Blenderized Tubefeeding Mayumi Nakamura|Clinical Dietitian

Division of Gastroenterology August 5th, 2019

Objectives

Participants will be able to:

• Identify candidates appropriate for blenderized tubefeeding (BTF) • Implement a basic BTF plan • Evaluate patients on BTF and BTF recipes • Identify resources needed for families to implement BTF • Appropriately use commercial whole food formulas

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Case Study

• FL is 5 yr old with West syndrome, seizure d/o, OSA, CLD, multiple hospital admissions for PNA, GERD, h/o constipation and GT dependence.

• Constipation: Miralax ½ cap daily • Emesis: >3x/week • FTT: weight for age curve • Started BTF 7/2018 • Follow up in Aero clinic 7/2019

– Constipation resolved, Miralax discontinued – No longer vomiting, occasional spit up – Malnutrition improved – GT feeds were decreased to slow down weight gain

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Let’s start with a story…….

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Consultation: 10 kg weight gain . . .

Recipe • 1 cup spinach • 9 oz prunes (~30 each) • 6 oz dried dates (~10-15 each) • 1 cup blueberries • 1 cup corn • 2 cups bananas • 1 quart soy milk • 1 cup rice milk • 1 cup fresh spinach • 1 cup carrots • 2 cups bananas • 16 oz tofu • 4 stalks celery • 2 apples • 1 cup whole almonds • ¼ cup flaxseed

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Weight: 36.6 kg 105 kcals/kg, 4 gm protein/kg

Where parents are looking for help with BTF...

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Current Literature

Only 50% of parents in a study (N=433) reported health care provider oversight for blenderized tubefeeding management

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Current Literature

Mayo clinic survey (54 adults) • 55.5% of patients utilized blended food • 90% expressed desire for BTF if provided with adequate information • 83% - no symptoms on BTF • 67% no symptoms on commercial formula Oley Foundation survey (125 pediatric respondents) • 89.6% pediatric patients used BTF • 71% of total daily intake from BTF • 75% used homemade blends • 25% used commercial blended food product • 90.2% reported no weight loss with BTF in comparison to formula

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Current Literature

Improved tolerance to feeding and GI symptoms • 33 pediatric patients with feeding disorders requiring Gtube +

Nissen fundoplication • >50% of participants had 76-100% reduction of gagging and retching

Intestinal Failure • 10 pediatric patients with mean small bowel length < 48.3 cm • Solely tubefed with 20 kcal/oz elemental or peptide formulas • 9 of 10 patients had improved stooling pattern, able to transition

to 30 kcal formula with real food ingredients

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Microbiome/Gut Health

Elderly on single formula diet had least variation of gut microbiota • 178 elderly patients, diverse diet promotes diverse gut microbiota • 20 pediatric outpatients, proteobacteria reduced Changes in gut microbiome with BTF Stool bacterial diversity was improved upon a transition from commercial formula to BTF in 20 medically complex pediatric patients

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Why do families want BTF

• Allergies and Intolerance: Food allergens can be avoided in a customized blended recipe.

• Symptoms: Chronic gagging, retching, constipation, other symptoms of intolerance with commercial formula may improve with blended foods.

• Variety: The ability to customize blended food recipes allows for variation from meal to meal and day to day.

• Family Inclusion: Your entire family including your tube-fed child can share in the same meal.

• Transition: Exposure to the smells and tastes of whole foods can aid in the transition from a feeding tube to an oral diet.

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• have enthusiastic families

• have the necessary kitchen appliances and supplies

• >1 year of age

• can tolerate a variety of foods

• are fed through the stomach – Mature site – Tube size – Duration of feeds

• are medically stable

• are committed to regular medical follow-up

Best Candidates

Case Study

• AB is a 10 month ex-35 week preemie with VACTERL association, TEF with long gap esophageal atresia s/p repair, h/o esophageal stricture s/p dilation with concerns for laryngeal cleft, now s/p GT and nissen fundoplication at OSH. Recent UGI study showing delays in transit time at the level of anastamosis suggesting a partial stricture

• Formulas trialed: cows milk, elemental (via GT) • Regimen: 117 ml over 60-90 mins with breaks • Symptoms: constant fussiness after 60 ml formula delivered • PO: started refusing all POs after surgery

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• have enthusiastic families

• have the necessary kitchen appliances and supplies

• >1 year of age can start adding food to formula at 6 months

• can tolerate a variety of foods sometimes you don’t know and may have to start just like you would a 6 month old oral feeder

