NHD Paediatric Hub

WHAT IS BLENDED DIET?

Blended diet has grown in popularity over the last decade and there is now a growing number of parents/carers requesting blended diet as a means to feed their tube-fed child in place of commercial formula.  Blended diet can be defined as giving solid food blended and mixed with water or any other liquid through the feeding device of a patient requiring tube feeding.  Blended diet can be given as a sole source of nutrition or as an adjunct to commercial formulae (2).

WHAT ARE THE BENEFITS?

Benefits of blended diet have been well documented within the literature (2-4). There are reports of improvements around GI symptoms, such as reflux, constipation and loose stooling, often with an associated reduction in the use of medicines to treat these conditions. There are psychological benefits too, both for the parents/carers and for patients receiving a blended diet.  A positive impact on the gut microbiome has been reported (2), which will be linked to improved GI symptoms and there is a feeling of improved wellbeing within this patient group.

ANY AREAS OF CONCERN?

Blended diet however also comes with risks and areas of concern. These include tube blockage, food hygiene, questions regarding nutritional adequacy of the diet, and medication absorption.

CONSIDERATIONS ON INTRODUCING BLENDED DIET

Before a child is started on blended diet, the family, paediatrician and a dietitian (with experience of blended diet) should meet and have a discussion with the parents. Within this meeting, the family’s expectations should be discussed and a risk assessment carried out. Healthcare professionals should highlight the benefits and potential risks of blended diet and a joint decision made as to what is best for the patient (5). For H in our case study, the decision was made to start blended diet; therefore, more in depth discussions took place with the dietitian.

POTENTIAL RISKS DISCUSSED

The BDA practice Toolkit was launched in 2021 and provides detailed information regarding commencing blended diet, along with an example blended diet competency tool (5).  The three main areas of potential risk are tube blockage, nutritional adequacy of blends and food hygiene risk. each of these should be highlighted and discussed in turn with parents/carers.

1. Tube blockage

The consistency of blends should be clearly explained to parents/carers to minimise this risk. The International Dysphagia Diet Standardisation Initiative (IDDSI) provides a framework explaining textures of food and liquids and can be a useful starting resource to explain the consistency of blends. Level 4 is the blend usually required to provide adequate consistency and examples of this can be given. If parents find the blend too stiff to administer then additional liquid should be added. Blended food can be given throughout the day as boluses and will require to be increased in volume over time. 

Families starting on their blended diet journey will require a high-power blender to ensure meals are blended smooth enough to prevent tube blockage. There are a variety of blenders available and the higher the power the smoother the blender should be able to get the food, making it safer and reducing the risk of tube blockage.

It is recommended that blends are given via a 60ml syringe and depending on the child and tolerance they may need to build up to this volume. Typically, children will take two to four syringes for meals depending on age and tolerance. Thicker blends should be given in 5-10ml increments, which is felt to be a similar rate to children chewing and swallowing a meal. The full volume of blends should be administered in around 20 minutes.  It is not recommended to give blended diet via feeding pump. 

2. Nutritional adequacy of blends

When feeding with a commercial formula, dietitians know exactly how much macro- and micronutrients a child is receiving. As commercial formula is decreased and real food diets are increased, this becomes more difficult to know. Another concern is that as blends are made more dilute to ensure they are able to pass through the feeding tube, the calories become reduced. Parents should be given advice from a paediatric dietitian who should use their knowledge and skills to ensure blended meals will meet the nutritional needs of the tube-fed individual. The amount of support a family requires will vary depending on their own knowledge, and support should be specific to their needs.  

3. Food hygiene

Blended diet is not sterile and, therefore, can cause infection or food poisoning. Care should be given to discuss food hygiene recommendations, including safe cooking, cooling and storage of blends, to minimise risk.