Health Outcomes and Quality of Life Indices of Children Receiving Blenderized Feeds via Enteral Tube

Understanding how foods and enteral feedings influence the gut microbiome

The gut microbiome supports both gut and overall health. Diet is known to be one of the driving factors that influences the gut microbiome. The foods we eat, the dietary and nondietary components they contain, various food consumption patterns, and the ratio of nutrients consumed have been shown to impact gut microbiome composition and function. Studies indicate that many acute and chronic diseases are associated with alterations to the gut microbiome. There are many patients who rely on enteral tube feeding for their nutrition support. More recently, enteral tube feeding formulations of "real food" have become commercially available. However, little is known about how enteral tube feeding impacts the gut microbiome in patients requiring this specialized form of nutrition therapy. This review summarizes the existing evidence regarding the food sources of commonly consumed macronutrients and their impact on the gut microbiome. Also presented is what is known regarding "standard" and real food enteral formulations on the gut microbiome. Existing evidence is suggestive that real food enteral formulations positively impact the gut microbiome. Still, more research is needed on ready-to-feed formulations, particularly in patients with various clinical conditions, and how gut microbiome modulation impacts clinical outcomes.

State-of-the-art review of blenderized diets-Status and future directions

This state-of-the-art review was produced by a multidisciplinary team composed of pediatric gastroenterology and nutrition healthcare providers to provide a comprehensive overview of the use of blenderized tube feeds (BTFs). The team developed 12 vital questions to address gaps in the current understanding and practice of using BTFs, then performed a comprehensive search of literature published between 2000 and 2023 using PubMed, MEDLINE, Embase databases, and an individual search of references. There was a scarcity of well-designed randomized clinical trials, and most of the studies were prospective or retrospective observational reports from heterogeneous patient demographics, varieties of BTFs, and medical conditions. Use of BTFs was associated with improved outcomes, including higher satisfaction, reduced gastroesophageal reflux, retching, gagging, constipation, frequency of hospitalization for respiratory disease, and greater diversity of the gut microbiome. However, homemade and commercially manufactured BTFs varied in nutrient composition and physical properties, such as viscosity, which posed challenges related to ease of administration and comparison of clinical outcomes. Therefore, whereas the use of BTFs as an alternative to standard commercial formulas has become increasingly popular, further evidence is warranted to provide guidelines on best practices for usage, monitoring, and comparing clinical outcomes. Pediatric dietitians and clinician practitioners must regularly monitor children receiving BTFs to ensure nutritional adequacy, optimize safe and effective delivery, and promote optimal growth. The team proposed future directions regarding best practices for using BTFs, primarily related to clinical application and nutritional outcomes in children and adolescents.

Pediatric and adult commercial blenderized and real-food ingredient enteral formulas: A comparison study

BACKGROUND

Traditional pediatric, cow milk-based formulas provide >90% of dietary reference intakes ("complete" nutrition) when a child receives a standard amount of formula. We aimed to assess the adequacy of essential nutrients provided to children by commercial real-food ingredient formulas and commercial blenderized formulas.

METHODS

We systematically identified all US-based real-food-based formulas via Google searches. We analyzed macronutrient and micronutrient nutriture by simulating feeds to 3-, 8-, 13-, and 18-year-olds and compared these with the dietary reference intakes and tolerable upper intake limits. We assessed the amounts provided by 1000 ml and 1000 kcal (at ages 3 and 8 years), 1500 ml and 1500 kcal (at all ages) and 2000 ml and 2000 kcal (at ages 13 and 18 years).

RESULTS

We identified 33 formulas (20 pediatric; 13 adult) of which 70% were vegan. Different nutrients, including essential amino acids and polyunsaturated fatty acids, were deficient at various volume and energy amounts. At age 13, adult formulas more consistently met dietary reference intakes (vs pediatric formulas). Nonvegan formulas were more likely to meet dietary reference intakes at various age groups (vs vegan formulas) but were also more likely to exceed tolerable upper intake limits.

CONCLUSIONS

Nutrition provided by food-based formulas may not meet all the needs of children, particularly those exclusively fed these formulas. Adult formulas should be considered in teens and nonvegan formulas may increase nutrient adequacy. Children with gastrointestinal diseases or low energy needs may be at higher risk of nutrient deficiencies when on these formulas.

Role of home-blended tube feedings in pediatric patients with gastrostomy tubes: A retrospective study

BACKGROUND

Both blended tube feed (BTF) and commercial tube feed (CTF) can be administered through a gastrostomy tube (GT). There is very little evidence about using home BTF (HBTF). Nevertheless, families increasingly request this type of nutrition because they attribute some benefits to it. Our objective was to evaluate the efficacy and safety of using HBTF via GT as an alternative to CTF.

METHODS

Single-center, retrospective, and observational study of patients under 18 years old who underwent GT between 2014 and 2020. We reviewed demographics, anthropometrics, clinical characteristics, and types of diet and gastrointestinal (GI) symptoms over 12 months after the placement of the GT.

RESULTS

Forty patients (40% boys) were included. The median age at GT placement was 15 months (interquartile range 5-57.5). The most common underlying diagnosis was a neurological disorder (45%). In 75% of patients, Nissen fundoplication was performed. At the 12-month follow-up, 18 patients (45%) were receiving 100% HBTF, 14 (35%) were receiving a mixed diet (HBTF + CTF), four (10%) were receiving 100% CTF, and four (10%) were no longer using the GT. Those with a 100% HBTF diet showed a statistically significant higher weight at the 12-month follow-up than those who had received any percentage of CTF. No other statistically significant differences in anthropometric indices or GI symptoms were found between the two groups. Only three cases of mechanical complications were reported.

CONCLUSION

In our experience, using HBTF via the GT provides an alternative to CTF in pediatric patients who require enteral nutrition.

Use of blended feeds in children requiring tube feeding

AIM

The use of blended tube feeding (BTF) in children is a controversial area with persistent concerns regarding the nutritional adequacy and risk of associated infections and equipment complications. Parents in Australia are electing to use BTF in their children despite local hospital guidelines, calling for further research to support its use.

METHODS

A retrospective case-series study was conducted at a tertiary paediatric hospital, to characterise the paediatric population electively using BTF and evaluate their clinical outcomes. Demographic, anthropometric and clinical data were collected from pre-existing medical records.

RESULTS

Data from 178 clinical visits of 26 participants were included in analysis. The median age of participants was 4.1 years (range 7 months -14 years). BTF was most commonly used for symptom control (n = 8, 30.8%). The most common cause of clinical presentation during the use of BTF was respiratory conditions (number of presentations = 60, 47.2%). There was no reported increase in hospital presentations, gastrointestinal infections or equipment complications with the use of BTF. BTF did not promote weight gain in this population of children, particularly those who were already underweight.

CONCLUSION

This case-series found the use of BTF in a paediatric population with underlying complex medical conditions requiring enteral nutrition was driven by parental preference and the goals of symptomatic control. BTF did not demonstrate benefits of weight gain, though it was not associated with an increase in complications and hospital admission.

Clinical effects of pediatric commercial food-based formulas: A systematic review

Blenderized tube feeding (BTF) uses a feeding tube to deliver blended whole foods directly to the gastrointestinal (GI) system and has had renewed interest over the last two decades. This was initially delivered in the form of homemade BTF (HBTF) and led to the development of commercial food-based formula (CFBF). The safety and clinical outcome data for CFBF are limited. From our systematic review of the clinical benefits of pediatric CFBF, we found that families are very satisfied with CFBF despite the paucity of research. Most included studies evaluated both HBTF and CFBF, with only a few evaluating CFBF alone. The limited data suggests that CFBF may improve upper and lower GI symptoms such as nausea, vomiting, retching, constipation, and diarrhea; however, the effects of CFBF on growth have been mixed.

