BLENDED DIET FOR TUBE FED CHILDREN IN THE UK
Practicalities of Blended Diet
Step 4
Categorising where your child fits when starting blended diet.
Your child will usually fit into one of these 5 groups
Your child may not fit exactly into one of these or be able to use exactly one of the methods outlined, but they can be easily modified. Every child writes their own manual.
BABIES ON BREAST OR BABY MILK GIVEN AS A TYPICAL FEED
Babies who are on breast or baby milk and have never had medical formula, and are on 3-4 hourly feeds as normal.
Wean via the tube as you would any baby
Switching from breast or baby formula directly to BD is as straightforward as feeding an orally eating baby. Simple first tastes like apples, avocado or baby rice, or baby pouches, blended fine enough to go down the tube (NG or gastrostomy) in teaspoon (5 ml) size amounts, via a syringe or mixed with their feed, is easiest. The WHO recommend 6 months to start first tastes with babies, with baby milk or breast milk being the main staple for the first 12 months. This advice can be found in any weaning book and Annabel Karmel books are ideal. Feeding BD from 6 months is probably the easiest as you simply follow normal weaning advice and add foods one at a time in addition to their normal milk. This way the baby becomes used to food and it checks for any intolerances. After 12 months give blended foods via a syringe as if they were eating orally. This should be well tolerated.
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If the baby has an NG tube see the article on this in the FACTS section of the website.
CONTINUOUS FORMULA ONLY FED CHILDREN VIA PUMP
Children who have always been pump fed continuous feeds (24/7) of medical formula, and/or breast/baby milk.
Gradual transition/Screen for allergies and Intolerances
These children are likely to have very small stomach capacity and need to be given very small amounts of blended food either via a pump, or gravity fed, or tiny amounts via a syringe over a prolonged period. With a small stomach the aim is to stretch it slowly so that it can accept greater volumes. It is particularly important to give the water bolus half an hour before the feed, but this will be a much smaller amount. It’s very much a juggling act to give yourself a couple of hours formula free to start small amounts (5-20 ml) of BD after giving the same volume of water half an hour before (less if not tolerated). If you know your child tolerates 30 or more mls at a time you can start with that volume. Increase very gradually.
An example would be finish the overnight feed at 8 am and do not start another feed until 10 am. At 8.30 am give 20 mls of free water and at 9 am give 20 mls baby puree (Ella's Kitchen pouch). If possible speed up the pump feed to make up for those 2 hours. Observe for any difficulties the child may have, vomiting etc.
If your child tolerates formula, you can mix the baby puree with some of their formula to not lose calories. Then gradually increase the amount of real food and decrease the formula.
FORMULA ONLY FED CHILD WHO HAS BOLUS FEEDS.
Toddlers and children who have medical formula throughout the day at set intervals (3-6 times)
in boluses, either via a pump or via a syringe
Screen for allergies and intolerances
The stomach should be able to accept BD volumes similar to their formula. Always do a free water bolus half an hour before the feed. Free water is usually part of a formula regime anyway. This should be the same volume as the BD feed, although some people find a smaller amount better tolerated. Provided the right amount of water is given at some point this is an individual choice. This clears and preps the stomach and appears to stretch the stomach and allow it to accept their ‘meal’ more easily. The water is absorbed very quickly and does not add to the volume of the BD feed. The water should be part of their daily water consumption, which should be worked out according to age and weight.
So, for example, if a formula feed of 250 mls is given, then give 250 mls of water half an hour beforehand and then 250 mls of blended food. Give it over the same time as the formula was given. Flush with 15-20 mls water. Your dietican should help work out your water boluses.
CONTINUOUS FORMULA ONLY FED CHILDREN VIA A PUMP WITH FUNDOPLICATION
Very gradual transition/Screen for allergies and intolerances
If a child has had a fundoplication and has had continuous pump feeding it is especially important to increase volumes very very slowly, because a child will normally vomit if the stomach becomes fuller than they can cope with, but with a fundo this can’t happen and the child could be in severe pain and retching. Do the same method as children fed continuous formula via a pump, but keep the volumes tiny to start with.
CHILDREN WHO HAVE EATEN ORALLY IN THE PAST OR WHO STILL EAT SMALL AMOUNTS
Toddlers or children who have eaten orally up to a certain age and then have had gastrostomies for various reasons.
Swap like for like in volumes and foods unless pump fed
It is very easy to transition these children as you will already be aware of allergies and food intolerances. They will usually have some volume tolerance unless they have moved onto continuous pump feeding, in which case follow the gradual transition to BD as outlined, using the foods you know are tolerated.
Method 1
Suitable for children given formula as a bolus either by syringe or pump
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Bolus = 20-30 minutes
It’s advisable to give baby foods, such as Heinz or Ella’s Kitchen pouches, as additional to their formula feed as they are usually low calorie initially, unless the child is overweight.
Give them in a formula free time frame so that you can assess whether it is tolerated.