• are fed through the stomach – Mature site – Tube size – Duration of feeds

• are medically stable discussed options with medical team

• are committed to regular medical follow-up

Candidates

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• Time and labor

• Clogged tubes

• Food safety

• Volume – Blended whole foods often require a more volume for the same nutrient density

• Ongoing follow up visits

• Cost –may need to purchase an industrial strength blender and other supplies, be prepared for power outages or other natural disasters such as earthquakes

• Travel considerations

Challenges

Tools & Supplies

• Industrial blender (Vitamix and Blendtec) • Cutting boards and knives • Spatulas and spoons • Measuring cups • Measuring spoon • Strainer • Containers to store BTF • Thermometers • Dish rack - to air dry utensils and tools • Cold storage: refrigerator, freezer, portable, travel cooler

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Options for Blended Foods at CHLA

• 1) Commercial blended food product

• 2) CHLA standard recipes • 3) Custom recipe using a recipe matrix

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CHLA Standard Recipes

Inpatient orders available: • Standard 1.0 kcal/mL • Baby Foods 0.8 kcal/mL • Fluid Restricted 1.5 kcal/mL • Low Allergen 1 kcal/mL • Vegetarian 1 kcal/mL • Vegan 1 kcal/mL

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Pureed by G-Tube (Cincinnati Children's)

Recipe Ingredients: – commercial formula – sugar – oil – infant foods (stage 2) – Infant cereal

• No feeding pump needed • No blender needed • No whole foods needed • No cutting boards/knives needed • No refrigerator needed

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Custom Recipes: Recipe Matrix

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Building your own recipe

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Commercial Products

Evaluating BTF recipe/patients on BTF

Outcome Measures: • Anthropometrics: growth curves • Recipe Analysis

– Macronutrient balance – Micronutrients (DRI for age)

• Labs: – electrolytes – urine sodium – Specific nutrients dependent on recipe analysis

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In the works: Family Resource Guide

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Online Resources

• Tubefeeding: Oley Foundation • Food Safety:

– https://www.eatright.org/homefoodsafety – https://www.foodsafety.gov

• Recipes: – www.mealtimenotions.com – www.foodfortubies.com

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Insurance Auth for Whole Food Commercial Products

• Blended food products are NOT covered under MediCal/CCS

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References

Bobo E. Reemergence of blenderized tube feedings: exploring the evidence. Nutr Clin Pract. 2016;31(6):730–735. doi: 10.1177/0884533616669703 Claesson, M. J., Jeffery, I. B., Conde, S., Power, S. E., O’Connor, E. M., Cusack, S.,et al. (2012). Gut microbiota composition correlates with diet and health in the elderly. Nature 488, 178–184. doi: 10.1038/nature11319 Epp L. Blenderized feeding options - the sky's the limit. Pract Gastroenterol. 2018;(June) Hurt RT, Edakkanambeth Varayil J, Epp LM, et al. Blenderized tube feeding use in adult home enteral nutrition patients: a crosssectional Gallagher K, Mouzaki M, Haliburton B, et al. The blend study: A feasibility study looking at children transitioning onto blenderized tube feeds. J Parenter Enteral Nutr 2015;61:S206–S207 Johnson TW, Spurlock AL, Epp L, Hurt RT, Mundi MS. Reemergence of blended tube feeding and parent's reported experiences in their tube fed children. J Altern Complement Med. 2018;24(4):369–373. doi: 10.1089/acm.2017.0134. Mortensen M. Blenderized Tube Feeding Clinical Perspectives on Homemade Tube Feeding. Natl (Pediatric Nutr Pract Group) PNPG Post. 2006;17(1):1–4 Novak P, Wilson KE, Ausderau K, Cullinane D. The Use of blenderized tube feedings. ICAN Infant, Child, Adolesc Nutr. 2009;1(1):21–23. doi: 10.1177/1941406408329196. Pentiuk S, O’Flaherty T, Santoro K, Willging P, Kaul A. Pureed by gastrostomy tube diet improves gagging and retching in children with fundoplication. Journal of Parenteral and Enteral Nutrition. May 2011;35(3):375-379. Samela K, Mokha J, Emerick K, Davidovics ZH. Transition to a tube feeding formula with real food ingredients in pediatric patients with intestinal failure. Nutr Clin Pract 2017;32:277–281.

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BTF Phone a Friend

• • Mayumi Nakamura, MPH, RD, CSP, CNSC

Division of Gastroenterology, Hepatology & Nutrition • Children's Hospital Los Angeles

4650 Sunset Blvd., Mailstop #78 | Los Angeles, CA 90027 Phone: 323.361.6612 | manakamura@chla.usc.edu

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BLENDING TIME!

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