BLENDED DIET FOR TUBE FED CHILDREN IN THE UK
A BASIC GUIDE TO STARTING BLENDED DIET
Step 2
Starting Blended Diet needn't be daunting. This beginners guide is as comprehensive as I can make it, but there are plenty of hints and tips in my 'Useful Links' Section.
I have been asked how people do the basic transition from tube feeding formula to blended diet so I asked a few people how they managed and pulled together a few tips plus used our own experience. I have also reread some of the ‘Complete Tubefeeding’ book by Eric Aadhaar. I would always advise anyone to get this book before starting out as it is so detailed and covers most of the questions people have. Tubefeeding generally and blended diet in particular is quite a complex subject initially, but eventually you wonder why you worried so much!
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This is just a basic starting out guide to give you an idea of the different issues you may face and how to deal with them. More detailed advice, recipes and troubleshooting can be found in the links on the last page of the website.
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I’ve kept it simple and assume there are no physical problems like slow gastric emptying which make any feeding difficult. This doesn’t make BD impossible but you would need to make adjustments to the volume and time frame. I am sticking to a normal digestive system here to simplify things and only to children who have G tubes or NG tubes or a JG tube where BD can be given via the G port.
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Basically, there isn’t one perfect way, but many different approaches. I’ve put down a few I know about but every child is an individual so their tolerance needs to be taken into account.
I have considered different ages for starting BD and the method of feeding at present. I am working on the assumption that you want to give your child meal size portions at meal times wherever possible. I’ve also looked at pump feeding if bolus feeds are not tolerated, although many children can progress to bolus feeds over time.
If possible get your dietician to help you formulate a healthy, safe transition plan when
switching to a blended diet.
Some Points to Consider
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Allergies
‘Complete Tubefeeding’ gives advice on checking for allergens in food so Chapter 18 is a must.
In brief, GIVE FOODS EXPERIMENTALLY using the ‘four day rule’. This is feed a new food four days in a row and if there is an adverse reaction you will know it is the new food. Continue with the foods which you have already ‘cleared’ in this way, then, if the new food is fine, start with another new food for four days.
It is especially important to check for food allergies or intolerances with children who have never had food.
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Pump Feeds
BD can be given via a pump but most pumps will constantly block and alarm and they can’t be hung for more than 4 hours because of food safety concerns. The pumps can be adjusted and the rep will usually have to do this, but they still won’t accept a thick fluid. Pump feeding BD over 4 hours will be more successful if the blend is sieved with a fine sieve. Giving the bag a squeeze every 20 minutes or so helps sediment to not sit at the bottom, and reduces the possibility of blockages, People have managed to fiddle with some of the giving sets to allow pumping but it’s not something I’ve done. There is a you tube video of pump giving set adjustment, but whether this is desirable I can’t comment. see the section on BLENDS Project as there is a pump available but will probably need to be privately purchased.
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Medications
Some medications may be affected by the type of food/formula.
Epilepsy medication may be absorbed more easily from formula than from food, and therefore, medications may need to be increased. Discuss this with the prescriber and the dietician or a pharmacist who can find out for you if you may be affected.
Reflux medication need to be withdrawn slowly or you get a rebound effect. Consult the prescriber.
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Starter Foods
There are smooth baby foods in pouches like Ella’s kitchen, baby rice and commercially prepared baby puree. These are easiest even with bigger children to get started simply because they are of the right consistency and won’t block the tubes. They are ready prepared and safe. They are also very easily digested foods. What they are not is calorific, so you will have to calculate your child’s calorie needs (add up the calories on the formulas given) and only deduct the calories (not the volume) from the formula, or give as additional where possible.
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Volume Tolerance
If you have a toddler or a child of any age who has been formula fed throughout their life who you want to transition to BD there are two basic types; children who are on continuous feeds and children who manage bolus feeds. The reasons for trying BD may be vomiting and reflux or it might be parental choice, but the technique is the same.
If the child has been bolus fed via a syringe or a rapid pump feed then they will have some volume tolerance and hopefully, their stomach will be normal in size. If a child has continuous pump feeds the stomach never gets the chance to stretch to normal size and can be quite small. This means volumes won’t be tolerated initially. However any stomach can stretch. Nothing is permanent. Obese people have huge floppy stomachs and anorexics have shrunken ones. Both become normal in size if eating becomes normal. Increasing stomach size and tolerance to being full takes time and here it is especially important to give water boluses as indicated below.
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Weight Gain
Weight gain is not usually rapid unless the child is seriously underweight and vomiting several times a day which resolves immediately on BD. Initially it can be quite slow, but with the correct volumes and calories, this will resolve. Again children are variable.