1
|
Velly Miguel M, Haubrick K. Systematic review: exploring outcomes of commercial and homemade blenderized tube-feeding regimens on feeding tolerance in pediatric patients. Nutr Rev 2024; 82:1208-1215. [PMID: 37791488 DOI: 10.1093/nutrit/nuad118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023] Open
Abstract
CONTEXT Increasing numbers of patients and caregivers are requesting transition to blenderized tube feeding. There is a lack of systematic reviews addressing the outcomes of blenderized tube feeding. OBJECTIVE The aim was to evaluate the association of blenderized tube feeding on feeding tolerance in enterally fed pediatric patients. DATA SOURCES A literature search for articles from 2012-2022 using PubMed, Medline, Embase, and CINAHL yielded 78 articles. DATA EXTRACTION A description and evaluation of the study's sample, purpose, and results were summarized for 9 studies using the Academy of Nutrition and Dietetics Evidence Analysis Library Worksheet. DATA ANALYSIS Nine studies were evaluated using the Evidence Analysis Library Quality Criteria checklist. CONCLUSIONS Studies demonstrated an improvement in vomiting (n = 7), gagging/retching and heartburn (n = 6), abdominal pain/upset and distension (n = 3), and diarrhea (n = 6) with blenderized tube feeding. The outcomes of blenderized tube feeding on gas (n = 5) and constipation (n = 9) are variable and remain unclear. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration no. CRD42022369247.
Collapse
Affiliation(s)
- Mariana Velly Miguel
- Department of Health and Human Performance, University of Houston, Houston, TX, USA
- Food and Nutrition, Clinical Nutrition, Texas Children's Hospital, Houston, TX, USA
| | - Kevin Haubrick
- Department of Health and Human Performance, University of Houston, Houston, TX, USA
| |
Collapse
|
2
|
da Silva ITF, Medeiros CO, Leobet J, Beux MR, Rabito EI, Etgeton SAP, Fiori LS. Assessment of the risk of contamination of enteral nutrition bottles based on the simulation of home use conditions and hygiene procedures. Nutr Clin Pract 2024; 39:873-880. [PMID: 38491970 DOI: 10.1002/ncp.11144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 02/07/2024] [Accepted: 02/25/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Home-prepared enteral formulations are supplied to patients through enteral nutrition bottles, via a gravity bag or other container, which may be inadequately sanitized and reused more times than recommended by the manufacturer. Such procedures increase the risk of contamination and can compromise the patient's clinical outcome. In light of this, the present study aimed to assess the risk of contamination of enteral nutrition bottles by simulating home use conditions and hygiene procedures. METHODS A simulation of bottle usage was conducted across the three categories of enteral nutrition (homemade enteral preparations, blended enteral preparations, and commercial enteral formulas) for 3 days, using three hygiene procedures reported by caregivers: use of detergent (DET); use of detergent and boiling water (DET+BW); and use of detergent and bleach (DET+BL). The microbiological contamination was determined by the analysis of aerobic mesophilic microorganisms. RESULTS The bottles that were used for 3 days, regardless of the enteral nutrition category, were within the acceptable limit for aerobic mesophilic microorganisms (between <4 and 8.0 colony-forming units [CFU]/cm2) when sanitized using the DET+BW and DET+BL procedures. The enteral nutrition bottles, when cleaned using the DET procedure during the 3 days of usage, showed low microbial contamination (between <4 and 3.0 CFU/cm2) in blended preparation and commercial formula only. CONCLUSION Thus, regardless of the enteral nutrition category, we found that the bottles can be used for 3 days, as long as the DET+BW or DET+BL hygiene procedure is applied and safe food handling measures are adopted.
Collapse
Affiliation(s)
| | - Caroline O Medeiros
- Department of Nutrition, Federal University of Parana, Paraná, Brazil
- Postgraduate Program in Food and Nutrition, Department of Nutrition, Federal University of Parana, Paraná, Brazil
| | - Jaqueline Leobet
- Department of Nutrition, Federal University of Parana, Paraná, Brazil
| | - Márcia R Beux
- Postgraduate Program in Food and Nutrition, Department of Nutrition, Federal University of Parana, Paraná, Brazil
| | - Estela I Rabito
- Department of Nutrition, Federal University of Parana, Paraná, Brazil
- Postgraduate Program in Food and Nutrition, Department of Nutrition, Federal University of Parana, Paraná, Brazil
| | - Schaina A P Etgeton
- Postgraduate Program in Food and Nutrition, Department of Nutrition, Federal University of Parana, Paraná, Brazil
| | - Lize S Fiori
- Department of Nutrition, Federal University of Parana, Paraná, Brazil
- Postgraduate Program in Food and Nutrition, Department of Nutrition, Federal University of Parana, Paraná, Brazil
| |
Collapse
|
3
|
Fraser LK, Bedendo A, O'Neill M, Taylor J, Hackett J, Horridge KA, Cade J, Richardson G, Phung H, McCarter A, Hewitt CE. Safety, resource use and nutritional content of home-blended diets in children who are gastrostomy fed: findings from 'YourTube' - a prospective cohort study. Arch Dis Child 2024; 109:628-635. [PMID: 38129118 PMCID: PMC11287525 DOI: 10.1136/archdischild-2023-326393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 12/02/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE To assess the risks, benefits and resource implications of using home-blended food in children with gastrostomy tubes compared with currently recommended formula feeds. DESIGN This is a cohort study. Data were collected at months 0, 12 and 18 from parents and clinicians using standardised measures. SETTING 32 sites across England: 28 National Health Service trusts and 4 children's hospices. PATIENTS Children aged 6 months-18 years who were gastrostomy fed. MAIN OUTCOME MEASURE The main outcome measure was the PedsQL Gastrointestinal Symptoms Scales score. Secondary outcomes included quality of life, sleep (child, parent), dietary intake, anthropometry, healthcare usage, safety outcomes and resource use. RESULTS 180 children and families completed the baseline data collection, with 134 (74%) and 105 (58%) providing follow-up data at 12 and 18 months. There were fewer gastrointestinal (GI) symptoms at all time points in the home-blended diet group, but there was no difference in change over time within or between the groups. The nutritional intake of those on a home-blended diet had higher calories per kilogram and fibre, and both home-blended and formula-fed children have values above the dietary reference values for most micronutrients. Safety outcomes were similar between groups and over time. The total costs to the statutory sector were higher among children who were formula fed, but the costs of purchasing special equipment for home-blended food and the total time spent on childcare were higher for families with home-blended diet. CONCLUSIONS Children who are gastrostomy fed a home-blended diet have similar safety profile, adequate nutritional intake and lower burden of GI symptoms than formula-fed children. Trial registration number ISRCTN13977361.
Collapse
Affiliation(s)
- Lorna K Fraser
- Cicely Saunders Institute, King's College London, London, UK
- Health Sciences, University of York, York, UK
| | | | | | - Jo Taylor
- Health Sciences, University of York, York, UK
| | | | | | | | | | - Han Phung
- University of York Centre for Health Economics, York, UK
| | | | | |
Collapse
|
4
|
Weston S, Weisbrod V, Duro D. Applications of culinary medicine in the pediatric gastroenterology, hepatology, and nutrition field. J Pediatr Gastroenterol Nutr 2024. [PMID: 38953165 DOI: 10.1002/jpn3.12308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 06/12/2024] [Accepted: 06/17/2024] [Indexed: 07/03/2024]
Abstract
Key points
Culinary medicine can enhance a provider's ability to counsel patients using “food as medicine” to treat disease‐specific areas.
Applying culinary medicine in pediatric gastroenterology is a practical way to empower patients to better manage their condition, minimize gastrointestinal symptoms, and promote a healthier relationship with food.
Collapse
Affiliation(s)
- Sharon Weston
- Department of Clinical Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Vanessa Weisbrod
- Department of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
- Celiac Disease Foundation, Woodland Hills, California, USA
| | - Debora Duro
- Pediatric Gastroenterology, Hepatology and Nutrition at Salah Foundation Children Hospital at Broward Health, Fort Lauderdale, Florida, USA
- Clinical Pediatrics at NOVA Southeastern University, Fort Lauderdale FL and Florida International University (FIU), Miami, Florida, USA
| |
Collapse
|
5
|
Imdad A, Sherwani R, Wall K. Pediatric Formulas: An Update. Pediatr Rev 2024; 45:394-405. [PMID: 38945989 DOI: 10.1542/pir.2023-006002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 01/30/2024] [Accepted: 02/06/2024] [Indexed: 07/02/2024]
Abstract
The recent shortage of pediatric formulas in the United States, caused by supply chain issues and contamination of formula products in 1 of the major manufacturing plants, led many families to seek an alternate formula for their children. The Food and Drug Administration (FDA) allowed import of infant formulas from selected European and non-European countries. The European infant formulas differ from those produced in the United States regarding the primary source of the formula, age category, mixing instructions, labeling requirements, and formula composition in terms of macronutrients and micronutrients. Although most European infant formulas are nutritionally adequate, pediatricians and families need to be aware of the differences between the European and FDA-regulated formulas for their correct use and preparation for infants and young children. Supplementation with cow milk is recommended for children beyond infancy, and older infant formulas are not recommended for otherwise healthy growing children. However, pediatric formulas have been used to support the nutrition needs of children with feeding difficulties, especially those dependent on tube feeding and with certain medical conditions. The FDA does not regulate the production of pediatric formulas beyond infant formula, and significant variations exist in their composition. The pediatric formulas are available as polymeric (intact), hydrolyzed, elemental, or food-based blenderized formulas. The plant-based nonformula (milk) drinks are being used increasingly for children. These products might not be nutritionally complete and should be avoided in infants and children dependent on liquid nutrition.
Collapse
Affiliation(s)
- Aamer Imdad
- Division of Gastroenterology, Hepatology, Pancreatology, and Nutrition, Department of Pediatrics, Stead Family Children's Hospital, University of Iowa, Iowa City, IA
| | - Rida Sherwani
- Department of Pediatrics, State University of New York Upstate Medical University, Syracuse, NY
| | - Kellie Wall
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, State University of New York Upstate Medical University, Syracuse, NY
| |
Collapse
|
6
|
Allen L, Min J, Zong W. Blenderized tube feeding in pediatrics - current evidence, guidelines, and considerations. Curr Opin Pediatr 2024:00008480-990000000-00193. [PMID: 38957106 DOI: 10.1097/mop.0000000000001377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Abstract
PURPOSE OF REVIEW Recently, blenderized tube feeding (BTF) consisting of blended whole food components is emerging as a preferred approach to enteral nutrition in pediatric patients. Differences in the nutritional profile, viscosity, and other characteristics between BTF and conventional tube feeding formulas may impact clinical outcomes and practice considerations. RECENT FINDINGS Increasing guidance and evidence are emerging for BTF in pediatric populations requiring tube feeding. The characteristics of each BTF formulation vary, which may affect patient tolerance and clinical outcome. SUMMARY BTF is safe and generally well tolerated in children. It is shown to improve symptoms, clinical outcomes, and quality of life for many patients. A thorough risk assessment and nuanced approach may be required to optimize BTF administration.
