LisaEpp,RDN,LD,CNSC

DisclosuresIhaveacommercialrelationshipwithNestle,AbbottandHalyardHealthasaconsultant/memberofspeaker’sbureau,etc.andwillprovidepracticerecommendationsthatarebasedonformalstructuredreviewoftheliterature.

Objec.ves! Evaluatewhoisusingblenderizedtubefeeding(BTF).! DefinecriteriathatshouldbemetpriortostartingBTF.

! BeabletolisttoolsneededtomakeandadministerBTF.

! ConstructsamplerecipesforBTF.! Discussdifferencesbetweenthepremadewholefoodformulas.

Whoisblending?

Mayopa.entsblending! AuthorsconductedastudyofMayopatients(54adults).

! BTFwasusedby55.5%ofpatients.!  90%expressedadesiretouseBTFifprovidedwithadequateinformation

!  GIsymptoms!  83%hadnosymptomsonBTF!  67%hadnosymptomsoncommercialformula

Results:BTFistoleratedaswellascommercialformulas

HurtRT,EdakkanambethVarayilJ,EppLM,etal.BlenderizedTubeFeedingUseinAdultHomeEnteralNutritionPatients:ACross-SectionalStudy.NutrClinPract.Dec2015;30(6):824-829.

OleyFounda.onSurveyPediatrics(125respondents)

!  89.6%ofpediatricpatientsusedBTF!  71%oftotaldailyintake!  75%usedhomemadeblends!  90.2%reportednoweightlosswhenusingBTFcomparedto58.9%reportedno

weightlosswhenusingcommercialformulasAdults(91respondents)

!  65.9%ofadultpatientsusedBTF!  56%oftotaldailyintake!  67%usedhomemadeblends!  51(85%)reportednoweightlosswhenonBTFvs31(32%)reportingnoweightloss

withcommercialenteralformulas.!  Results:usingcommercialENformulawasmorelikelytoleadtoweightlossthanusing

BTF(P<.0001).Epp,L.,Lammert,L.,Vallumsetla,N.,Hurt,R.T.,Mundi,M.S.UseofBlenderizedTubeFeedinginAdultandPediatricHomeEnteralNutritionPatients.NutrClinPractApril2017.

HENDemographicssurvey! OnlinesurveylinkedonOleyFoundationandFeedingTubeAwarenessFoundationonline.

! CoramandPediatricHomeServicesalsohelpedadministerthesurveys.

!  1519surveyscompleted!  1062<18yearsold

!  23.6%reporteduseofBTF

!  457≥18yearsold!  14.9%reporteduseofBTF

AbstractpresentedatASPENNutritionScienceandPracticeConferenceJanuary2018https://www.nutritioncare.org/uploadedFiles/Documents/ASPEN_2018/ASPEN18_Abstracts/WEDNESDAY%20POSTERS%202018.pdf

Takeaway! Manypatientsareblendingandthisshouldbepartofeverynutritionassessmentforanenterallyfedpatient.

! Cliniciansrefusingtoconsidertheseformulasorhomemaderecipesmayleadtopatientharm.

!  Somepatientsmaynotbeabletoblendandmayfeel“shame”.

!  “muchmoreenergywithblenderizedfeedings&regularbowelmovements”

!  “itsgreattohaveflexibilityandchoice”!  “FeelthebestIhavein10years”

Criteria!  Talktoyourprimarycareprovider!  Maturestoma

!  12Frenchorgreatertube!  SmallerFrenchsizesmayworkwithsomecommercial

formulasandthinnerhomeblends.

!  Someformulasmayworkwithnasaltubes!  Determineasystemformonitoring!  Nutritionprofessionalavailable

PerceivedbenefitsRDNrapport!  2,448dietitiansresponded!  58%useandrecommendBTF! Mostcommonreasonforusewasparentrequest(70.2%)Parents!  244parentsresponded,50%usingBTFinsomeway

!  Onlyhalf(49.3%)ofparentsusingBTFreferredtodietitiansforfeedingoversight

Johnson,TeresaW.;Spurlock,Amy;Pierce,LeahSurveyStudyAssessingAttitudesandExperiencesofPediatricRegisteredDietitiansRegardingBlendedFoodbyGastrostomyTubeFeeding.NutritioninClinicalPractice,Jun2015;30(3):402-405.(4p)JohnsonT,SpurlockA,EppL,etal.ReemergenceofBlendedTubeFeedingandParent’sReportedExperiencesinTheirTubeFedChildren.TheJournalofAlternativeandComplementaryMedicine.November2017,aheadofprint.

