NHD Paediatric Hub

Blended diet: where are we now?

Within paediatrics, we are now seeing a growing number of children living with complex medical conditions, which has led to an increase in the number of children requiring enteral tube feeding with complex diets.(1) The use of blended diet (BD) is becoming an increasingly popular feeding option for this cohort of children.

The use of BD has increased over the last few years, with many parents opting to feed their poorly children full BD or combine feed with commercial formula. With this increase in use oif BD, we are seeing a growing body of evidence and more debate about the advantages and the potential risks.(2-4) With more available robust evidence however, paediatric dietitians can better support the families and young people they care for and improve outcomes for young people.

BD is the term used to describe the process of giving liquidised or blended food into the enteral feeding device of patients who require tube feeding. BD is different from an orally offered puree diet. It can be used to provide all or part of the nutrition. The BDA produced a statement in 2019 supporting open discussion around BD, allowing dietitians to raise this as a potential option if it was felt to benefit patients and families.(5) The BDA then went on to produce a toolkit in 2021 to support dietitians in the practicalities of administering BD.(6)

Case study: child with cerebral palsy

A is a four-year-old child who has cerebral palsy. She has been exclusively tube-fed since birth and has never weaned. She has a complex background with prolonged hospital stays due to respiratory issues and issues around feed tolerance. She has been jejunally fed for around three years via a jejunal extension and her gastrostomy was used for aspiration for comfort. She has now progressed onto full gastric feeds of a standard whole protein 1.5kcal/ml feed, which she tolerates well.  A's parents are keen to consider BD, but are anxious given her background of feeding issues and poor tolerance.

Given A’s complex past, we feel it is important to discuss the family’s expectations. We meet with A's parents and explore why they believe BD would work for A. Both parents are very keen to be able to prepare meals for her and believe the psychological impact of feeding their child with homemade meals will be very positive. There is, however, huge anxiety as A has been tube-fed since birth; the family are unsure of the types of foods to use, the quantities required and potential allergies that certain foods can cause.

We discuss the reported benefits of BD from the research, such as reduced incidence of gastro-oesophageal reflux and improved stooling and some families being able to stop stool softeners. We discuss the strategies to introduce blends and, given A’s complex past, we agree this would be done slowly to ensure volume is tolerated. We advise the calorific value initially would be negligible and there would be no reduction in feeds. We discuss the concerns around potential allergies and agree we would introduce all foods to her diet. A's parents then commence BD by giving a small amount of fruit puree twice daily. They increase the amount over several weeks and then begin to introduce other meals.

Reflux remains problematic, with A having an increase in symptoms with certain foods, such as tomatoes, strawberries and some spices. We then discuss strategies to decrease the acidity of tomato sauces, as is making up a large component of her meals. This helps improve A's tolerance. We also discuss adding products such as yoghurt to spicier dishes to add tolerance.

BD has led to A having more formed stool, but whilst this has helped in terms of leakage of stool, she dislikes the feeling of passing stool and this has led to issues with with-holding stool. This has required a degree of support work to ensure she passes stool without issues. Stool softeners have been introduced and extra fluid administered. Whilst A's parents were initially keen for full BD, they feel now that they would prefer to continue with two meals per day until A’s stooling issues settle.

Whilst A has benefited from the wide variety of food in her BD,  the main benefit is for her family who are delighted to be able to make her meals and involve A in family mealtimes.(7)

Reported considerations of blended diet

Minimal work has been done to look at quality of life in patients fed via gastrostomy, but from what we do know there is an increased burden of care on parents who are delivering overnight feeds, with disturbed sleep, overnight pad changes and issues with pump alarms or vomiting. Some families feel unable to have their child sleep unsupervised for fear of vomiting and aspiration. Breaks, Block & Smith (2022) reported that parents appreciated the freedom of choice when providing BD to their child.(8) They also found that parents of children on BD reported improvements in overall health compared with those on commercial formula.

There is a growing body of evidence supporting the improvement in GI symptoms when a child is fed with BD compared with commercial formula. Batsis et al (2019) found that 95% of patients receiving BD had improved upper GI symptoms within the first three months of starting.(9)  21% of patients reported developing constipation since starting BD – this is similar symptom to the one A demonstrated in our case study above.

Conclusion

We as dietitians continue to learn about the benefits and uses of BD. Research remains lacking but is growing and is proving useful in determining the efficacy in certain patient groups. In our case study, whilst A was previously jejunally fed, she had transitioned back to full gastric feeds prior to trial of blends. We do have a growing number of patients who are jejunal-feed dependant and unable to tolerate commercial formula gastrically. We are considering trialling BD gastrically to see if it helps tolerance.

BD is certainly not a one-size-fits-all approach; it is something that some families may find beneficial in terms of gastric tolerance. BD has a positive impact on families, as parents/carers can prepare food for a child with complex feeding needs and they in turn can be involved in mealtimes.

Instagram: kidsnutritionrd
Website: www.kids-nutrition.com

Hazel Duncan, RD

Paediatric Dietitian, Kids Nutrition

References

  1. Köglmeier J, Assecaira I, Banci E, De Koning B, Haiden N, Indrio F, Kastelijn W, Kennedy D, Luque V, Norsa L, Verduci E, Sugar A. 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. J Pediatr Gastroenterol Nutr. 2023 Jan 1;76(1):109-117. doi: 10.1097/MPG.0000000000003601. Epub 2022 Sep 2. PMID: 36053165
  2. Bakewell C, Batra A, Beattie RM Advancing the conversation around blended diets for gastrostomy-fed children Archives of Disease in Childhood Published Online First: 08 April 2024. doi: 10.1136/archdischild-2023-326659
  3. McCormack S, Patel K, Smith C. Blended diet for enteral tube feeding in young people: A systematic review of the benefits and complications. J Hum Nutr Diet. 2023; 36: 1390–1405. https://doi.org/10.1111/jhn.13143
  4. Gallagher K, Flint A, Mouzaki M, 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. JPEN J Parenter Enteral Nutr 2018;42:1046–60. doi:10.1002/jpen.1049
  5. British Dietetic Association. The Use of Blended Diet with Enteral Feeding Tubes. BDA, 2019. https://www.bda.uk.com/resource/ the-use-of-blended-diet-with-enteral-feeding-tubes.html
  6. BDA British Dietetic Association practice Toolkit: the use of blended diet with Enteral feeding tubes. 2021. Available: https://www.bda.uk.com/static/33331d33-21d4-47a5-bbb79142980766a7/FINAL-Practice-Toolkit-The-Use-of-Blended-Diet-with-Enteral-Feeding-Tubes-NOV-2021.pdf
  7. Sleigh G Mothers’ voice: a qualitative study on feeding children with cerebral palsy. Child Care Health Dev, 2005, 31 373–383
  8. Breaks A, Bloch S, Smith C. Determinants in parents' decision to use blended diets with gastrostomy-fed children and young people: A mixed methods study. Clin Nutr ESPEN. 2022 Oct;51:288-294. doi: 10.1016/j.clnesp.2022.08.013. Epub 2022 Aug 18. PMID: 36184218
  9. Batsis ID, Davis L, Prichett L, Wu L, Shores D, Au Yeung K, Oliva-Hemker M. Efficacy and Tolerance of Blended Diets in Children Receiving Gastrostomy Feeds. Nutr Clin Pract. 2020 Apr;35(2):282-288. doi: 10.1002/ncp.10406. Epub 2019 Sep 24. PMID: 31549432

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