Collapse
Affiliation(s)
- Lindsay Allen
- Division of Gastroenterology, Hepatology, and Nutrition, UT Southwestern Medical Center, Dallas, Texas
| | - James Min
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Wenjing Zong
- Division of Gastroenterology, Hepatology, and Nutrition, UT Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
7
|
Fraser LK, Bedendo A, O'neill M, Taylor J, Hackett J, Horridge K, Cade J, Richardson G, Phung H, Mccarter A, Hewitt C. 'YourTube' the role of different diets in gastrostomy-fed children: Baseline findings from a prospective cohort study. Dev Med Child Neurol 2024; 66:755-764. [PMID: 37946550 DOI: 10.1111/dmcn.15799] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 09/02/2023] [Accepted: 10/05/2023] [Indexed: 11/12/2023]
Abstract
AIM To assess the risks, benefits, and resource implications of home-blended food for children with gastrostomy tubes compared with a formula diet. METHOD This prospective cohort study of children (aged 0-18 years) collected baseline data on gastrointestinal symptoms, nutritional intake, anthropometric outcomes, parent and child quality of life, and resource use. A propensity score-weighted generalized linear mixed model was used to compare children receiving a home-blended versus formula diet. RESULTS Baseline data were obtained for 180 children (2019-2021; 107 males, 73 females; mean age 9 years 7 months [SD 4 years 5 months]). Children receiving a home-blended diet (n = 104) had similar diagnoses and age but more lived in areas of lower deprivation and parental education was higher compared to the parents of children receiving a formula diet (n = 76). Children receiving home-blended diets had significantly better gastrointestinal scores than those receiving formula diets (B = 13.8, p < 0.001). The number of gut infections and tube blockages were similar between the two groups but with fewer stoma site infections in the group receiving home-blended food. Children receiving a home-blended diet had more fibre in their diet compared to children receiving a formula diet. INTERPRETATION Home-blended diets should be seen as a safe option for children who are gastrostomy-fed unless clinically contraindicated. Equality of access to home-blended diets for children with gastrostomy should be assessed by local clinical teams. WHAT THIS PAPER ADDS Children with gastrostomy receiving a home-blended diet had fewer gastrointestinal symptoms compared to children receiving a formula diet. Children with gastrostomy receiving a home-blended diet had no more complications than children receiving a formula diet.
Collapse
Affiliation(s)
- Lorna K Fraser
- Department of Health Sciences, University of York, York, UK
- Cicely Saunders Institute, Kings College London, London, UK
- Department of Women and Children's Health, School of Life Sciences and Population Health, King's College London, London, UK
| | - Andre Bedendo
- Department of Health Sciences, University of York, York, UK
| | - Mark O'neill
- Department of Health Sciences, University of York, York, UK
| | - Johanna Taylor
- Department of Health Sciences, University of York, York, UK
| | - Julia Hackett
- Department of Health Sciences, University of York, York, UK
| | | | - Janet Cade
- Nutritional Epidemiology Group, School of Food Science and Nutrition, University of Leeds, Leeds, UK
| | | | - Han Phung
- Centre for Health Economics, University of York, York, UK
| | | | | |
Collapse
|
8
|
Brown T, Johnson T, Gomes A, Samavat H, Byham-Gray L. Knowledge and clinical practice of ASPEN registered dietitian nutritionist members regarding blenderized tube feedings. Nutr Clin Pract 2024; 39:651-664. [PMID: 38506319 DOI: 10.1002/ncp.11145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/17/2024] [Accepted: 02/25/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND Blenderized tube feedings (BTFs) are used by patients/caregivers who report improvements in gastrointestinal tolerance compared with standard commercial feedings. Despite positive outcomes, registered dietitian nutritionists or international equivalents (RDN/Is) hesitate to recommend BTFs. We aimed to determine if an association exists between dietitian characteristics and willingness to recommend BTFs. METHODS A BTF-specific survey (N = 157) assessed for validity and reliability was administered to the American Society for Parenteral and Enteral Nutrition (ASPEN) RDN/I members. Binary logistic regression analyses examined the association between age, years of clinical practice, BTF training/education, patient population served, and willingness to recommend BTFs. RESULTS The response rate was 4.3% of ASPEN RDN/I members. Most respondents were White females with a median age of 39.0 years and 12 years of clinical experience. Although 98.7% of respondents expressed a willingness to support and 73% to recommend BTFs, 60% were not using BTFs in clinical practice. For 94.8% of RDN/Is, the primary reason for BTF use was patient/caregiver requests. After adjustment for age and years of clinical practice, RDN/Is who served pediatric populations (odds ratio [OR] = 4.28; 95% CI, 1.52-12.09) or used three or more professional resources (OR = 2.49; 95% CI, 1.12-5.57), industry-sponsored resources (OR = 3.15; 95% CI, 1.39-7.15), or one or more experiential learning resources (OR = 3.14; 95% CI, 1.38-7.17) were more likely to recommend BTFs whereas those serving adults were less likely to recommend BTFs (OR = 0.33; 95% CI, 0.12-0.95). CONCLUSION Pediatric RDN/Is and individuals with BTF-specific education/training were more inclined to recommend BTFs.
Collapse
Affiliation(s)
- Terry Brown
- Food and Nutrition Services, HealthTrust Supply Chain, Coppell, Texas, USA
- Department of Clinical and Preventive Nutrition Sciences, Rutgers School of Health Professions, Newark, New Jersey, USA
| | | | - Allison Gomes
- Department of Nutrition, Cedar Crest College, Allentown, Pennsylvania, USA
| | - Hamed Samavat
- Department of Clinical and Preventive Nutrition Sciences, Rutgers School of Health Professions, Newark, New Jersey, USA
| | - Laura Byham-Gray
- Department of Clinical and Preventive Nutrition Sciences, Rutgers School of Health Professions, Newark, New Jersey, USA
| |
Collapse
|
9
|
Schultz ER, Kim Y. Clinical outcomes associated with blenderized tube feedings in adults: A systematic review. Nutr Clin Pract 2024; 39:330-343. [PMID: 37867408 DOI: 10.1002/ncp.11087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 09/18/2023] [Accepted: 09/24/2023] [Indexed: 10/24/2023] Open
Abstract
Nearly half a million individuals in the United States are dependent on enteral nutrition to meet their nutrition needs. Public interest in blenderized tube feeding (BTF) has increased over the past decade; however, medical professionals indicate a lack of knowledge about these products and their effects. The purpose of this review is to analyze clinical outcomes in adults who use a BTF formula as their primary nutrition source. A literature search was conducted in PubMed, Scopus, and CINAHL using search terms "adult," "enteral nutrition," "tube feeding," "BTF," blenderized," "blended," "homemade," and "pureed." Nine studies met the inclusion criteria and were analyzed in the review. Under close monitoring, BTF does not pose a higher risk for deterioration in anthropometric measurements. Furthermore, BTF use is consistently associated with improvements in diarrhea. As such, clinicians should consider the use of these formulas in the acute care or rehabilitation settings. Additional research is needed in patients with diverse clinical backgrounds in free-living communities. Larger populations sizes and longer intervention time frames are crucial to providing statistically significant results needed to strengthen the quality of evidence on this topic.
Collapse
Affiliation(s)
- Erin R Schultz
- School of Rehabilitation and Medical Sciences, Central Michigan University, Mount Pleasant, Michigan, USA
| | - Yeonsoo Kim
- School of Rehabilitation and Medical Sciences, Central Michigan University, Mount Pleasant, Michigan, USA
| |
Collapse
|
10
|
Joosten K, Niseteo T. Better understanding of use of blended diets and its benefits. Evid Based Nurs 2024:ebnurs-2023-103859. [PMID: 38307708 DOI: 10.1136/ebnurs-2023-103859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2024] [Indexed: 02/04/2024]
Affiliation(s)
- Koen Joosten
- Department of Neonatal and Paediatric Intensive Care, Division of Paediatric Intensive Care, Erasmus MC, Sophia Children's Hospital, Rotterdam, Zuid-Holland, The Netherlands
| | - Tena Niseteo
- Referral Center for Pediatric Gastroenterology and Nutrition, Children's Hospital Zagreb, Zagreb, Croatia
| |
Collapse
|
11
|
Walker S, Johnson TW, Carter H, Spurlock AY, Johnson K, Hussey J. Blenderized food tube feeding in very young pediatric patients with special healthcare needs. Nutr Clin Pract 2024; 39:202-209. [PMID: 36871186 DOI: 10.1002/ncp.10975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 01/18/2023] [Accepted: 02/05/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND Up to 85% of children with severe developmental disabilities have feeding disorders and require enteral tube feeding. Many caregivers desire blenderized tube feeding (BTF) instead of commercial formula (CF) for their child, citing a desire for a more physiologic feeding, to reduce gastrointestinal (GI) symptoms and/or promote oral intake. METHODS In this retrospective, single-center study, medical records (n = 34) of very young children (aged ≤36 months) with severe developmental disabilities were reviewed. Comparisons of growth parameters, GI symptoms, oral feeding, and GI medication use were made between the initial introduction of BTF and again at the last patient encounter when the children aged out of the program. RESULTS Of the 34 charts reviewed (16 male and 18 female patients), comparisons between baseline BTF introduction and the last patient encounter indicated reductions in adverse GI symptoms, significant GI medication reduction (P = 0.000), increased oral food intake, and nonsignificant improvements in growth parameters. These positive outcomes were realized whether children received full or partial BTF or type of BTF formulation. CONCLUSION Consistent with similar research studies, transitioning very young children with significant special healthcare needs from CF to BTF resulted in improvement in GI symptoms, reduced need for GI medications, supported growth goals, and contributed to improved oral feeding.
