AJSLP

Research Article

Texture Consumption Patterns of 8- to

12-Month-Old Infants: A Reflection
of Typical Feeding Development
Amy L. Delaney,a Megan Van Hoorn,b Sarah Staskiewicz,c Mary Beth Feuling,b
Stephanie Pladies,d Naveen K. Bansal,e and Praveen S. Godayf

Purpose: The lack of age-appropriate expectations for the and energy intake by texture. When applied to data from a
acquisition of feeding skills and consumption of textured future population sample, findings will provide a threshold
food in early childhood inhibits early and accurate identification for age expectations for typical and disordered feeding
of developmental delay in feeding and pediatric feeding development to aid in the detection of developmental delay
disorder. The objective of this study was to describe texture in feeding and pediatric feeding disorder.
intake patterns in a cohort of typically developing infants What Is Known:
between 8 and 12 months of age, with the aim of informing
future research to establish targets for feeding skill acquisition. • Expectations regarding early feeding development
Method: Using cross-sectional methodology, we studied the have been focused on nutrition parameters.
presence of liquid and solid textures and drinking methods in • Lack of standardized, age-appropriate expectations
the diet, consumption patterns by texture and drinking methods,
for texture progression in infancy and early childhood
and caloric intake by texture via caregiver questionnaire and
3-day dietary intake record in 63 healthy infants between 8 inhibits early and accurate identification and treat-
and 12 months of age. Descriptive statistics and a one-way ment of pediatric feeding disorder.
analysis of variance were conducted to compare the effect What Is New:
of age on texture intake patterns.
Results: Findings reveal rapid advancement of intake patterns • We have described changes in dietary composition by
for texture overall and for energy intake by texture between 8 texture and drinking method in healthy infants.
and 12 months of age. Whereas liquids continue to provide a
large proportion of total energy through this time, solids • Together with nutritional composition, this study de-
contribute an equal proportion of energy by 12 months of age. scribes a more comprehensive assessment of infant
Conclusions: This study describes texture intake patterns feeding, particularly to clinicians who need to diag-
in a cohort of typically developing infants between 8 and nose feeding skill deficits.
12 months of age by examining the presence of texture and Supplemental Material: https://doi.org/10.23641/asha.
drinking methods, liquid and solid consumption patterns, 16879615

S
upporting the development of oral feeding skills is
a
Department of Speech Pathology and Audiology, Marquette
dependent on the safe and timely exposure to new food
University, Milwaukee, WI textures in concert with developmental ability and pro-
b
Department of Clinical Nutrition, Children’s Wisconsin, Milwaukee actively responding to changing nutrient requirements. Parents,
c
Sarah Staskiewicz Nutrition, LLC, Verona, NJ caregivers, and clinicians must attempt to align evolving feed-
d
Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN ing skills with the introduction of specific textures to prompt
e
Department of Mathematics, Statistics and Computer Science, ongoing skill development (Gisel, 1991; Green et al., 2017).
Marquette University, Milwaukee, WI The profoundly dynamic nature of the development of the oral,
f
Division of Pediatric Gastroenterology and Nutrition, Medical gross, and fine motor skills required for successful feeding
College of Wisconsin, Milwaukee
necessitates ongoing oversight and reassessment to guide the
Correspondence to Amy L. Delaney: [email protected]
Editor-in-Chief: Katherine C. Hustad
Editor: Georgia A. Malandraki
Received February 9, 2021
Disclosure: Praveen S. Goday serves as a consultant to Nutricia and serves on a
Revision received May 17, 2021 Data Safety and Monitoring Board for Shire Pharmaceuticals. The remaining
Accepted July 22, 2021 authors have declared that no other competing financial or nonfinancial interests
https://doi.org/10.1044/2021_AJSLP-21-00048 existed at the time of publication.