Attitudes of health and social care professionals towards the use of blended diets for enteral tube feeding for children and young people

Using a blended diet as an alternative to commercial formula is becoming more popular amongst parents and carers of children and young people (CYP) requiring long-term enteral tube feeding (ETF). Emerging evidence has demonstrated physiological and social benefits; however, families report feeling unsupported to use a blended diet in settings outside the home. This study aimed to explore the attitudes of health and social care staff towards the use of blended diets for CYP. Health and social care professionals with experience of blended diets were invited to partake in an online semi-structured qualitative interview. Thematic analysis was used to identify themes. Five participants from health, education and social care settings were interviewed. Online interviews worked effectively for data collection to allow flexibility to accommodate participants' care roles and avoid face-to-face contact necessary with Coronavirus disease 2019 restrictions. Three themes were identified in the data:• Change from medicalised enteral tube feeding practice.• Individual, person-centred approach.• Open support networks and responsibility.Findings showed that blended diets can be accommodated; however, barriers to implementation remain. Medicalisation of ETF continues to impair acceptance of blended diets whilst effective multi-disciplinary team communication and support facilitates its use in settings outside the home.

Blended diets for children and young people: applying the evidence to nursing practice

Enteral tube feeding is commonly used for children and young people with complex health and care needs. Blended diets are becoming more widely used and there is increasing evidence to show the benefits of a blended diet for children, young people and their families. This article aims to collate recent evidence on blended diets and describe the implications for nursing practice. Studies exploring blended diets have identified benefits such as improved gastrointestinal symptoms, positive engagement with families around food and mealtimes and the normalisation of enteral tube feeding. Research has also explored the nutritional and microbial content of food blends as well as the viscosity and risk of tube blockage. These are key considerations when supporting families to make informed decisions and use blended diets safely. Nurses play an important role in supporting the safe and effective use of blended diets as part of a wider multidisciplinary team. It is necessary that they have an understanding of the evidence underpinning nursing practice in this area.

Blenderized tube feeding in pediatrics - current evidence, guidelines, and considerations

PURPOSE OF REVIEW

Recently, blenderized tube feeding (BTF) consisting of blended whole food components is emerging as a preferred approach to enteral nutrition in pediatric patients. Differences in the nutritional profile, viscosity, and other characteristics between BTF and conventional tube feeding formulas may impact clinical outcomes and practice considerations.

RECENT FINDINGS

Increasing guidance and evidence are emerging for BTF in pediatric populations requiring tube feeding. The characteristics of each BTF formulation vary, which may affect patient tolerance and clinical outcome.

SUMMARY

BTF is safe and generally well tolerated in children. It is shown to improve symptoms, clinical outcomes, and quality of life for many patients. A thorough risk assessment and nuanced approach may be required to optimize BTF administration.

Systematic review: exploring outcomes of commercial and homemade blenderized tube-feeding regimens on feeding tolerance in pediatric patients

CONTEXT

Increasing numbers of patients and caregivers are requesting transition to blenderized tube feeding. There is a lack of systematic reviews addressing the outcomes of blenderized tube feeding.

OBJECTIVE

The aim was to evaluate the association of blenderized tube feeding on feeding tolerance in enterally fed pediatric patients.

DATA SOURCES

A literature search for articles from 2012-2022 using PubMed, Medline, Embase, and CINAHL yielded 78 articles.

DATA EXTRACTION

A description and evaluation of the study's sample, purpose, and results were summarized for 9 studies using the Academy of Nutrition and Dietetics Evidence Analysis Library Worksheet.

DATA ANALYSIS

Nine studies were evaluated using the Evidence Analysis Library Quality Criteria checklist.

CONCLUSIONS

Studies demonstrated an improvement in vomiting (n = 7), gagging/retching and heartburn (n = 6), abdominal pain/upset and distension (n = 3), and diarrhea (n = 6) with blenderized tube feeding. The outcomes of blenderized tube feeding on gas (n = 5) and constipation (n = 9) are variable and remain unclear.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42022369247.

Assessment of the risk of contamination of enteral nutrition bottles based on the simulation of home use conditions and hygiene procedures

BACKGROUND

Home-prepared enteral formulations are supplied to patients through enteral nutrition bottles, via a gravity bag or other container, which may be inadequately sanitized and reused more times than recommended by the manufacturer. Such procedures increase the risk of contamination and can compromise the patient's clinical outcome. In light of this, the present study aimed to assess the risk of contamination of enteral nutrition bottles by simulating home use conditions and hygiene procedures.

METHODS

A simulation of bottle usage was conducted across the three categories of enteral nutrition (homemade enteral preparations, blended enteral preparations, and commercial enteral formulas) for 3 days, using three hygiene procedures reported by caregivers: use of detergent (DET); use of detergent and boiling water (DET+BW); and use of detergent and bleach (DET+BL). The microbiological contamination was determined by the analysis of aerobic mesophilic microorganisms.

RESULTS

The bottles that were used for 3 days, regardless of the enteral nutrition category, were within the acceptable limit for aerobic mesophilic microorganisms (between <4 and 8.0 colony-forming units [CFU]/cm2) when sanitized using the DET+BW and DET+BL procedures. The enteral nutrition bottles, when cleaned using the DET procedure during the 3 days of usage, showed low microbial contamination (between <4 and 3.0 CFU/cm2) in blended preparation and commercial formula only.

CONCLUSION

Thus, regardless of the enteral nutrition category, we found that the bottles can be used for 3 days, as long as the DET+BW or DET+BL hygiene procedure is applied and safe food handling measures are adopted.

Safety, resource use and nutritional content of home-blended diets in children who are gastrostomy fed: findings from 'YourTube' - a prospective cohort study

OBJECTIVE

To assess the risks, benefits and resource implications of using home-blended food in children with gastrostomy tubes compared with currently recommended formula feeds.

DESIGN

This is a cohort study. Data were collected at months 0, 12 and 18 from parents and clinicians using standardised measures.

SETTING

32 sites across England: 28 National Health Service trusts and 4 children's hospices.

PATIENTS

Children aged 6 months-18 years who were gastrostomy fed.

MAIN OUTCOME MEASURE

The main outcome measure was the PedsQL Gastrointestinal Symptoms Scales score. Secondary outcomes included quality of life, sleep (child, parent), dietary intake, anthropometry, healthcare usage, safety outcomes and resource use.

RESULTS

180 children and families completed the baseline data collection, with 134 (74%) and 105 (58%) providing follow-up data at 12 and 18 months. There were fewer gastrointestinal (GI) symptoms at all time points in the home-blended diet group, but there was no difference in change over time within or between the groups. The nutritional intake of those on a home-blended diet had higher calories per kilogram and fibre, and both home-blended and formula-fed children have values above the dietary reference values for most micronutrients. Safety outcomes were similar between groups and over time. The total costs to the statutory sector were higher among children who were formula fed, but the costs of purchasing special equipment for home-blended food and the total time spent on childcare were higher for families with home-blended diet.

CONCLUSIONS

Children who are gastrostomy fed a home-blended diet have similar safety profile, adequate nutritional intake and lower burden of GI symptoms than formula-fed children. Trial registration number ISRCTN13977361.