Collapse
Affiliation(s)
- Shawna Walker
- The Resource Exchange, Colorado Springs, Colorado, USA
| | - Teresa W Johnson
- Kinesiology & Health Promotion, Troy University, Troy, Alabama, USA
| | - Holly Carter
- Kinesiology & Health Promotion, Troy University, Troy, Alabama, USA
| | - Amy Y Spurlock
- School of Nursing, Boise State University, Boise, Idaho, USA
| | - Kelly Johnson
- Kinesiology & Health Promotion, Troy University, Troy, Alabama, USA
| | - Jenna Hussey
- Kinesiology & Health Promotion, Troy University, Troy, Alabama, USA
| |
Collapse
|
12
|
Clancy O, McCormack S, Graham M, O'Sullivan K, Bennett AE. Experiences and perceptions of multidisciplinary paediatric teams of blended tube feeding in children. Nutr Health 2024:2601060231218049. [PMID: 38281935 DOI: 10.1177/02601060231218049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
Background: Blended tube feeding (BTF) is the administration of pureed whole foods via gastric feeding tubes. There is some evidence to suggest that BTF may have clinical and psychosocial benefits when compared to commercial formula, but further investigation of how BTF is understood and recommended by health professionals is needed. This study aims to investigate awareness and knowledge of BTF among multi-disciplinary paediatric staff in Ireland. Methods: A cross-sectional observational study was conducted among paediatric staff in Children's Health Ireland (CHI). The 16-item anonymous online survey gathered information on awareness of BTF, willingness to recommend BTF, confidence in BTF knowledge, and self-assessed competence in managing BTF. Results: Of the 207 responses, doctors (n68), nurses (n66), and dietitians (n32) provided 80.3% of responses. Two-thirds (n136, 66%) of the total group were aware of BTF. Of these, 68.1% had cared for a child on BTF and 70% (n = 63/90) were willing to recommend BTF. Three in five (n = 39/63, 61.9%) stated they were somewhat confident in their BTF knowledge and one in five (n = 12/56, 21.4%) were not yet competent in managing children on BTF. The most common reasons for recommending BTF were parental desire (n17, 39.5%) and commercial formula intolerance (n15, 34.9%). The most common barrier to recommending BTF was family logistics (n18, 41.9%). The most valuable sources of information on BTF for two-thirds (68.3%) of participants were other healthcare professionals (HCPs) and patients/caregivers. Conclusion: Healthcare settings should provide evidence-based training to HCPs on BTF to optimise the treatment and safety of children under their care.
Collapse
Affiliation(s)
- Orlaith Clancy
- Department of Clinical Medicine, Trinity Centre for Health Sciences, Trinity College Dublin, Dublin, Ireland
| | | | - Meave Graham
- Children's Health Ireland at Temple Street, Dublin, Ireland
| | | | - Annemarie E Bennett
- Department of Clinical Medicine, Trinity Centre for Health Sciences, Trinity College Dublin, Dublin, Ireland
| |
Collapse
|
13
|
Doyle C, Louw J, Shovlin A, Dowd L, Kavanagh M. Blended feeding in gastrostomy-fed children-A scoping review. Child Care Health Dev 2024; 50:e13222. [PMID: 38265135 DOI: 10.1111/cch.13222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 09/08/2023] [Accepted: 12/03/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND Blended feeding has become increasingly prevalent in recent years with its practice gaining some momentum. With anecdotal reports of benefits and little evidence of harm in the literature regarding blended feeding, this scoping review was deemed important. The aim of this scoping review was to summarise the published evidence about blended feeding in gastrostomy-fed children. METHOD The scoping review methodology used included searches in specific online databases: PUBMED, PsychINFO, CINAHL, SCOPUS, AMED and EMBASE for articles that addressed issues pertaining to blended feeds in gastrostomy-fed children. Grey literature was also considered. Inclusion criteria included papers that pertained to information and research on blended feeding in gastrostomy-fed children. Studies published in English over the past 11 years (2011-2022) were included. This resulted in 59 papers being included in this scoping review. RESULTS Thematic analysis of the literature identified eight overall themes. It was clear that parents found blended feeding promoted the normalising of feeding, their own involvement in decision-making around foods and promotion of a socially inclusive mealtime. The need for dietician and health professional input and support is key, whereas a lack of guidelines acts as a barrier to blended feeding. Furthermore, risks associated with blended feeding are identified but also the benefits to the physical well-being of the child are considered. CONCLUSION The review was comprehensive in that it identified a broad range of literature, exploring the extent, range and nature of research activity related to the use of blended feeds. The lack of original research is a concern. However, it is expected this review will provide direction for researchers, and in particular inform policy and practitioners working in the field where blended feeds may be an option for gastrostomy-fed children.
Collapse
Affiliation(s)
- Carmel Doyle
- School of Nursing & Midwifery, Trinity College, Dublin, Ireland
| | - Julia Louw
- Trinity Centre for Practice and Healthcare Innovation, Trinity College, Dublin, Ireland
| | | | | | | |
Collapse
|
14
|
Phillips G, Coad J. Blended diets for tube-fed children and young people: a rapid review update. Arch Dis Child 2023; 108:1014-1018. [PMID: 37595987 DOI: 10.1136/archdischild-2023-325929] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 08/06/2023] [Indexed: 08/20/2023]
Abstract
BACKGROUND Many children and young people with complex health and care needs use enteral feeding tubes to optimise their nutritional intake in the UK and other countries. Blended diets as an alternative to the exclusive use of commercial formula are becoming more commonly used, and there is evidence to support the benefits of using a blended diet on the child or young person and their wider family.A rapid review was published in 2017 exploring blended diets as a valid alternative to commercial formula for enteral feeding for children and young people. An update was necessary to ensure that professional practice is informed by the latest evidence, which has expanded significantly since the publication of the original article. METHODS A rapid review method was used and the PRISMA checklist formed the basis of the protocol devised ahead of data collection. Key databases included: PubMed, MEDLINE, CINAHL, PsychINFO, Google Scholar. RESULTS 29 articles were included and four themes were identified from the collated data. (1) Symptom improvement and clinical outcomes, (2) nutritional content, (3) caregiver experiences and (4) blended diet practices. Findings showed that blended diets can have a positive impact on physical symptoms as well as social influences extending to families and carers. CONCLUSION Nutritional content, food hygiene and viscosity of food blends are important considerations for professionals and families to ensure safe practice when using blended diets for enteral feeding.
Collapse
Affiliation(s)
| | - Jane Coad
- School of Health Sciences, University of Nottingham, Nottingham, UK
| |
Collapse
|
15
|
Carpenter A, Pfarr MA. Clinical guideline highlights for the hospitalist: The use of blended diets in children with enteral feeding tubes. J Hosp Med 2023; 18:1010-1012. [PMID: 37113045 DOI: 10.1002/jhm.13110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 04/13/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023]
Abstract
GUIDELINE TITLE The Use of Blended Diets in Children With Enteral Feeding Tubes: A Joint Position Paper of the ESPGHAN Committees of Allied Health Professionals and Nutrition RELEASE DATE: January 1, 2023 PRIOR VERSION(S): n/a DEVELOPER: ESPGHAN Committees of Allied Health Professionals and Nutrition FUNDING SOURCE: ESPGHAN Committees of Allied Health Professionals and Nutrition TARGET POPULATION: Pediatricians, Pediatric Hospitalist.
Collapse
Affiliation(s)
- Ariel Carpenter
- Department of Pediatrics, Division of Pediatric Hospital Medicine, Division of Hospital Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Marie A Pfarr
- Department of Pediatrics, Division of Pediatric Hospital Medicine, Division of Hospital Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| |
Collapse
|
16
|
Chen CB. Nutritional and feeding challenges in aerodigestive patients. Curr Opin Pediatr 2023; 35:561-565. [PMID: 37489246 DOI: 10.1097/mop.0000000000001275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
PURPOSE OF REVIEW Aerodigestive disorders encompass conditions that affect both the airway and gastrointestinal tract. These include conditions such as acquired and congenital defects of the airway and esophagus as well as neuromuscular disorders. Patients often suffer from dysphagia, aspiration, and respiratory disorders. This article will provide a review of current practices in the management of feeding disorders, oropharyngeal dysphagia, and nutritional support in the aerodigestive population. RECENT FINDINGS Oral aversion, aspiration, and feeding-tube dependence are all commonly encountered problems in the aerodigestive population. Intensive inpatient and outpatient programs along with use of appetite stimulants and psychotropic medications may help to improve feeding-related disorders. Aspiration affects many patients and requires close monitoring of clinical symptoms along with routine assessment with video fluoroscopy. Developments in blenderized feeds and formula supplementation have also provided new options for patients with feeding intolerance. SUMMARY Patients with aerodigestive disorders require complex medical care, and multidisciplinary teams are the most effective in addressing their medical needs. Advances in feeding, occupational, and pharmacologic therapy have allowed healthcare providers to better address the needs of these patients.
Collapse
Affiliation(s)
- Charles B Chen
- Department of Child Health, University of Missouri School of Medicine, 400 N. Keene St., 65201, Columbia, Missouri, USA
| |
Collapse
|
17
|
Katagiri S, Ohsugi Y, Shiba T, Yoshimi K, Nakagawa K, Nagasawa Y, Uchida A, Liu A, Lin P, Tsukahara Y, Iwata T, Tohara H. Homemade blenderized tube feeding improves gut microbiome communities in children with enteral nutrition. Front Microbiol 2023; 14:1215236. [PMID: 37680532 PMCID: PMC10482415 DOI: 10.3389/fmicb.2023.1215236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/09/2023] [Indexed: 09/09/2023] Open
Abstract
Enteral nutrition for children is supplied through nasogastric or gastrostomy tubes. Diet not only influences nutritional intake but also interacts with the composition and function of the gut microbiota. Homemade blenderized tube feeding has been administered to children receiving enteral nutrition, in addition to ready-made tube feeding. The purpose of this study was to evaluate the oral/gut microbial communities in children receiving enteral nutrition with or without homemade blenderized tube feeding. Among a total of 30 children, 6 receiving mainly ready-made tube feeding (RTF) and 5 receiving mainly homemade blenderized tube feeding (HBTF) were analyzed in this study. Oral and gut microbiota community profiles were evaluated through 16S rRNA sequencing of saliva and fecal samples. The α-diversity representing the number of observed features, Shannon index, and Chao1 in the gut were significantly increased in HBTF only in the gut microbiome but not in the oral microbiome. In addition, the relative abundances of the phylum Proteobacteria, class Gammaproteobacteria, and genus Escherichia-Shigella were significantly low, whereas that of the genus Ruminococcus was significantly high in the gut of children with HBTF, indicating HBTF altered the gut microbial composition and reducing health risks. Metagenome prediction showed enrichment of carbon fixation pathways in prokaryotes at oral and gut microbiomes in children receiving HBTF. In addition, more complex network structures were observed in the oral cavity and gut in the HBTF group than in the RTF group. In conclusion, HBTF not only provides satisfaction and enjoyment during meals with the family but also alters the gut microbial composition to a healthy state.
