Carol Rees Parrish, M.S., R.D., Series Editor Blenderied .
NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #136Carol Rees Parrish, M.S., R.D., Series EditorBlenderized Tube Feeding:Suggested Guidelines to CliniciansArlene A. EscuroBlenderized tube feeding has been gaining momentum among patients despite theavailability of commercially prepared and nutritionally complete enteral formulas.There is little published research on the efficacy of this feeding option, yet beforecommercial formulas, this was the only option. This article will review perspectivesand provide clinicians with basic guidelines for planning and implementingblenderized enteral feedings when our patients request this feeding option.INTRODUCTIONBefore the availability of commercial enteralformulas, “blenderized” foods were prepared inhospital kitchens to create liquid mixtures givenby bolus syringe method through large-bore nasogastricand gastric tubes. As technology continued to advance inthe 1970s, commercial formulas of defined compositionwere introduced for tube feedings.1 Blenderized tubefeeding (BTF) became a less desirable option whencommercial formulas became more affordable, easyto use, and widely available. The risk of microbialcontamination and labor intensity were the primaryreasons BTF were abandoned by most healthcarefacilities. Commercial enteral formulas are packagedaseptically and are approved to hang for 48 hours as aclosed system reducing administration error and timeinvolved with tube feeding. Unfortunately, the onlyArlene A. Escuro, MS, RD, LD, CNSC, AdvancedPractice Dietitian, Nutrition Therapy, M17,Center for Human Nutrition, Digestive DiseaseInstitute, Cleveland Clinic, Cleveland, OH58tubing available in the U. S. for use with these productscannot hang for more than 24 hours (so this touted48 hour benefit is not really a benefit). Studies havedemonstrated that the microbial quality of hospitalprepared BTF was not within the published guidelinesfor safety.2-3 However, in many parts of the world,especially in developing countries, the use of hospitalprepared formula is a routine practice due to economicor cultural reasons.2-4Compared with commercial formulas, preparationof BTF can be labor intensive and the cost (is rarely,if ever) covered in medical plans. In addition, thereare food safety concerns and uncertainty about thenutritional value of non-standardized recipes. Forthese reasons, clinicians are hesitant to recommend thisoption to an already stressed and exhausted patient and/or caregiver. Several studies have shown that hospitalprepared formulas provided unpredictable levels ofmacro and micronutrients, delivered less than thedesired amounts of nutrients, and increased the risk of(continued on page 60)PRACTICAL GASTROENTEROLOGY DECEMBER 2014
Blenderized Tube Feeding: Suggested Guidelines to CliniciansNUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #136(continued from page 58)tube occlusion due to viscosity, making it unsuitablefor reliable infusion through feeding tubes.2,4However, there remains a subset of the populationwho are interested in this feeding option. BTF has beengaining popularity among home enteral nutrition (HEN)patients, particularly the pediatric population. Manypatients and families choose BTF because of perceivedhealth benefits, intolerance to commercial feedingformulas, food allergies, improved bowel function,psychosocial reasons, or personal preference (desirefor “real” food, organic, vegetarian, etc.).5-6Use of Blenderized Tube FeedingBTF is defined as the use of blended foods and liquidsgiven directly via the feeding tube. Historically, thesetypes of enteral formulas have been called “blendeddiet”, “blenderized feeding,” “blended formula,”or “homemade blended formula.” The practice ofincorporating BTF into a feeding regimen could be acombination of a commercial formula and commercialpureed baby food, or three meals a day of homemadeblenderized foods supplemented by nocturnal feedingof a commercial formula, or complete feedings usinghomemade BTF made from recipes, and many variationsin between. The introduction of ready to use BTF in themarketplace has also provided HEN patients with anoption over commercial enteral formulas. Regardlessof how a patient uses BTF, it is essential to identify acommercial enteral formula for emergency situations,or when traveling when refrigeration is not available.7There is little published research available tosupport the efficacy of BTF that translate into anytype of beneficial outcomes of this feeding technique.There are numerous anecdotal reports from patients,caregivers, and medical professionals of positiveexperiences that have been shared through informalpatient questionnaires, feeding support groups on theinternet, social media, professional discussions