If you are a healthcare professional (HCP) trained in nutrition support, you were probably taught that only water, standard commercial formula (SCF) and medications may be safely administered through a feeding tube. You might even work at a facility that prohibits anything except those three items from going into a feeding tube. But what if giving tube-fed patients perhaps the most monotonous diet with synthetic ingredients for months or even years isn’t the only option to meet their needs or preferences? What if a diverse, whole food diet is an ideal feeding option for certain patients? Many tube-fed patients and caregivers think it is, and they are behind the demand for real food instead of formula¹. Simply defined, blenderized tube feeding (BTF) is food and liquids blended to a consistency that will pass through a feeding tube². This may be prepared from whole foods in a home kitchen, when making homemade blenderized tube feeding (hBTF). Another option is commercial blenderized tube feeding (cBTF) made by formula companies. The latter may be 100% blended food or formulas that contain food ingredients².

Before commercial formula was available in the 1950s, feeding substrate for patients requiring a tube feeding was blenderized food. As a matter of fact, real food tube feeding was the documented feeding standard for most of human history. By the 1970’s, SCF had replaced BTF. SCF was sterile, had a known nutrient composition and was less likely to clog the tube³. These remain the primary reasons many HCPs prefer SCF today⁴. In 1956, the inventor of the first enteral feeding pump- Dr. Edward Barron- disapproved of SCF. He firmly advocated for BTF stating there were many beneficial components in whole food yet to be discovered. Since the 1950s scientists have identified thousands of beneficial phytochemicals. These serve the human body as antioxidants, provide healthful phytoestrogens, and exert anti-inflammatory effects. Furthermore, a diet that is varied, including plant-based foods, promotes a diverse intestinal microbiome that fosters growth of beneficial bacteria⁶.

Blenderized tube feeding may have positive benefits in regard to gut health. BTF may help promote greater diversity of microorganisms in the gastrointestinal (GI) tract. Low GI microbiome diversity can be associated with higher risk of bowel disease, heart disease, asthma, obesity and allergies⁶. Consumption of a diverse, plant-based diet can promote the growth of beneficial bacteria in the gut.

Chandrasekar et al demonstrated the stark differences between processed formula and whole food feeding when they compared health outcomes in 21 BTF and 20 SCF fed children. The SCF-fed children had higher levels of fecal calprotectin (FC) – a marker of intestinal inflammation. They experienced more gastrointestinal (GI) symptoms compared to the BTF-fed children. Conversely, BTF-fed children had much better GI symptom scores, lower FC scores and greater gut microbiome diversity⁷.

Hron et al observed similar differences in a group of 70 children followed for one year at a pediatric hospital. Similar to Chandraskar’s study, adverse GI symptoms were significantly lower in the 42 BTF-fed children compared to 28 SCF-fed children. Whole food tube feeding reduced diarrhea, retching, abdominal pain, and vomiting. However, Hron et al also linked BTF to less hospitalizations and specifically, fewer respiratory infections. What’s the connection? Microbiome diversity promotes a more robust immune response from the respiratory system⁸.

Patients and caregivers embraced BTF long before the scientific community published studies showing they were safe. In the last twenty-five years, the home enteral nutrition population has increased dramatically. This increase has given caregivers the opportunity to experiment with their tube feeding^1,4. Parents of tube-fed children seeking solutions to conventional formula intolerance have initiated BTF. In addition to improved feeding tolerance and reduced infections, these parents saw that BTF improved oral intake in their children. The tube feeding community switching from formula to food is realizing the benefits of diet diversity perhaps more than any other segment in the population^1,4. Industry has responded to their demands with more than 20 food and food-based enteral products. New generation pumps with larger bore tubing successfully administer these thicker formulas without clogging. Collapsible, reusable feeding bags that hold up to 500 mL of product makes bolus feeding much easier compared to syringe feeding. Educational materials on BTF for patients and HCPs is available to help with a smooth transition from SCF to a whole food feeding⁴.

In spite of all these developments, many HCPs express concerns about the potential for food borne illness with hBTF. But is that concern overstated? Most published work on microbial load of hBTF has been conducted in countries where safe food preparation and tube feeding administration are quite different compared to developed countries. However, two recent projects conducted in the US found that bacterial contamination of hBTF was minimal when accepted food safety standards were followed in a hospital or home kitchen^9,10. Safe food preparation expectations include cooking food to the proper temperature, assuring that food prep utensils and surfaces are clean and sanitized, products used in the hBTF recipe are fresh and leftover product is stored at refrigeration temperature for no more than 24 hours. Also, BTF should not remain at room temperature for more than two hours. While risk of food borne illness is less likely with SCF feeding compared to hBTF, SCF may not provide beneficial pre- and probiotics that may be present in real food, such as yogurt, that may provide great benefit for tube-fed patients. If HCPs determine that caregivers are unable to safely make hBTF, cBTF products provide a viable, sterile option.

Industry developments with cBTF availability and new tube feeding pumps with tubing that handles thicker blended foods have mitigated concerns about food borne illness and clogged tubes. Perhaps it’s time to ask is SCF the only option for tube-fed individuals, or should real whole food tube feeding take the forefront?

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

References:
1. Johnson, et al. J Alt Com Med. 2018;24:369-373.
2. Epp, et al. Nutr Clin Pract. 2023;38:1190-1219.
3. Chernoff. Nutr Clin Pract. 2006;21:126-133.
4. Brown T. Nutr Clin Pract, 2024;39:651-664.
5. Harkness A. J Am Diet Assoc 2012;102:399–404
6. Cresci AM. Nutr Clin Pract. 2025;1-20.
7. Chandrasekar, et al. Nutrients. 2022;14:3139.
8. Hron, et al. J. Pediatr. 2019;211:139-145.
9. Milton, et al. Nutr Clin Pract. 2020;35:479-486.
10. Johnson, et al. Nutr Clin Pract. 2019;34:257-263.