Collapse
Affiliation(s)
- Sayaka Katagiri
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Yujin Ohsugi
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Takahiko Shiba
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
- Department of Oral Medicine, Infection, and Immunity, Harvard School of Dental Medicine, Boston, MA, United States
| | - Kanako Yoshimi
- Department of Dysphagia Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Kazuharu Nakagawa
- Department of Dysphagia Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Yuki Nagasawa
- Department of Dysphagia Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Aritoshi Uchida
- Department of Dysphagia Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Anhao Liu
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Peiya Lin
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Yuta Tsukahara
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Takanori Iwata
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Haruka Tohara
- Department of Dysphagia Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| |
Collapse
|
18
|
McCormack S, Patel K, Smith C. Blended diet for enteral tube feeding in young people: A systematic review of the benefits and complications. J Hum Nutr Diet 2023; 36:1390-1405. [PMID: 36692240 DOI: 10.1111/jhn.13143] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 01/16/2023] [Indexed: 01/25/2023]
Abstract
BACKGROUND Interest and use of blended diets (BD) for young people who are tube fed has significantly increased in the last decade, driven primarily by the desires of motivated caregivers. This review identified, appraised and synthesised the available evidence on the benefits and complications of BD versus commercial feeds. METHODS A systematic review following PRISMA guidance and registered with PROSPERO was conducted across PubMed, Embase, CINAHL, Scopus and Cochrane up to August 2022. INCLUSION CRITERIA English language studies including (1) children, (2) original research (interventional and observational) and (3) examination of BD outcomes. Exclusion criteria were (1) unoriginal research or case reports, (2) focus on feeding management, preparations or attitudes and (3) comparing commercial blends only. Data were synthesised using an established narrative synthesis approach using the Mixed Methods Appraisal Tool. RESULTS Eight hundred and six database results were identified and 61 were sought for retrieval. A full-text article review revealed seven eligible studies, involving 267 participants (age range 9 months to 26 years). Studies reported differences in gastrointestinal symptoms (n = 222), medication use (n = 119), growth (n = 189) and complications or adverse events (n = 91). The results indicate positive outcomes, particularly in gastrointestinal symptom control, with few reports of mild adverse events in the included studies. CONCLUSIONS There is a paucity of data in this area and much heterogeneity in the included studies, but the available literature points towards positive outcomes. This is an important and highly relevant topic, and more primary research, ideally using standardised reporting, is required to answer the key questions.
Collapse
Affiliation(s)
- Siobhan McCormack
- Department of Paediatrics, Brighton and Sussex Medical School, Brighton, UK
- Department of Child Development and Neurodisability, Children's Health Ireland at Tallaght, Dublin, Ireland
| | - Kamal Patel
- Department of Paediatrics, Brighton and Sussex Medical School, Brighton, UK
- Department of Paediatrics, Royal Alexandra Children's Hospital, Brighton, UK
| | - Chris Smith
- Department of Paediatric Dietetics, Royal Alexandra Children's Hospital, Brighton, UK
| |
Collapse
|
19
|
Hron B, Ng T, Voss S, Rosen R. Effect of blenderized tube feeds on gastric emptying: A retrospective cohort study. JPEN J Parenter Enteral Nutr 2023; 47:654-661. [PMID: 37165611 PMCID: PMC11223061 DOI: 10.1002/jpen.2513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 04/12/2023] [Accepted: 04/29/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Blenderized tube feeds (blends) are associated with lower hospital admissions and reduced gastroesophageal symptoms, but their high viscosity may theoretically prolong gastric emptying. Our objective was to compare differences in gastric emptying with blends vs with formula. METHODS We retrospectively identified individuals 6 months to 20 years with enteral tubes who underwent 1-h liquid gastric emptying scintigraphy from 1998 to 2020 at Boston Children's Hospital. Examinations were excluded if a postpyloric tube was present, tracer was administered orally or with diet differing from habitual, habitual diet was indeterminable, imaging was terminated early, or >50% of input counts emptied during bolus administration. Emptying was classified as delayed if gastric residual at 1 h was ≥60% of ingested dose. RESULTS Eighteen examinations (15 individuals) were performed with blends and 35 examinations (32 individuals) with formula. Although percentage of residual at 1 h was significantly higher in patients receiving blends compared with formula (54 ± 17 vs 40 ± 25, P = 0.04), the number of patients with delayed gastric emptying did not differ (39% vs 29%, respectively, P = 0.54). Type of diet, feed volume or concurrent medications did not predict delayed gastric emptying. Children with blends received higher bolus volumes (106 ± 55 vs 66 ± 59 ml; P = 0.02), and this significantly predicted percentage of residual (β = 0.14; P = 0.01). CONCLUSION The proportion of patients with delayed gastric emptying was similar in children receiving blends and formula. Although the mean percentage of gastric residual was higher with blends, this may be explained by higher bolus volumes administered. This preliminary work suggests that blends compare favorably to formula.
Collapse
Affiliation(s)
- Bridget Hron
- Division of Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Boston Children’s Hospital, Boston, MA
| | - Thomas Ng
- Department of Radiology, Massachusetts General Hospital, Boston, MA
- Joint Program in Nuclear Medicine, Harvard Medical School, Boston, MA
| | - Stephan Voss
- Joint Program in Nuclear Medicine, Harvard Medical School, Boston, MA
- Department of Radiology, Boston Children’s Hospital, Boston, MA
| | - Rachel Rosen
- Division of Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Boston Children’s Hospital, Boston, MA
| |
Collapse
|
20
|
Klepper CM, Moore J, Gabel ME, Fleet SE, Kassel R. Pediatric formulas: Categories, composition, and considerations. Nutr Clin Pract 2023; 38:302-317. [PMID: 36815542 DOI: 10.1002/ncp.10954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/29/2022] [Accepted: 12/31/2022] [Indexed: 02/24/2023] Open
Abstract
Formulas, liquid nutrition, may be consumed orally or via a feeding tube to provide partial or complete nutrition that a given individual could not obtain using natural food stuffs in their native form. A wide range of commercially available formulas exist, which may be used as sole-source nutrition or in conjunction with other foods. Physicians and dietitians must understand the nature of and indications for specific formulas to treat diseases, provide complete nutrition to patients, and avoid harm. Products vary in macronutrient and micronutrient content and calorie concentration among many other factors. They are formulated specifically for patients of specific ages, correlating to nutritional needs and medical diagnoses. Additionally, formula availability, insurance coverage, mode of consumption, physiologic tolerance, and caregiver preference influence formula selection. Caregivers may also make their own pediatric formulas. We review commercial and homemade pediatric formulas.
Collapse
Affiliation(s)
- Corie M Klepper
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Joseph Moore
- Department of Clinical Nutrition and Lactation, Children's of Alabama, Birmingham, Alabama, USA
| | - Megan E Gabel
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York, USA.,Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Rochester Medical Center, Rochester, New York, USA
| | - Sarah E Fleet
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Rachel Kassel
- Department of Pediatrics, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA.,Division of Gastroenterology, Hepatology and Nutrition, Birmingham, Alabama, USA
| |
Collapse
|
21
|
Shrager S, Adigun A, Motolongo S, Santos CS, Rowe-King P, Duro D. Comparison of Home-Blenderized Formula and Commercial Enteral Formulas for Gastrostomy Tube-Fed Children: A Retrospective, Prospective Cohort Study. Cureus 2023; 15:e37944. [PMID: 37220453 PMCID: PMC10200265 DOI: 10.7759/cureus.37944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2023] [Indexed: 05/25/2023] Open
Abstract
Background Blenderized gastrostomy tube feedings (BGTFs) consist of pureed table foods and liquids that are administered as enteral tube feedings. Compared to commercial enteral formulas (CEFs), BGTF has been shown to have fewer side effects. Despite these results, apprehensions have been raised about microbial contamination, nutritional deficiencies or surplus, risk of gastrostomy tube (GT) blockages, and lack of consistency in clinical outcomes. The goal of this retrospective, prospective, 18-month-long study is to report the clinical and nutritional outcomes of GT-dependent pediatric patients who attended a multidisciplinary feeding clinic. Methodology After Institutional Review Board (IRB) approval and consent were obtained, 25 children who were receiving tube feeding via G were enrolled in a retrospective, prospective, observational, cohort study from August 2019 to February 2021. A multidisciplinary team was formed, and multivariate logistic regression was performed comparing subjects on BGTF versus CEF, per os diet versus nil per os, CEF versus homemade blenderized tube feeding (HBTF) versus blenderized tube feeding (BTF), and how they compared at the beginning and end of the study. Results The mean age of the patients was 4.4 years (SD ±2.2). Gastroesophageal reflux disease (GERD) and short bowel syndrome (SBS) were the most common comorbid gastrointestinal (GI) conditions. Of the 25 patients enrolled in the study, seven were initially on BGTF, while 14 ended the study on BGTF. There were no statistically significant differences in malnutrition status, feeding intolerance, emergency room visits, hospitalizations, and GT blockages between all different comparison groups when comparing between the CEF versus HBTF versus commercial blenderized tube feeding (CBTF) groups. Of the patients who were in the BGTF group, there was a resolution of vitamin A deficiency, vitamin D deficiency, and anemia (n = 1). In total, two patients had resolved vitamin deficiencies, namely, vitamins A and D. Conclusions When comparing BGTF and CEF, there was no statistically significant difference in outcomes. This study suggests that BGTF is at least equivalent to CEF in clinical outcomes, meaning BGTF should be considered standard nutrition for GT-dependent patients.
Collapse
Affiliation(s)
- Sebastian Shrager
- Pediatrics, Salah Foundation Children's Hospital at Broward Health Medical Center, Fort Lauderdale, USA
| | - Ayoola Adigun
- Pediatrics, Salah Foundation Children's Hospital at Broward Health Medical Center, Fort Lauderdale, USA
| | - Sonia Motolongo
- Pediatrics, Salah Foundation Children's Hospital at Broward Health Medical Center, Fort Lauderdale, USA
| | - Cristhiane S Santos
- Pediatrics, Salah Foundation Children's Hospital at Broward Health Medical Center, Fort Lauderdale, USA
| | - Patricia Rowe-King
- Pediatrics, Salah Foundation Children's Hospital at Broward Health Medical Center, Fort Lauderdale, USA
| | - Debora Duro
- Pediatric Gastroenterology, Salah Foundation Children's Hospital at Broward Health Medical Center, Fort Lauderdale, USA
- Pediatrics, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
- Pediatrics, Florida International University, Herbert Wertheim College of Medicine, Miami, USA
| |
Collapse
|
22
|
Duncan DR, Cohen A, Golden C, Lurie M, Mitchell PD, Liu E, Simoneau T, Rosen RL. Gastrointestinal factors associated with risk of bronchiectasis in children. Pediatr Pulmonol 2023; 58:899-907. [PMID: 36510759 PMCID: PMC9957932 DOI: 10.1002/ppul.26276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/08/2022] [Accepted: 12/10/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To evaluate gastrointestinal (GI) risk factors for bronchiectasis in children. We hypothesized that upper GI tract dysmotility would be associated with increased risk of bronchiectasis. STUDY DESIGN Subjects in this retrospective cohort study included those evaluated for persistent pulmonary symptoms in the Aerodigestive Center at Boston Children's Hospital who underwent chest computed tomography (CT) between 2002 and 2019. To determine gastrointestinal predictors of bronchiectasis, baseline characteristics, comorbidities, enteral tube status, medications received, gastroesophageal reflux burden, adequacy of swallow function, esophageal dysmotility, gastric dysmotility, and neutrophil count on bronchoalveolar lavage (BAL) were compared between patients with and without bronchiectasis. Proportions were compared with Fisher's exact test and binary logistic regression with stepwise selection was used for multivariate analysis. ROC analyses were utilized to compare BAL neutrophils and bronchiectasis. RESULTS Of 192 subjects, 24% were found to have evidence of bronchiectasis on chest CT at age 7.9 ± 0.5 years. Enteral tubes (OR 5.77, 95% CI 2.25-14.83, p < 0.001) and increased BAL neutrophil count (OR 5.79, 95% CI 1.87-17.94, p = 0.002) were associated with increased risk while neurologic comorbidities were associated with decreased risk (OR 0.24, 95% CI 0.09-0.66, p = 0.006). Gastroesophageal reflux was not found to be a significant risk factor. Neutrophil counts >10% had 72% sensitivity and 60% specificity for identifying bronchiectasis. CONCLUSIONS Enteral tubes were associated with significantly increased risk of bronchiectasis but gastroesophageal reflux was not. Providers should consider obtaining chest CT to evaluate for bronchiectasis in children found to have unexplained elevated BAL neutrophil count.
