BLENDED DIET FOR TUBE FED CHILDREN IN THE UK
Reasons given not to support your choice.
These are real concerns that parents have been given over the years. Some are reasonable questions; some are based on outdated information; and some confuse “not recommended” with “unsafe”.
My aim here isn't to tell you that blended diet has no risks. It does. It's to look at the reasons commonly given for refusing it and explain what we actually know.
Your child will become ill with food poisoning because you are unable to provide a sterile or clean environment to store and prepare food.
BD is not an easy option. Feeding any child well is not easy! BD is more expensive for the parent, more time-consuming and requires more nutritional knowledge than the norm. For these reasons, parents who opt to feed BD are generally well informed, willing to learn and able to understand the importance of good food hygiene.
If you are unsure about food hygiene, it is inexpensive and straightforward to complete a food hygiene certificate online, and I would strongly recommend doing one.
BD does require careful food hygiene, but food safety is not unique to blended diet. Whether food is being eaten orally or given through a feeding tube, careful preparation, storage and handling are important.
Older research raised concerns about bacterial contamination of blended feeds, much of it from hospital-based preparation and feeding. More recent work has helped us understand how preparation, storage and handling affect this risk. We now know that carefully prepared blended food can be used safely when appropriate food-hygiene practices and storage times are followed.
When I first wrote this website, there was much more resistance to BD, so I included a lot of the research to challenge the idea that blended food was inherently unsafe. Thankfully, we don't need quite so much evidence to make that argument now!
The important thing is simple: learn good food hygiene, prepare food carefully, follow appropriate storage and administration guidance, and treat BD with the same care you would any food prepared for a child.
Your child will become malnourished
The nutritional side of BD can be understood and implemented using conventional learning, supported by nutritional input from a dietitian. A high-speed blender is usually helpful, although it is not essential when starting out. Food provides a wide range of nutrients and naturally contains compounds, including fibre and naturally occurring microorganisms, that are not necessarily present in the same way in every formula. The human digestive system evolved to process food, and for some children, returning to normal digestion and bowel movements can make a positive difference to constipation and toilet training.
Many children enjoy being part of family mealtimes, even when their own food is blended and given through their tube. A child can be involved in choosing and preparing their food, and parents can once again experience the pleasure of nurturing their child with food.
If a child is able to eat orally, seeing and smelling food and joining in with family meals may also help stimulate interest in eating. Some families choose to combine BD with formula, while others eventually move towards a fully food-based diet. There is no single right way.
A well-balanced blended diet can provide all the nutrients a child needs when it is appropriately planned for their individual requirements. For some children, particularly those who have struggled with vomiting or gastrointestinal symptoms on formula, families report improvements in tolerance, appetite, bowel function and overall wellbeing.
Good nutrition supports growth, development and health — and food can be about much more than calories and nutrients. It can be part of family life, enjoyment and nurturing too.
You will block the tube. The child will need surgery to replace it.
Yes and no.
Tube blockage is a genuine possibility with any type of enteral feeding, but it can be reduced considerably by careful preparation. Using a high-speed blender and, where appropriate, sieving the blend can help produce a smooth enough consistency for the particular tube or button being used.
Medication is one of the most common causes of feeding-tube blockages, and this can happen with formula as well as BD. With us, fruit seeds have been the main culprits!
Some larger-bore PEG tubes are less likely to block because of their wider lumen. However, if a bumper-style PEG does become blocked, replacement may require medical intervention, which is clearly something everyone would prefer to avoid. Careful blending and sieving are therefore particularly important with these tubes.
Buttons and NG tubes can usually be replaced without surgery when necessary, but replacement is still inconvenient and can be expensive. It makes sense to reduce the risk of blockage wherever possible.
Research has also looked at the relationship between tube size and blockage when giving bolus blended feeds. One laboratory study found that larger tubes were less prone to blockage, while blockages in the smaller tubes tested could be cleared with water. The study provides useful information about tube size and blended-feed consistency, although laboratory findings cannot predict exactly what will happen with every child and every blend.