American Journal of Speech-Language Pathology • Vol. 30 • 2643–2652 • November 2021 • Copyright © 2021 American Speech-Language-Hearing Association 2643
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infant’s feeding journey (Birch & Doub, 2014; Delaney & requirements occur in parallel to changes in feeding skill
Arvedson, 2008). function during the first few years of life, and oral–motor
Although typically developing infants are born with development is required to support the consumption of ade-
the physiological ability to consume adequate liquid textures quate age-appropriate food for healthy growth and devel-
to sustain health (i.e., breast milk and/or formula), a success- opment. Thus, associating nutrition intake and texture
ful introduction and acceptance of advanced textures depends acceptance is necessary to provide meaningful insights into
on the maturation and coordination of highly complex oral age-dependent expectations for feeding skill development.
sensorimotor skills (Arvedson & Lefton-Greif, 1996; Delaney In several studies, food intake patterns have been ro-
& Arvedson, 2008), a process that is subject to interference bustly measured for exposure to and presence of new food,
when developmental and/or medical issues arise (Goday et al., the frequency of consumption of food, the number of differ-
2019). Criteria that define age-appropriate oral intake of vari- ent food, and energy intake by food groups (Concina et al.,
ous textures are necessary for the successful identification of 2018; Demonteil et al., 2018; Grummer-Strawn et al., 2008;
infants and children who may not be following the expected Kudlova & Rames, 2007; Reidy et al., 2017). These analyses
trajectory of feeding advancement. Furthermore, age- of age-specific food intake patterns present an opportunity
appropriate norms are needed to facilitate the effective to further develop feeding expectations by which to compare
utilization of diagnostic criteria for pediatric feeding disorder children learning and struggling to eat. Guidance on the
(PFD). Unlike growth and nutrient intake targets that have types of food an infant or child should consume at any given
established standards (Butte, 2006; Institute of Medicine, feeding stage must be driven by feeding skills that are ex-
Food and Nutrition Board, 2000), the lack of evidence- pected to be present (Delaney & Arvedson, 2008).
based expectations for texture consumption by age in in- The role of texture in food acceptance and feeding skill
fancy and early childhood can inhibit early and accurate development has been observed. In a group of 32 children with
identification and treatment of feeding disorders. a mean age of 39 months, texture modification was observed
A high prevalence of feeding disorder exists in children as a significant influencer of food acceptance, more than taste
under the age of 5 years: Kovacic et al. (2021) report between (p < .001) or color (p < .01) modification (Werthmann et al.,
one in 23 and one in 37 of children in this age group are diag- 2015). A randomized controlled trial provided evidence that
nosed with feeding disorders per International Classification exposure to texture at 8 months of age can impact the devel-
of Disease, Ninth Revision and International Classification of opment of chewing skills (da Costa et al., 2017). Furthermore,
Disease, Tenth Revision coding. Recently, a consensus def- the timing of introduction of more advanced textures has been
inition and conceptual framework was established for associated with a later risk of picky eating; evidence suggests
PFD, a unifying diagnostic term defined as “impaired there are ideal windows of time in which to begin to expose
oral intake that is not age-appropriate, and is associated infants to more complex textures, and failing to do so has
with medical, nutritional, feeding skill and/or psychosocial implications that can persist later into childhood (Coulthard
dysfunction” (Goday et al., 2019). According to Goday et al. et al., 2009; Emmett et al., 2018; Northstone et al., 2001).
(2019), feeding skill function is a measure of texture progres- Two studies have highlighted a “sensitive period” for texture
sion, feeding position and use of equipment during intake, acceptance and skill development may be around 9 months
and whether modified feeding strategies are employed dur- of age (Coulthard et al., 2009; Emmett et al., 2018). Although
ing feeding; these factors are to be considered in the context an essential insight into the dynamics of feeding skill develop-
of oral sensorimotor and pharyngeal functioning. Thus, cri- ment and food acceptance, identification of “sensitive periods”
teria for age-appropriate intake must include textures of in the feeding journey is only a preliminary step in providing
food and positioning, seating, and method of intake, along- more robust recommendations around feeding milestones.
side whether specific strategies are required for safe and ef- More recently, analysis of exposure to various food
ficient oral intake (Goday et al., 2019). textures has been incorporated into studies evaluating food
In outlining an assessment of age-related texture intake consumption patterns during the complementary feeding
patterns, one must also consider other key areas related to stage. However, categorization of food by texture is often
the multidimensional aspects of feeding: nutrient intake dichotomously labeled as either liquids or solids (Grummer-
guidelines and feeding skill norms (Carruth & Skinner, 2002; Strawn et al., 2008). Some studies distinguish semisolids
Delaney & Arvedson, 2008; Evans Morris & Dunn Klein, or soft and hard solids (Kudlova & Rames, 2007; Reidy
2000; Gisel, 1991; Le Révérend et al., 2014). Traditionally, et al., 2017). Primary analyses include the presence of tex-
feeding guidelines have been focused on nutrition parame- ture and the frequency of consumption by age, such as solid
ters and descriptions of changes in food intake patterns (nonliquid) food within different food groups (Grummer-
(American Academy of Pediatrics Committee on Nutrition, Strawn et al., 2008), the number of solid food consumed per
2014; Fewtrell et al., 2017; World Health Organization day (Kudlova & Rames, 2007), and the frequency of
[WHO], 2001). Current guidelines address the presence consumption of food by texture (Demonteil et al., 2018;
and duration of breastfeeding, age of onset of complemen- Kudlova & Rames, 2007). Data available to date do not
tary feeding, feeding frequency, and the presence and allow for prescriptive guidelines for age-appropriate texture
proportion of energy intake by food groups and nutrients exposure throughout the feeding journey.
(American Academy of Pediatrics Committee on Nutrition, Criteria that define age-appropriate texture intake
2014; Fewtrell et al., 2017). However, changes in nutrient patterns are necessary to serve as a clinical reference in the

