Introducing solids

following repair for

OA/TOF
A leaflet provided courtesy of TOFS
(Tracheo-Oesophageal Fistula Support)
Helping those born unable to swallow
Contents
Introduction to introducing solids 3

The scary bit first 3

What causes ‘stickies’? 4

Positive experiences 5

Lets go! 5

The noise 7

Drinks 7

Moving on with textures 8

‘Bite and dissolve’ finger foods 10

(IDDSI – Transitional foods)

Forwards and backwards 14

Further help 15

Conclusion 15

Summary of content
The content for this guide has been
written by Julia Faulkner, Paediatric
Dietitian, who has a child born with
OA/TOF. It was funded through numerous
kind donations from the members of the
TOFS charity. We hope it gives you
confidence in feeding your child. With the
large variability in the feeding ability of individual children
born with OA/TOF, this guide should serve as general advice
and does not replace individual advice given by your
healthcare professionals. Please consult an appropriate
medical professional (eg speech and language therapist) for
specific dietary advice.
Julia wishes to thank and acknowledge Helen Marks, Speech and
Language Therapist at Bristol Royal Hospital for Children for her
support, encouragement, and expertise in preparing the information
for this leaflet.

Cover photo: Athena Chalmers, born with OA

Photography by: Thomas Byron Photography

2
Introduction to introducing solids
The thought of introducing solids to your child with
OA/TOF can seem daunting. This information should
help you to feel prepared, and, along with your
healthcare team, help guide you through the process.

Before you start introducing food, check with your

healthcare team when/if they feel that your child is ready
to start. If your child was born preterm (before 37 weeks
gestation), they are likely to be ready to start solids
between 4–6 months corrected age (that is 4–6 months
after their due date). Children born at term are likely to
be ready to start solids at around 6 months of age.

The scary bit first

You maybe worried about your child coughing/choking.
In fact most parents report that their child has had an
episode of food getting stuck in the oesophagus. This is
known as a food bolus obstruction, or you will often
hear other families referring to it as a ‘stickie’.

The most important thing is to be prepared, and try to

remain calm so as not to frighten your child. See
www.redcross.org.uk for first aid advice on the choking
baby.

Some parents find back slaps help their child to clear the
blockage, others report they just have to calm their child
and reassure them whilst they wait for it to pass or for
the child to cough and vomit it back up themselves.
There is no particular right/wrong way but you will find
what works best with your child.

3
What causes ‘stickies’?
Children with OA/TOF may have one or a combination
of the following:

Oesophageal dysmotility – the oesophagus may be

working in an uncoordinated way. You can have an
upper part squeezing to push food down and a lower
part also squeezing to push food down, resulting in
some food being stuck in the middle until it relaxes
again.

Oesophageal stricture – this is a narrowing in the

oesophagus, usually at the site of the anastomosis (the
join). Signs of this developing would be a gradual
decrease in feeding ability. You may notice your child
struggling or having more ‘stickies’ with lumps/thicker
purees, before then struggling with thinner purees. If
you think your child may be developing a stricture you
should contact your surgical team for advice.

4
Positive experiences
To help your child develop their feeding skills, it’s
important that they have positive experiences with food.
Allowing them to get messy, play with purees and
experience the feeling, smell and taste of foods will help
them to become more confident in trying things.

Lets go!
As with anything new, change one thing at a time.

Initially as you start, we recommend staying with the

same tastes for the first 2–3 days. That way it is easy to
see how your child is coping, and if any issues become
apparent it is easier to determine the cause. Once it is
clear that they are coping with the texture, we then
recommend adding in a range of different tastes.

Start at a time of the day that is convenient. Your child

should be wide awake but not over-hungry. First foods
are for tastes only, so just offer a few teaspoons initially.

There is an internationally recognised way of describing

food and fluid textures known as the International
Dysphagia Diet Standardisation Initiative (IDDSI). We
recommend starting your child on IDDSI level 3 or 4
when introducing solids.