The important message is that a blocked tube is not inevitable. Good blending, appropriate sieving, adequate flushing and careful medication administration can all help reduce the risk. Always follow the instructions given by your clinical team for preventing and clearing blockages.
We cant allow BD because if something goes wrong we can be sued.
This was a concern I heard quite often in the early days of BD.
The risk of complaints or litigation can be managed in much the same way as other areas of healthcare: with appropriate assessment, clear communication, good training, proper hygiene and nutritional advice, and agreed procedures for supporting the child.
A written agreement or disclaimer can help clarify what has been discussed and agreed between the parent and the organisation, although it is not necessarily legally binding. Risk-assessment and planning documents, such as those developed by PENG, can also be very useful in making sure that everyone understands their responsibilities.
Parents should receive appropriate advice and support, just as they would when using formula, but with the additional considerations that come with preparing and administering BD.
Of course, things can go wrong with any form of healthcare or feeding. The important thing is to identify and manage the risks rather than assume that BD cannot be provided simply because there is a possibility of a complaint or litigation.
Good procedures, appropriate training and clear responsibilities protect everyone — the child, the family and the organisation.
The blended food would need to be so thin to go down the tube it would have very little nutritional value.
This is another common misconception.
BD does not necessarily have to be as thin as formula. If a child has limited volume tolerance, an ordinary meal can be made more calorie-dense by adding nutritious, energy-rich ingredients rather than simply increasing the volume.
Most of my meals are around 400 calories in 250 ml. This is similar in principle to formula, which concentrates calories into a relatively small volume.
A blend also does not have to be watery. Provided it can be given through the child's tube or syringe without excessive pressure, it can be a much thicker consistency — more like a thick batter.
It is therefore possible to make relatively small-volume, energy-dense meals. In my experience, blends of 1.5–2 kcal/ml can be achieved, although the appropriate consistency, volume and energy density will vary from child to child.
If your child has poor volume tolerance or is underweight, nutritional planning with a dietitian is particularly important.
The cost implication for the NHS is too great
There may initially be an additional cost in dietetic and nursing time while a family learns how to prepare and manage BD safely. Once the principles are established, however, many families become confident and independent, with ongoing nutritional monitoring forming part of their child's usual care.
There are also potential savings to consider. Home-prepared BD can substantially reduce the amount of commercial formula required, particularly for children who move towards a predominantly food-based diet.
If a child has previously experienced vomiting, constipation or other gastrointestinal problems associated with formula, improvements in tolerance may also reduce the need for some medications or additional healthcare. These potential savings are worth considering by the NHS, provided they are not expected to fund an £800 blender. They can signpost charities though.
It is also important to remember that a child who does not tolerate formula may require considerable dietetic, medical and hospital input. For some families, supporting BD may therefore require less ongoing intervention rather than more.
The tube might burst and the blend needs to be much thicker
We have already covered tube pressure and the different types of feeding tubes and buttons in The Facts section.
Blended food does not necessarily need to be thinned to the consistency of formula. If it can be given by bolus without excessive pressure, a blend can be considerably thicker — even a thick-batter consistency.
The nutritional value does not have to be sacrificed to achieve this. In my experience, it is possible to make relatively small, energy-dense meals, for example around 250 ml providing 1.5–2 kcal/ml, depending on the ingredients and the child's individual requirements.
The important thing is to use equipment appropriate for the blend, avoid excessive pressure and follow the manufacturer's and clinical team's advice.
For more information about tube pressures, tube size and the different types of buttons and tubes, see The Facts.
In schools and respite it is a health and safety issue and also a storage issue
Food hygiene and appropriate storage are important whenever food is prepared for a child, but BD should not automatically be treated as something that cannot be accommodated in a school or respite setting.
Schools already have food-hygiene procedures and standards in place. The practical issue is usually how best to accommodate the individual child without disadvantaging them.