2644 American Journal of Speech-Language Pathology • Vol. 30 • 2643–2652 • November 2021

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comparison of children presenting with differences in feeding poststudy, without known medical diagnoses, progressing in
development to meet diagnostic criteria for PFD. Exploring feeding without pediatrician or caregiver concern and had a
these additional variables could lead to a comprehensive minimum of 2 weeks since introduction of solid food (non-
methodology as the first step in quantifying age-appropriate liquid), and typically developing without a history of or cur-
feeding skill expectations for the application of PFD diag- rent enrollment in developmental therapies or pediatrician
nostic criteria. Identifying feeding disorder and potential nu- or caregiver concern for development.
tritional risk at the earliest age could facilitate intervention If the child met initial inclusion criteria, the caregiver
and reduce the chronic nature of feeding problems, thereby was mailed the CSBS for a formal screening of communi-
improving developmental and nutrition-related outcomes. A cation. Final eligibility was confirmed if the child received
comprehensive assessment of texture intake patterns should a total standard score of 85 or greater (−1 SD or less be-
include several important elements in early feeding: food low the mean) on the CSBS. The CSBS was determined to
texture exposure, feeding and food intake patterns, and nu- be an accurate tool for screening for this study due to its
trient intake guidelines. predictive validity of prelinguistic skills and later language
Therefore, the objective of this study was to describe outcomes (Eadie et al., 2010). Since normal communica-
texture intake patterns in a cohort of typically developing tion development is reliant on the interplay of motor, cog-
infants between 8 and 12 months of age via the presence of nitive, sensory, and linguistic skills (Nip et al., 2011), it
texture and drinking methods, liquid and solid consump- was determined that a communication screener would be
tion patterns, and energy intake by texture, with the aim a more effective means to capture subtle differences in de-
of informing future research that will develop a normative velopment compared to screening for motor skill delays,
standard for age-appropriate oral intake. especially since not all delays are visibly overt. The CSBS,
in combination with other inclusion criteria of pediatri-
cian screening, lack of caregiver concerns, and lack of de-
Method velopmental therapy, was deemed to sufficiently identify
Study Population and Design typically developing children. Enrollment was confirmed
with caregivers via e-mail. Poststudy eligibility was deter-
This investigation employed cross-sectional method-
mined based on confirmation that the child was continu-
ology to examine feeding practices of infants from three
ing to meet growth trajectory criteria.
target age groups: 8, 10, and 12 months of age. To reduce
Children were excluded from the study if they did not
performance variability, the age range of eligible subjects
meet inclusion criteria, failed the initial eligibility screening
was limited to ± 2 weeks from the target age in months
interview, had a known medical diagnosis, were enrolled in
(i.e., 8 months ± 2 weeks, etc.). Based on power analysis,
developmental therapy to address developmental concern,
21 children were recruited for each age group, for a total
or did meet scoring criteria for the CSBS. Excluded children
of 63 children. The study was approved by the institutional
were referred to their pediatrician to discuss concerns.
review board at Marquette University.
Participation in the study required the caregiver to
complete all study materials and return them to the PI ac-
Recruitment cording to the study timeline. Participants received a gift
This study was part of a larger investigation of oral card or toy/book equal to $10.
feeding skill development that included videotaping children
during a feeding observation. Participants were recruited Data Collection
through community-wide flyers placed at day care centers,
local pediatrician offices, and child-friendly locations such Caregivers of enrolled children received a packet in
as “Mommy and Me” classes throughout southern Wisconsin. the mail with all study materials, including the participant
Interested caregivers were instructed to contact the principal informed consent form, feeding instructions, a 3-day die-
investigator (PI; A.L.D.) for a screening interview. The tary intake record, and the Developmental Questionnaire
interview—lasting up to 30 min—was conducted via phone (see Supplemental Material S1). The Developmental Ques-
to determine eligibility. tionnaire was developed based on factors relevant to typical
feeding development as reported in the literature (Carruth &
Skinner, 2002; Delaney & Arvedson, 2008; Evans Morris &
Inclusion/Exclusion Criteria Dunn Klein, 2000; Gisel, 1991; Le Révérend et al., 2014).
Eligibility was determined based on the initial screening Caregivers completed the dietary intake record and the De-
phone interview and a child’s score on the Communication velopmental Questionnaire prospectively according to the
and Symbolic Behavioral Scales (CSBS) Infant–Toddler instructions provided. The data were collected by the child’s
Checklist (Wetherby et al., 2002). Initial eligibility required caregiver, in either the child’s home or day care setting, de-
that participants were born at full-term gestation (i.e., ≥ pending on the caregiver preference.
37 weeks postconceptual age), determined to be at ≥ 5th
percentile (z score of −1.645) for birth weight on the WHO Presence of Texture and Drinking Method
growth chart and following a weight gain trajectory of ≥ 5th To assess the presence of different textures and
percentile at the time of study enrollment and 3 months drinking methods within the child’s diet, as well as related