andclinical experiences.5-9One feeding clinic reported both medical andemotional benefits from the use of BTF.7 It allowedfor some normalization of the feeding process forgastrostomy tube-fed patients, greater volume tolerance,and improvement in reflux and constipation, and itfacilitated the transition from tube to oral feeding. Theuse of blenderized foods allowed for inclusion of atube-fed patient in family mealtimes and a sense of“normalization” of gastrostomy tube feedings. It also60 Table 1. Factors to Consider Before UsingBlenderized Tube Feeding5,7,9 Medically stable HEN patient Medical team support Dietitian support and availability for guidanceand direction Patient/family demonstrate understanding ofgood food practices, importance of cleanequipment, etc. Size of Gastrostomy tube is 14 French G tube site has matured, healed withno infection Patient with proven tolerance to bolus feedings Availability of bolus extension set for low-profileG tubes Stable on commercial enteral formula (unlessthere is severe tolerance issue with commercialformulas) Patient/family motivated and willing to committhe time to prepare BTF Ability to follow recipe instructions and meetfood safety guidelines Adequate financial and material resources(refrigeration, heavy-duty blender, air tightstorage containers, clean water supply, food,multivitamins) HEN patient with jejunal feeding tube shouldseek medical permissionpromoted the view of the G tube as another mouth,thereby priming the gastrointestinal system for thecomplexities of food.The interdisciplinary feeding team at the CincinnatiChildren’s Hospital Medical Center (CCHMC)conducted a feeding trial using a pureed diet givendirectly into the feeding tube, referred to as the pureedby gastrostomy tube (PBGT) diet. It was designed forchildren with gagging and retching after fundoplicationsurgery.8 This was the first clinical trial using BTFPRACTICAL GASTROENTEROLOGY DECEMBER 2014
Blenderized Tube Feeding: Suggested Guidelines to CliniciansNUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #136Table 2. Obtaining Enteral Formulafrom the Oley Foundation1. Check the Oley website:www.oley.org/equipexchange.htmlfor a complete list of donated products.2. Send a list of product(s) needed tooleyequipment@aol.comor call (866) 454-7351 to confirm the productis still available. HEN patient/caregiver will beprovided with donor’s contact information.3. HEN patient/caregiver is required to arrange andcover the cost of shipping the donation.4. Shipping options: UPS (800) 742-5877or Federal Express (800) 463-33395. Things to consider: Each case of enteral formulaweighs approximately 17 lbs. and shipping maycost 20 per case depending on the distance.6. Make sure to inform the Oley equipment/supplyexchange program after receipt of donated formulato keep the list of available items updated.to manage the complications associated with enteralfeeding. Fifty-two percent of parents reported a decreasein gagging and retching after their child started thePBGT diet and 57% of children were reported to havean increased oral intake.8When to Consider Blenderized Tube FeedingTable 1 outlines the prerequisites before seriouslyconsidering the use of BTF. Ideally, a clinician mustfirst determine if a patient is a good candidate forBTF. However, a tube-fed patient may already havetransitioned to either partial or full homemade BTFregimen before a referral is made. Working with adietitian is essential to ensure that the homemade dietis adequate and whether the current homemade BTFrecipe plan needs modification. The best candidate isa patient and/or caregiver who made the decision to“try” this feeding option, and is willing to commit theirtime and effort for instruction and preparation of BTF.A patient who is having tolerance issues or allergy toa commercial enteral formula may also be a candidateafter discussion with the medical team and dietitian.PRACTICAL GASTROENTEROLOGY DECEMBER 2014 When Not to ConsiderBlenderized Tube FeedingBTF is not an option for all tube-fed patients. Patientswith complicated medical and gastrointestinal issuesand those who require frequent hospitalization maynot tolerate and sustain a BTF regimen. Often, thesepatients require specialized enteral formulas. A patientwho requires continuous feeding is not a good candidatesince a homemade blended formula is not recommendedfor feedings that will last for more than 2 hours due toconcerns over food safety and bacterial contamination.5Homemade BTF is generally thicker and canpotentially clog the feeding pump making it difficultto flow through the feeding set. Some patients havesuccessfully infused BTF through a feeding pump aslong as the mixture is thinned with additional fluid,blended, and strained sufficiently. Bolus syringe methodworks best