Don’t Fear the Blender: creating and implementing a blenderized tube feeding

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?

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• 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%)

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The Benefits

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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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Creating a recipe from scratch!

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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

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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.