Once your child is managing a range of tastes within an

IDDSI texture, you can then consider progressing to the
next IDDSI level.

Once your child is managing fruit and vegetable purees

you can start to include foods that are part of your
family’s usual diet which are commonly associated with
food allergies. Foods that can cause food allergy include
egg, peanut, other nuts, dairy foods, fish/seafood, and
wheat. These should be introduced separately, one at a
time.

Some examples of how to introduce egg/peanut are

included in the table on page 6.

5
See the table below for examples of foods, and
descriptions of texture based on the International
Dysphagia Diet Standardisation Initiative (IDDSI).
First texture & Examples
IDDSI classification
IDDSI level 3 – Liquidised stewed vegetables
Liquidised/moderately (especially bitter tastes:
thick broccoli, cauliflower, swede,
kale, cabbage)
Smooth texture with Liquidised stewed fruit
no ‘bits’ (lumps, Liquidised fresh fruit (banana,
fibres, bits of strawberries, blueberries)
shell/skin, husk). Runny baby rice/cereal made
up with baby’s usual milk
Cannot be eaten with Fromage frais
a fork as it drips Smooth yogurt
slowly in dollops Stage 1 baby foods
through the prongs. (all above thinned down with
baby’s usual milk to make
IDDSI level 3)
Ideas for introducing peanut/egg at this texture
(IDDSI Level 3 or 4)
Peanut – Use boiling water to thin down smooth
peanut butter. Let it cool and add more water/baby's
usual milk if required to adjust the consistency.
Alternatively, stir peanut flour into a previously
tolerated puree.

Egg – Thin down a stage 1 baby jar/pouch containing

egg (eg egg custard).
Alternatively, mash a cake with child’s usual milk,
liquidise and sieve, adjust consistency with additional
milk.
IDDSI – Level 4 Pureed Pureed stewed fruit
Smooth texture with Pureed stewed vegetables
no lumps. Baby rice/cereal made up with
Holds shape on a babys usual milk
spoon. Fromage frais
Falls off spoon in a Smooth yogurt
single spoonful when Pureed meat/fish/pulses/lentils
tilted. Stage 1 baby foods
NOT sticky.

6
It’s not uncommon for children to pull faces when trying
foods, as this is the first time they have experienced these
different tastes; as they continue to be offered them they
learn to accept the tastes. The key message is keep offering
new tastes and offer a variety of new tastes.

The noise
Children with OA/TOF can make different noises with eating
likely to be related to tracheomalacia. Careful assessment
is required to determine the difference between ‘normal
noises for the OA/TOF child’ and a possible swallowing
problem.

If you have concerns, ask your consultant for a referral to a

speech and language therapist, ideally one who is familiar
with OA/TOF.

Drinks
It's important that drinks are offered from the very start of
the weaning process. A cup can be introduced at around 6
months of age when your child is sitting up and able to
hold their head steady. An open cup is the best choice to
encourage the skill of sipping. Free-flow lidded beakers
(those that let the liquid run out when tipped upside down)
are also suitable but ideally the lid should be removed and
it be used as an open cup as soon as the infant has learnt
how to drink.

‘No spill’, or ‘anyway up’ cups/beakers aren’t recommended

as these have to be sucked, and don’t teach the skill of
sipping.

7
Moving on with textures
Once managing IDDSI stage 3 or 4 textures and sips of
fluid, you can gradually progress through the IDDSI
textures. We would encourage offering sips of water
with meals to help move food down into the stomach.

Beware of some of the ready made baby foods that can

have big lumps in a smooth puree; these often cause
children to gag as they are expecting a smooth puree
and are then surprised by a lump. Not all the stage 2
products are like this so it is worth looking at a few
different brands of jars and pouches.

IDDSI Classification Examples

IDDSI – Level 5 Add couscous, quinoa,
Minced & moist food crushed rice crispies, ground
nuts to a level 4 IDDSI.
Soft and moist with
no separate thin Meat – finely minced/pureed
liquid. in a mildly/moderately thick
smooth sauce/gravy.
Small lumps visible
within the food no Fish – Finely mashed in a
bigger than 2mm mildly/moderately thick
width, and 8mm smooth sauce/gravy.
length. Fruit – finely minced, chopped
or mashed. If needed, serve in
Lumps are easy to mildly/moderately smooth
squash with tongue. sauce, eg yogurt/custard.