and provides the pressure needed to move ahomemade blended formula down a feeding tube. It isrecommended for gastrostomy tubes 14 French size orlarger to prevent clogging and for ease of administeringthe diet.Tools for Success Heavy duty blendero Blendtec HP3 blender:www.blendtec.com(800) 253-6383o Vitamix : Inquire about Vitamix MedicalNeeds Discount Program which is availableto all eligible candidates at (800) 848-2469or email: household@vitamix.comreference code 07-0036-0011 Strainer or fine sieve if using a regularkitchen blender or stick blender(see Figure 1) Airtight storage containers, ice cube trays forfreezing individual portions Adequate refrigeration/ freezer space 60 mL syringe with plunger Bolus extension set for low-profilegastrostomy tube Feeding pump (if using)61
Blenderized Tube Feeding: Suggested Guidelines to CliniciansNUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #136Table 3. Commercial Ready to Use Blenderized Tube Feeding ProductsReal Food Blends NutrientsLiquid Hope (3-meal varieties)Serving sizeCompleat 360 mL (foil pouch)237 mL (foil pouch)250 mL cartonCalories (Kcals)440330-340265Protein (g)2311-1412Fat (g)1918-2010Carbohydrate (g)4728-3233Dietary fiber (g)102.2- 4.41.5Water (%)6375-8085 18.16 12.42 15.09Cost/1000 Kcalso Make sure BTF is thin enough to floweasily through the pumpo Discard BTF after 2 hours maximum if keptat room temperature for that long Insulated bag or ice chest with ice packswhen traveling Patient education on food safety guidelines(www.fsis.usda.gov, www.foodsafety.gov,www.homefoodsafety.org)Getting Started with a HomemadeBlenderized Tube Feeding Evaluate the patient’s medical history, success (ornot) with current feeding regimen (feeding tube, oralintake), food tolerances, lifestyle/ethnic/religiouspreferences, ability to obtain individual ingredientsand tools needed for preparing a homemade BTF.o USDA Choose My ls/supertracker.htmlThe supertracker feature providesindividualized worksheets where a profilecan be created to calculate and track a menuplan. A sample 1000 calorie meal plan willinclude: Grains: 3 servings Fruits: 1 serving Vegetables: 1 serving Protein (meat, beans, ornuts): 2 servings Milk or milk substitute:2 servings Fats: 3 servings Determine goals for calories, protein, fluids, andvitamin, mineral, and electrolyte supplementation.o Homemade blended formula worksheetsby Dunn Klein M, Morris SE. Homemadeblended formula handbook. MealtimeNotions, LCC, Tucson, AZ, 2007; 117-128;www.mealtimenotions.comThe worksheets were adapted from theUSDA My Pyramid. Develop a meal plan and starter recipe. Thefollowing tools can be used as starting point tocreate a meal plan based on caloric goals:o Sample Blenderized Tube Feeding Recipesat www.ginutrition.virginia.edu underResources for Nutrition Support Clinicians Discuss with medical team and determine if patientis ready to start the transition. Most patientstransition slowly and use a commercial formulafor part of nutrient requirements.(continued on page 64)62 PRACTICAL GASTROENTEROLOGY DECEMBER 2014
Blenderized Tube Feeding: Suggested Guidelines to CliniciansNUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #136(continued from page 62)Figure 1. Stick Blendero Nutrition and recipe analysis applications.Computerized nutrition programs such asFood Processor , Nutritionist Pro allowsthe clinician to add and modify foods whilemonitoring the total caloric and proteinlevels along with vitamin and mineralprofile. The clinician can save and retrievethe data for future reference.o USDA National Nutrient Database forStandard Reference: http://www.nal.usda.gov/fnic/foodcomp/searcho Exchange Methodo Food company websites/food labels Determine macronutrient food sources. Thefollowing examples work well in blenderizedtube feedings:o Grains: cooked cereals, boiled white orbrown rice, cooked quinoa, oats, regular orwhole grain breado Fruits: avocado, applesauce, peach, pear,banana, papaya, blueberries, 100% fruitjuice (pulp free). Commercial pureed babyfood (stage 2) can be used for variety,consistent nutritional value, and it alsoavoids the potential complication ofclogging the feeding tube. It is convenientespecially when traveling, and avoids theneed to purchase an expensive heavy-dutyblender. The patient can eventually advanceand transition to blenderized table foods.o Vegetables: white potato, sweet potato,carrots, squash, well-cooked broccoli. Canuse commercial pureed baby food (stage 2).o Protein: chicken, beef, legumes, soft tofu,smooth 100% peanut butter, cooked eggs,canned tuna or other fish without bones. Acommercial enteral formula can be used asthe base for a blended diet instead of meat,milk, or yogurt as the sole protein source(see Table 2). Milk and yogurt tend to blendmore easily than cheese.o Milk or milk