Collapse
Affiliation(s)
- Daniel R. Duncan
- Aerodigestive Center, Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, Massachusetts
| | - Alexandra Cohen
- Aerodigestive Center, Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, Massachusetts
| | - Clare Golden
- Aerodigestive Center, Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, Massachusetts
| | - Margot Lurie
- Aerodigestive Center, Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, Massachusetts
| | - Paul D. Mitchell
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, MA
| | - Enju Liu
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, MA
| | - Tregony Simoneau
- Division of Pulmonary Medicine, Boston Children’s Hospital, Boston, MA
| | - Rachel L. Rosen
- Aerodigestive Center, Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, Massachusetts
| |
Collapse
|
23
|
Gastroesophageal Reflux Treatment in Infancy Through Young Adulthood. Am J Gastroenterol 2023; 118:452-458. [PMID: 36717189 DOI: 10.14309/ajg.0000000000002160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 12/20/2022] [Indexed: 02/01/2023]
Abstract
Gastroesophageal reflux treatment varies greatly across the pediatric age spectrum. Infant reflux treatments rely heavily on nutritional interventions, whereas reflux in older children is treated more commonly with medications. However, because of the broad differential diagnosis, treatment nonresponse merits a re-evaluation of the diagnosis being treated and additional testing to provide a more precision-medicine approach to care.
Collapse
|
24
|
Sforza E, Limongelli D, Giorgio V, Margiotta G, Proli F, Kuczynska EM, Leoni C, Rigante D, Contaldo I, Veredice C, Rinninella E, Gasbarrini A, Zampino G, Onesimo R. The Impact of Blenderized Tube Feeding on Gastrointestinal Symptoms, a Scoping Review. APPLIED SCIENCES 2023; 13:2173. [DOI: 10.3390/app13042173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/08/2023]
Abstract
Severe gastrointestinal symptoms are one of the main reasons for switching from conventional artificial tube feeding to blenderized tube feeding (BTF). This study aimed to describe and quantify the impact of BTF on gastrointestinal symptoms in children and adults. We analyzed four databases (PubMed, Scopus, Cochrane Library, and Google Scholar). The review was performed following the PRISMA extension for Scoping Reviews checklist. The methodological quality of articles was assessed following the NIH quality assessment tools. The initial search yielded 535 articles and, after removing duplicates and off-topic articles, 12 met the inclusion criteria. All included papers unanimously converged in defining an improvement of gastrointestinal symptoms during blenderized feeding: the eight studies involving pediatric cohorts report a decrease from 30 to over 50% in gagging and retching after commencing BTF. Similar rates are reported for constipation and diarrhea improvement in most critically ill adults. Experimental studies and particularly randomized controlled trials are needed to develop robust evidence on the effectiveness of BTF in gastrointestinal symptom improvement with prolonged follow-up and adequate medical monitoring.
Collapse
Affiliation(s)
| | | | - Valentina Giorgio
- Università Cattolica Sacro Cuore, 00168 Rome, Italy
- Center for Rare Diseases and Birth Defects, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Pediatric Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | | | - Francesco Proli
- Pediatric Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Eliza Maria Kuczynska
- Center for Rare Diseases and Birth Defects, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Chiara Leoni
- Center for Rare Diseases and Birth Defects, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Pediatric Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Donato Rigante
- Università Cattolica Sacro Cuore, 00168 Rome, Italy
- Center for Rare Diseases and Birth Defects, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Pediatric Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Ilaria Contaldo
- Pediatric Neuropsychiatry, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Chiara Veredice
- Pediatric Neuropsychiatry, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Emanuele Rinninella
- Università Cattolica Sacro Cuore, 00168 Rome, Italy
- Clinical Nutrition Unit, Department of Medical and Abdominal Surgery and Endocrine-Metabolic Scienze, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Antonio Gasbarrini
- Università Cattolica Sacro Cuore, 00168 Rome, Italy
- Center for Diagnosis and Treatment of Digestive Diseases, CEMAD, Gastroenterology Department, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Giuseppe Zampino
- Università Cattolica Sacro Cuore, 00168 Rome, Italy
- Center for Rare Diseases and Birth Defects, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Pediatric Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Roberta Onesimo
- Center for Rare Diseases and Birth Defects, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Pediatric Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| |
Collapse
|
25
|
Diamanti A, Capriati T, Mosca A, Trovato CM, Laureti F, Mazzoli B, Bolasco G, Caldaro T, De Peppo F, Staccioli S, Papa RE, Cerchiari A, De Angelis P, Maggiore G. Neurological impairment and malnutrition in children: The role of home enteral nutrition in real life. Front Nutr 2023; 10:1087603. [PMID: 37032763 PMCID: PMC10073451 DOI: 10.3389/fnut.2023.1087603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 02/17/2023] [Indexed: 04/11/2023] Open
Abstract
Objective Recent decades have brought an increased survival of children with Neurologic Impairment (NI) but malnutrition and digestive comorbidity remain important challenges to face. We designed the present study to assess the course of nutritional status following standardized Home Enteral Nutrition (HEN) program and to evaluate impact of changing mode of feeding, as a part of overall multidisciplinary management, on digestive co-morbidity as Gastro-Esophageal Reflux Disease (GERD), Oropharyngeal Dysphagia (OPD), constipation and airway aspiration. Methods We performed a retrospective analysis on NI children entered into Institutional HEN program due to NI disorders between January 2011 and 2019. Demographic, anthropometric characteristics (BMI z-score and weight for age z-score) and symptoms (GERD, OPD constipation and airway aspiration) were collected at the enrolment and during the follow up. Results We enrolled 402 patients (median age: 39 months); overall survival was 97%. Nutritional status was significantly improved by HEN; in particular growth profile significantly changed within the first 2 years following HEN beginning; GERD and airways aspirations decreased after HEN beginning. Constipation and OPD remained unchanged over time. Conclusions Malnutrition and digestive complaints are distinctive features of NI children. Nutritional status improve after 2 years from the beginning of standardized nutritional interventions. Overall multidisciplinary care, including standardized HEN protocols, seems to also impact on GERD and airway aspirations, which can decrease over time. It is possible that constipation and OPD, unchanged over time, are more dependent on underlying diseases than on overall treatments.
Collapse
Affiliation(s)
- Antonella Diamanti
- Hepatology, Gastroenterology and Nutrition Unit, Bambino Gesù Children Hospital, Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- *Correspondence: Antonella Diamanti
| | - Teresa Capriati
- Hepatology, Gastroenterology and Nutrition Unit, Bambino Gesù Children Hospital, Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Antonella Mosca
- Hepatology, Gastroenterology and Nutrition Unit, Bambino Gesù Children Hospital, Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Chiara Maria Trovato
- Hepatology, Gastroenterology and Nutrition Unit, Bambino Gesù Children Hospital, Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Francesca Laureti
- Hepatology, Gastroenterology and Nutrition Unit, Bambino Gesù Children Hospital, Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Bianca Mazzoli
- Hepatology, Gastroenterology and Nutrition Unit, Bambino Gesù Children Hospital, Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Giulia Bolasco
- Hepatology, Gastroenterology and Nutrition Unit, Bambino Gesù Children Hospital, Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Tamara Caldaro
- Hepatology, Gastroenterology and Nutrition Unit, Bambino Gesù Children Hospital, Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Francesco De Peppo
- Unit of Palidoro Pediatric Surgery, Department of Specialized Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Susanna Staccioli
- Department of Neurorehabilitation, Bambino Gesù Children's Hospital, Rome, Italy
| | - Raffaele Edo Papa
- Pediatrics Unit, University Department of Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Antonella Cerchiari
- Department of Neurorehabilitation, Bambino Gesù Children's Hospital, Rome, Italy
| | - Paola De Angelis
- Hepatology, Gastroenterology and Nutrition Unit, Bambino Gesù Children Hospital, Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Giuseppe Maggiore
- Hepatology, Gastroenterology and Nutrition Unit, Bambino Gesù Children Hospital, Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| |
Collapse
|
26
|
Corsello A, Scatigno L, Govoni A, Zuccotti G, Gottrand F, Romano C, Verduci E. Gut dysmotility in children with neurological impairment: the nutritional management. Front Neurol 2023; 14:1200101. [PMID: 37213895 PMCID: PMC10196023 DOI: 10.3389/fneur.2023.1200101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/20/2023] [Indexed: 05/23/2023] Open
Abstract
Intestinal motility disorders represent a frequent problem in children with neurological impairment. These conditions are characterized by abnormal movements of the gut, which can result in symptoms such as constipation, diarrhea, reflux, and vomiting. The underlying mechanisms leading to dysmotility are various, and the clinical manifestations are often nonspecific. Nutritional management is an important aspect of care for children with gut dysmotility, as it can help to improve their quality of life. Oral feeding, when safe and in the absence of risk of ingestion or severe dysphagia, should always be encouraged. When oral nutrition is insufficient or potentially harmful, it is necessary to switch to an enteral by tube or parenteral nutrition before the onset of malnutrition. In most cases, children with severe gut dysmotility may require feeding via a permanent gastrostomy tube to ensure adequate nutrition and hydration. Drugs may be necessary to help manage gut dysmotility, such as laxatives, anticholinergics and prokinetic agents. Nutritional management of patients with neurological impairment often requires an individualized care plan to optimize growth and nutrition and to improve overall health outcomes. This review tries to sum up most significant neurogenetic and neurometabolic disorders associated with gut dysmotility that may require a specific multidisciplinary care, identifying a proposal of nutritional and medical management.