Vegetables – finely minced,

chopped, or mashed. If
needed, serve in mildly/
moderately smooth sauce/
gravy. Depending on degree
of dysmotility, some may still
struggle.

Cereal – thick and smooth

with small soft lumps. Texture
fully softened.

Stage 2 baby foods –

described as textured not
lumpy.

8
9
‘Bite and dissolve’ finger foods
(IDDSI – Transitional foods)
Moving on to ‘transitional’ finger foods helps your child
to learn to manage lumps and establish chewing skills.
They allow your child to practise picking the food up and
putting it in their mouth, and once in the mouth it
melts/dissolves, making it easy for them to swallow. We
would encourage parents to try products themselves
before giving them, to see for themselves how easy a
food is to dissolve in the mouth, as it does vary between
products, and then start with the easiest.

IDDSI Classification Examples

IDDSI – Transitional Wotsits®, Skips®, Quavers®
foods Ryvita cracker bread®
Organix finger foods carrot
Foods that start as sticks®
one texture but Kiddylicious Fruity puffs®
change into another Kiddylicious smoothie melts®
texture with moisture Ella’s Kitchen melty puffs®
like water/saliva or Meringue
when a change in Pink wafer biscuits
temperature occurs. Ice cream wafers
Sponge fingers
Tongue pressure can Shortbread
be used to break
these foods once the
texture has been
changed by moisture/
saliva/temperature.

These help to teach

chewing skills usually
given alongside IDDSI
level 5 foods.

10
Once managing transitional foods, your child can try
IDDSI level 6, bigger soft lumps in foods, to continue to
develop chewing skills.

IDDSI Classification Examples

IDDSI – Level 6 Soft & Meat/fish cooked tender and
bite-sized served in pieces no bigger
than 8mm x 8mm
‘Bite-sized’ pieces no
bigger than 8mm x Casserole/stew/curry – liquid
8mm in size. portion mildly/moderately
thick, can contain soft and
Foods can be tender pieces of meat, fish or
mashed/broken down vegetables no greater than
with pressure from 8mm x 8mm
fork. Soft, chopped fruit no bigger
than 8mm x 8mm, eg drained
tinned mandarins broken up,
very ripe pear in small pieces

Vegetables steamed or boiled

until soft, in pieces no bigger
than 8mm x 8mm

Tinned spaghetti cut into

small pieces

Rice in a thick smooth sauce

to hold it together

Cereal – smooth with soft

tender lumps no bigger than
8mm

11
Once managing IDDSI level 6, gradually move on to level
7 and beyond as illustrated below.
IDDSI classification Examples
IDDSI – Level 7 Meat – cooked until tender –
Regular easy to chew eg slow cooked/casserole. Cut
across the grain. Corned beef.
Normal everyday
foods of soft/tender Fish – eg poached – cooked
textures. soft enough to break apart
easily with a fork. Check for
No hard, tough, bones.
chewy, fibrous,
stringy, crunchy, Fruit – soft enough to break
crumbly bits, pips, apart into smaller pieces with
seeds, fibrous parts the side of a fork
of fruit, husks, or Tinned mandarins
bones. Very ripe peeled fruit, eg
finger slices of pear, avocado

Vegetables – steamed/boiled
until tender
Tinned baby carrots
Tinned green beans (remove
any stringy bits)
Over-cooked carrot
Over-cooked soft florets of
broccoli

Cheese triangles
Tinned spaghetti
Soft biscuits – Cornish wafers,
Ryvita cracker bread®
Rice
Soft finger pieces of cooked
potato/sweet potato
(Depending on degree of
dysmotility, some may still
struggle.)