Pediatric Formulas: An Update

The recent shortage of pediatric formulas in the United States, caused by supply chain issues and contamination of formula products in 1 of the major manufacturing plants, led many families to seek an alternate formula for their children. The Food and Drug Administration (FDA) allowed import of infant formulas from selected European and non-European countries. The European infant formulas differ from those produced in the United States regarding the primary source of the formula, age category, mixing instructions, labeling requirements, and formula composition in terms of macronutrients and micronutrients. Although most European infant formulas are nutritionally adequate, pediatricians and families need to be aware of the differences between the European and FDA-regulated formulas for their correct use and preparation for infants and young children. Supplementation with cow milk is recommended for children beyond infancy, and older infant formulas are not recommended for otherwise healthy growing children. However, pediatric formulas have been used to support the nutrition needs of children with feeding difficulties, especially those dependent on tube feeding and with certain medical conditions. The FDA does not regulate the production of pediatric formulas beyond infant formula, and significant variations exist in their composition. The pediatric formulas are available as polymeric (intact), hydrolyzed, elemental, or food-based blenderized formulas. The plant-based nonformula (milk) drinks are being used increasingly for children. These products might not be nutritionally complete and should be avoided in infants and children dependent on liquid nutrition.

'YourTube' the role of different diets in gastrostomy-fed children: Baseline findings from a prospective cohort study

AIM

To assess the risks, benefits, and resource implications of home-blended food for children with gastrostomy tubes compared with a formula diet.

METHOD

This prospective cohort study of children (aged 0-18 years) collected baseline data on gastrointestinal symptoms, nutritional intake, anthropometric outcomes, parent and child quality of life, and resource use. A propensity score-weighted generalized linear mixed model was used to compare children receiving a home-blended versus formula diet.

RESULTS

Baseline data were obtained for 180 children (2019-2021; 107 males, 73 females; mean age 9 years 7 months [SD  4 years 5 months]). Children receiving a home-blended diet (n  = 104) had similar diagnoses and age but more lived in areas of lower deprivation and parental education was higher compared to the parents of children receiving a formula diet (n  = 76). Children receiving home-blended diets had significantly better gastrointestinal scores than those receiving formula diets (B  = 13.8, p  < 0.001). The number of gut infections and tube blockages were similar between the two groups but with fewer stoma site infections in the group receiving home-blended food. Children receiving a home-blended diet had more fibre in their diet compared to children receiving a formula diet.

INTERPRETATION

Home-blended diets should be seen as a safe option for children who are gastrostomy-fed unless clinically contraindicated. Equality of access to home-blended diets for children with gastrostomy should be assessed by local clinical teams.

WHAT THIS PAPER ADDS

Children with gastrostomy receiving a home-blended diet had fewer gastrointestinal symptoms compared to children receiving a formula diet. Children with gastrostomy receiving a home-blended diet had no more complications than children receiving a formula diet.

Knowledge and clinical practice of ASPEN registered dietitian nutritionist members regarding blenderized tube feedings

BACKGROUND

Blenderized tube feedings (BTFs) are used by patients/caregivers who report improvements in gastrointestinal tolerance compared with standard commercial feedings. Despite positive outcomes, registered dietitian nutritionists or international equivalents (RDN/Is) hesitate to recommend BTFs. We aimed to determine if an association exists between dietitian characteristics and willingness to recommend BTFs.

METHODS

A BTF-specific survey (N = 157) assessed for validity and reliability was administered to the American Society for Parenteral and Enteral Nutrition (ASPEN) RDN/I members. Binary logistic regression analyses examined the association between age, years of clinical practice, BTF training/education, patient population served, and willingness to recommend BTFs.

RESULTS

The response rate was 4.3% of ASPEN RDN/I members. Most respondents were White females with a median age of 39.0 years and 12 years of clinical experience. Although 98.7% of respondents expressed a willingness to support and 73% to recommend BTFs, 60% were not using BTFs in clinical practice. For 94.8% of RDN/Is, the primary reason for BTF use was patient/caregiver requests. After adjustment for age and years of clinical practice, RDN/Is who served pediatric populations (odds ratio [OR] = 4.28; 95% CI, 1.52-12.09) or used three or more professional resources (OR = 2.49; 95% CI, 1.12-5.57), industry-sponsored resources (OR = 3.15; 95% CI, 1.39-7.15), or one or more experiential learning resources (OR = 3.14; 95% CI, 1.38-7.17) were more likely to recommend BTFs whereas those serving adults were less likely to recommend BTFs (OR = 0.33; 95% CI, 0.12-0.95).

CONCLUSION

Pediatric RDN/Is and individuals with BTF-specific education/training were more inclined to recommend BTFs.

Exploring parental thoughts and clinical experiences on blended food in a paediatric population, a qualitative study

Background

There's a growing interest in blended food (BF) as an alternative to commercial food (CF) for tube-fed children. Thus, we investigated parental and medical experiences with BF as an option for tube feeding in children.

Methods

In this cross-sectional study, all patients were already using BF, chosen by parents. In March 2022, all patients using BF provided consent and completed a questionnaire assessing their experiences. Medical data were collected retrospectively from patient charts, including biometric changes, dietary adjustments, and nutritional status. A non-validated parent satisfaction score was computed from 17 questions, rated on a scale from one to five. A score of ≥ 51 points, indicating an average score of > 3 per question, was deemed indicative of a positive parental experience with BF.

Results

Nine children receiving BF were identified (median age: 4.7 years; weight: 14.9 kg; 66% male). All parents were satisfied with BF, reflected in the parent satisfaction score. Parents cited reduced feeding-related discomforts as the main reason for switching to BF. Weight (+0.3 SD) and length (+0.5 SD) showed positive changes. None discontinued BF, though modifications were made for five patients by the dietician. Nutritional deficiencies, mainly iron with or without zinc deficiency, were observed in four patients, with uncertain onset due to lack of pre-BF laboratory testing.

Conclusions

In this small BF cohort overseen by an experienced multidisciplinary team, BF was well tolerated, resulting in high parental satisfaction and maintaining good nutritional status.

Clinical outcomes associated with blenderized tube feedings in adults: A systematic review

Nearly half a million individuals in the United States are dependent on enteral nutrition to meet their nutrition needs. Public interest in blenderized tube feeding (BTF) has increased over the past decade; however, medical professionals indicate a lack of knowledge about these products and their effects. The purpose of this review is to analyze clinical outcomes in adults who use a BTF formula as their primary nutrition source. A literature search was conducted in PubMed, Scopus, and CINAHL using search terms "adult," "enteral nutrition," "tube feeding," "BTF," blenderized," "blended," "homemade," and "pureed." Nine studies met the inclusion criteria and were analyzed in the review. Under close monitoring, BTF does not pose a higher risk for deterioration in anthropometric measurements. Furthermore, BTF use is consistently associated with improvements in diarrhea. As such, clinicians should consider the use of these formulas in the acute care or rehabilitation settings. Additional research is needed in patients with diverse clinical backgrounds in free-living communities. Larger populations sizes and longer intervention time frames are crucial to providing statistically significant results needed to strengthen the quality of evidence on this topic.

Blenderized food tube feeding in very young pediatric patients with special healthcare needs

BACKGROUND

Up to 85% of children with severe developmental disabilities have feeding disorders and require enteral tube feeding. Many caregivers desire blenderized tube feeding (BTF) instead of commercial formula (CF) for their child, citing a desire for a more physiologic feeding, to reduce gastrointestinal (GI) symptoms and/or promote oral intake.

METHODS

In this retrospective, single-center study, medical records (n = 34) of very young children (aged ≤36 months) with severe developmental disabilities were reviewed. Comparisons of growth parameters, GI symptoms, oral feeding, and GI medication use were made between the initial introduction of BTF and again at the last patient encounter when the children aged out of the program.

RESULTS

Of the 34 charts reviewed (16 male and 18 female patients), comparisons between baseline BTF introduction and the last patient encounter indicated reductions in adverse GI symptoms, significant GI medication reduction (P = 0.000), increased oral food intake, and nonsignificant improvements in growth parameters. These positive outcomes were realized whether children received full or partial BTF or type of BTF formulation.

