BLENDED DIET FOR TUBE FED CHILDREN IN THE UK
Practicalities of Blended Diet
Step 4
Categorising where your child fits when starting blended diet.
Which Starting Point Fits Your Child?
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 STARTING WEANING
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
Method 1
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.
If the baby has an NG tube see the article on this in the FACTS section of the website.
CHILDREN WITH PREVIOUS ORAL FEEDING AND MIXED FEEDING
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
Method 2
It is usually very easy to transition these children, as you will already be aware of their 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 outlined above, using foods you know they tolerate.
You can mix blended diet with formula during the transition phase, or continue with this combination long term if you prefer.
Some families report that continuing with formula prolongs vomiting or other issues, so bear this in mind if you find problems continue. It can be a good alternative, though, and if your child tolerates formula well, just do what you feel happiest with.
You could start by adding smooth Ella's Kitchen pouches to formula and then gradually increase the variety of foods, if this is helpful for your child. Reduce the volume of formula to match the volume of Ella's Kitchen puree being added. If you suspect an allergy or intolerance symptom just leave that food out for a while.
Often this type of child can eat safely but becomes tired and cannot eat enough to gain weight well. If that is the case feed what they can eat orally, then blend the remainder, add a little water and give it via the tube.
Again, be careful if your child is underweight. In this situation, do not reduce the formula until the calories provided by the blended diet match or exceed those being provided by the formula.
BOLUS FORMULA FEEDING
Toddlers and children who have medical formula throughout the day at set intervals (3-6 times) in boluses, either via a fast pump delivery or via a syringe
Screen for allergies and intolerances
Method 3
For Bolus Feeds over approx 30 minutes (although times can vary enormously)
If your child already tolerates a particular bolus volume of formula, this can provide a useful starting point for the volume of blended food. However, blended food may be tolerated differently, so start slowly and adjust according to your child's response.
A free-water bolus before the meal can help some children with volume tolerance. We find around 30-60 minutes beforehand works well. The amount should be individualised and forms part of the child's total daily fluid requirement. Your dietitian can help work out appropriate water and feed volumes.
Smooth commercial baby foods can be useful introductory foods because their consistency is predictable, although many are relatively low in calories. Initially, they may be better used alongside formula rather than as a direct replacement.
Introduce new foods gradually and start with foods that are usually well tolerated, such as smooth baby foods, sweet potato, avocado or banana. There is no need to follow a strict timetable.
When your child is comfortably managing enough blended food to provide the calories and volume of a formula feed, you can gradually replace that formula feed with BD. Continue adjusting the balance of food, calories and formula according to your child's tolerance, weight and nutritional needs.
Many families find it helpful to leave the overnight feed until later, particularly if it provides a significant proportion of their child's calories. Once your child is managing several daytime meals and snacks, you can discuss reducing or removing it with your dietitian.
Increase feed volumes gradually. There are no hard-and-fast rules. If your child shows discomfort, vomits or appears unable to tolerate the volume, slow the feed or reduce the amount and discuss persistent problems with your clinical team.
Some children find larger amounts of fat less well tolerated. If this happens, your dietitian can help adjust the balance of the meal while still providing sufficient energy and essential fats.
Take it slowly. Small amounts, familiar foods and a comfortable feeding rate can make the transition much easier. Every child is different.
CONTINUOUS PUMP FEEDING
For children who have always been continuously pump fed (24/7) with medical formula and/or breast/baby milk.
Gradual transition/Screen for allergies and Intolerances
Method 4
These children may initially tolerate only very small amounts of blended food. BD can be introduced gradually by pump or small amounts by syringe, depending on the child's tube, equipment and tolerance.
Start with a small amount of BD during a formula-free period and increase very gradually. A free-water bolus beforehand may help some children with volume tolerance; the amount should be individualised and included within their total daily fluid requirement.
For example, you might finish the overnight feed at 8 am and create a formula-free period until 10 am. During this time, you could give a small amount of water followed by 5–20 ml of a smooth blended food, such as a baby purée. Observe how your child responds and adjust the amount and timing according to their tolerance.
If your child tolerates formula, you can initially combine a small amount of blended food with some formula so that calories aren't lost. Alternatively, replace a small amount of the continuous formula with the equivalent volume of blended food during the formula-free period. As tolerance improves, gradually increase the real food and reduce the formula.
If your child is underweight or struggling to maintain their calories, it is particularly important to involve your dietitian when reducing formula. Higher-energy foods such as avocado or, once appropriately introduced, ground nuts can help increase the calories in a small volume.
There are different ways to make the transition. Some families gradually replace both the volume and calories of formula with blended food; others introduce small boluses of BD between pump feeds and gradually extend the formula-free periods. The approach will depend on your child's tolerance, nutritional needs and existing feeding pattern.
Don't worry if the process seems fiddly at first. It is a gradual juggling act, and there is no single correct way to do it.
Keep a close eye on your child's total fluid intake as the balance between formula, blended food and additional water changes. As you move away from continuous formula feeding and increase the amount of food, their free-water requirements may change. Your dietitian can help calculate the appropriate total fluid intake.
If your child shows discomfort, vomits or otherwise struggles with the volume, slow the feed or reduce the amount. Persistent vomiting or feeding intolerance should be discussed with the child's clinical team.
FUNDOPLICATION/VERY LIMITED TOLERANCE
Children with an established Fundoplication
Very Gradual Transition. Screen for Allergies and Intolerance
Method 5
If your child has had a fundoplication and has been continuously pump fed, take the transition very slowly. A child who does not have a fundoplication may vomit when their stomach becomes too full, but after a fundoplication this may not be possible. They may instead experience pain, retching or distress.
Use the same gradual approach as in Method 4 (moving from continuous formula feeding), but start with very small volumes and increase only as your child shows they can cope.
It is possible to give blended food through a pump, although it can be more complicated than bolus feeding. The blend needs to be extremely smooth to pass through the tubing, and fine sieving can remove some of the fibre and other nutrients.
A high-powered blender can make a big difference. I once made an overnight pumped blend containing goat's milk, banana, oats, cherry juice, fresh cherries and lettuce juice — all chosen because they were supposed to help with sleep! It was a major effort involving both a blender and a juicer, and it didn't improve anyone's sleep, but it did go through the pump without blocking. 😄
If too much of the blend is being lost through sieving, consider whether small bolus feeds of a thicker blend might be a better long-term option, particularly if nutritional intake is being compromised.
Some pumps may be able to handle thicker fluids with appropriate manufacturer-approved modifications or accessories, so it is worth asking your pump representative what is available. Currently I only know about the Kangaroo OMNI pump which can deliver thicker feeds. Do not alter giving sets yourself unless the change has been confirmed as safe and appropriate by the manufacturer or clinical team.
Keep blends moving through the giving set by squeezing the bag to prevent solids settling. Good hygiene is particularly important with pump-fed blends because the feed may be in the giving system for a prolonged period. Follow current clinical guidance and the equipment manufacturer's instructions for preparation, storage and administration times.
Some children cannot tolerate their required water as a bolus and may need water given via the pump. In my experience, giving water before rather than after a bolus blend can sometimes help with tolerance.