ClinicalBenefits!  Improvereflux! Decreaseinvomiting! Bowelregularity

!  Improveddiarrhea

!  Increasedbacterialdiversityofgut! Boweladaptationimproved

PentiukS,O'FlahertyT,SantoroK,WillgingP,KaulA.Pureedbygastrostomytubedietimprovesgaggingandretchinginchildrenwithfundoplication.JPENJParenterEnteralNutr.May2011;35(3):375-379.KolacekS,GrgurićJ,PerclM,etal.Home-mademodulardietversussemi-elementalformulainthetreatmentofchronicdiarrhoeaofinfancy:aprospectiverandomizedtrial.EurJPediatr1996;155:997–1001.ClaessonMJ,JefferyIB,CondeS,etal.Gutmicrobiotacompositioncorrelateswithdietandhealthintheelderly.Nature2012;488:178–84.GallagherK,FlintA,MouzakiM,etal.BlenderizedEnteralNutritionDietStudy:Feasibility,Clinical,andMicrobiomeOutcomesofProvidingBlenderizedFeedsThroughaGastricTubeinaMedicallyComplexPediatricPopulation.JournalofParenteralandEnteralNutrition.January2018SamelaK,MokhaJ,EmerickK,DavidovicsZH.TransitiontoaTubeFeedingFormulaWithRealFoodIngredientsinPediatricPatientsWithIntestinalFailure.NutrClinPract.2016Aug4.pii:0884533616661011.

ClinicalHesita.on!  Limitedpublishedpeerreviewedpublications! Microbialcontamination! Variabilityofnutritionalcomposition!  Increaseinclinician’stime! Potentialincreaseincost/losereimbursement! Possibletubeclogging,tubewearsoutmorequickly! Maybemoredifficulttotravel!  Facilityorhospitalmaynotsupportit

SullivanMM,Sorreda-EsguerraP,SantosEE,etal.BacterialcontaminationofblenderizedwholefoodandcommercialenteraltubefeedingsinthePhilippines.JHospInfect.Dec2001;49(4):268-273VieiraMM,SantosVF,BottoniA,etal.Nutritionalandmicrobiologicalqualityofcommercialandhomemadeblenderizedwholefoodenteraldietsforhome-basedenteralnutritionaltherapyinadults.ClinNutr2016DecJalaliM,SabzghabaeeAM,BadriiSS,etal.Contaminationofhospital-preparedenteraltubefeedingformulasinIsfahan,Iran.JResMedScii2009May-Jun;14(3):149–156.WailaC,VanHoornM,EdlbeckA,etal.TheRegisteredDietitianNutritionist’sguidetohomemadetubefeeding.JAcadNutrDiet.2016;Mar

Toolsneeded

Tools!  Blenderstudy

!  Blenderstested:OsterBlender,Cuisinartfoodprocessor,MagicBullet,MegaKitchen-NinjaSystemandVitamix.

!  Vitamixseemstoblendbetterthanallofthedevices,forthickerrecipes,withtheexceptionoftheMegaKitchen-NinjaSystem.

!  Increasedblendingtimehelpedwithlesspowerfulblender!  BlendtecworkedaswellasVitamix.