substitute: cow’s milk, soymilk, almond milk, rice milk, yogurt, nonfat milk powder.64 o Fats: canola, olive, flaxseed, hemp and cornoils.o Example of a 1000 calorie blend: Grains: 1 cup cookedoatmeal and ½ cup cookedbrown rice Fruits: ½ cup peaches(canned or fresh) and ½ cupunsweetened apple juice Vegetables: ½ cup cookedcarrots and ½ cup cookedsweet potato, butternutsquash or pumpkin Protein: 2 ounces cookedchicken Dairy: 1 cup whole milkand 1 cup yogurt (plain) Fats: 3 tsp olive oil Review and modify the recipe using a recipeanalysis program to adjust the ratios ofmacronutrients to the desired composition.o A modular product (glucose, MCT oil,protein, fiber such as Benefiber ) can beadded to enhance the nutrient profile ofblenderized enteral feedings.PRACTICAL GASTROENTEROLOGY DECEMBER 2014
Blenderized Tube Feeding: Suggested Guidelines to CliniciansNUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #136Table 4. Additional Resources on Blenderized Tube FeedingGeneral Complete Tube Feeding: everything you need to know about tube feeding, tube nutrition, and blended dietsby Eric Aadhaar O’ Gorman, 2012, www.completetubefeeding.net Coping Well with Home Enteral Nutrition by Cheryl Thompson, PhD, RD, www.copingwell.com/copingwell Feeding Tube Awareness Foundation: non-profit organization dedicated to promote awareness and provideparents and caregivers of a child who is tube-fed, www.tubefeedingawareness.orgRecipes Homemade Blended Formula Handbook by Marsha Dunn Klein MEd., OTR/L andSuzanne Evans Morris, PhD, CCC-SLP, 2007, available for purchase at www.mealtimenotions.com Making your own food for tube feeding: www.oley.org/lifeline/TubetalkSO07.html Sample Blenderized Tube Feeding Recipes at www.ginutrition.virginia.edu under Resources forNutrition Support Clinicians Food for Tubies is a blended food resource group at www.foodfortubies.org Seattle Children’s: Homemade Blenderized Tube Feeding, www.seattlechildrens.org Complex Child e-magazine articles on GI and Nutrition at www.complexchild.com/gi.htmlFood Allergies Adult Allergies and Enteral Nutrition Tables for Selected Allergies by Kendra Glassman, MS, RD, CNSC,www.ginutrition.virginia.edu under Resources for Nutrition Support Clinicians Groetch M. Food Allergies: Dietary Management. Practical Gastroenterology 2013;XXXVII(11):46. Henry M. Nutrition Guidelines for Treatment of Children with Eosinophilic Esophagitis. PracticalGastroenterology 2014;XXXVIII(6):21. Determine fluid goals. The percentage of freewater is calculated from the blended recipeby multiplying the total volume of fluidcontaining ingredients (commercial formula,meats, fruits, vegetables, milk, and yogurt)in ounces by 0.75. This is based on theassumption that most infant foods containroughly 75% free water (9). Additional freewater is determined from the differencebetween estimated daily fluid requirementand amount of free water of the blendedrecipe. Determine need for vitamin, mineral, andelectrolyte supplementation. Perform a recipeanalysis. Request labs as appropriate for anynutrients of concern. A multivitamin may becrushed and added to one of the bolus feeds.A liquid multivitamin is an option, but is notalways complete—make sure patient gets thePRACTICAL GASTROENTEROLOGY DECEMBER 2014 right one. Oral rehydration solution (ORS)can be given instead of free water flushesbetween bolus feeds. Patient and/or caregiver educationo meal plan, ingredients, starter recipeo equipment: blender, strainer, 60 mL syringe,storage containerso preparation detailso proper sanitation methodo proper storage and refrigerationo administration method and feeding schedule(bolus syringe, pump)o water or oral rehydration solution flusheso vitamin/mineral/electrolyte supplementationif neededo travel/emergency plan65
Blenderized Tube Feeding: Suggested Guidelines to CliniciansNUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #136 Patient monitoring and follow-up. Schedulecall-back, follow-up visit to monitor weights/weight changes, modify/adjust BTF recipe.Commercial Ready to Use BlenderizedTube Feeding Products — See Table 3 Liquid Hope . Ready to use organic wholefoods. The manufacturer recommendsswitching to Liquid Hope slowly, one mealper day until the transition is complete. Theunopened formula is shelf stable for up to 2years. It has a 3-hour room temperature holdtime and unused formula can be refrigeratedfor 48 hours. The formula can be diluted withwater to achieve the desired consistency.Patients can order online ( 7.99 per 12-ozserving; available in units of 6, 12, or 24).Medicare approved code for this product isB4149 (blenderized natural foods with com Real Food Blends . Pre-made blenderizedmeals, available in 3-meal varieties (SalmonOats and Squash, Orange Chicken Barleyand Carrots, Quinoa Kale and