BLENDED DIET FOR TUBE FED CHILDREN IN THE UK
Getting Started with Blended Diet
Step 3
The practicalities of starting BD should be taken slowly and built up as tolerance improves.
Starting Blended Diet
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START WITH ONE MEAL A DAY
Use the different methods below to work towards a full ‘meal’ of BD so that you can cut out a ‘formula session’, or reduce the formula time and amount (if 24/7 fed)
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Leave the overnight feed until last if it is tolerated as it provides a good amount of calories and is usually well tolerated. The overnight feed can be continued indefinitely as some parents find the calories can be significant. There is no right or wrong way to transition.
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Usually breakfast is the simplest meal to change to BD but if your child attends school or nursery then you could change the evening meal to BD first so that you could monitor their reaction.
TAKE IT SLOWLY
Times to transition can vary from 1 day to 1 year which goes to show the variability of children with tubes! Slowly is much better though as the child’s system needs to adjust to coping with digesting and eliminating food normally. Volume tolerance is a major stumbling block and needs to be increased gradually. If your child is swallowing as you feed, looking or saying they feel uncomfortable, or they vomit up some of the BD, volumes need to be reduced.
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Aim for 45-65% carbohydrates and 20-35% fats and 10-35% proteins throughout the day. Each meal doesn’t need to be perfectly balanced but its best to balance out over the course of the day. These are general recommendations and you may find your child’s protein or fats need is greater. Your dietician should help here as she knows your child’s medical problems, if any.
The Practicalities
Writing down the foods you give and checking with a nutrition app will give you a good idea of where you may need more or less of a nutrient. I've linked with permission to this web article, as there are details of how to ensure good nutrition for individual children using more scientific methods.
https://simpletangles.wordpress.com/2013/10/08/feed-food-and-maths/
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The NHS Eatwell site contains useful advice on food types and amounts
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http://www.nhs.uk/Livewell/goodfood/Pages/the-eatwell-guide.aspx
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Another method of working out how much to feed is to aim to match the calories in the formula feed with your blends, divided up through the day. That’s the easiest way to start. This may need adjusting as full BD is taken.
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This may be difficult initially as you may not achieve volume tolerance for some time. In which case fats are high in calories as are simple sugars, and low in volume. It is easy to find a list of high calorie foods on the internet. Try to make them healthy and not empty calories. Avocado for example is high in good fats and calorie packed. If your child does not tolerate fat well you will need to use carbohydrates instead. Look for high calories ones. Snacks between 'meals' can be helpful as the volume is low and you can make the calorie count high.
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If you have a supportive dietician ask them to work out some meal plans and the calories and fluids your child needs in a day..
The thicker the blend the better it stays in the stomach. I aim for a thick batter consistency that will run slowly off the spoon.
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We use Kimberley Clarke extension sets. The only syringes available now are Enfit ones, which have a screw in cap to the extension tube and to the PEG tube. There are various extension sets for bolus feeds so be aware you need something that is fairly straight. Worth shopping around to find what is right.
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60 ml syringes are best once volumes have been reached. Reusable ones can be washed according to the manufacturer’s instructions, and if stiff, a little cooking oil makes it smoother to push. Most people have found the 'O' ring syringes best. These are the ones with a thin rubber band and not the thick black bung, which are a nightmare to push. We like the Medicina reusable syringes. They are more cost effective, as reusable so advise the prescriber of this when you discuss syringe preference.
We put the blend into a non plastic bowl drawn up through the syringe. Prime the extension set and give slowly. About the same rate as you would eat the meal. Children are different so take it at your child’s pace. It may need to be given over an hour, which is time consuming but usually improves with time.
Initially calorie and volume count, but eventually you will know the types of foods and volume your child tolerates so you can stop unless there is a specific reason it needs to be exact.
You can blend a portion of the family meal after it is cooked. This suits some families but ensure calories and volume are adequate.
You can batch cook and freeze individual portions. Defrost in the fridge and give at a comfortable temperature. Very cold food can be unpleasant for the child.
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You can make a ‘perfectly balanced’ blend at the beginning of the day and keep it in the fridge and decant into portions during the day. This is ideal if the child is unable to eat anything.
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You can have ‘typical’ meals, meat, fish, vegetables. This is great as the child can eat some of the blend if they are on pureed meals.
Children usually will ‘taste’ some of their blends when they reflux or burp, so I believe they should not taste awful, but at least have a pleasant or neutral taste.
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We don’t flush before the feed as it adds to the volume, and we only flush 20 mls after to clear the tube. Again it increases the volume of the feed which can overload the stomach.
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Until your child is on a full blended diet with all the vitamins and minerals necessary for healthy growth, give a good quality multivitamin and mineral supplement, appropriate for their age and weight. Simple ABIDEC is easy to obtain and in a liquid form. Additional supplements can still be given after full BD provided safe limits are kept. We give extra vitamin C as blending or storing may destroy this fragile vitamin. It's also advisable to give vitamin D in the darker months.
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It is very important to ensure the right amount of free water needed for your child’s weight and age. The blends will have more fluid than a normal diet but not a huge amount more unless they are very watery so get most of the free water outside the blend. If your child is well hydrated they should pass light yellow urine every 3-4 hours, a good amount, their mouth should look moist and they should not be passing hard, constipated stools. Constipation is often an issue but plenty of fruit and veg in the blend with adequate fluids will usually sort this out.
Giving a free water bolus half to one hour (for us half an hour is enough but slow gastric emptying means sometimes one hour is better in some children) before the BD meal is very important as it preps the stomach, helping it to stretch to receive the blended food better. The volume varies with the child but we find giving the same volume of water as the feed works best. The volumes can also be half that of the feed, but there never seem enough hours in the day to get the rest of the water in if we do that. What we have found it that giving water overnight very slowly via a pump, really ups the water volume to a normal level and is easy to achieve.
As always it’s what suits the individual child. The water leaves the stomach very quickly and doesn’t cause the meal to become diluted.