Delaney et al.: Normal Texture Progression in Infancy 2645

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developmental milestones, caregivers completed a question- regular solid texture; drinking method (breast, bottle, or
naire created for this study. Caregivers reported details on cup); and volume by each texture.
developmental milestones and feeding history on the ques-
tionnaire. For development, the age of onset of general Statistical Analyses
gross motor and communication milestones and oral sen- Descriptive data were generated for chronological
sory presentation were reported. For feeding, the age of ages and age at introduction of food textures. To assess the
introduction of various complementary food, textures, and presence of different textures and drinking methods within
cup drinking; feeding behaviors; current presence or absence the infant diet, group means were taken within each of the
of various textures and drinking methods in the child’s diet; three age groups to describe the presence of each texture
and daily frequency with which each texture and drinking and drinking method. Texture consumption patterns were
method were offered was captured. determined by the proportion of meals each texture was
For the purposes of documenting the first exposures present; the consumption of texture at each meal was aver-
to food and textures that typically appear early in the com- aged across the 3-day dietary intake record. A one-way
plementary feeding period, a list of select food/textures between-subjects analysis of variance (ANOVA) was con-
(i.e., infant cereal by spoon, pureed fruits/vegetables, and ducted to compare the effect of age on feeding frequency,
finger food) was provided for the caregiver to indicate the proportion of meals that the various textures and drink-
age of introduction. For all other outcomes being measured, ing methods were present, and the number of unique food
the textures of interest included liquids (expressed breast items by texture offered. Post hoc analysis using Tukey’s
milk, formula, milk, water, and juice), purees (smooth pu- honestly significant difference (HSD) test was used to deter-
rees, textured purees, and adult purees [i.e., pureed food mine age-specific differences in performance. A p value of <
often maintained into adulthood such as yogurt and ap- .05 was considered as a statistically significant effect.
plesauce]), and solids. Solids were further differentiated as Analysis of the overall contribution to daily energy
either easily dissolvable (e.g., crackers that dissolve with sa- intake by different textures was conducted using Nutritionist
liva), soft/well cooked, crunchy, or regular (i.e., regular table Pro. The quantity of energy consumption by texture was
food provided without modification). Drinking methods averaged across the 3-day dietary intake record for each
included breast, bottle, and cup (i.e., sipper cup [not spill participant. Distribution of energy analyses excluded children
proof], sipper cup with valve [spill proof], open/regular cup, who fed directly at the breast.
and straw). Full details of the Developmental Questionnaire
can be found in Supplemental Material S1.
Results
Consumption Patterns
Subject Characteristics
Caregivers prospectively completed a dietary intake Sixty-three children—21 per age group—met inclu-
record (Livingstone et al., 2004) tracking three consecutive sion criteria and were enrolled in the study. Sex and age
days of feedings. Caregivers recorded the start and end time characteristics of each age group were as follows: 8 months:
of each feeding opportunity (i.e., meals, snacks, breast, or 52% male (n = 11), chronological age (M ± SD) = 31.8 ±
bottle feeding), each liquid or food offered, and an estimated 1.37 weeks; 10 months: 52% male (n = 11), chronological
amount consumed for each. Consumption of each liquid age = 39.8 ± 1.37 weeks; and 12 months: 33% male (n = 7),
and food item was estimated based on the number of bites chronological age = 47.6 ± 1.12 weeks. All children had
of the food eaten, liquid fluid ounces consumed, or an ap- weights > 5th percentile (z score of −1.645) for age at all
proximate amount of food or liquid consumed based on three time points required for inclusion in the study. Sixty-
comparison to a standard measuring cup. Breastfeeding two children (98%) were White/Caucasian, and one child
was recorded by the start and end time of the feeding (2%) was Black. All the participants’ mothers were White/
opportunity. Caucasian. Maternal education level was high in this co-
hort, with 62 of 63 (98%) of the participants’ mothers having
received a college education. Of note, one caregiver indi-
Energy Consumption
cated that they were utilizing a baby-led weaning approach,
Each food and liquid item on subjects’ dietary intake
in addition to traditional spoon feeding.
records was entered into Nutritionist Pro nutrient analysis
software (Nutritionist Pro, n.d.). The energy content of certain
food was ascertained through the U.S. Department of Agri- Timing of Texture and Cup Introduction
culture (n.d.) food composition database and brand-specific A total of 58 caregivers provided data on the timing
websites. of texture and cup introduction: n = 20 for 8 months, n =
18 for 10 months, and n = 20 for 12 months. Participants’
ages when textures and cup drinking were introduced are
Data Analysis summarized in Table 1. In this cohort, the introduction of
Texture Coding texture began at approximately 4.4 months of age via in-
Each item on the 3-day dietary intake record was coded fant cereal, then progressed through pureed fruits and veg-
by the PI (A.L.D.) as liquid, puree, dissolvable solid, or etables, other smooth purees, then lumpy/textured purees

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 Table 1. Age of texture and cup introduction by age in months.

Age group, M (SD)

8 months 10 months 12 months
Texture/method (n = 20) (n = 18) (n = 20)

Puree (cereal)a 4.4 (0.65) 4.4 (1.01) 4.4 (1.13)

Puree (Stages 1 and 2)a,b 5.4 (0.68) 5.3 (1.08) 5.2 (0.9)
Puree (Stage 3 smooth)a 6.8 (1.24) 6.7 (1.11) 7.3 (1.44)
Puree (Stage 3 lumpy/textured)a 7.5 (1.15) 7.4 (1.01) 7.9 (1.33)
Dissolvable solidsc 7.4 (1.02) 7.6 (1.03) 8.2 (1.59)
Regular solidsd 7.9 (1.05) 8.5 (1.07) 9.9 (1.47)
Cupe 6.7 (1.46) 7.6 (1.47) 9.0 (2.07)
a
Fed by spoon. bStages 1 and 2: fruits and vegetables. cFinger food. dTable food. eAny cup.