Collapse
Affiliation(s)
- Antonio Corsello
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, Milan, Italy
| | - Lorenzo Scatigno
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, Milan, Italy
| | - Annalisa Govoni
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, Milan, Italy
| | - Gianvincenzo Zuccotti
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, Milan, Italy
- Department of Biomedical and Clinical Sciences L. Sacco, University of Milan, Milan, Italy
| | - Frédéric Gottrand
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, CHU Lille, University of Lille, Lille, France
| | - Claudio Romano
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Elvira Verduci
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, Milan, Italy
- Department of Health Science, University of Milan, Milan, Italy
- *Correspondence: Elvira Verduci,
| |
Collapse
|
27
|
Köglmeier J, Assecaira I, Banci E, De Koning B, Haiden N, Indrio F, Kastelijn W, Kennedy D, Luque V, Norsa L, Verduci E, Sugar A. The Use of Blended Diets in Children With Enteral Feeding Tubes: A Joint Position Paper of the ESPGHAN Committees of Allied Health Professionals and Nutrition. J Pediatr Gastroenterol Nutr 2023; 76:109-117. [PMID: 36053165 DOI: 10.1097/mpg.0000000000003601] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES This joint position paper of the Committees of Allied Health Professionals (CAHP) and Nutrition (CON) of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) provides a comprehensive guide for health professionals to manage blended diets in children via gastrostomy tubes. METHODS A systematic literature search was performed from 1992 to 2021 using Pubmed, MEDLINE, and Cochrane Database of Systematic Reviews and recent guidelines reviewed. In the absence of evidence, recommendations reflect the authors' expert opinion. Final consensus was obtained by multiple e-mail exchange and virtual meetings of the CAHP and CON. RESULTS Reported benefits of blended diets include reduced GERD and infections, improved defecation, level of alertness and attention span, skin conditions, and appearance of hair and nails. Families report a sense of greater normality. Small case series, cross-sectional surveys, questionnaire-based small case studies, reports of personal experience, and single-center pilot studies are available in the medical literature. A total of 20 recommendations for practice were made based on the results and consensus process. CONCLUSIONS There is little evidence published to formally inform about the potential health benefits or risks of this practice and how to use it in the best way. This leaves health professionals caring for such patients in a relative vacuum regarding what to consider when providing a duty of care to patients and carers who wish to pursue this method of feeding. This article provides guidelines for safe and appropriate use of a BD, but more research is needed.
Collapse
Affiliation(s)
- Jutta Köglmeier
- From the Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children NHS Foundation Trust London, United Kingdom
| | - Ines Assecaira
- the Medical University of Lisbon and Dietetic and Nutrition Department, University Hospital of Northern Lisbon, Lisbon, Portugal
| | - Elena Banci
- Dietetics Unit, Meyer Children's University Hospital, Florence, Italy
| | - Barbara De Koning
- Paediatric Gastroenterology, Erasmus MC-Sophia Children's Hospital Rotterdam, The Netherlands
| | - Nadja Haiden
- the Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Flavia Indrio
- the Department of Medical and Surgical Science University of Foggia, Italy
| | - Wendy Kastelijn
- the Department of Internal Medicine, Division of Dietetics, Erasmus MCUniversity Medical Center Rotterdam, The Netherlands
- the Department of Nutrition and Dietetics, School of Health Care Studies, Hanze University of Applied Sciences, Groningen, The Netherlands
| | - Denise Kennedy
- the First Dietitians, First Community Health and Care Redhill, Surrey, United Kingdom
| | | | - Lorenzo Norsa
- Pediatric Hepatology, Gastroenterology and Transplantation, ASST Papa Giovanni XXIIII, Bergamo, Italy
| | - Elvira Verduci
- the Department of Pediatrics, Ospedale dei Bambini Vittore Buzzi, University of Milan, Italy
| | - Analou Sugar
- the Department of Paediatric Speech and Language Therapy, Chelsea and Westminster Hospital NHS Foundation Trust London, United Kingdom
| |
Collapse
|
28
|
Batra A, Marino LV, Beattie RM. Feeding children with neurodisability: challenges and practicalities. Arch Dis Child 2022; 107:967-972. [PMID: 35105542 DOI: 10.1136/archdischild-2021-322102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 01/13/2022] [Indexed: 12/25/2022]
Abstract
Nutritional management for children with neurodisability can be challenging and there are an increasing number of children at risk of malnutrition. Management involves healthcare professionals in community and hospital working together with the family with the aim of optimising nutrition and quality of life. Feeding difficulties can be the result of physical causes like lack of oromotor coordination, discomfort associated with reflux oesophagitis or gastrointestinal dysmotility. Non-physical causes include parental/professional views towards feeding, altered perception of pain and discomfort, extreme sensitivity to certain textures and rigidity of feeding schedule associated with artificial feeding. Estimating nutritional needs can be difficult and is affected by comorbidities including epilepsy and abnormal movements, severity of disability and mobility. Defining malnutrition is difficult as children with neurodisability reflect a wide spectrum with disparate growth patterns and body composition and auxology is less reliable and less reproducible. Management involves selecting the type and method of feeding best suited for the patient. As artificial feeding can place a significant burden of care any decision-making should be, as much as possible, in concurrence with the family. Symptom management sometimes requires pharmacological interventions, but polypharmacy is best avoided. The article aims to discuss the pathways of identifying children at risk of malnutrition and available management options with a strong emphasis on working as a clinical team with the child and family.
Collapse
Affiliation(s)
- Akshay Batra
- Department of Paediatric Gastroenterology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - R Mark Beattie
- Department of Paediatric Gastroenterology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| |
Collapse
|
29
|
Marchesi JR, Allen S, Scott E, Jenkins H, Sadlier C, Thomas S. An observational investigation of the faical microbiota and metabonome of gastrostomy fed children, on blended and formula diets. Gut Microbes 2022; 14:2138661. [PMID: 36284401 PMCID: PMC9621064 DOI: 10.1080/19490976.2022.2138661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Gastrostomy fed children traditionally have a Formulae diet (FD), which fulfills nutritional requirements; however, many families are adopting Blended diets (BD), which are what the whole family would eat. We undertook an observational investigation of the colonic microbiota and metabonome in a small group of gastrostomy fed children, who were either on an FD or BD, and compared, where possible to their siblings (17 FD, 28 BD, 19 HS). There was no increase in complications in tube blockage or infection rates, but a significant improvement in the prevalence of bowel problems, a reduction in medication and an increase in quality of life. Metataxonomic analysis showed that the FD group was significantly different to the Sibling group, and that families did not cluster together. Whole sample metabonomics showed no differences between groups; however, univariate analysis of biologically important metabolites did differ. Changing to a BD resulted in no increase in complications or risks, but improved the overall quality of life for the children and families.
Collapse
Affiliation(s)
- Julian R. Marchesi
- Department of Metabolism, Digestion and Reproduction, St Mary’s Hospital, Imperial College London, London, UK,CONTACT Julian R. Marchesi Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, St Mary’s Hospital, Imperial College London, South Wharf Road, LondonW2 1NYUK
| | - Sophie Allen
- School of Biosciences, Cardiff University, CardiffUK
| | - Emma Scott
- Department of Metabolism, Digestion and Reproduction, St Mary’s Hospital, Imperial College London, London, UK
| | - Huw Jenkins
- Department of Paediatric Gastroenterology, Noah’s Ark Children’s Hospital for Wales, Cardiff, UK
| | - Claire Sadlier
- Department of Child Health, University Hospital of Wales, CardiffUK
| | - Sian Thomas
- Aneurin Bevan University Health Board, Royal Gwent Hospital, Newport, UK
| |
Collapse
|
30
|
Blenderised Tube Feeds vs. Commercial Formula: Which Is Better for Gastrostomy-Fed Children? Nutrients 2022; 14:nu14153139. [PMID: 35956316 PMCID: PMC9370549 DOI: 10.3390/nu14153139] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/23/2022] [Accepted: 07/28/2022] [Indexed: 11/25/2022] Open
Abstract
Blenderised tube feeds (BTF) have become a popular alternative to commercial formula (CF) for enterally fed children. This study sought to compare gastrointestinal (GI) symptoms, GI inflammation, and stool microbiome composition between children receiving BTF or CF. This prospective cohort study involved 41 gastrostomy-fed children, aged 2–18 years, receiving either BTF (n = 21) or CF (n = 20). The Paediatric Quality of Life Inventory Gastrointestinal Symptoms Scale (GI-PedsQL) was used to compare GI symptoms between the groups. Anthropometric data, nutritional intake, nutritional blood markers, faecal calprotectin levels, stool microbiota, and parental satisfaction with feeding regimen were also assessed. Caregivers of children on BTF reported greater GI-PedsQL scores indicating significantly fewer GI symptoms (74.7 vs. 50.125, p = 0.004). Faecal calprotectin levels were significantly lower for children receiving BTF compared to children on CF (33.3 mg/kg vs. 72.3 mg/kg, p = 0.043) and the BTF group had healthier, more diverse gut microbiota. Subgroup analysis found that 25% of caloric intake from BTF was sufficient to improve GI symptoms. The CF group had better body mass index (BMI) z-scores (−0.7 vs. 0.5, p = 0.040). Although growth was poorer in children receiving only BTF in comparison to the CF group, this was not seen in children receiving partial BTF. A combination of BTF and CF use may minimise symptoms of tube feeding whilst supporting growth.
Collapse
|
31
|
Stir, Shake or Blend: A Comparison of Methods Used to Reduce Viscosity of Blenderized Tube Feedings. J Pediatr Gastroenterol Nutr 2022; 75:110-112. [PMID: 35623084 DOI: 10.1097/mpg.0000000000003479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Blenderized tube feeding (BTF) refers to formula composed of whole foods and purees, blended to a consistency that can be administered through an enteral feeding device. BTFs have a higher viscosity than conventional enteral formulas and may be mixed with extra liquid to aid in administration via an enteral feeding device. This study compared changes in viscosity of commercially available BTF s when stirred, shaken, or blenderized. The International Dysphagia Diet Standardisation Initiative flow test was used to provide an objective level of viscosity. Our results indicate that the method chosen to thin BTFs results in significant differences in viscosity and varies depending on the percent of water by volume added to the formula as well as the presence of additional non-food ingredients such as synthetic supplements. We conclude that the method used to thin BTFs should be taken into account when a consistent viscosity level is desired.
Collapse
|
32
|
Zenitani M, Nose S, Oue T. Clinical Usefulness of Blenderized Food for Selenium Deficiency in Pediatric Patients with Severe Motor and Intellectual Disabilities. ANNALS OF NUTRITION & METABOLISM 2022; 78:345-351. [PMID: 35700713 DOI: 10.1159/000525450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 06/06/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION This study aimed to assess the preventive or therapeutic effects of blenderized food (BF) on selenium deficiency in pediatric patients with severe motor and intellectual disabilities (SMID). METHODS The medical records of all 40 consecutive pediatric patients with SMID who underwent nutritional assessment were retrospectively reviewed and compared between two groups: the enteral formula (EF) group and the BF group fed with BF providing more than 10% of total caloric intake. Next, for the selenium-deficient patients who were newly started on blenderized tube feeds after the first nutritional assessment, improvement of selenium deficiency and change of dietary contents were assessed. RESULTS The BF group patients had a significantly lower prevalence of selenium deficiency and higher serum selenium levels than the EF group patients. In all 7 selenium-deficient patients who started blenderized tube feeds after the first nutritional assessment, serum selenium levels were significantly increased at the second nutritional assessment, even though total selenium intake, selenium intake by EF, and total caloric intake did not differ significantly, and, in fact, caloric intake was significantly decreased by EF. CONCLUSION Combined feeding of BFs can be useful for prevention and therapy of selenium deficiency in pediatric SMID patients.