CONCLUSION

Consistent with similar research studies, transitioning very young children with significant special healthcare needs from CF to BTF resulted in improvement in GI symptoms, reduced need for GI medications, supported growth goals, and contributed to improved oral feeding.

Experiences and perceptions of multidisciplinary paediatric teams of blended tube feeding in children

Background: Blended tube feeding (BTF) is the administration of pureed whole foods via gastric feeding tubes. There is some evidence to suggest that BTF may have clinical and psychosocial benefits when compared to commercial formula, but further investigation of how BTF is understood and recommended by health professionals is needed. This study aims to investigate awareness and knowledge of BTF among multi-disciplinary paediatric staff in Ireland. Methods: A cross-sectional observational study was conducted among paediatric staff in Children's Health Ireland (CHI). The 16-item anonymous online survey gathered information on awareness of BTF, willingness to recommend BTF, confidence in BTF knowledge, and self-assessed competence in managing BTF. Results: Of the 207 responses, doctors (n68), nurses (n66), and dietitians (n32) provided 80.3% of responses. Two-thirds (n136, 66%) of the total group were aware of BTF. Of these, 68.1% had cared for a child on BTF and 70% (n = 63/90) were willing to recommend BTF. Three in five (n = 39/63, 61.9%) stated they were somewhat confident in their BTF knowledge and one in five (n = 12/56, 21.4%) were not yet competent in managing children on BTF. The most common reasons for recommending BTF were parental desire (n17, 39.5%) and commercial formula intolerance (n15, 34.9%). The most common barrier to recommending BTF was family logistics (n18, 41.9%). The most valuable sources of information on BTF for two-thirds (68.3%) of participants were other healthcare professionals (HCPs) and patients/caregivers. Conclusion: Healthcare settings should provide evidence-based training to HCPs on BTF to optimise the treatment and safety of children under their care.

Blended feeding in gastrostomy-fed children-A scoping review

BACKGROUND

Blended feeding has become increasingly prevalent in recent years with its practice gaining some momentum. With anecdotal reports of benefits and little evidence of harm in the literature regarding blended feeding, this scoping review was deemed important. The aim of this scoping review was to summarise the published evidence about blended feeding in gastrostomy-fed children.

METHOD

The scoping review methodology used included searches in specific online databases: PUBMED, PsychINFO, CINAHL, SCOPUS, AMED and EMBASE for articles that addressed issues pertaining to blended feeds in gastrostomy-fed children. Grey literature was also considered. Inclusion criteria included papers that pertained to information and research on blended feeding in gastrostomy-fed children. Studies published in English over the past 11 years (2011-2022) were included. This resulted in 59 papers being included in this scoping review.

RESULTS

Thematic analysis of the literature identified eight overall themes. It was clear that parents found blended feeding promoted the normalising of feeding, their own involvement in decision-making around foods and promotion of a socially inclusive mealtime. The need for dietician and health professional input and support is key, whereas a lack of guidelines acts as a barrier to blended feeding. Furthermore, risks associated with blended feeding are identified but also the benefits to the physical well-being of the child are considered.

CONCLUSION

The review was comprehensive in that it identified a broad range of literature, exploring the extent, range and nature of research activity related to the use of blended feeds. The lack of original research is a concern. However, it is expected this review will provide direction for researchers, and in particular inform policy and practitioners working in the field where blended feeds may be an option for gastrostomy-fed children.

Blended diets for tube-fed children and young people: a rapid review update

BACKGROUND

Many children and young people with complex health and care needs use enteral feeding tubes to optimise their nutritional intake in the UK and other countries. Blended diets as an alternative to the exclusive use of commercial formula are becoming more commonly used, and there is evidence to support the benefits of using a blended diet on the child or young person and their wider family.A rapid review was published in 2017 exploring blended diets as a valid alternative to commercial formula for enteral feeding for children and young people. An update was necessary to ensure that professional practice is informed by the latest evidence, which has expanded significantly since the publication of the original article.

METHODS

A rapid review method was used and the PRISMA checklist formed the basis of the protocol devised ahead of data collection. Key databases included: PubMed, MEDLINE, CINAHL, PsychINFO, Google Scholar.

RESULTS

29 articles were included and four themes were identified from the collated data. (1) Symptom improvement and clinical outcomes, (2) nutritional content, (3) caregiver experiences and (4) blended diet practices. Findings showed that blended diets can have a positive impact on physical symptoms as well as social influences extending to families and carers.

CONCLUSION

Nutritional content, food hygiene and viscosity of food blends are important considerations for professionals and families to ensure safe practice when using blended diets for enteral feeding.

Clinical guideline highlights for the hospitalist: The use of blended diets in children with enteral feeding tubes

GUIDELINE TITLE

The Use of Blended Diets in Children With Enteral Feeding Tubes: A Joint Position Paper of the ESPGHAN Committees of Allied Health Professionals and Nutrition RELEASE DATE: January 1, 2023 PRIOR VERSION(S): n/a DEVELOPER: ESPGHAN Committees of Allied Health Professionals and Nutrition FUNDING SOURCE: ESPGHAN Committees of Allied Health Professionals and Nutrition TARGET POPULATION: Pediatricians, Pediatric Hospitalist.

Nutritional and feeding challenges in aerodigestive patients

PURPOSE OF REVIEW

Aerodigestive disorders encompass conditions that affect both the airway and gastrointestinal tract. These include conditions such as acquired and congenital defects of the airway and esophagus as well as neuromuscular disorders. Patients often suffer from dysphagia, aspiration, and respiratory disorders. This article will provide a review of current practices in the management of feeding disorders, oropharyngeal dysphagia, and nutritional support in the aerodigestive population.

RECENT FINDINGS

Oral aversion, aspiration, and feeding-tube dependence are all commonly encountered problems in the aerodigestive population. Intensive inpatient and outpatient programs along with use of appetite stimulants and psychotropic medications may help to improve feeding-related disorders. Aspiration affects many patients and requires close monitoring of clinical symptoms along with routine assessment with video fluoroscopy. Developments in blenderized feeds and formula supplementation have also provided new options for patients with feeding intolerance.

SUMMARY

Patients with aerodigestive disorders require complex medical care, and multidisciplinary teams are the most effective in addressing their medical needs. Advances in feeding, occupational, and pharmacologic therapy have allowed healthcare providers to better address the needs of these patients.

Homemade blenderized tube feeding improves gut microbiome communities in children with enteral nutrition

Enteral nutrition for children is supplied through nasogastric or gastrostomy tubes. Diet not only influences nutritional intake but also interacts with the composition and function of the gut microbiota. Homemade blenderized tube feeding has been administered to children receiving enteral nutrition, in addition to ready-made tube feeding. The purpose of this study was to evaluate the oral/gut microbial communities in children receiving enteral nutrition with or without homemade blenderized tube feeding. Among a total of 30 children, 6 receiving mainly ready-made tube feeding (RTF) and 5 receiving mainly homemade blenderized tube feeding (HBTF) were analyzed in this study. Oral and gut microbiota community profiles were evaluated through 16S rRNA sequencing of saliva and fecal samples. The α-diversity representing the number of observed features, Shannon index, and Chao1 in the gut were significantly increased in HBTF only in the gut microbiome but not in the oral microbiome. In addition, the relative abundances of the phylum Proteobacteria, class Gammaproteobacteria, and genus Escherichia-Shigella were significantly low, whereas that of the genus Ruminococcus was significantly high in the gut of children with HBTF, indicating HBTF altered the gut microbial composition and reducing health risks. Metagenome prediction showed enrichment of carbon fixation pathways in prokaryotes at oral and gut microbiomes in children receiving HBTF. In addition, more complex network structures were observed in the oral cavity and gut in the HBTF group than in the RTF group. In conclusion, HBTF not only provides satisfaction and enjoyment during meals with the family but also alters the gut microbial composition to a healthy state.