Cereal served with texture

softened, eg Shreddies® just
soaked in milk so that they
can be finger fed

12
Harder foods Grated carrot/apple.
made easier Cut meat up against the grain.
Dark meat from chicken is more moist
so easier to chew and swallow.
Minced meat – bolognaise, shepherd’s
pie etc (if mince is sticking together in
lumps, give quick blitz with a blender
to break it up).

Beware Doughy foods Wholemeal/

doughy/ such as soft brown bread is
sticky foods white bread can easier to manage
be difficult. – start with small
Sticky foods like pieces of this
nut butters and toasted.
scrambled egg Brioche bread is
can also be tricky. also easier to
manage – start
with small pieces.
White bread is
the hardest to
manage but
toasting it makes
it easier.
Toasting and
buttering bread
makes it easier to
manage.

13
Forwards and backwards
It’s important to remember that any child who is unwell
during the introduction of solids may struggle more with
textures and go back a few stages. This is particularly
important with children with OA/TOF. They may have
been managing quite well with lumps but then an illness
or stricture means they have gone back to managing
pureed food. In this case, when they are well again you
just work through gradually increasing the textures as
tolerated.

Parents of OA/TOF children anecdotally report ‘bad days’

when foods seem to just get stuck during early
childhood. Whilst it’s important to consider whether
there is an underlying problem, eg a stricture, there isn’t
always a clear reason, and it may be put down to
intermittent illness/teething and, anecdotally, to growth
spurts.

14
Further help
Speech and language therapists (SaLT). A SaLT will be
able to assess a child’s feeding and give individual advice
on the safest way to feed. If there are concerns, ask your
consultant for a referral to a SaLT.

Paediatric dietitians can help with ensuring that the child

is meeting their nutritional requirements. They can also
help with moving on with textures, dealing with fussy
eaters and providing specific advice if required on allergy
or high-energy weaning.

Conclusion
We hope that this guide is helpful and gives you
confidence and encouragement with moving your child
on with their feeding. There will be some regression of
progress along the way with illness/stricture/growth
spurt, but you should try moving on with textures again
once your child has recovered.

It is important in moving on with textures that one thing

is changed at a time, so that if something isn’t tolerated
it is clear what the cause may be. So when starting a
new texture, start with a familiar accepted flavour and
as it becomes clear that this texture is tolerated, then
extend the range of flavours at this texture. Once it’s
clear that they are tolerating a range of different foods
and tastes at a particular texture, then it’s time to
consider moving on to the next texture.

We know that there is large variability in the feeding

ability of individual children with OA/TOF, so this just
serves as general advice and does not replace individual
advice given by your healthcare professionals.

15
Additional Resources
Bliss – is the charity for premature and sick babies. On
their website you can see further advice on ‘Weaning
your premature baby’
https://www.bliss.org.uk

First Steps Nutrition Trust – is an independent

public health charity. On their website you can find
‘Eating well: the first year. A guide to introducing
solids and eating well up to baby’s first birthday’.
https://www.firststepsnutrition.org/

International Dysphagia Diet Standardisation

Initiative – Provides a common terminology to
describe food textures. Further resources available via
the website/app.
https://iddsi.org/ OR IDDSI app on the App
Store/Google Play

TOFS now has two fantastic books available to

buy via our site. The TOF Book is an invaluable
guide for families of those born with OA/TOF and
VACTERL. Written in a language that is easy to
comprehend and superbly illustrated, it details
the conditions from infancy until adulthood.
Moving on, The Soft Food Recipe Book contains a
compilation of tasty recipes, tried and tested by
parents of those born with OA/TOF.

For additional copies of this booklet, or for more information

about TOFS, please contact:
TOFS
St George’s Centre,
91 Victoria Road, Netherfield
Nottingham NG4 2NN
+44 (0)115 961 3092
tofs.org.uk
info@tofs.org.uk lifelong support for those
Registered Charity no. 327735 Company no. 2202260
born unable to swallow

Any use of the information herein is subject to our full disclaimer at

tofs.org.uk/disclaimer-publications
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