!  CathetertipOringsyringes!  Don’tgetsticky!  Easiertopush!  Mayhelptooilsyringes

!  Straightbolusextensionsets

Manpreet Mundi, MD; Lisa Epp, RDN; Wanda Duellman, RDN; Jacob Davidson; Satyanarayana Yaramala, MBBS; Steve Corner; Ryan Hurt, MD. Efficiency of Blenders used to Prepare Home Blenderized Tube Feeding. ASPEN Clinical Nutrition Week 2017

Tools!  Largeboregravitybags! EnteraLite®Infinity®pump

! Mayneedtoincreasepumpratetocompensate!  Viscositymayresultsininconsistentfeedingtimes

! Bolee™bags

https://www.nutritioncare.org/uploadedFiles/Documents/ASPEN_2018/ASPEN18_Abstracts/WEDNESDAY%20POSTERS%202018.pdf

ItsJustFoodandWater

Recipedevelopment

! Exchanges!  Standardrecipe! Platemethod

Recipeidea500kcal(exchanges)INGREDIENT AMOUNT

Starch–well-cookedoatmeal,rice,pastaorpotato ½cup

Yogurt,reducedfat(2%) ¼cup

Milk,1% ¾cup(6oz)

Oil,canola 2teaspoons

Fruit–canned,freshorfrozenapple,banana,peaches,mandarinoranges

½cup

Vegetable–canned,freshorfrozenwellcookedbroccoli,carrots,greenbeansorcauliflower

½cup

Meat–cookedtenderchicken,turkey,beef,fishorsmooth,softtofu ½cup

PROCEDURE:Putallitemsinablenderandmixwell.ThisfitsintoaMagicBullet.Refrigerateifnotusedimmediately.

StandardRecipe1000kcal

FamilyMeals

https://www.choosemyplate.gov/MyPlate-Daily-Checklistaccessed4/25/17

ConsumerRecipeshortcomings! Toomanyfruits/vegetables! Toomuchprotein!  Lowinsaltandpotassium!  Forgetthecarbohydrate! Toomuchwater! Notenoughwater

Thefollowinginformationisbeingprovidedforalearningexperienceandnottopromoteanyoneproductoveranother.

Commercialproducts1.  Compleat®,Compleat®Pediatric,Compleat®

PediatricReducedCalorie,Compleat®OrganicBlends

2.  KateFarms®Komplete,CoreEssentials,PeptidePlus1.5,KateFarmsPediatricPeptide1.5,KateFarmsPediatricStandard1.2

3.  LiquidHope®andNourish®4.  PediasureHarvest™5.  RealFoodBlends™6.  Ultrient™(comingsoon)

Conclusion! BlendedformulaappearstobeusedinthemajorityofMayo/OleyHENpatients

! Canmeetnutritionneedswiththehelpofaregistereddietitian.

! TherearemanyoptionsavailableforpatientswhowishtouseBTF.

References!  HurtR,EdakkanambethVarayilJ,EppL,etal.BlenderizedTubeFeedingUseinAdultHomeEnteral

NutritionPatients:ACross-SectionalStudy.NutrClinPract2015Dec;30(6):824-9.doi:10.1177/0884533615591602

!  MundiMS,EppL,HurtRT.IncreasedForceRequiredWithProposedStandardizedEnteralFeedConnectorinBlenderizedTubeFeeding.NutrClinPract,2016Apr18.pii:0884533616639126

!  WailaC,VanHoornM,EdlbeckA,etal.TheRegisteredDietitianNutritionist’sGuidetoHomemadeTubeFeeding.JAcadNutrDiet.2016Mar16.pii:S2212-2672(16)00117-9.doi:10.1016/j.jand.2016.02.007.

!  Epp,L.,Lammert,L.,Vallumsetla,N.,Hurt,R.T.,Mundi,M.S.UseofBlenderizedTubeFeedinginAdultandPediatricHomeEnteralNutritionPatients.NutrClinPractApril2017

!  SullivanMM,Sorreda-EsguerraP,SantosEE,etal.BacterialcontaminationofblenderizedwholefoodandcommercialenteraltubefeedingsinthePhilippines.JHospInfect.Dec2001;49(4):268-273

!  UnitedStatesDepartmentofAgricultureFoodSafetyandInspectionService,http://www.fsis.usda.gov/wps/portal/fsis/topics/food-safety-education/get-answers/food-safety-fact-sheets/safe-food-handling,accessedMay1,2017.!  A.S.P.E.N.EnteralNutritionPracticeRecommendations.NormaA.Metheny,CharlesMueller,

SandraRobbins,JacquelineWesselandtheA.S.P.E.N.BoardofDirectors.JPENJParenterEnteralNutr2009;33;122originallypublishedonlineJan26,2009;DOI:10.1177/0148607108330314