over the next 3–3.5 months. The mean (± SD) age of intro- the presence of regular solid food between 8 and 10 months
duction of dissolvable solids (i.e., food that melts in the of age (see Table 2). More than nine out of 10 children
mouth with minimal chewing such as “puffs,” graham crack- had some regular solid food in their diet at 10 months of
ers, butter crackers) was between 7.4 (± 1.02) and 8.2 (± 1.59) age. For drinking method, breastfeeding was present for
months, which was similar to the mean age of introduction about half of children at both 8 and 10 months of age but
of lumpy/textured purees, between 7.4 (± 1.01) and 7.9 declined to 15% by the first birthday. Conversely, bottle
(± 1.33) months. The introduction to cup drinking varied feeding was maintained at a much higher percentage at
from a mean age of 6.7 (± 1.46) to 9.0 (± 2.07) months, the 12 months of age, appearing for 75% of participants. Most
widest range of age of introduction for the feeding milestones children drank from a cup, particularly the sipper cup, with
captured in this study. limited presence of an open cup and straw. Nearly all chil-
Due to the subjectivity involved in the caregiver- dren used a combination of drinking methods. Table 2
reported data and the lack of standardized texture catego- summarizes the presence of drinking methods and textures
ries available and to ensure accurate and consistent coding across the participants.
across the data set, the more detailed categories initially
used to document the presence or absence of various tex-
tures or drinking methods in the child’s current diet (see Consumption Patterns
Developmental Questionnaire in Supplemental Material A total of 42 3-day dietary intake records were col-
S1) were simplified for coding and data analysis. Textures lected (n = 17 for 8 months, n = 13 for 10 months, and
were grouped into three main categories: liquids (e.g., free- n = 13 for 12 months). There was a statistically significant
flowing consistency such as breast milk, formula, or water), difference between group means as determined by a one-
purees (e.g., cohesive semisolid that requires no chewing way between-subjects ANOVA for the number of feedings
such as smooth or blended food), and solids (e.g., nonliquid per day, F(2, 40) = 4.109, p = .024; the number of liquid-
consistency that requires varying levels of chewing). Two
subcategories were maintained for the solid category: dis- Table 2. Percentage of children with drinking methods and textures
solvable and regular solids. Drinking methods were collapsed in their diet per parent report.
into three categories, including breast (putting infant to
breast), bottle (any type of infant bottle), and cup (sipper Age group, % (n)
cup [not spill-proof], sipper cup with valve [spill proof], open/
Drinking method and 8 months 10 months 12 months
regular cup, or straw). textures (n = 21) (n = 21) (n = 21)

Drinking method
Presence of Texture and Drinking Method Breast 43 (9) 53 (11) 15 (3)
Bottle 100 (21) 84 (18) 75 (16)
A total of 63 caregivers provided information on the Cup 81 (17) 100 (21) 100 (21)
presence of various textures and drinking methods, n = 21 Sipper cup (spill proof) 62 (13) 85 (18) 75 (16)
for each age group. Liquid texture was maintained in the Sipper cup (not spill 33 (7) 35 (7) 45 (9)
diet across all age groups. Pureed textures were dominant proof)
Open/regular 24 (5) 30 (6) 35 (7)
across age groups, appearing in 100% of the diets of 8-
Straw 0 (0) 15 (3) 20 (4)
month-olds and between 86% and 90% of the diets of 10- Combination of methods 95 (20) 95 (20) 100 (21)
and 12-month-olds. Fifteen percent of 8-month-olds had Liquids 100 (21) 100 (21) 100 (21)
no solid textures in the diet; all 10- and 12-month-olds’ Purees 100 (21) 86 (18) 90 (19)
diets did include solid food. The presence of dissolvable Solids 86 (18) 100 (21) 100 (21)
Easily dissolvable solids 86 (18) 95 (20) 86 (18)
solids remained high and mostly unchanged between 8 and Regular solids 57 (12) 95 (20) 95 (20)
12 months. As expected, there was a dramatic increase in