Collapse
Affiliation(s)
- Masahiro Zenitani
- Department of Pediatric Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Satoko Nose
- Department of Pediatric Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Takaharu Oue
- Department of Pediatric Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| |
Collapse
|
33
|
Zong W, Troutt R, Merves J. Blenderized enteral nutrition in pediatric short gut syndrome: Tolerance and clinical outcomes. Nutr Clin Pract 2022; 37:913-920. [PMID: 35638571 PMCID: PMC9283279 DOI: 10.1002/ncp.10866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 04/06/2022] [Accepted: 04/23/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Blenderized feeds consisting of whole food components are emerging as a preferred approach to enteral nutrition. However, there is limited evidence-based guidance for this strategy in short bowel syndrome (SBS). We aimed to explore the tolerance and clinical outcome of blenderized feeds in patients with SBS. METHOD We conducted a single-center, retrospective study of blenderized feeds in pediatric SBS. Of the 376 patients screened, 58 met inclusion criteria. Three patients were excluded because of a history of bowel transplant. Demographics, clinical history, and nutrition history were collected and analyzed. RESULT Patients had improved diarrhea though worsening gas while receiving blenderized feeds. There was no significant difference in small bowel length in patients who discontinued blends compared with those who continued. However, patients with colonic resection were more likely to discontinue the blends. In a subgroup of patients who lost weight despite improved diarrhea (n = 19), most had a history of ileocecal valve (ICV) and colonic resection, but no difference in small bowel length compared with those who did not lose weight. CONCLUSION Our cohort of patients with SBS experienced improved gastrointestinal symptoms and stool quality on blenderized feeds. Patients without an ICV and with colonic resection were more prone to weight loss. Stepwise titration of blenderized formula with previous formula regimen may be needed in a subset of patients to optimize tolerance and weight gain. Further study is warranted to understand factors contributing to variable tolerance and weight gain on blenderized formulas to guide their use in patients with SBS.
Collapse
Affiliation(s)
- Wenjing Zong
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Renee Troutt
- Division of Clinical Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jamie Merves
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| |
Collapse
|
34
|
Brekke G, Raun AMT, Sørensen SB, Kok K, Sørensen JL, Born AP, Mølgaard C, Hoei‐Hansen CE. Nutrition and preparation of blenderized tube feeding in children and adolescents with neurological impairment: A scoping review. Nutr Clin Pract 2022; 37:783-796. [PMID: 35403308 PMCID: PMC9541810 DOI: 10.1002/ncp.10853] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/18/2022] [Accepted: 03/12/2022] [Indexed: 12/18/2022] Open
Abstract
Background The use of homemade tube feeding formula has become increasingly popular for children requiring enteral nutrition. This project aimed to investigate nutrition and preparation of blenderized tube feeding in the field of children and adolescents with neurological impairment. Methods A scoping review was performed using established methodologies. In January 2021, we searched PubMed, Embase, CINAHL Complete, the Cochrane Central Register of Controlled Trials, and gray literature to identify relevant articles. Major findings Twenty‐two papers were included describing the composition of food items, preparation procedures, and food safety. No randomized controlled trials and only a few prospective studies were included. A broad variety of food items from all food groups and many examples of recipes were presented. Most recipes provided 1.0 kcal/ml but tended to contain less energy and nutrients than expected, which could be due to preparation issues, such as sieving and the high viscosity of the blend. Preparation requires a commercial‐grade household blender and diligence to ensure thorough household hygiene for adequate food safety. Conclusions This review revealed practical experience in the nutrition and preparation aspects of blenderized tube feeding but minimal empirical evidence. Multiple examples of the composition of food items and preparation procedures for blenderized tube feeding were found, but uncertainty regarding the ideal composition or preparation was also exposed. The future of blenderized tube feeding would benefit from clinically tested recipes that include an evaluation of nutrients, viscosity, and microbial contamination, as well as the effect of the food's appearance and scent on the target group.
Collapse
Affiliation(s)
- Ghita Brekke
- Department of Pediatrics Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Pediatric Nutrition Unit Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
| | - Anne Mette Terp Raun
- Department of Pediatrics Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Pediatric Nutrition Unit Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
| | - Sarah B. Sørensen
- Department of Pediatrics Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Pediatric Nutrition Unit Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
| | - Karin Kok
- Pediatric Nutrition Unit Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
| | - Jette L. Sørensen
- Juliane Marie Centre Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Denmark
| | - Alfred P. Born
- Department of Pediatrics Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
| | - Christian Mølgaard
- Pediatric Nutrition Unit Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Department of Nutrition, Exercise and Sports University of Copenhagen Frederiksberg C Denmark
| | - Christina E. Hoei‐Hansen
- Department of Pediatrics Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Denmark
| |
Collapse
|
35
|
YouTube as a Source of Information on Blenderised Tube Feeding. J Pediatr Gastroenterol Nutr 2022; 74:541-545. [PMID: 34724449 DOI: 10.1097/mpg.0000000000003342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Blenderised tube feeding (BTF) has become an increasingly popular method of nutrition support for long-term tube-fed patients mostly children. This study surveyed perceptions and experiences on BTF shared on YouTube. From 71 videos analysed, attitudes towards BTF were mostly positive (91%) and included psychosocial benefits and improvements in gastrointestinal symptoms; no differences between caregivers and healthcare professionals were observed. Very few speakers (8%) felt there was a lack of support regarding use of BTF in schools and from healthcare professionals, because it is not part of the standard clinical management protocols. The most commonly used food items in blends included carrots (n = 16) and chicken (n = 11), and experiences from those who have used BTF included tips on recipes for blends, storing feeds and ensuring nutritional adequacy. Analysis of YouTube content on BTF was considerably positive and suggests that BTF is feasible and safe way to provide nutrition to tube-fed patients.
Collapse
|
36
|
Milton D, Murphy B, Johnson TW, Carter H, Spurlock AY, Hussey J, Johnson K. Low risk for microbial contamination of syringe and tube feeding bag surfaces after multiple reuses with home blenderized tube feeding. Nutr Clin Pract 2022; 37:907-912. [PMID: 35233842 DOI: 10.1002/ncp.10835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Guidelines for the reuse of enteral tube feeding (ETF) equipment guidelines are limited to manufacturer recommendations. ETF equipment reuse studies are needed as the enteral population has increased, along with blenderized tube feeding (BTF). METHODS This experiment tested microbial contamination of a reusable gravity feeding bag and syringe after 15 BTF reuses and cleanings. Eight bags and syringes were filled with the BTF, held at room temperature for 20 min, and then emptied, washed, and air dried. After the last air drying, the inner surfaces of the bag and syringe were swabbed, and aerobic microbial counts were performed using serial dilutions and plate counts. RESULTS The microbial counts for all syringes and six bags were <1 colony-forming unit (CFU)/cm2 ; one bag was <5 CFU/cm2 and one bag was 12.5 CFU/cm2 . No legal guidelines for surface cleanliness exist for the food sector. Several studies propose a safe microbial level to be <2.5 CFU/cm2 , and the European Commission recommended <10 CFU/cm2 . Based on these proposed guidelines, microbial counts of all syringes and seven bags were within the proposed guidelines, except for one bag just above 10 CFU/cm2 . CONCLUSION The feeding bag used in this study may be used multiple times for BTF with a reduced risk of microbial contamination when manufacturer's cleaning guidelines are followed. Although bolus tube feeding is an off-label use for syringes, they are frequently used for BTF, and in this study the cleaning after 15 uses over 5 days was effective to reduce microbial counts.
Collapse
Affiliation(s)
- Debra Milton
- Department of Molecular Biology, Umeå University, Umeå, Sweden
| | - Brie Murphy
- Biological Sciences, Troy University, Troy, Alabama, USA
| | - Teresa W Johnson
- Department of Kinesiology and Health Promotion, Troy University, Troy, Alabama, USA
| | - Holly Carter
- School of Nursing, Troy University, Troy, Alabama, USA
| | | | - Jenna Hussey
- School of Nursing, Troy University, Troy, Alabama, USA
| | - Kelly Johnson
- School of Nursing, Troy University, Troy, Alabama, USA
| |
Collapse
|
37
|
Hirsch S, Solari T, Rosen R. Effect of Added Free Water to Enteral Tube Feeds in Children Receiving Commercial Blends. J Pediatr Gastroenterol Nutr 2022; 74:419-423. [PMID: 34560723 PMCID: PMC9531939 DOI: 10.1097/mpg.0000000000003308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To determine the impact of free water administration on clinical outcomes in medically complex patients, based on the hypothesis that patients receiving more thin liquids have worse outcomes related to increased risk of gastroesophageal reflux. METHODS This was a retrospective chart review of children initiated on commercial blenderized tube feedings from 2010 to 2019. The percentage of gastrostomy intake that was a thin liquid was determined, with thin liquids including free water or thin formula based on the International Dysphagia Diet Standardization Initiative (IDDSI) framework. Patients were categorized into those receiving low volumes of thin liquids ("percent thin" ≤20%) and those receiving higher volumes ("percent thin" >20%). Emergency room visits, hospital admissions, and chest X-rays during the year after starting the blend were compared. RESULTS Forty-five patients age 12 months to 18.7 years (median 3.7 years) were included. Twenty patients (44%) were receiving a blend with an IDDSI-categorized thin consistency and 25 patients (56%) were receiving a thicker blend. In addition to the blend, patients received a median of 320 mL per day of water (range 0-1000 mL). Patients receiving <20% thin liquids were less likely to undergo chest X-rays during follow-up than patients receiving larger amounts of thin liquids (10% in the minimal thin group versus 48% in the greater thin group, P = 0.03). In a multivariable logistic regression, this relationship remained significant after controlling for underlying pulmonary disease, aspiration, method of feed administration (bolus or continuous feeds), fundoplication status, and oral intake status. CONCLUSIONS Our study demonstrates that patients on blenderized tube feeds receive widely variable amounts of added thin liquids, like water. The addition of water to tube feeds, while typically given for hydration, can modify feed viscosity and clinical outcomes, such as chest X-ray performance.
