creating and implementing a blenderized tube feeding1cb444df-77c3-4d94-82fa-e366d7d6ce04}/… ·...
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Objectives
• Review the benefits and challenges associated with blenderized
tube feeding (BTF)
• Provide a rubric for developing a new BTF recipe and plan for
transition
• Outline excellent available resources for clinicians and
caregivers
• Overall goal minimize apprehension around BTF
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An Evolving Perspective?
4
• 2014 ASPEN survey involving 244 pediatric RDs regarding
experience in providing blended food via g-tube1
– 70% reported positive outcomes with BTF
– 58% recommend and use blended food via gtubes
– 12% don’t use BTF
– 70% attribute this to parent request
– 23% due to feeding intolerance with commercial formulas
• Older RDs were more familiar with BTF but less likely to use
them
The Benefits
• Physiologic
• May aid in transition to oral diet
• A natural product
– Consider: food components vs. whole foods
– Increased variety
• Improved GI symptoms2-4
– Decreases gagging/retching
– Decreases reflux symptoms
– Constipation or diarrhea
– Improve quality of life
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The Benefits
• Prospective cross-sectional study in 54 enterally fed adults4
– 50% used BTF
– 80% expressed a desire to use BTF
• Motivation for using BTF
– Natural (43%)
– Eating what the family eats (33%)
– Better tolerance (30%)
6
The Challenges
• Time commitment
– Caregiver: meal planning, daily/weekly preparation, follow-up
appointments
– Clinician: office visits, recipe analysis to ensure DRIs are met
• Sensitivity to volume, gastric dysmotility
• Small french size (< 14)
• Lack of support from medical team
• Acute illness or immunosupression
• Existing food allergies/intolerances
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The Deal Breakers
• Patient age < 4-6 months
– AKA homemade infant formula (GROW 2016 topic?)
• Inadequate kitchen for safe prep and storage
• History of poor adherence/follow-up
• Post-pyloric feeding
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Start with PROTEIN
• Protein g/kg/cm goals from individualized assessment
• Compleat Pediatric is 15% protein with 38 g pro/1L
• Choose a solid and a liquid for viscosity and to meet 80-90% total
protein needs
• 10-20% max protein will come from cereals, legumes, nuts
– Solids: infant stage 2 chicken/turkey (7-8g per 2.5 oz jar), soft tofu
– Liquid: formula, 2% lactaid, yogurt, bone broth, alternative milks
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Choose your CARBOHYDRATES
1. Fruits and vegetables: choose from both the Vit A & Vit C groups
– Vitamin A: squash, carrots, sweet potato, peaches, apricots
– Vitamin C: applesauce, pears, green peas, green beans, spinach
– Consider GI concerns: prunes, green beans
– Note: adds bulk without adding significantly to calorie delivery
2. Thickening agents: grains for additional kcal, cho, fiber
– Dry infant cereals: gerber oatmeal, other gerber cereals
– Whole grain based: soaked cheerios, steamed grains, white rice,
quinoa, barley, etc
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Choose your FAT
• Important source of kcal
• Compleat Pediatric is 34% fat, in-pt recipes are ~30%
• Lower saturated fat vegetable oils: olive, canola, flax
• Consider avocado for added fiber
• Consider anti-inflammatory omega-3s
• Include sardines or salmon, 1x week
• Walnuts, hemp (hulled) and chia, caution with blending
• Also remember to choose other food items that are higher in fat to boost
kcal, ie whole fat greek yogurt or barley
13
Calculate Fluid
• If unable to use nutrient analysis software, free water can be
easily calculated if using infant purees, standard formulas or milks
• Calculate total ounces of pureed fluid-containing infant foods
(meats, fruits, vegetables, yogurt)
– Multiply by 0.75, most infant foods contain ~75% free water
• Add free water from formula and milk (typically ~85%)
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Caregiver Education – getting started
• First, a great BLENDER
– Vitamix
– Blendtec
– Nutribullet
– Magic Bullet
– My Blend
• Measuring utensils or scale
• Thermometer
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Caregiver Education
• Preparation
– Wash hands, sanitize work space
– Assemble equipment (utensils, measuring cups, blender, recipe)
– Cook meat, chicken, poultry, eggs to appropriate temperatures
– Cook grains, vegetables as appropriate
• Blending
– Cut up whole foods
– Blend solids first, gradually increase speed
– Add liquids gradually while evaluating consistency
– Some foods don’t blend well
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Caregiver Education
• Storage
– Cover and store in the refrigerator
– Refrigerated blended feeds should be used within 24-48 hrs
– Freezer stored foods can be stored for up to 3 months
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Caregiver Education
• Foods to use with caution:
– Low moisture content (dried fruit, chicken breast)
– High insoluble fibers (corn, nuts, seeds)
– Acidic foods (citrus, pineapple)
– Added sugars and supplements (increase osmotic load)
– High soluble fibers (can increase viscosity, clogging)
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BTF - is it working?
• Growth monitoring
• Consider micronutrient needs
– Calcium, iron, sodium, zinc
– Can use software to analyze
– Consider MVI + variety offered
• GI symptoms
• Hydration status
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Miscellany
• Consider the supplemental BTF when getting started
• It’s ok to not know – caregivers become your best resource
• Emergency Preparedness (in a pinch or for travel )
– Nestle Compleat line
– Liquid Hope + Real Food Blends
• Provide a letter of medical necessity
– Blendtech offers a free blender
– Vitamix offers a reduced-cost refurbished blender
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Additional Resources
• Blenderized Tube Feeding: Suggested Guidelines to Clinicians5
• The Use of Blenderized Tube Feedings in Pediatric Patients6
• Foodfortubies.org
– Non-profit resource group: forum, recipe ideas, education
• Mealtimenotoins.com
– The Homemade Blended Formula Handbook by Marsha Dunn Klein,
MEd, OTR/L and Suzanne Evans Morris, PhD, CCC-SLP
• Seattle Children’s patient/family education materials
• Oley Foundation
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References
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1. Johnson, Teresa W., Amy Spurlock, and Leah Pierce. "Survey Study Assessing Attitudes and Experiences
of Pediatric Registered Dietitians Regarding Blended Food by Gastrostomy Tube Feeding." Nutrition in
Clinical Practice 30.3 (2015): 402-405.
2. Novak, Patricia, et al. "The use of blenderized tube feedings." ICAN: Infant, Child, & Adolescent
Nutrition 1.1 (2009): 21-23.
3. Bills, Hannah Bowman. USE OF HOMEMADE BLENDERIZED FORMULA IN GASTROSTOMY TUBE
DEPENDENT PEDIATRIC PATIENTS WITH FEEDING INTOLERANCE: A SERIES CASE STUDY. Diss. The Ohio
State University, 2015.
4. Hurt, Ryan T., et al. "Blenderized Tube Feeding Use in Adult Home Enteral Nutrition Patients A Cross-
Sectional Study." Nutrition in Clinical Practice(2015): 0884533615591602.
5. Escuro, Arlene A. "Blenderized Tube Feeding: Suggested Guidelines to Clinicians." PRACTICAL
GASTROENTEROLOGY (2014).
6. Schoenfeld, Laura. The Use of Blenderized Tube Feeding in Pediatric Patients: Evidence and Guidelines for
Dietetic Practice (Chapel Hill, North Carolina). Diss. University of North Carolina at Chapel Hill, 1913.
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