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only feedings per day, F(2, 40) = 6.734, p = .003; the fre- for breast and bottle-feeding frequency, which were constant
quency of cup usage, F(2, 40) = 6.334, p = .004; the propor- at about two feedings per day. This occurred alongside in-
tion of meal purees, F(2, 40) = 10.98, p ≤ .001, and regular creases in the frequency of consumption of liquids by cup,
solids, F(2, 40) = 23.871, p ≤ .001, present; and the variety which were significantly different between 8 and 10 months
of food for purees, F(2, 40) = 5.662, p ≤ .007, dissolvable of age and between 8 and 12 months of age (p = .004; see
solids, F(2, 40) = 4.546, p ≤ .017, and regular solids, F(2, 40) = Table 3).
24.733, p ≤ .001, as shown in Table 3. For texture variety, post hoc comparisons using
Post hoc comparisons using Tukey’s HSD test re- Tukey’s HSD test revealed specific age differences. As ex-
vealed specific age differences. The average number of pected, the average number of different purees was higher at
feedings per day was significantly lower at 12 months of 8 months versus 12 months, likely reflecting a greater reli-
age than at 8 and 10 months of age (p < .024). As expected, ance on purees at a younger age. The variety of dissolvable
the average number of pureed feedings decreased from solids peaked at 10 months of age. The variety of regular
8 months (2.7) to 12 months (1.5) of age, whereas the aver- solids increased across the three age groups, reflecting the
age number of solid feedings increased over the same time largest increase in variety of the metrics measured. Overall,
frame (0.7–2.7, p < .001). The proportion of meals when liq- the variety of purees consumed decreased with age as the
uids were present did not significantly differ by age, but the variety of regular solids increased (see Table 3).
average number of liquid-only feedings (i.e., entire meal
consisting of a liquid) was significantly different between
8 and 12 months. Overall, the number of feedings per day
declined from about seven at 8 and 10 months of age to
Distribution of Energy
five and a half at 1 year of age; most of this change was In the 27 children who were not directly feeding at
accounted for by the decrease in liquid-only feedings (see the breast at the time of the 3-day dietary intake record
Table 3). completion, the overall daily energy intake average was
For consumption by texture, as stated above, liquid 377.5 kcal/day (± 212.5) at 8 months (n = 8, 30% male),
consumption remained stable as children aged, but there 717.1 kcal/day (± 441) at 10 months (n = 8, 30% male),
was an expected decline in the number of pureed feedings and 712.5 kcal/day (± 522.8) at 12 months (n = 11, 40%
with a concomitant increase in regular solid food feedings male). The proportion of energy intake from liquids was
between 8 and 12 months of age. There was no change in essentially unchanged between 8 and 10 months and then
the frequency of the presence of dissolvable solids at meal declined at 12 months (see Figure 1). At 8 months, liquids
occasions (see Table 3). and purees almost equally contributed to energy con-
There was a statistically significant difference in sumption. At 10 months, the amount of energy consumed
the average number of cup feedings, increasing from 8 to by purees decreased as solid consumption increased. By
10 months and again from 10 to 12 months. There were 12 months, there was little reliance on purees and a reduc-
no statistically significant differences between group means tion in liquids for energy intake due to a sharp increase in

Table 3. Consumption patterns for meal frequency, drinking methods, and textures in 8- to 12-month-old children: means (standard
deviations) from 3-day dietary intake records.

Age groups
8 months 10 months 12 months
Variable % Meals M (SD) % Meals M (SD) % Meals M (SD) Comparisona p

Feeding frequency
Feedings per day 6.9 (1.9) 7.1 (1.5) 5.5 (1.2) 10 > 12 .024
Liquid-only 55 3.8 (1.8) 52 3.7 (1.4) 35 1.9 (1.2) 8 > 12 .003
Breast 25 1.7 (2.2) 20 1.4 (2.0) 5 0.3 (0.6) n/a .095
Bottle 36 2.5 (1.6) 32 2.3 (1.6) 42 2.3 (1.5) n/a .868
Cup 10 0.7 (0.7) 25 1.8 (1.6) 38 2.1 (1.1) 8 < 10, 8 < 12 .004
Proportion of total meals texture present
Liquids 71 4.9 (1.6) 76 5.4 (1.8) 82 4.5 (1.2) n/a .321
Purees 39 2.7 (0.7) 31 2.2 (0.9) 27 1.5 (0.7) 8 > 12 < .001
Dissolvable solids 14 1 (0.8) 17 1.2 (0.8) 13 0.7 (0.6) n/a .215
Regular solids 10 0.7 (0.7) 28 2 (0.9) 49 2.7 (0.8) 8 < 10 < 12 < .001
Number of different food by texture
Purees 7.4 (3.2) 5.5 (2.6) 3.9 (2.4) 8 > 12 .007
Dissolvable solids 1.5 (1.3) 2.7 (1.6) 1.1 (1.2) 10 > 12 .017
Regular solids 2.2 (2.9) 7.2 (4.4) 14 (6.2) 8 < 12; 10 < 12 < .001

Note. Bold rows indicate significant group differences.

a
Based on Tukey’s comparison at familywise error rate of .05.

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Figure 1. Distribution of daily energy intake by texture for nonbreastfed participants (n = 27): Means from 3-day dietary intake records.