Hemp) and isshelf stable for 18 months. Unused formulashould be refrigerated and used within 24hours. The quinoa meal is slightly thickerand may require additional fluid to floweasily. Patients can order online ( 49.95 for12-pack meals); approved by CMS HCPCSfor code B4149 (blenderized natural foodswith intact nutrients).http://www.realfoodblends.com Compleat . Formulated with real foodingredients: chicken, peas, carrots,tomatoes, and cranberry juice. Available in250 mL carton and 1 liter closed system.HCPCS code B4149 (blenderized naturalfoods with intact nutrients). tUse of Blenderized Tube Feedingand the New ENFit ConnectorsThe new enteral connector (ENFit) system is beingintroduced in phases and is expected to be completedin 2015. GEDSA (Global Enteral Device Supplier66 Association), Kimberly-Clark, and A.S.P.E.N.(American Society for Parenteral and Enteral Nutrition)recently conducted experiments to determine thepressure required to dispense a BTF through a 60 mLsyringe (catheter tip and ENFit) and to check the gravityflow (mL/min) of BTF through the connectors.10 TheBTF was tested just coming out of the refrigerator tosimulate clinical conditions. It took about the samepressure to push the BTF through the catheter tip andENFit syringe, but was actually easier with the ENFitconnector. The testing also showed that the gravity flow(mL/min) of BTF for ENFit and catheter tip syringeswere essentially equivalent through two gastrostomytubes (Kimberly-Clark 18fr/20fr PEG with solid bolsterand balloon retained G tube feeding systems).SUMMARYThe process of transitioning to BTF can be anoverwhelming task for both the patient and clinician.Homemade blended diets are often described asnutritionally unbalanced, have increased risk for foodcontamination, and may compromise the enteral accessdevices. BTF can be used for partial, supplemental, orcomplete nutrition support. It can be safely used andimplemented with the involvement of the medical teamand support from the RD to assess, educate, and monitorthe patient’s progress toward this feeding option. SeeTable 4 for additional resources. nReferences1.Campbell SM: An anthology of advance in enteral tube feedingformulations. Nutr Clin Pract 2006; 21: 411-415.2. Sullivan MM, Sorreda-Esguerra P, Platon MB, et al: Nutritionalanalysis of blenderized enteral diets in the Philippines. Asia PacJ Clin Nutr 2004;13(4):385-390.3. Jalali M, Sabzghabaee AM, Badri SS, et al: Bacterial contamination of hospital-prepared tube feeding formulas in Isfahan, Iran.J Res Med Sci 2008;14(3):149-156.4. Borghi R, Araujo TD, Vieira RIA, et al: ILSI task force onenteral nutrition; estimated composition and costs of blenderizeddiets. Nutr Hosp 2013;28 (6):2033-2038.5. Klein MD, Morris SE. In: Homemade Blended Formula,Mealtime Notions, LLC, Tucson, AZ, 2007.6. Johnson TW, Spurlock A, Galloway P: Blenderized formula bygastrostomy tube: a case presentation and review of the literature. Top Clin Nutr 2013;28(1):84-92.7. Novak P, Wilson KE, Ausderau K, et al: The use of blenderizedtube feedings. ICAN: Infant, Child, & Adolescent Nutrition2009;1:21-23.8. Pentiuk S, O’Flaherty, Santoro K, et al: Pureed by gastrostomytube diet improves gagging and retching in children with fundoplication. J Parenter Enteral Nutr 2011;35:375-379.9. O’Flaherty T, Santoro K, Pentiuk S: Calculating and preparinga pureed-by-gastrostomy-tube (PBGT) diet for pediatric patientswith retching and gagging postfundoplication. ICAN: Infant,Child, & Adolescent Nutrition 2011; 3:361-364.10. Guenter P, McMichael D: Further updates on blenderized dietuse with the new enteral connectors. In: Lifeline Letter, TheOley Foundation, 2014;XXXV(4):3.PRACTICAL GASTROENTEROLOGY DECEMBER 2014
48 hour benefit is not really a benefit). Studies have demonstrated that the microbial quality of hospital-prepared BTF was not within the published guidelines for safety.2-3 However, in many parts of the world, especially in developing countries, the use of hospital-prepared formula is a
Revenge of the Cyst –Part II NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #55 Joe Krenitsky, MS, RD, Nutrition Support Specialist; Diklar Makola, MD, MPH, PhD, Gastroen-terology Fellow; Carol Rees Parrish MS, RD, Nutrition Support Specialist all at Digestive Health Center of Excellence, University of Virginia Health System, Charlottesville, VA.
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WEST COAST HOTEL CO. v. PARRISH. 379 Syllabus. WEST COAST ttOTEL CO. v. PARRISH ET AL. APPEAL FROM THE SUPREME COURT OF WASHINGTON. No. 293. Argued December 16, 17, 1936.-Decided March 29, 1937. 1. Deprivation of liberty to contract is forbidden by the Constitution if without due process of law; but restraint or regulation of this .
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