The Use of Blended Diet with Enteral Feeding Tubes

Introduction

Purpose

The purpose of this statement is to:

• Create a culture where tube-fed individuals and their families and/or carers feel able to openly and honestly discuss the feeding plan they follow or plan to follow with the dietitians involved in their care.

• Create a culture where dietitians feel supported professionally, to raise the topic of blended diet with their patients and other healthcare professionals and offer blended diet as an option to tube-fed individuals where they deem it appropriate.

Recommendations

• The dietitian is the expert in enteral tube-feeding and should lead multi-professional discussions in relation to blended diet, in the best interests of the individual under their care. Dietitians can suggest blended diet as an option where they believe there to be potential physiological, social or emotional benefits to the tube-fed individual and their family.
• For the majority of tube-fed individuals, particularly those who are tube-fed, short term in hospital; the use of commercially prepared formula, designed specifically for enteral tube-feeding remains the first line choice.
• It is acknowledged that commercial formulas, irrespective of type or brand, are not tolerated by a small group of long-term tube-fed individuals. The reasons for this are not understood; the use of blended diet may provide clinical benefit in this patient group.
• The jejunum does not have the same food storage capacity or gastric acids, which protect against infection, in comparison to the stomach. Therefore, it is likely to be safer to administer blended diet into a gastrostomy rather than a jejunostomy.
• A shared decision-making approach to care, alongside employer’s clinical governance procedure should be followed by the dietitian (10). The dietitian should ensure families receive individualised information they need to enable them to make an informed decision. Consideration should be given to patients with complex medical conditions and those who may be immunocompromised. Planning and preparing blended diet requires a significant commitment and families should have realistic expectations of the labour and financial cost involved. The shared decision should be justified and clearly documented in the individual’s records by the dietitian.
• If a dietitian’s employer (trust or board) has a policy which specifically prohibits the use of blended diets, dietitians should adhere to it. This BDA policy statement cannot supersede an employer’s stated policy. However, dietitians should use this BDA policy statement and the evidence contained within it to encourage a change in any trust or board policy that prohibits the use of blended diets. 
• For children >1-year-old and adults, blended diet can be used either as a sole source of nutrition or in combination with commercially prepared enteral formula.
• Blended foods should not be introduced before weaning age (around 6 months). Small amounts of blended food may be introduced alongside breast milk and/or infant formula in line with current recommendations for oral complementary feeding (11). 
• Steps should be taken to educate the family to ensure blended diet is used as safely as possible. This should include advice on food hygiene and storage, enteral feeding tube care and education on a healthy balanced diet. The level of education and dietetic input needed should be tailored to the individual needs of the family.
• The dietitian should work with other professionals and agencies to facilitate the implementation of blended diet in all care settings attended by the tube-fed individual. For example, respite care, school or college. Ultimately, the decision to provide blended diet rests with the individual care provider.
• Families should be made aware that the provision of blended diet in the inpatient setting is dependent on the individual trust’s policy and food preparation facilities. Blended diet is less likely to be permitted in the ICU/HDU setting. Patients who are fed blended diet in the community should have a plan in the case of admission.
• Administration of blended diet is likely to be easier with some enteral tube-feeding devices in comparison to others. Further information regarding choice of enteral feeding tube is provided in the updated practice toolkit. However, individual manufacturers ‘information for use’ should be clarified when a decision is made to administer blended diet.
• The increasing prevalence of blended diet should be considered when reviewing enteral feeding contracts as this may have an impact on the service level in place.

References

1. Coad, J., Toft, A., Lapwood, S., Manning, J., Hunter, M. Jenkins, H. et al. Blended Foods for Tube-Fed Children: A Safe and Realistic Option? A Rapid Review of the Evidence'. Archdischild 2017 102 (3), 274-278
2. British Dietetic Association Policy Statement use of Liquidised Food with Enteral Feeding Tubes (2013).
3. Durnan, S. ‘It’s Just Food, Blended’: Exploring Parents’ Experiences of Choosing Blended Diet for their Tube-fed Child. 2018 Coventry University. Doctoral Thesis.
4. Philips, G. Patient and carer experience of blended diet via gastrostomy: a qualitative study’ JHumNutrDiet 2018. 32 (3) 391-399
5. Gallagher, K., Flint, A., Mouzaki, M., Carpenter, A. Haliburton, B., Bannister,L.et al. Blenderized Enteral Nutrition Diet Study: Feasibility, Clinical, and Microbiome Outcomes of Providing Blenderized Feeds through a Gastric Tube in a Medically Complex Pediatric Population  J Parenter Enteral Nutr. 2018 42 (6) 1046-1060
6. Pentiuk, S., O'Flaherty, T., Santoro, K., Willging, P. and Kaul,  A. Pureed by gastrostomy tube diet improves gagging and retching in children with fundoplication. J Parenter Enteral Nutr. 2011 35 (3) 375-379
7. Thomas, S., Marchesi, J., Sadlier, C. and Jenkins, H. To blend or not to blend? The benefits/risks of a blended diet in gastrostomy fed children. In BSPGHAN: Oxford
8. Armstrong, J., Buchanan, E., Duncan, H., Ross, K. and Gerasimidis K. Armstrong et al. Dietitians' Perceptions and Experience of Blenderised Feeds for Paediatric Tube-Feeding'. Archdischild 2017 102 (2), 152-156
9. Cantwell, L. and Ellahi, B. The use and experience of registered dietitians with blended diets given via a gastrostomy in the UK ESPEN 2016
10. NHS England Shared Decision Making –Summary guide. Available from https://www.england.nhs.uk/wp-content/uploads/2019/01/shared-decision-making-summary-guide.pdf
11. Zettle, S. Deconstructing Pediatric Blenderized Tube Feeding Getting Started and Problem Solving Common Concerns Enteral Nutrition 2014 31 (6) 773-779

Further information

• BDA Paediatric Specialist Group
• BDA Parenteral and Enteral Nutrition Group (PENG) 
• Dietitians Interested in Special Children (DISC) Group
• PINNT (Patients on Intravenous and Nasogastric Nutrition Therapy) is a support group for patients receiving parenteral or enteral nutrition therapy -