Blended diet for enteral tube feeding in young people: A systematic review of the benefits and complications

BACKGROUND

Interest and use of blended diets (BD) for young people who are tube fed has significantly increased in the last decade, driven primarily by the desires of motivated caregivers. This review identified, appraised and synthesised the available evidence on the benefits and complications of BD versus commercial feeds.

METHODS

A systematic review following PRISMA guidance and registered with PROSPERO was conducted across PubMed, Embase, CINAHL, Scopus and Cochrane up to August 2022.

INCLUSION CRITERIA

English language studies including (1) children, (2) original research (interventional and observational) and (3) examination of BD outcomes. Exclusion criteria were (1) unoriginal research or case reports, (2) focus on feeding management, preparations or attitudes and (3) comparing commercial blends only. Data were synthesised using an established narrative synthesis approach using the Mixed Methods Appraisal Tool.

RESULTS

Eight hundred and six database results were identified and 61 were sought for retrieval. A full-text article review revealed seven eligible studies, involving 267 participants (age range 9 months to 26 years). Studies reported differences in gastrointestinal symptoms (n = 222), medication use (n = 119), growth (n = 189) and complications or adverse events (n = 91). The results indicate positive outcomes, particularly in gastrointestinal symptom control, with few reports of mild adverse events in the included studies.

CONCLUSIONS

There is a paucity of data in this area and much heterogeneity in the included studies, but the available literature points towards positive outcomes. This is an important and highly relevant topic, and more primary research, ideally using standardised reporting, is required to answer the key questions.

Effect of blenderized tube feeds on gastric emptying: A retrospective cohort study

BACKGROUND

Blenderized tube feeds (blends) are associated with lower hospital admissions and reduced gastroesophageal symptoms, but their high viscosity may theoretically prolong gastric emptying. Our objective was to compare differences in gastric emptying with blends vs with formula.

METHODS

We retrospectively identified individuals 6 months to 20 years with enteral tubes who underwent 1-h liquid gastric emptying scintigraphy from 1998 to 2020 at Boston Children's Hospital. Examinations were excluded if a postpyloric tube was present, tracer was administered orally or with diet differing from habitual, habitual diet was indeterminable, imaging was terminated early, or >50% of input counts emptied during bolus administration. Emptying was classified as delayed if gastric residual at 1 h was ≥60% of ingested dose.

RESULTS

Eighteen examinations (15 individuals) were performed with blends and 35 examinations (32 individuals) with formula. Although percentage of residual at 1 h was significantly higher in patients receiving blends compared with formula (54 ± 17 vs 40 ± 25, P = 0.04), the number of patients with delayed gastric emptying did not differ (39% vs 29%, respectively, P = 0.54). Type of diet, feed volume or concurrent medications did not predict delayed gastric emptying. Children with blends received higher bolus volumes (106 ± 55 vs 66 ± 59 ml; P = 0.02), and this significantly predicted percentage of residual (β = 0.14; P = 0.01).

CONCLUSION

The proportion of patients with delayed gastric emptying was similar in children receiving blends and formula. Although the mean percentage of gastric residual was higher with blends, this may be explained by higher bolus volumes administered. This preliminary work suggests that blends compare favorably to formula.

Gut dysmotility in children with neurological impairment: the nutritional management

Intestinal motility disorders represent a frequent problem in children with neurological impairment. These conditions are characterized by abnormal movements of the gut, which can result in symptoms such as constipation, diarrhea, reflux, and vomiting. The underlying mechanisms leading to dysmotility are various, and the clinical manifestations are often nonspecific. Nutritional management is an important aspect of care for children with gut dysmotility, as it can help to improve their quality of life. Oral feeding, when safe and in the absence of risk of ingestion or severe dysphagia, should always be encouraged. When oral nutrition is insufficient or potentially harmful, it is necessary to switch to an enteral by tube or parenteral nutrition before the onset of malnutrition. In most cases, children with severe gut dysmotility may require feeding via a permanent gastrostomy tube to ensure adequate nutrition and hydration. Drugs may be necessary to help manage gut dysmotility, such as laxatives, anticholinergics and prokinetic agents. Nutritional management of patients with neurological impairment often requires an individualized care plan to optimize growth and nutrition and to improve overall health outcomes. This review tries to sum up most significant neurogenetic and neurometabolic disorders associated with gut dysmotility that may require a specific multidisciplinary care, identifying a proposal of nutritional and medical management.

Pediatric formulas: Categories, composition, and considerations

Formulas, liquid nutrition, may be consumed orally or via a feeding tube to provide partial or complete nutrition that a given individual could not obtain using natural food stuffs in their native form. A wide range of commercially available formulas exist, which may be used as sole-source nutrition or in conjunction with other foods. Physicians and dietitians must understand the nature of and indications for specific formulas to treat diseases, provide complete nutrition to patients, and avoid harm. Products vary in macronutrient and micronutrient content and calorie concentration among many other factors. They are formulated specifically for patients of specific ages, correlating to nutritional needs and medical diagnoses. Additionally, formula availability, insurance coverage, mode of consumption, physiologic tolerance, and caregiver preference influence formula selection. Caregivers may also make their own pediatric formulas. We review commercial and homemade pediatric formulas.

Comparison of Home-Blenderized Formula and Commercial Enteral Formulas for Gastrostomy Tube-Fed Children: A Retrospective, Prospective Cohort Study

Background Blenderized gastrostomy tube feedings (BGTFs) consist of pureed table foods and liquids that are administered as enteral tube feedings. Compared to commercial enteral formulas (CEFs), BGTF has been shown to have fewer side effects. Despite these results, apprehensions have been raised about microbial contamination, nutritional deficiencies or surplus, risk of gastrostomy tube (GT) blockages, and lack of consistency in clinical outcomes. The goal of this retrospective, prospective, 18-month-long study is to report the clinical and nutritional outcomes of GT-dependent pediatric patients who attended a multidisciplinary feeding clinic. Methodology After Institutional Review Board (IRB) approval and consent were obtained, 25 children who were receiving tube feeding via G were enrolled in a retrospective, prospective, observational, cohort study from August 2019 to February 2021. A multidisciplinary team was formed, and multivariate logistic regression was performed comparing subjects on BGTF versus CEF, per os diet versus nil per os, CEF versus homemade blenderized tube feeding (HBTF) versus blenderized tube feeding (BTF), and how they compared at the beginning and end of the study. Results The mean age of the patients was 4.4 years (SD ±2.2). Gastroesophageal reflux disease (GERD) and short bowel syndrome (SBS) were the most common comorbid gastrointestinal (GI) conditions. Of the 25 patients enrolled in the study, seven were initially on BGTF, while 14 ended the study on BGTF. There were no statistically significant differences in malnutrition status, feeding intolerance, emergency room visits, hospitalizations, and GT blockages between all different comparison groups when comparing between the CEF versus HBTF versus commercial blenderized tube feeding (CBTF) groups. Of the patients who were in the BGTF group, there was a resolution of vitamin A deficiency, vitamin D deficiency, and anemia (n = 1). In total, two patients had resolved vitamin deficiencies, namely, vitamins A and D. Conclusions When comparing BGTF and CEF, there was no statistically significant difference in outcomes. This study suggests that BGTF is at least equivalent to CEF in clinical outcomes, meaning BGTF should be considered standard nutrition for GT-dependent patients.

Gastrointestinal factors associated with risk of bronchiectasis in children

OBJECTIVE

To evaluate gastrointestinal (GI) risk factors for bronchiectasis in children. We hypothesized that upper GI tract dysmotility would be associated with increased risk of bronchiectasis.