solids. Dissolvable solids contributed a negligible amount As expected, our data demonstrate an inverse rela-
of energy at 8 and 10 months of age (see Figure 1). tionship between a decreasing presence of purees with an
Consumption of purees primarily consisted of com- increasing presence of solids as children age. This finding
mercial infant cereal and baby food, yogurt, applesauce, reflects the general progression of textures seen in the liter-
and oatmeal. Consumption of dissolvable solids primarily ature (Demonteil et al., 2018; Tournier et al., 2021). Puree
consisted of commercial finger food such as puffs and melts, was largely present in an 8-month-old infant’s diet. Al-
crackers, and dry cereal. Consumption of solids primarily though most children in the study had dissolvable solids
consisted of canned and fresh fruits (e.g., banana, peach, in their diet, there was a sharp increase from 8 to 10 months
and pear), canned and cooked vegetables (e.g., peas, green of age in exposure to and presence of regular solid food. Our
beans, and carrots), processed animal protein (e.g., deli data demonstrate a rapid transition from simple to more
meat, meatballs, and chicken nugget), and food high in complex textures in the latter half of the first year that likely
starch (e.g., pancakes, waffles, bread, and macaroni and reflects feeding skill acquisition. Appropriately, liquids per-
cheese). sisted in the diets of 100% of children in each age group.
The presence of different drinking methods provides
insight into breastfeeding rates of the cohort, oral–motor
development, and feeding practices (Scarborough et al., 2018).
Discussion The rate of breastfeeding in our cohort at 8 months was
This study examined feeding patterns in a cohort of 43%, and the rate at 12 months was 15%. Based on 2017
typically developing children 8–12 months of age and de- data from the Centers for Disease Control and Prevention
scribed texture intake patterns via the presence of texture (CDC), U.S. breastfeeding rates were 58% at 6 months of
and drinking methods, food and liquid consumption patterns, age and 35% at 12 months of age (CDC, 2017). The rate
and energy intake. We expanded on traditional descriptions of breastfeeding at 8 months of age in our cohort may
of the presence of texture and drinking methods by describing align with the CDC’s 6-month data; however our rate at
consumption patterns—the number of feedings per day, the 12 months of age was considerably lower. Although the bot-
proportion of meals with a given texture, and the variety of tle was offered at least twice per day for all children in the
food within a texture category—and the distribution of en- study regardless of age, cup drinking—a more advanced
ergy intake by texture. We quantified the presence and drinking method—did not increase to twice per day until
consumption patterns of different textures and drinking 12 months of age, which may indicate increased oral–motor
methods, assessed the contribution of different textures control for liquid consumption (Scarborough et al., 2018).
to energy intake, and described how these factors contrib- The sipper cup (or trainer cup) was more prevalent in this
ute to changes in the overall feeding schedule. Data gathered cohort than other drinking methods, which may reflect the
can help inform future research that can establish age- popularity and/or traditional guidance of offering these cups
appropriate comparison standards for children presenting in infancy, or it could reflect parental preference for a spill-
with differences in feeding development to meet diagnostic proof cup. Nearly all children utilized a combination of
criteria for PFD. drinking methods regardless of age.

Delaney et al.: Normal Texture Progression in Infancy 2649

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 Our data also reflect a consolidation of mealtimes be- in feeding related to the presence of texture, consumption
tween 10 and 12 months of age. At 8 and 10 months of age, patterns (i.e., frequency and interval of eating occasions) re-
children had more frequent feedings with a mean of seven lated to texture, method of food consumption, and changes
per day. A significant shift occurred between 10 months and in food and beverage sources that comprise energy intake
the first birthday, with feeding frequency declining to five to (American Academy of Pediatrics Committee on Nutrition,
six feedings per day; this is attributed to fewer liquid-only 2014; Fewtrell et al., 2017; Hagan et al., 2017; WHO,
feedings. This observation reflects the natural and expected 2001). Guidance on the types of food an infant or child
progression to relying less on infant formula and/or breast should consume at any given feeding stage must be driven
milk to meet nutritional needs and moving to a more “ma- by feeding skills that are expected to be present. Further-
ture” feeding schedule, with solid textures offered at meals more, it is vital to consider and emphasize nutrition require-
and snacks, in addition to liquids (American Academy of ments into texture and feeding skill considerations.
Pediatrics Committee on Nutrition, 2014; Hagan et al., 2017; It is of critical importance to understand the progres-
Reidy et al., 2017). Such a feeding schedule is possible when sion from first exposure to a complementary food to the
the child’s feeding skills and endurance allow the consump- solid establishment of more advanced textures with increasing
tion of more nutrition per feeding. Thus, the feeding sched- variety and drinking methods. Our data provide a preliminary
ule is one metric that could help establish expectations for basis for understanding some of the more subtle, but of vital
age-specific feeding stages. importance, changes that occur during the feeding journey.
Unsurprisingly, there was a significant reduction of the From a cross-sectional view, our data demonstrate
frequency of puree consumption between 8 and 12 months. age-specific feeding profiles of children in infancy. At
Purees were offered at most meals at 8 and 10 months of age 8 months, infants had transitioned to purees, consuming ad-
(31% and 27%, respectively) but were offered less often by equate amounts for this new texture to contribute nearly
the first birthday. We observed the opposite trend in the of- 50% of their energy intake. They continued with seven feed-
fering of regular solids, with less than one per day offered at ings per day. Cup drinking and regular solids were not a
8 months of age, increasing to two per day at 10 months of prominent feature of their diet. At 10 months, infants con-
age, and offered at nearly three meals per day by the first tinued with more frequent feedings, but cup drinking and
birthday. We suspect this increase in regular solid offerings regular solid feedings were a prominent feature of meals
was due to successful acceptance of solids by the child and during the day. A range of purees and regular solids were
may reflect improved oral–motor coordination, chewing consumed. There was equal distribution of energy intake
skills, and general feeding development. Although the ex- across purees and solids. By 12 months of age, children were
planation for the increase in solids is speculative, the authors largely on a mature feeding schedule with cup and regular
conjecture this highlights the importance to look beyond solids at meals with a large range of different solid food (see
the mere presence of a texture in a child’s diet. Assessing Table 3). Solid food and liquids contributed equal propor-
for the proportion of meals that texture provides may of- tions of their energy intake. Given that a PFD is defined ac-
fer a more robust expression of feeding development than cording to age-related measures (Goday et al., 2019), it is
the presence of a texture alone. critically important to have reliable age-based comparison
The dynamic nature of a feeding schedule over the metrics that can identify children with evolving feeding
first year of life reflects the ever-present changes in age and problems based on feeding skill deficits and subsequent de-
ability. More specifically, the presence of textures and lays with texture advancement.
drinking methods in the diet provides some reflection of Although broad age ranges for stages of feeding de-
skill development. However, the appearance of a texture velopment provide a framework for developmental expec-
does not necessarily equate to the ability to consume that tations, we have demonstrated that more discrete changes
texture efficiently, enough for it to contribute meaningfully occur throughout feeding development. In the 6 months
to energy or nutrient requirements. The amount that a spe- following onset of complementary feeding, although pres-
cific food and/or texture contributes to total nutrient intake ence of textures is important, the frequency by which dif-
may be an underappreciated metric in assessing feeding ferent textures are consumed may be a more important
skill performance. The distribution of energy intake by tex- measure of feeding development. Studying not only the
ture may be a key factor in determining age-appropriate presence of textures in the diet but also consumption pat-
texture intake expectations. In our study, by 8 months of terns of various textures may be a more sensitive assessment
age, purees contributed to nearly half of all energy intake. of skill development and more useful in distinguishing typi-
Although energy requirements were still largely obtained cal developmental variation. Within the feeding schedule
from liquids between 8 and 10 months of age, there was analysis, frequency and volume of texture consumption
also a decline in the energy obtained from pureed food, can provide a measure of age-specific abilities in feeding
which corresponded to the increased number and volume development as a complement to nutritional assessment. With
of solid feedings offered to the older infants. By 12 months, larger cohorts of children, these proposed feeding stages can
an equal proportion of intake from liquids and solids was be confirmed or revised to reflect critical changes in feeding
observed. expectations and provide more discrete guidance for medical
The developmental time frame after the onset of com- professionals and caregivers and form the basis by which
plementary feeding includes rapid and frequent transitions PFD can be diagnosed.