Slowly built up the amounts and the calories by adding an extra food every four days. Stick with easily tolerated foods like baby pouches, sweet potato, avocado, and banana initially.
When you have reached a volume and a calorie intake equivalent to one of the formula feeds you can drop it and substitute a BD meal. As you start to get nearer the calorie and volume amount of your formula feed you can drop some of the formula amount. It’s a bit of juggling act at this time, but is entirely dependent on the child’s tolerance, weight and reaction to formula and to food.
Continue this way until all the daily meals are switched. Just ensure adequate water in a 24 hour period.
Drop the overnight feed last if it is reasonably well tolerated as it offers significant calories. Once you have reached 3 bolus meals a day plus 1 or 2 snacks you can look to increasing the volumes and the calories in each of those meals to compensate for dropping the overnight feed.
To increase bolus feeds first increase the preceding water volume an hour before the feed and, if tolerated, give the same amount of feed. Increase 10 ml at a time but it can be less or more depending on how well your child copes. There are no hard or fast rules. If your child indicates discomfort, vomits or is swallowing as you feed, it may be too much volume or it may be given too fast
I would always advise to take it very slow if possible. Easily tolerated foods, small amounts, given slowly and single foods initially. Fats can take longer to digest and be less well tolerated so be aware and substitute carbohydrates instead if this seems to be the case. You will eventually find a comfortable speed to give the food
Method 2(a)
Suitable for pump fed children given continuous feeds or with a fundoplication
Continuous feed = 4 hours
Replace volume (eg 10 mls) given via pump with the same volume of blended food (Ella’s kitchen type) Simply deduct 10 mls (more or less depending on your child) from the feed and give it as a bolus of blended diet in between pumped feeds. Just be aware that if your child is underweight method 1 is going to be safer.
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Give them in a formula free time frame so that you can assess whether it is tolerated. If continuous feeding, create an hour or two formula free and if possible speed up the remaining formula if tolerated. If not ensure the BD is of the equivalent calories, such as banana, avocado, ground almonds (when tested), mixed with the baby pouches.
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Because you can only add one food at a time every 4 days look to add things like avocado or ground almonds which have good higher calories, to your pouches. Again, when you have enough in one of your bolus meals calorie wise then you can extend the formula free time and drop a formula feed.
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Alternatively for every ml and every calorie you give BD deduct that from the formula. So, formula 1 ml = 1 cal. Ella’s Kitchen 1 ml = ½ cal. Give 2 ml EK and drop 1 ml of formula. Sounds a bit fiddly but it’s quite simple really. Again it is entirely dependent on tolerance.
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Just watch free fluid (water) intake, and ensure not too little or excessive amounts. Ideally ask your dietician to work this out for you. Once you start to progress away from 4 hourly feeding and replace with food, you will need to look at the amount of free fluid (water) that is needed as it will probably need to increase.
Method 2(b)
Suitable for pump fed children or children with a fundoplication
Continuous feed = 4 hours
Replace pump feeds with pumped blended diet. It can be done. I have made an overnight (4 hours) feed with goat’s milk, banana, oats, cherry juice (proper cherries!) and lettuce juice. All supposed to make you sleepy. It was a major effort, using a blender and a juicer and it didn’t work for sleeping anyway, so I was glad to stop! But it did go through the pump without blocking.
To blend for a pump you have to use a very fine strainer and end up losing some of the fibre and goodness in your blend so it’s not ideal. This is where an expensive Vitamix blender will be worth its weight in gold as they blend very fine. Worth trying tweaking the giving set but I would only pump feed as a last resort if boluses couldn’t be tolerated. If you alter the giving set make sure it is not an infection risk and is safe. Some pumps can be modified by the rep to accept thicker fluids, such as carobel so it’s worth asking for this. Squeeze the bags intermittently to prevent solids settling at the bottom. If you are losing too much of the blend in the sieve I would think again about how you can progress to small boluses of thicker blends because the nutritional status of the child may be compromised.
Pump feeds must be prepared with great care re hygiene as they need to hang for no more than 4 hours. They also need to be decanted into sterile bags and kept frozen or refrigerated for the shortest time possible and hung cold. Some people need to pump water as this is not tolerated as a bolus. This is best done before rather than after a bolus feed of the blend.
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The BLENDS Project page has links to a Vygon blended diet pump but I believe it is only available privately.
Method 3
Mixed Feeding
Mix blended diet with formula during the transition phase, or use this as a method if you prefer long term. The author of ‘complete tubefeeding’ does not recommend this and gives some very good reasons in his book. I personally would prefer a complete home blended diet rather than using formula because you can choose exactly what you know is healthy and know exactly what your child is eating.
Some families do find this a good alternative though and their child tolerates formula well, so honestly, just do what you feel happiest with. Start adding EK pouches to formula and then increase the food variety using the 4 day rule. Reduce the volume of feed to match the volume of EK puree accordingly.
Again be careful if your child is underweight, in which case do not reduce the formula until the calories in the blends match or exceed those in the formula.