STUDY DESIGN

Subjects in this retrospective cohort study included those evaluated for persistent pulmonary symptoms in the Aerodigestive Center at Boston Children's Hospital who underwent chest computed tomography (CT) between 2002 and 2019. To determine gastrointestinal predictors of bronchiectasis, baseline characteristics, comorbidities, enteral tube status, medications received, gastroesophageal reflux burden, adequacy of swallow function, esophageal dysmotility, gastric dysmotility, and neutrophil count on bronchoalveolar lavage (BAL) were compared between patients with and without bronchiectasis. Proportions were compared with Fisher's exact test and binary logistic regression with stepwise selection was used for multivariate analysis. ROC analyses were utilized to compare BAL neutrophils and bronchiectasis.

RESULTS

Of 192 subjects, 24% were found to have evidence of bronchiectasis on chest CT at age 7.9 ± 0.5 years. Enteral tubes (OR 5.77, 95% CI 2.25-14.83, p < 0.001) and increased BAL neutrophil count (OR 5.79, 95% CI 1.87-17.94, p = 0.002) were associated with increased risk while neurologic comorbidities were associated with decreased risk (OR 0.24, 95% CI 0.09-0.66, p = 0.006). Gastroesophageal reflux was not found to be a significant risk factor. Neutrophil counts >10% had 72% sensitivity and 60% specificity for identifying bronchiectasis.

CONCLUSIONS

Enteral tubes were associated with significantly increased risk of bronchiectasis but gastroesophageal reflux was not. Providers should consider obtaining chest CT to evaluate for bronchiectasis in children found to have unexplained elevated BAL neutrophil count.

Gastroesophageal Reflux Treatment in Infancy Through Young Adulthood

Gastroesophageal reflux treatment varies greatly across the pediatric age spectrum. Infant reflux treatments rely heavily on nutritional interventions, whereas reflux in older children is treated more commonly with medications. However, because of the broad differential diagnosis, treatment nonresponse merits a re-evaluation of the diagnosis being treated and additional testing to provide a more precision-medicine approach to care.

The Impact of Blenderized Tube Feeding on Gastrointestinal Symptoms, a Scoping Review

Severe gastrointestinal symptoms are one of the main reasons for switching from conventional artificial tube feeding to blenderized tube feeding (BTF). This study aimed to describe and quantify the impact of BTF on gastrointestinal symptoms in children and adults. We analyzed four databases (PubMed, Scopus, Cochrane Library, and Google Scholar). The review was performed following the PRISMA extension for Scoping Reviews checklist. The methodological quality of articles was assessed following the NIH quality assessment tools. The initial search yielded 535 articles and, after removing duplicates and off-topic articles, 12 met the inclusion criteria. All included papers unanimously converged in defining an improvement of gastrointestinal symptoms during blenderized feeding: the eight studies involving pediatric cohorts report a decrease from 30 to over 50% in gagging and retching after commencing BTF. Similar rates are reported for constipation and diarrhea improvement in most critically ill adults. Experimental studies and particularly randomized controlled trials are needed to develop robust evidence on the effectiveness of BTF in gastrointestinal symptom improvement with prolonged follow-up and adequate medical monitoring.

Neurological impairment and malnutrition in children: The role of home enteral nutrition in real life

Objective

Recent decades have brought an increased survival of children with Neurologic Impairment (NI) but malnutrition and digestive comorbidity remain important challenges to face. We designed the present study to assess the course of nutritional status following standardized Home Enteral Nutrition (HEN) program and to evaluate impact of changing mode of feeding, as a part of overall multidisciplinary management, on digestive co-morbidity as Gastro-Esophageal Reflux Disease (GERD), Oropharyngeal Dysphagia (OPD), constipation and airway aspiration.

Methods

We performed a retrospective analysis on NI children entered into Institutional HEN program due to NI disorders between January 2011 and 2019. Demographic, anthropometric characteristics (BMI z-score and weight for age z-score) and symptoms (GERD, OPD constipation and airway aspiration) were collected at the enrolment and during the follow up.

Results

We enrolled 402 patients (median age: 39 months); overall survival was 97%. Nutritional status was significantly improved by HEN; in particular growth profile significantly changed within the first 2 years following HEN beginning; GERD and airways aspirations decreased after HEN beginning. Constipation and OPD remained unchanged over time.

Conclusions

Malnutrition and digestive complaints are distinctive features of NI children. Nutritional status improve after 2 years from the beginning of standardized nutritional interventions. Overall multidisciplinary care, including standardized HEN protocols, seems to also impact on GERD and airway aspirations, which can decrease over time. It is possible that constipation and OPD, unchanged over time, are more dependent on underlying diseases than on overall treatments.

The Use of Blended Diets in Children With Enteral Feeding Tubes: A Joint Position Paper of the ESPGHAN Committees of Allied Health Professionals and Nutrition

OBJECTIVES

This joint position paper of the Committees of Allied Health Professionals (CAHP) and Nutrition (CON) of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) provides a comprehensive guide for health professionals to manage blended diets in children via gastrostomy tubes.

METHODS

A systematic literature search was performed from 1992 to 2021 using Pubmed, MEDLINE, and Cochrane Database of Systematic Reviews and recent guidelines reviewed. In the absence of evidence, recommendations reflect the authors' expert opinion. Final consensus was obtained by multiple e-mail exchange and virtual meetings of the CAHP and CON.

RESULTS

Reported benefits of blended diets include reduced GERD and infections, improved defecation, level of alertness and attention span, skin conditions, and appearance of hair and nails. Families report a sense of greater normality. Small case series, cross-sectional surveys, questionnaire-based small case studies, reports of personal experience, and single-center pilot studies are available in the medical literature. A total of 20 recommendations for practice were made based on the results and consensus process.

CONCLUSIONS

There is little evidence published to formally inform about the potential health benefits or risks of this practice and how to use it in the best way. This leaves health professionals caring for such patients in a relative vacuum regarding what to consider when providing a duty of care to patients and carers who wish to pursue this method of feeding. This article provides guidelines for safe and appropriate use of a BD, but more research is needed.

Feeding children with neurodisability: challenges and practicalities

Nutritional management for children with neurodisability can be challenging and there are an increasing number of children at risk of malnutrition. Management involves healthcare professionals in community and hospital working together with the family with the aim of optimising nutrition and quality of life. Feeding difficulties can be the result of physical causes like lack of oromotor coordination, discomfort associated with reflux oesophagitis or gastrointestinal dysmotility. Non-physical causes include parental/professional views towards feeding, altered perception of pain and discomfort, extreme sensitivity to certain textures and rigidity of feeding schedule associated with artificial feeding. Estimating nutritional needs can be difficult and is affected by comorbidities including epilepsy and abnormal movements, severity of disability and mobility. Defining malnutrition is difficult as children with neurodisability reflect a wide spectrum with disparate growth patterns and body composition and auxology is less reliable and less reproducible. Management involves selecting the type and method of feeding best suited for the patient. As artificial feeding can place a significant burden of care any decision-making should be, as much as possible, in concurrence with the family. Symptom management sometimes requires pharmacological interventions, but polypharmacy is best avoided. The article aims to discuss the pathways of identifying children at risk of malnutrition and available management options with a strong emphasis on working as a clinical team with the child and family.