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Limitations to understand the impact of family dynamics on texture intake
patterns. These data may also help expand current guid-
Potential limitations of this study include the homo-
ance on complementary feeding to include recommendation
geneity of the cohort, which does not account for racial or
on texture exposure and progression. For this exploratory
demographic diversity or socioeconomic status, factors
study, we decided to use general, more global categories of
known to influence feeding. In addition, since this is a cross-
textures for the analysis so as to avoid overinterpretation of
sectional study, longitudinal changes in individual infants
textures that are not standardized appropriately. Our next
could not be captured. This study also investigated children
step would be to determine a texture framework that can be
at broad feeding stages and lacks a wide age range of chil-
used with this methodology to describe texture progression
dren to reflect changes across the expanse of feeding devel-
in much greater detail with a much larger cohort of children
opment than can only be obtained from a much larger study.
without PFD. Finally, we will examine oral sensorimotor
In addition, we did not review the dietary recalls with the
skills required to support success with a variety of food tex-
caregiver, and this may have led to inconsistencies in the
tures and drinking methods.
data. Furthermore, the Developmental Questionnaire devel-
oped for this study was not validated.
A major limitation of this study is the lack of stan- Author Contributions
dardized texture categories and definitions that account for
Amy L. Delaney: Conceptualization (Lead), Data
oral skill development during the first few years of life. Such
curation (Lead), Methodology (Lead), Formal analysis (Lead),
standardization is available for adults with dysphagia who
Writing – original draft (lead), Writing – review & editing
have experienced the loss of skill via the International Dys-
(Lead). Megan Van Hoorn: Conceptualization (Lead), Data
phagia Diet Standardization Initiative (IDDSI; Cichero
curation (Equal), Methodology (Equal). Sarah Staskiewicz:
et al., 2017), but this framework is not intended for use in
Formal analysis (Equal), Methodology (Supporting), Writing –
a scenario where skills are expected to evolve and develop,
review & editing (Supporting). Mary Beth Feuling: Concep-
as is the case in typical early development. Likewise, the
tualization (Supporting), Methodology (Supporting). Stephanie
food textures and liquid thickness described within the IDDSI
Pladies: Data curation (Supporting). Naveen K. Bansal: For-
framework are based on the objective of providing common
mal analysis (Equal). Praveen S. Goday: Conceptualization
terminology of food and drink to improve the safety of indi-
(Equal), Formal analysis (Equal), Visualization (Equal),
viduals with swallowing difficulties. Hence, the purpose and
Writing – original draft (Supporting), Writing – review &
objective of the IDDSI framework is foundationally different
editing (Equal).
from one that would exist for the purposes of guiding texture
progression during typical oral–motor development. Indeed,
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