The Practicalities of Blended Diet

Step 3

Slowly and Surely Wins the Race

START SLOWLY

Many families find it easiest to start by replacing one formula feed or meal with blended food and gradually increase the amount as their child tolerates it. There is no single correct transition schedule. The gastrointestinal system may need time to adjust to the different volume, composition, fibre content and consistency of blended food. 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. If this happens it could be they don't tolerate a particular volume, this may be a sign that the feed needs to be slowed or the volume reduced. Discuss persistent vomiting or feeding intolerance with the child's clinical team.

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.

BUILD A BALANCED DIET

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. Blend consistency needs to be individualised. The blend should be smooth enough to pass safely through the child's tube and feeding equipment while providing a consistency they tolerate well. For us we found a thick batter like consistency worked best.

MAKING AND GIVING BLENDS

Equipment varies between tube types and manufacturers. Your tube specialist or dietitian can advise which extension sets and syringes are compatible with your child's tube. Follow the manufacturer's instructions for cleaning and reuse, where reusable equipment is supplied. Many families find it helpful to give a bolus feed slowly, broadly reflecting the time a meal might take to eat. The appropriate rate and volume will vary between children. 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.

60 ml syringes are best once volumes have been reached. Most people have found the 'O' ring syringes best. These are the ones with a thin rubber band. Ask the prescriber for a different brand if you find you're pushing too hard.

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.

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. We have a type 1 diabetic so count carbs with the NutraCheck App.

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. 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.

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.

Personally we just do a tiny flush of 5 mls before the feed as it adds to the volume (always a problem initially), and just 20 mls to flush at the end as again it increases the volume of the feed. Too much water can overload the stomach and make the child uncomfortable or vomit. Different children however, have different tolerances to flushes. If the need for a flush is simply to clear the tube then 20mls should be sufficient, but always discuss with your dietician.

VITAMINS AND SUPPLEMENTS

Homemade blended diets may need vitamin and mineral supplementation, depending on the foods used and your child's individual requirements so 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.

A paediatric dietitian can assess the blend and advise whether supplementation is needed and which products and doses are appropriate. Avoid adding extra supplements without checking the total daily intake.

WATER AND HYDRATION

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.

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 seems to really help with toleration issues. 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 if they tolerate it better, but there never seem enough hours in the day to get the rest of the water in so giving water slowly overnight via a pump, works for us.

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. Urine colour and frequency can provide useful clues about hydration, urine should be a pale straw colour and passed in reasonable amounts. The child's overall condition will indicate good hydration. Normal soft stools, moist mouth and lack of thirst. Your dietitian or medical team can calculate the total fluid your child needs based on normal intake charts, but they should also use the child's physical condition.

Adequate fluid and fibre may help constipation, although some children need additional treatment. Persistent constipation should be discussed with the child's healthcare team. However, the amount and timing of water should be individualised, particularly for children with delayed gastric emptying or fluid restrictions. Some families find that giving prescribed additional water gradually overnight is an easier way of meeting the child's total fluid requirement.

YOUR CHILD, YOUR JOURNEY

Use the different methods I've outlined 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). If you don't want full blended diet then do what suits your child and you, all I want to do is make life easier not complicate it. Dieticians these days are usually very supportive of parents, unlike 14 years ago when we started.

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.

Use the 'Blended Diet UK' facebook group as a supportive community, as well as the healthcare professionals looking after your child. 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.