If BD is prepared at home, it can be refrigerated and transported appropriately, with the school or respite setting following the agreed storage and administration arrangements. It is often easiest for the parent to send the prepared food in a form that is straightforward for staff to manage, such as clean containers or prepared syringes, provided this fits with local procedures.
Some schools and hospices are now preparing blended meals from their own menus for tube-fed children. It is becoming much more normal than it was when we started our journey.
For more information about food storage and administration times, see the guidance in The Facts section.
The balloon will burst if the feed is too thick
This is another concern I have heard about giving thicker blends through a button.
The feed travels through a separate channel within the button, alongside the balloon that holds the button in place. It would be very difficult to exert enough pressure at the precise point needed to rupture the channel and damage the balloon simply by giving a thicker blend.
As with any feeding equipment, however, excessive pressure should never be used. If a blend is too thick to pass easily through the button, stop and check the consistency and equipment rather than forcing it.
This video shows food, water and formula travelling through a button into an imaginary stomach and is useful for visualising how the different fluids travel through the device.
Food may go into the abdominal cavity and cause peritonitis if the balloon or tubing burst
When a gastrostomy is first created, a bumper-style PEG is often used to hold the stomach securely against the abdominal wall. Over time, the stomach wall and abdominal wall form a tract around the gastrostomy site, creating a sealed channel between the stomach and the outside.
According to the gastric surgeon who explained this to me, this joining rarely breaks down, although it is possible.
If the tract did break down and stomach contents entered the abdominal cavity, peritonitis could occur and this would be a serious medical emergency. This applies whether the stomach contents are blended food or formula — the important issue is that the material has entered the abdominal cavity.
A breakdown of the tract is more likely if there is significant inflammation or infection around the gastrostomy site. These problems should be visible and treated promptly.
This is a rare but serious complication of gastrostomy feeding, rather than something unique to blended diet. Any concerns about pain, swelling, leakage or a change in the appearance of the gastrostomy site should be discussed promptly with the child's medical team.
If the child vomits blended food and aspirates it into their lungs, its not so bad if it is sterile formula
Aspiration of anything into the lungs can be serious. Sterile formula is not harmless simply because it is sterile — it is still a substance that is not supposed to be in the lungs.
Both formula and blended food can cause serious respiratory complications if aspirated, so the important issue is preventing aspiration and managing the individual child's risk, rather than assuming that formula is automatically safer.
Of course, many families report that their child's vomiting and reflux improve when they move to BD. This may reduce the opportunities for aspiration in children for whom vomiting has been a problem, although this is not something that can be guaranteed for every child.
If your child has a known aspiration risk, this should always be discussed with their medical team before changing their feeding method.
There has been no research to support giving blended diet and what research there has been has been negative.
This was certainly an argument I heard in the early days of BD, but things have changed considerably.
There is now a growing body of research into blended diet in both children and adults, with studies reporting positive outcomes, particularly around gastrointestinal symptoms, tolerance and quality of life. The evidence is still developing and much of the research is relatively small or observational, but it is certainly not accurate to say that there is no research supporting BD or that the available research is negative.
Research has also looked specifically at children with gastrostomies and fundoplications, with encouraging findings around reflux and gastrointestinal symptoms.
There have been historical reports of illness associated with liquidised tube feeding, particularly in hospital settings. These highlighted the importance of food hygiene, preparation and storage, but they should be viewed in the context of the feeding practices and healthcare environment of the time.
Today, we understand much more about safe food preparation and storage. At home, preparing a child's blended meal can be very similar to preparing the same meal for the rest of the family — the food is simply blended and then administered through the feeding tube using appropriate hygiene and equipment.
The research is no longer saying “don't do it”. It is helping us understand when BD may be beneficial, how to do it safely, and where more research is still needed.
There is an ever growing body of evidence linked to feeding tubes, blended diet, safety and support from very reputable sources. I've not linked them or cited them as AI search engines can easily pull this evidence up should you require it. Evidence can quickly become old and outdated, hence I've omitted the research data previously used to support this website.