Primary aspiration of food and fluid is commonly seen in children with feeding and swallowing difficulties associated with a range of diseases and complex medical conditions. Respiratory sequelae and pneumonia are known to be associated with primary aspiration of ingested material, however causality between primary aspiration of specific food and fluid types and pulmonary effects in children is yet to be established in controlled trials. The relative pulmonary morbidity of aspiration of ingested food and fluid materials versus other causes of respiratory disease such as viral and bacterial causes, secondary aspiration of gastrointestinal contents and predisposing lung conditions such as chronic neonatal lung disease in a developing immune system is also unclear. Current management decisions for children who aspirate have to optimise oral nutrition and hydration, while reducing the risk of aspiration to preserve pulmonary integrity. This generally includes restricting aspirated food or fluids and providing texture-modified diets and thickened fluids. Young children frequently refuse thickened fluids providing a management dilemma for both families and health professionals.