By Teresa Johnson, DCN, RDN, FAND

Jake began his life in the intensive care unit due to prematurity. He overcame many problems before being discharged but one issue persisted. Jake had under-developed lungs. This made breathing difficult and Jake’s calorie needs much higher than normal. He was given a high calorie infant formula in his bottle. Later, baby food was added to his diet, but Jake could not take in enough calories to grow. A nighttime tube feeding was added to supplement what he ate during the day. The nighttime tube feeding made things worse. Jake started vomiting, retching, and suffered from stomach pain when given food or formula. He stopped taking any food by mouth and even rejected his pacifier. For Jake, eating was a painful experience, and he wanted nothing to do with it. The healthcare team tried everything to resolve his feeding issues- including medications and surgery. Jake was referred to a feeding clinic to restore oral feeding skills and get his growth on track. The efforts of the team were useless until Jake’s mom made an unusual request: could Jake have real food tube feeding instead of formula?

This story reflects the growing desire for real food by many in the tube feeding population. Caregivers and patients have heard about the benefits of a whole food blenderized tube feeding (BTF). Many healthcare professionals (HCPs) endorse a healthy varied diet, and this same concept can be applied to tube-fed patients. Healthcare professionals are typically trained that only formula, water and medications should be put in a feeding tube. Parents have an opportunity to speak with healthcare professionals about BTF.

Step 1: Talk to Your Healthcare Provider/Medical Team

You’ll need to be prepared to explain why you are interested in BTF. There is strong evidence showing the benefit of BTF¹. Some who switched to BTF were able to wean completely from their tube feeding and eat by mouth. Partner with your medical team and provide them with resources and research articles like this one.

Step 2: Make sure you/the person you are caring for is a candidate for BTF

Practically anyone requiring a tube feeding is a candidate for BTF, but there are some considerations.

• Is the tube-fed person generally stable at home? In cases of acute care, a commercial formula might be needed until issues are resolved.
• Are you or the person you are caring for able to prepare safe food in a clean home environment if homemade blenderized tube feeding (hBTF) is the preferred option? Refrigeration temperature needs to be less than 41 degrees F. If BTF is stored in a freezer, the temperature needs to be zero degrees Fahrenheit. All utensils need to be clean. It’s best to cook all the ingredients to reduce risk of food-borne illness. Some foods do not blend as well as others. The Registered Dietitian-Nutritionist (RDN) can help with recipe development. It’s important to speak with your healthcare professional to determine the best option for you before proceeding.
• Do you or the person you care for require a specialized formula because of a digestion issue? Commercial peptide BTF formulas might be appropriate in this case. Check with your healthcare professional to discuss this option.
• What about the size of the feeding tube? Small bore tubes make it difficult to feed thick BTF. Although BTF may be given through any feeding tube, gastrostomy tube is preferred and at least a 12 to 14 French size is recommended.
• Do you or the person you care for require small volume feeding given over many hours? This is called continuous feeding, and it requires a feeding pump. Older pumps can’t handle the thicker BTF feeds. Although new feeding pumps are designed to deliver BTF, food safety guidelines prohibit food from being at room temperature for more than two hours. It might not be possible to deliver adequate nutrition in a two-hour time frame for a patient who can only take in small amounts. However, some commercial blenderized tube feeding products (cBTF) can be at room temperature for extended periods of time and can be delivered by pump.
• How will the BTF be given? Pump? Syringe? Gravity? New generation pumps on the market are designed specifically for BTF. A 60 mL syringe is the typical size. Feeding can take longer, and hand strength could be a challenge. A simple handle tool for enteral syringe feeding is available to help provide the force needed when feeding via bolus syringe. Gravity feeding using a feeding bag is also an option. However, the BTF must be given within the two-hour food safety window. The feeding should not be given too quickly; bolus feeding should equal the amount of time it takes to eat a plate of food- about 20 minutes. Smaller snacks in between meals take about 10 minutes to deliver.
• Another consideration is Will a provider cover the cost of the BTF? Most companies offering a commercial blenderized tube feeding product can help clients obtain coverage. Insurance companies do not cover the cost of homemade blenderized tube feeding. Nutricia Navigator is a helpful product coverage and access assistance program, which you may contact for free personalized one-on-one support.
• Those wanting homemade blenderized tube feeding need to account for the time commitment of cooking multiple meals per day. An expensive, high-capacity blender (1100 watts or greater) will be needed. The pitcher should be large enough to accommodate a liter of BTF (34 ounces or more). Most retail blenders cannot handle the volume of blending that homemade blenderized tube feeding requires. Baby food recipes are available for those who want to experiment with BTF before purchasing a commercial grade blender. Another option is to utilize one of the many available commercially prepared BTF products, such as Real Food Blends®. These are convenient alternatives to preparing BTF at home. Real Food Blends is 100% real food with no synthetic ingredients, offers variety with 8 different meals and a snack, and most closely mimics homemade blenderized tube feeding compared to other blenderized enteral formulas.
• Some make batch feedings and freeze homemade blenderized tube feeding for the week. This requires a lot of food storage space and must be taken into account. Others use a combination of commercial blenderized tube feeding and homemade blenderized tube feeding. Containers will need to be labeled and dated when stored in the refrigerator or freezer. Discard any unused homemade blenderized tube feeding in the refrigerator after 24 hours.
• Make a plan for situations where homemade blenderized tube feeding is not practical (e.g., travel, hospital admissions, school, etc.).

Step 3: Start Transition

After determining the type of BTF preferred and getting the needed materials to support BTF, transition begins. If homemade blenderized tube feeding is used, start with simple recipes and watch for any adverse reaction to a food. Ideally, one bolus commercial formula feeding will be replaced with BTF over several days. Some on a continuous tube feeding replace half of the commercial formula with a commercial blenderized tube feeding over several days. If no problems are observed, full transition can proceed over a one-week period. Your healthcare professional can also help identify a commercial blenderized tube feeding if desired. Many use commercial blended products exclusively or in combination with homemade blenderized tube feeding. The RDN can help with trouble shooting. Work closely with the RDN to make sure the prescribed BTF volume is given, and the patient meets nutritional needs and receives the proper amount of extra water.

Step 4: Monitor

Everyone on a tube feeding needs to have follow up with an RDN. This is especially true for the BTF-fed individual. The nutrition profile of the BTF needs to be compared to the nutrition needs of the individual and adjustments made if/when issues arise. Homemade BTF recipes need to be analyzed. Homemade recipe adjustment or supplements might be needed. Lab work, weight and growth patterns will need frequent monitoring. Drug/nutrient interactions should be considered.

Back to Jake

The feeding team mixed baby food green beans in Jake’s tube feeding formula while in the clinic and gave him a bolus feeding. They waited for the usual response- retching, vomiting, stomach pain- but it didn’t happen! Although the RDN and Jake’s mom had no experience with BTF, they worked together to find resources and transition him to home blended real food feeding. He began to take food by mouth again and was eventually weaned completely from the tube feeding.

Everyone’s story will be a little different. Jake’s mom was concerned for her son’s health as he could not tolerate more than ½ an ounce of formula in an hour! Others switch to BTF because they want feeding to feel less like another medical treatment. Many have different journeys to blended tube feeding, but state it’s the best decision they have ever made.

Dr. Teresa Johnson is a consultant for Nutricia North America and has been compensated to write this blog post.