Enteral Nutrition Selection
A nutrition assessment is recommended when choosing an enteral feed type to meet the specific nutrition needs of the child. Breastmilk is the optimal choice for infants. Breastmilk can be fortified to provide additional nutrition if required. If breastmilk supply is insufficient or unavailable, formula may be used in conjunction with breastmilk or as an appropriate substitute.
There are a wide variety of formulas designed for infants as well as older children and adults (see Table 11 ). Formula for enteral feeding may be selected based on age, growth, nutrition requirements, underlying disease state, (e.g. food allergy, conditions requiring specific formulations, absorptive capacity), fluid allowance, palatability, and accessibility. The formula may also be modified with additives for individual patients to better meet nutritional goals (National Health and Medical Research Council, 2012) (ESPGHAN Committee, 2010) (Boullata, et al., 2017) (NSW Office of Kids and Families, 2016) (Alberta Health Services, 2013a).
Home blended food for tube feeding may also be considered in discussion with a dietitian and the interdisciplinary team. Home blended food for tube feeding can be defined as whole foods and liquids blended into fine puree or liquid that is administered through an enteral tube (Coad, et al., 2017) (Epp, 2018) (Johnson, Spurlock, & Pierce, 2015). Commercially prepared blended foods and liquids for tube feeding may be referred to as blenderized formulas to distinguish from blends prepared in the home setting. Medical stability, absence of malnutrition, a mature stoma, adequate tube size, tolerance to bolus feeding, ability to tolerate variable nutrient, electrolyte and fluid intake, and family ability to prepare feeds and assume the additional workload are all factors contributing to successful home blended food for tube feeding (Gallagher, et al., 2018) (Zettle, 2016) (Coad, et al., 2017) (Epp, 2018).
Home Blended Food for Tube Feeding
Benefits and indications for home blended food for tube feeding
Blended food diets have been shown to have a positive effect on the health outcomes of enterally-fed children including improvements in nausea, vomiting, gagging, retching, diarrhea, gastroesophageal reflux, constipation, overall wellness, and oral intake (Phillips, 2019); (Soscia, et al., 2021); (Trollip, Lindeback, & Banerjee, 2020); (Batsis, et al., 2020); (Breaks, Smith, Bloch, & Morgan, 2018); (Durnan, Toft, & Flaherty, 2018).
In some instances, reduced medication requirements (Gallagher, et al., 2018), hospital admissions, and emergency visits were observed after the first year on a blended diet (Batsis, et al., 2020); (Kernizan, et al., 2020); (Breaks, Smith, Bloch, & Morgan, 2018).
Positive experiences and outcomes are often reported by families using home blended food for tube feeding over commercial formula. Parent empowerment, de-medicalization of the feeding relationship, and mental health benefits have been cited (Breaks, Smith, Bloch, & Morgan, 2018); (Durnan, Toft, & Flaherty, 2018); (Phillips, 2019); (Soscia, et al., 2021); (Trollip, Lindeback, & Banerjee, 2020). Children were reported as having improved well-being, were happier, more relaxed, more energetic, and had better social inclusion (Soscia, et al., 2021); (Trollip, Lindeback, & Banerjee, 2020).
Home blended food for tube feeding may be recommended in the following populations:
- infants (from around 6 months of age) and children who are medically stable (Association of UK Dieticians, 2019); (Durnan, Toft, & Flaherty, 2018)
- children with a well-healed gastrostomy stoma and minimum tube size 12 French (Fr) or greater (Kernizan, et al., 2020); (Association of UK Dieticians, 2019); (Coad, et al., 2017); (Gallagher, et al., 2018); (Epp, Salonen, Hurt, & Mundi, 2019)
- children with reflux symptoms that are challenging to manage and who may benefit from a higher viscosity feed (Hron, et al., 2019); (Hron & Rosen, Viscosity of Commercial Food-based Formulas and Home-prepared Blenderized Feeds, 2020)
- children who have undergone fundoplication experiencing rapid gastric emptying and dumping syndrome leading to upper GI symptoms (Batsis, et al., 2020); (Coad, et al., 2017)
- families who have a suitable home environment with access to a kitchen with a fridge and a high-power blender, and are willing to monitor their child’s nutrition and fluid intake (Coad, et al., 2017)
Concerns with home blended food for tube feeding
Reported disadvantages of home blended food for tube feeding may include:
- initial increased start up costs such as purchasing a high-power blender
- a change from formula coverage to planning for food costs
- increased preparation time compared to commercial formula (Batsis, et al., 2020)
- inconvenience compared to commercial formula availability
- shorter administration time due to food safety
- blended food getting stuck in the tube
- volume tolerance
- meeting nutrition needs
Many families are willing to overlook these challenges due to the perceived benefits and improvements observed in children receiving home blended food for tube feeding (Durnan, Toft, & Flaherty, 2018); (Soscia, et al., 2021); (Phillips, 2019).
Administration of home blended food for tube feeding
Home blended food for tube feeding is best administered as bolus feeding using a syringe due to its thickness. Less viscous blends may be administered by gravity large bore feeding sets but can be prone to clogging due to inadequate blending and sediment accumulation (Gallagher, et al., 2018); (Johnson, et al., 2019); (Breaks, Smith, Bloch, & Morgan, 2018); (Coad, et al., 2017).
Children unable to tolerate syringe or gravity bolus feeding may achieve improved volume tolerance using a pump, being mindful of the short hang time (up to 2 hours). Blends with an IDDSI (International Dysphagia Diet Standardization Initiative) level 2 thickness (mildly thick) or less (level 1 slightly thick or level 0 thin) may be administered using select feeding pumps (Batsis, et al., 2020); (Epp, Salonen, Hurt, & Mundi, 2019); (Coad, et al., 2017). See Table 12 - Feeding Pump Criteria and Figure 11 - Feeding Pump Selection .
International Dysphagia Diet Standardization Initiative to determine IDDSI level of thickness: