BLENDED DIET FOR TUBE FED CHILDREN IN THE UK
About Blended Diet
There are so many misconceptions surrounding giving Blended Diet to a child with a feeding tube. Hopefully this website will help parents and carers to feel more confident, and will allow professionals to look again at their practice, and how they can support parental choices.
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Commercially available formula feeds suit many children and adults and have many well documented advantages.
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However they do not suit everyone and my concentration is on children as their problems differ in many ways from adults.
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The most important difference is that their bodies are growing at a rapid rate and require a nutritional focus to reflect this. Their gastric problems also often stem from genetic or birth problems and have therefore not been acclimatised to normal feeding which will develop a healthy digestive system and enteric flora.
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Unfortunately many children who have otherwise normal digestive tracts have problems with vomiting, constipation and failure to thrive when fed a diet exclusively of commercially available formulas despite efforts to find a formula which is accepted by the body.
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In these cases many parents have found that feeding blended food instead of, or combined with, formula feeds alleviate most of the above problems.
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Reasons to give blended diet (BD) are multiple. Most importantly there have been decades of research into the benefits of a healthy, well balanced and rounded diet. Food can be tailored to each child’s needs. Constipation with increased vegetable and fruit fibre, vomiting with decreased volume and thicker blends. Dairy intolerance avoided, specialist diets given under dietetic guidance and so on.
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Hundreds of children in the UK with gastrostomies or naso gastric tubes are being fed BD. Their parents have mainly reached this path because of serious health problems with formula feeding, but more are coming to BD because the overall benefits of food are compelling, as is the need to nurture and feed their child in a natural way.
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The case against BD centres around hygiene, the effects of poor hygiene on the child, nutrition, blockage of devices, litigation and cost.
All the above can be ameliorated with the use of the PENG risk assessment guide, shown on the page about getting BD into school and respite)
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BD is not an easy option. Feeding any child well is not easy. BD is more expensive for the parent. BD is more time consuming for the parent and BD requires more nutritional knowledge than the norm. For these reasons parents who opt to feed BD are well informed, willing to learn and understand the importance of food hygiene. Its inexpensive to complete a food hygiene certificate online. Using formula feeds is not without its risks if not handled well or tubes are not adequately cleaned if reusable. Feeding a child with a feeding tube BD requires the same degree of food hygiene preparation as feeding an orally eating child and the vast majority of parents understand the importance of good hygiene.
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It has been noted that there were issues with gastroenteritis caused by food borne bacteria in the 1970s when liquidised food feeding was the norm. Although this is true the ‘norm’ was in a hospital setting and hospitals are full of pathogenic bacteria. The research quoted by NICE in ‘Evidence Update 64 (September 2014)’ from a Polish study (which appears superficially to confirm the superiority of formula feeding but which NICE accepts has ’limitations’ and ’could not show causality’) makes no mention of gastroenteritis in its list of hospital admissions on people fed liquidised food at home. So despite having no obvious food hygiene training, these families managed to safely feed their relative. What they probably didn't have was nutritional support or the right equipment.
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The nutritional aspect can be understood and implemented using conventional learning techniques and aided by nutritional input from a dietician. The use of a high speed blender is usually necessary but not essential especially when starting out on food blending. Ultimately giving food can only be in the best nutritional interests of the child. Food encourages normal gut bacteria. Food can provide micronutrients not provided by formula feeds. Probiotics are not added to formula but occur naturally in food. The human gut evolved to digest food. The natural process of digesting food and eliminating it normally can facilitate toilet training which would have otherwise been difficult.
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The main ingredients of many formulas are maltodextrin, vegetable oil, milk protein, sucrose and emulsifiers with added vitamins and minerals which may not be recommended as a diet for the long term. The need for medications to reduce reflux, gastric problems and constipation can usually be stopped under medical guidance. If the child is able to eat normally feeding palatable food will often stimulate the appetite. Many children eat their meals with the rest blended and fed via a tube. A child can be involved in their own feeding if food is blended. A parent can feel they are nurturing their child. This is all possible with BD and the use of nutritionally complete foods. The child will usually gain weight and height on a well balanced diet which will have a positive impact on their learning and health, particularly if vomiting has been a major issue on formula and oral aversion has developed.
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The issue surrounding blockage of feeding devices can easily be solved by blending food in a high speed blender and/or sieving. The most common blockers of tubes are medications. Frekka PEGs are less likely to block because of the wide bore but they are the most problematic because of the need for surgical replacement. Sieving should always be recommended with these devices. The buttons and NG tubes are easily replaced although from a cost point of view its important to ensure blockages do not take place by use of high speed blenders and sieving if unavailable. The issue of whether it is 'safe' to use the plastics used in enteral feeding has been raised. The Enteral Plastics Safety Group (EPSG) is a group of manufacturers and suppliers of enteral plastic products who have met and issued a statement on their position with regard to feeding Liquidised Food/Blended Diet. The EPSG statement say they do not endorse liquidised food via their products. However they do not say it is unsafe, damages the plastics or will cause any harm. They can't, because it has never been demonstrated to do these things. It has only been tested with formula feeds. It has not been tested with medications. They do state it is possible to feed BD with a full risk assessment. Two manufacturers of feeding tubes (Halyards and AMT) have stated on their website and on their social media pages that they endorse blenderised diet when it is given safely via the Mic-key and Mini button.
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Litigation or complaints against the health or school authority if feeding blended diet is mitigated by the use of the Risk Assessment document and using disclaimers which are in line with patient consent forms. Proper advice on hygiene, nutrition and support should also be given as they would be normally, only with the focus on BD instead of formula. Litigation would only occur if there was genuine negligence and with guidelines in place this is an unlikely scenario, but would be viewed as any other case of negligence, such as giving the wrong medication.
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The cost implication is something that would take many years to fully assess. The obvious cost benefit to the NHS would be the savings in expensive formula feeds. A secondary saving would be in medications to combat gastric problems and constipation as these usually improve on BD, as well as expensive appointments to gastric paediatricians and hospital care requirements for these conditions. The improvement in the overall health of children on BD would theoretically save the health service money with fewer hospital admissions. With improved nutrition and physical wellbeing children with physical difficulties may be better able to lead independent lives. Children in school if better nourished would have increased learning ability.
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There would initially be a cost implication for dieticians and nurses involved in the care of the child when there would be greater supervision in the initial period, but once the principles are established there should be little further input apart from regular height and weight measurements which are made routinely anyway. Indeed if formulas are not tolerated the dietician may have more to do with the child than one fed on BD.
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BD could be promoted by dieticians and should be offered as a choice, especially if a child is not thriving on formulas. If not parent's wishes should be taken into account and supported.
An Overview of Blended Diet
Some of the Benefits of BD
These are some of the health benefits parents have seen with blended diet. It is not only the physical improvements parents see, but the emotional feeling that you are giving your child a much better quality of life via their nutrition
Reduced Vomiting
In many children formula feeds, after an initial honeymoon period, seem to cause endless vomiting. Children can usually come off their medications when fed BD. Medical advice is usually needed as some need to be reduced slowly. Vomiting is upsetting for the child and others around them, particularly in a school setting. It creates endless washing. It adds to the risk of oral aversion which in itself makes eating orally less likely where possible.
Reduced/Eliminated Constipation
Because you can vary the amount of dietary fibre with BD the child can have a normal bowel movement once you have worked out the optimum amount of fruit and vegetables they need. This eliminates medication and gives you a better opportunity to toilet train a child.
Reduced Reflux
Reflux, where the contents of the stomach splash up into the lower part of the oesophagus is very painful for the child and medication does not always help. Long term use of ppi meds may not be good for the child. A gastro surgeon said to me once TD (typically developing) children are on their feet and eating solid food reflux usually stops naturally. BD provides solid food and has helped most children. Many are now trying BD and finding the operation to stop reflux (fundoplication) is not needed.
Weight Gain
Children can put weight on with formula, but if they are vomiting constantly or just not putting enough weight on then BD will usually sort this out. BD can be tailored to the child's needs and extra calories can be added. There is usually an issue with volume tolerance to begin with, but its usually manageable and tolerance builds up slowly.
Better Health
Its pretty obvious that if you can give a child a super healthy diet with all those superfoods mixed in, the child will become healthier. If they are well fed and healthier, their energy levels will increase and their mood will improve. It is lovely to see your child with a clear skin, shiny hair and bright eyes. Their resistance to illness improves and if they do get ill they recover faster. This is so important if your child is medically fragile.
Improved Eating
Surprisingly children do not lose interest in food and eating if they are well fed. Their appetite usually increases and they want to try the food you have prepared. Obviously if their swallow is impaired they can't be given the food, but if not many children go on to eat better orally. I prefer to make a 'proper' meals and blend them so they are edible. Elliot loves Korma curry and will eat a little. At school he kept stealing the other childrens custard puddings until it was decided he would have his own! He had a severe oral aversion but now tucks into Greggs sausage rolls and McDonalds chips.
Improved Sleeping
Anyone who has reflux and vomiting or feels underfed during the day will inevitably not sleep well. A child hooked up to an overnight feed will not move so freely or risk getting tangled in the giving set. Its also not natural for the gut to be active at night. BD often results in better sleeping, and eventually the night feed usually goes if enough calories can be taken in during the day.
Parental Satisfaction
You feel you are nurturing your child better and feeding in a way that's more natural. The sense of control BD gives you after so long with your child 'medicalised' cannot be underestimated. The child can have party food, a slice of their own birthday cake, or a superhealthy meal other children would balk at.
Reduced Medicalisation
You can feed at mealtimes and get rid of pumps and giving sets. No more continuous feeding and being hooked up to pumps. Most children can achieve this if they have a normal digestive tract. It takes a while but its worth it not to have to use the pump, except for emergencies, such as illness.