An observational investigation of the faical microbiota and metabonome of gastrostomy fed children, on blended and formula diets

Gastrostomy fed children traditionally have a Formulae diet (FD), which fulfills nutritional requirements; however, many families are adopting Blended diets (BD), which are what the whole family would eat. We undertook an observational investigation of the colonic microbiota and metabonome in a small group of gastrostomy fed children, who were either on an FD or BD, and compared, where possible to their siblings (17 FD, 28 BD, 19 HS). There was no increase in complications in tube blockage or infection rates, but a significant improvement in the prevalence of bowel problems, a reduction in medication and an increase in quality of life. Metataxonomic analysis showed that the FD group was significantly different to the Sibling group, and that families did not cluster together. Whole sample metabonomics showed no differences between groups; however, univariate analysis of biologically important metabolites did differ. Changing to a BD resulted in no increase in complications or risks, but improved the overall quality of life for the children and families.

Nutrition and preparation of blenderized tube feeding in children and adolescents with neurological impairment: A scoping review

BACKGROUND

The use of homemade tube feeding formula has become increasingly popular for children requiring enteral nutrition. This project aimed to investigate nutrition and preparation of blenderized tube feeding in the field of children and adolescents with neurological impairment.

METHODS

A scoping review was performed using established methodologies. In January 2021, we searched PubMed, Embase, CINAHL Complete, the Cochrane Central Register of Controlled Trials, and gray literature to identify relevant articles.

MAJOR FINDINGS

Twenty-two papers were included describing the composition of food items, preparation procedures, and food safety. No randomized controlled trials and only a few prospective studies were included. A broad variety of food items from all food groups and many examples of recipes were presented. Most recipes provided 1.0 kcal/ml but tended to contain less energy and nutrients than expected, which could be due to preparation issues, such as sieving and the high viscosity of the blend. Preparation requires a commercial-grade household blender and diligence to ensure thorough household hygiene for adequate food safety.

CONCLUSIONS

This review revealed practical experience in the nutrition and preparation aspects of blenderized tube feeding but minimal empirical evidence. Multiple examples of the composition of food items and preparation procedures for blenderized tube feeding were found, but uncertainty regarding the ideal composition or preparation was also exposed. The future of blenderized tube feeding would benefit from clinically tested recipes that include an evaluation of nutrients, viscosity, and microbial contamination, as well as the effect of the food's appearance and scent on the target group.

Blenderised Tube Feeds vs. Commercial Formula: Which Is Better for Gastrostomy-Fed Children?

Blenderised tube feeds (BTF) have become a popular alternative to commercial formula (CF) for enterally fed children. This study sought to compare gastrointestinal (GI) symptoms, GI inflammation, and stool microbiome composition between children receiving BTF or CF. This prospective cohort study involved 41 gastrostomy-fed children, aged 2–18 years, receiving either BTF (n = 21) or CF (n = 20). The Paediatric Quality of Life Inventory Gastrointestinal Symptoms Scale (GI-PedsQL) was used to compare GI symptoms between the groups. Anthropometric data, nutritional intake, nutritional blood markers, faecal calprotectin levels, stool microbiota, and parental satisfaction with feeding regimen were also assessed. Caregivers of children on BTF reported greater GI-PedsQL scores indicating significantly fewer GI symptoms (74.7 vs. 50.125, p = 0.004). Faecal calprotectin levels were significantly lower for children receiving BTF compared to children on CF (33.3 mg/kg vs. 72.3 mg/kg, p = 0.043) and the BTF group had healthier, more diverse gut microbiota. Subgroup analysis found that 25% of caloric intake from BTF was sufficient to improve GI symptoms. The CF group had better body mass index (BMI) z-scores (−0.7 vs. 0.5, p = 0.040). Although growth was poorer in children receiving only BTF in comparison to the CF group, this was not seen in children receiving partial BTF. A combination of BTF and CF use may minimise symptoms of tube feeding whilst supporting growth.

Stir, Shake or Blend: A Comparison of Methods Used to Reduce Viscosity of Blenderized Tube Feedings

Blenderized tube feeding (BTF) refers to formula composed of whole foods and purees, blended to a consistency that can be administered through an enteral feeding device. BTFs have a higher viscosity than conventional enteral formulas and may be mixed with extra liquid to aid in administration via an enteral feeding device. This study compared changes in viscosity of commercially available BTF s when stirred, shaken, or blenderized. The International Dysphagia Diet Standardisation Initiative flow test was used to provide an objective level of viscosity. Our results indicate that the method chosen to thin BTFs results in significant differences in viscosity and varies depending on the percent of water by volume added to the formula as well as the presence of additional non-food ingredients such as synthetic supplements. We conclude that the method used to thin BTFs should be taken into account when a consistent viscosity level is desired.

Clinical Usefulness of Blenderized Food for Selenium Deficiency in Pediatric Patients with Severe Motor and Intellectual Disabilities

INTRODUCTION

This study aimed to assess the preventive or therapeutic effects of blenderized food (BF) on selenium deficiency in pediatric patients with severe motor and intellectual disabilities (SMID).

METHODS

The medical records of all 40 consecutive pediatric patients with SMID who underwent nutritional assessment were retrospectively reviewed and compared between two groups: the enteral formula (EF) group and the BF group fed with BF providing more than 10% of total caloric intake. Next, for the selenium-deficient patients who were newly started on blenderized tube feeds after the first nutritional assessment, improvement of selenium deficiency and change of dietary contents were assessed.

RESULTS

The BF group patients had a significantly lower prevalence of selenium deficiency and higher serum selenium levels than the EF group patients. In all 7 selenium-deficient patients who started blenderized tube feeds after the first nutritional assessment, serum selenium levels were significantly increased at the second nutritional assessment, even though total selenium intake, selenium intake by EF, and total caloric intake did not differ significantly, and, in fact, caloric intake was significantly decreased by EF.

CONCLUSION

Combined feeding of BFs can be useful for prevention and therapy of selenium deficiency in pediatric SMID patients.

Blenderized enteral nutrition in pediatric short gut syndrome: Tolerance and clinical outcomes

BACKGROUND

Blenderized feeds consisting of whole food components are emerging as a preferred approach to enteral nutrition. However, there is limited evidence-based guidance for this strategy in short bowel syndrome (SBS). We aimed to explore the tolerance and clinical outcome of blenderized feeds in patients with SBS.

METHOD

We conducted a single-center, retrospective study of blenderized feeds in pediatric SBS. Of the 376 patients screened, 58 met inclusion criteria. Three patients were excluded because of a history of bowel transplant. Demographics, clinical history, and nutrition history were collected and analyzed.

RESULT

Patients had improved diarrhea though worsening gas while receiving blenderized feeds. There was no significant difference in small bowel length in patients who discontinued blends compared with those who continued. However, patients with colonic resection were more likely to discontinue the blends. In a subgroup of patients who lost weight despite improved diarrhea (n = 19), most had a history of ileocecal valve (ICV) and colonic resection, but no difference in small bowel length compared with those who did not lose weight.

CONCLUSION

Our cohort of patients with SBS experienced improved gastrointestinal symptoms and stool quality on blenderized feeds. Patients without an ICV and with colonic resection were more prone to weight loss. Stepwise titration of blenderized formula with previous formula regimen may be needed in a subset of patients to optimize tolerance and weight gain. Further study is warranted to understand factors contributing to variable tolerance and weight gain on blenderized formulas to guide their use in patients with SBS.

YouTube as a Source of Information on Blenderised Tube Feeding

Blenderised tube feeding (BTF) has become an increasingly popular method of nutrition support for long-term tube-fed patients mostly children. This study surveyed perceptions and experiences on BTF shared on YouTube. From 71 videos analysed, attitudes towards BTF were mostly positive (91%) and included psychosocial benefits and improvements in gastrointestinal symptoms; no differences between caregivers and healthcare professionals were observed. Very few speakers (8%) felt there was a lack of support regarding use of BTF in schools and from healthcare professionals, because it is not part of the standard clinical management protocols. The most commonly used food items in blends included carrots (n = 16) and chicken (n = 11), and experiences from those who have used BTF included tips on recipes for blends, storing feeds and ensuring nutritional adequacy. Analysis of YouTube content on BTF was considerably positive and suggests that BTF is feasible and safe way to provide nutrition to tube-fed patients.

