide you through the different services available from the NHS.
Telephone: 0161 778 5665
Email: pals@nca.nhs.uk.

Alternatively, you can write to: PALS Department, The Northern Care Alliance NHS Foundation Trust, Unit 7/8 Whitney Court, Southlink Business Park, Hamilton Street, Oldham. OL4 1DB

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Telephone: 0161 656 1141