Low risk for microbial contamination of syringe and tube feeding bag surfaces after multiple reuses with home blenderized tube feeding

BACKGROUND

Guidelines for the reuse of enteral tube feeding (ETF) equipment guidelines are limited to manufacturer recommendations. ETF equipment reuse studies are needed as the enteral population has increased, along with blenderized tube feeding (BTF).

METHODS

This experiment tested microbial contamination of a reusable gravity feeding bag and syringe after 15 BTF reuses and cleanings. Eight bags and syringes were filled with the BTF, held at room temperature for 20 min, and then emptied, washed, and air dried. After the last air drying, the inner surfaces of the bag and syringe were swabbed, and aerobic microbial counts were performed using serial dilutions and plate counts.

RESULTS

The microbial counts for all syringes and six bags were <1 colony-forming unit (CFU)/cm² ; one bag was <5 CFU/cm² and one bag was 12.5 CFU/cm² . No legal guidelines for surface cleanliness exist for the food sector. Several studies propose a safe microbial level to be <2.5 CFU/cm² , and the European Commission recommended <10 CFU/cm² . Based on these proposed guidelines, microbial counts of all syringes and seven bags were within the proposed guidelines, except for one bag just above 10 CFU/cm² .

CONCLUSION

The feeding bag used in this study may be used multiple times for BTF with a reduced risk of microbial contamination when manufacturer's cleaning guidelines are followed. Although bolus tube feeding is an off-label use for syringes, they are frequently used for BTF, and in this study the cleaning after 15 uses over 5 days was effective to reduce microbial counts.

Effect of Added Free Water to Enteral Tube Feeds in Children Receiving Commercial Blends

OBJECTIVES

To determine the impact of free water administration on clinical outcomes in medically complex patients, based on the hypothesis that patients receiving more thin liquids have worse outcomes related to increased risk of gastroesophageal reflux.

METHODS

This was a retrospective chart review of children initiated on commercial blenderized tube feedings from 2010 to 2019. The percentage of gastrostomy intake that was a thin liquid was determined, with thin liquids including free water or thin formula based on the International Dysphagia Diet Standardization Initiative (IDDSI) framework. Patients were categorized into those receiving low volumes of thin liquids ("percent thin" ≤20%) and those receiving higher volumes ("percent thin" >20%). Emergency room visits, hospital admissions, and chest X-rays during the year after starting the blend were compared.

RESULTS

Forty-five patients age 12 months to 18.7 years (median 3.7 years) were included. Twenty patients (44%) were receiving a blend with an IDDSI-categorized thin consistency and 25 patients (56%) were receiving a thicker blend. In addition to the blend, patients received a median of 320 mL per day of water (range 0-1000 mL). Patients receiving <20% thin liquids were less likely to undergo chest X-rays during follow-up than patients receiving larger amounts of thin liquids (10% in the minimal thin group versus 48% in the greater thin group, P = 0.03). In a multivariable logistic regression, this relationship remained significant after controlling for underlying pulmonary disease, aspiration, method of feed administration (bolus or continuous feeds), fundoplication status, and oral intake status.

CONCLUSIONS

Our study demonstrates that patients on blenderized tube feeds receive widely variable amounts of added thin liquids, like water. The addition of water to tube feeds, while typically given for hydration, can modify feed viscosity and clinical outcomes, such as chest X-ray performance.

Blenderized formulations in home enteral nutrition: a narrative review about challenges in nutritional security and food safety

Blenderized formulations (BFs) are prepared by homogenization of food that is normally used in oral nutrition. BFs are mainly used in home enteral nutrition (HEN), although their use has also been reported by hospitals when commercial enteral formulas are not available. HEN is applied when the patient has been discharged from the hospital. This nutritional therapy promotes the patient's reintegration into the family nucleus and promotes humanized care, and decreases treatment costs. However, the patient should continue to receive health and nutritional care, ranging from periodic nutritional re-evaluation to adaptation of the dietary plan. HEN provides the patient a greater contact with the family, whereas BFs promote the adaptation of the diet with food, respecting the food diversity and culture, lower cost, and easier access to food. Disadvantages of BFs include more time spent by the professional to calculate the dietary plan, greater difficulty in adjusting daily needs, and less microbiological and chemical stability. In this review, the nutritional, food security, and safety aspects of BF used in HEN are discussed. Technological quality aspects that are essential knowledge in the preparation of the patient's dietary plan also are presented.

Novel Advances in the Evaluation and Treatment of Children With Symptoms of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease has long been implicated as a cause for multiple pediatric symptoms ranging from abdominal pain and regurgitation to cough and dental erosions. Diagnostic testing has evolved greatly over the last 20 years; initial testing with pH-metry to measure esophageal acid reflux burden has evolved into measurement of both acid and non-acid reflux and liquid and gas reflux. However, measuring reflux burden alone only tells a small part of the GERD story and many symptoms originally thought to be reflux related are, in fact, related to other disorder which mimic reflux. The current paradigm which involves empiric treatment of symptoms with acid suppression has been replaced with early testing for not only gastroesophageal reflux but also for other diagnostic masqueraders. The focus for interventions has shifted away from acid suppression toward motility interventions and includes a greater recognition of both functional and motility disorders which present with reflux symptoms.

The parental experience and perceptions of blenderized tube feeding for children with medical complexity

Objectives

Parents of children with medical complexity are often expected to implement complicated plans of care, such as enteral tube feeding, to support the health of their child. Enteral feeding can have psychosocial implications for the parent, child, and family. Blenderized tube feeding (BTF) refers to the administration of pureed food and drinks through a feeding tube. Little is known regarding parents’ experiences with BTF. Therefore, the purpose of this qualitative study was to understand the lived experience of BTF from the parent’s perspective.

Methods

This qualitative study was a grounded theory analysis utilizing semi-structured interviews of parents who provided at least 50% of their child’s diet through BTF. Participants were recruited using purposive sampling from the Complex Care Program at a tertiary care paediatric centre. Interviews were conducted until thematic saturation was achieved. Themes were identified using constant comparative analysis of transcribed interviews.

Results

Parents (n=10) felt that BTF positively affected the experience of tube feeding and enhanced their child’s health and wellbeing. Parents described BTF as a means of self-empowerment and a mechanism to normalize feeding and care for the entire family. Despite reporting BTF as more time consuming than formula feeding, all parents were satisfied with having made the change, and planned on continuing the diet.

Conclusion

BTFs can improve the experience of tube feeding and positively address some of the negative psychosocial implications of enteral tube feeding, providing a sense of normalcy and control for parents caring for a child with medical complexity.

Introduction of blended diet for enteral tube feeding in paediatrics: A case report

Background: Advances in medical technology have resulted in changes to enteral tube feeding (ETF). Standard practice in the UK is to use commercial formula for ETF via the stomach or small intestine; however, blended diets are becoming increasingly popular. Emerging evidence shows benefits of a blended diet although evidence informing clinical guidance is sparse. Consequently, there is disparity in practice, and it remains unclear which patient groups may benefit most from a blended diet. Aim: To demonstrate the initiation of a blended diet in clinical practice. Methods: This case report features a 2-year-old child requiring ETF in the context of hypotonia, developmental delay and faltering growth. Results: In this instance, a blended diet resulted in improved gastrointestinal symptoms and adequate growth. Conclusion: This case demonstrates the successful implementation of a blended diet and associated benefits. Blended diets may benefit others requiring ETF and should be considered on an individualised basis.