Collapse
Affiliation(s)
- Suzanna Hirsch
- Aerodigestive Center, Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Hepatology & Nutrition, Boston Children’s Hospital, Boston, MA
| | - Toni Solari
- Aerodigestive Center, Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Hepatology & Nutrition, Boston Children’s Hospital, Boston, MA
| | - Rachel Rosen
- Aerodigestive Center, Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Hepatology & Nutrition, Boston Children’s Hospital, Boston, MA
| |
Collapse
|
38
|
Santos DCD, Ataide CDG, Mota da Costa N, Oliveira Junior VPD, Egea MB. Blenderized formulations in home enteral nutrition: a narrative review about challenges in nutritional security and food safety. Nutr Rev 2022; 80:1580-1598. [PMID: 35026011 DOI: 10.1093/nutrit/nuab121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Blenderized formulations (BFs) are prepared by homogenization of food that is normally used in oral nutrition. BFs are mainly used in home enteral nutrition (HEN), although their use has also been reported by hospitals when commercial enteral formulas are not available. HEN is applied when the patient has been discharged from the hospital. This nutritional therapy promotes the patient's reintegration into the family nucleus and promotes humanized care, and decreases treatment costs. However, the patient should continue to receive health and nutritional care, ranging from periodic nutritional re-evaluation to adaptation of the dietary plan. HEN provides the patient a greater contact with the family, whereas BFs promote the adaptation of the diet with food, respecting the food diversity and culture, lower cost, and easier access to food. Disadvantages of BFs include more time spent by the professional to calculate the dietary plan, greater difficulty in adjusting daily needs, and less microbiological and chemical stability. In this review, the nutritional, food security, and safety aspects of BF used in HEN are discussed. Technological quality aspects that are essential knowledge in the preparation of the patient's dietary plan also are presented.
Collapse
Affiliation(s)
- Daiane Costa Dos Santos
- D.C.d. Santos is with the Goiás Federal University (UFG), Institute of Tropical Pathology and Public Health, IPTSP-UFG, Goiânia, Goiás, Brazil. C.D.G. Ataide is with the Hospital DF Star, Asa Sul, Brasília, Brazil. N.M. da Costa, V.P. de Oliveira Junior, and M.B. Egea are with the Federal Institute of Education, Science, and Technology Goiano, Rio Verde, Goiás, Brazil
| | - Carla Daniela Gomes Ataide
- D.C.d. Santos is with the Goiás Federal University (UFG), Institute of Tropical Pathology and Public Health, IPTSP-UFG, Goiânia, Goiás, Brazil. C.D.G. Ataide is with the Hospital DF Star, Asa Sul, Brasília, Brazil. N.M. da Costa, V.P. de Oliveira Junior, and M.B. Egea are with the Federal Institute of Education, Science, and Technology Goiano, Rio Verde, Goiás, Brazil
| | - Nair Mota da Costa
- D.C.d. Santos is with the Goiás Federal University (UFG), Institute of Tropical Pathology and Public Health, IPTSP-UFG, Goiânia, Goiás, Brazil. C.D.G. Ataide is with the Hospital DF Star, Asa Sul, Brasília, Brazil. N.M. da Costa, V.P. de Oliveira Junior, and M.B. Egea are with the Federal Institute of Education, Science, and Technology Goiano, Rio Verde, Goiás, Brazil
| | - Valtemir Paula de Oliveira Junior
- D.C.d. Santos is with the Goiás Federal University (UFG), Institute of Tropical Pathology and Public Health, IPTSP-UFG, Goiânia, Goiás, Brazil. C.D.G. Ataide is with the Hospital DF Star, Asa Sul, Brasília, Brazil. N.M. da Costa, V.P. de Oliveira Junior, and M.B. Egea are with the Federal Institute of Education, Science, and Technology Goiano, Rio Verde, Goiás, Brazil
| | - Mariana Buranelo Egea
- D.C.d. Santos is with the Goiás Federal University (UFG), Institute of Tropical Pathology and Public Health, IPTSP-UFG, Goiânia, Goiás, Brazil. C.D.G. Ataide is with the Hospital DF Star, Asa Sul, Brasília, Brazil. N.M. da Costa, V.P. de Oliveira Junior, and M.B. Egea are with the Federal Institute of Education, Science, and Technology Goiano, Rio Verde, Goiás, Brazil
| |
Collapse
|
39
|
Rosen R. Novel Advances in the Evaluation and Treatment of Children With Symptoms of Gastroesophageal Reflux Disease. Front Pediatr 2022; 10:849105. [PMID: 35433543 PMCID: PMC9010502 DOI: 10.3389/fped.2022.849105] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/18/2022] [Indexed: 12/03/2022] Open
Abstract
Gastroesophageal reflux disease has long been implicated as a cause for multiple pediatric symptoms ranging from abdominal pain and regurgitation to cough and dental erosions. Diagnostic testing has evolved greatly over the last 20 years; initial testing with pH-metry to measure esophageal acid reflux burden has evolved into measurement of both acid and non-acid reflux and liquid and gas reflux. However, measuring reflux burden alone only tells a small part of the GERD story and many symptoms originally thought to be reflux related are, in fact, related to other disorder which mimic reflux. The current paradigm which involves empiric treatment of symptoms with acid suppression has been replaced with early testing for not only gastroesophageal reflux but also for other diagnostic masqueraders. The focus for interventions has shifted away from acid suppression toward motility interventions and includes a greater recognition of both functional and motility disorders which present with reflux symptoms.
Collapse
Affiliation(s)
- Rachel Rosen
- Boston Children's Hospital, Boston, MA, United States
| |
Collapse
|
40
|
Soscia J, Adams S, Cohen E, Moore C, Friedman JN, Gallagher K, Marcon M, Nicholas D, Weiser N, Orkin J. The parental experience and perceptions of blenderized tube feeding for children with medical complexity. Paediatr Child Health 2021; 26:462-469. [PMID: 34987677 PMCID: PMC8711682 DOI: 10.1093/pch/pxab034] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 05/03/2021] [Indexed: 01/11/2023] Open
Abstract
Objectives Parents of children with medical complexity are often expected to implement complicated plans of care, such as enteral tube feeding, to support the health of their child. Enteral feeding can have psychosocial implications for the parent, child, and family. Blenderized tube feeding (BTF) refers to the administration of pureed food and drinks through a feeding tube. Little is known regarding parents’ experiences with BTF. Therefore, the purpose of this qualitative study was to understand the lived experience of BTF from the parent’s perspective. Methods This qualitative study was a grounded theory analysis utilizing semi-structured interviews of parents who provided at least 50% of their child’s diet through BTF. Participants were recruited using purposive sampling from the Complex Care Program at a tertiary care paediatric centre. Interviews were conducted until thematic saturation was achieved. Themes were identified using constant comparative analysis of transcribed interviews. Results Parents (n=10) felt that BTF positively affected the experience of tube feeding and enhanced their child’s health and wellbeing. Parents described BTF as a means of self-empowerment and a mechanism to normalize feeding and care for the entire family. Despite reporting BTF as more time consuming than formula feeding, all parents were satisfied with having made the change, and planned on continuing the diet. Conclusion BTFs can improve the experience of tube feeding and positively address some of the negative psychosocial implications of enteral tube feeding, providing a sense of normalcy and control for parents caring for a child with medical complexity.
Collapse
Affiliation(s)
- Joanna Soscia
- Division of Paediatric Medicine, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sherri Adams
- Division of Paediatric Medicine, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Eyal Cohen
- Division of Paediatric Medicine, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Clara Moore
- Division of Paediatric Medicine, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jeremy N Friedman
- Division of Paediatric Medicine, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kelsey Gallagher
- Division of Paediatric Medicine, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Margaret Marcon
- Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - David Nicholas
- Faculty of Social Work, University of Calgary (Edmonton Division), Edmonton, Alberta, Canada
| | - Natalie Weiser
- Division of Paediatric Medicine, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Julia Orkin
- Division of Paediatric Medicine, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
41
|
Phillips G. Introduction of blended diet for enteral tube feeding in paediatrics: A case report. Nutr Health 2021; 28:483-487. [PMID: 34747244 DOI: 10.1177/02601060211054662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Advances in medical technology have resulted in changes to enteral tube feeding (ETF). Standard practice in the UK is to use commercial formula for ETF via the stomach or small intestine; however, blended diets are becoming increasingly popular. Emerging evidence shows benefits of a blended diet although evidence informing clinical guidance is sparse. Consequently, there is disparity in practice, and it remains unclear which patient groups may benefit most from a blended diet. Aim: To demonstrate the initiation of a blended diet in clinical practice. Methods: This case report features a 2-year-old child requiring ETF in the context of hypotonia, developmental delay and faltering growth. Results: In this instance, a blended diet resulted in improved gastrointestinal symptoms and adequate growth. Conclusion: This case demonstrates the successful implementation of a blended diet and associated benefits. Blended diets may benefit others requiring ETF and should be considered on an individualised basis.
Collapse
Affiliation(s)
- Gemma Phillips
- Leicestershire Nutrition and Dietetic Service, 9632Leicestershire Partnership NHS Trust, OSL House, East Link, Meridian Business Park, Leicester LE19 1XU, UK
| |
Collapse
|
42
|
Schmitz ÉPCR, Silva ECD, Lins Filho ODL, Antunes MMDC, Brandt KG. Blenderized tube feeding for children: an integrative review. REVISTA PAULISTA DE PEDIATRIA 2021; 40:e2020419. [PMID: 34495278 PMCID: PMC8431998 DOI: 10.1590/1984-0462/2022/40/2020419] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 01/29/2021] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To analyze scientific evidence on the use of blenderized tube feeding in children regarding nutritional composition, family satisfaction, and health outcomes. DATA SOURCE Survey was conducted in the PubMed, Scopus, Embase, and Virtual Health Library (VHL) databases using the following search terms: blenderized tube feeding OR blended tube feeding OR homemade OR pureed AND enteral nutrition AND enteral tube. The methodological quality of the selected articles was evaluated using the Critical Appraisal Skill Programme and Hierarchical Classification of Evidence. DATA SYNTHESIS After analysis, 11 articles were included in the present review. Most studies demonstrated improvements in health outcomes and greater family satisfaction after replacing the commercial enteral feeding with blenderized tube feeding. CONCLUSIONS When guided and monitored by the healthcare team, a blenderized tube feeding ensures an adequate nutritional composition. The use of this method is also associated with positive health outcomes such as reductions in gastrointestinal symptoms and hospitalizations. Moreover, a high frequency of family satisfaction was verified.
Collapse
|
43
|
Maddison J, Taylor J, O'Neill M, Cade J, Hewitt C, Horridge K, McCarter A, Fraser LK, Beresford B. Outcomes for gastrostomy-fed children and their parents: qualitative findings from the 'Your Tube' study. Dev Med Child Neurol 2021; 63:1099-1106. [PMID: 33792913 DOI: 10.1111/dmcn.14868] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2021] [Indexed: 12/20/2022]
Abstract
AIM To identify child and parent outcomes relevant to having a gastrostomy, and to specify outcomes believed to be particularly salient to type of diet (formula vs blended food). METHOD Twenty parents, two children (both 12y), and 41 professionals (dietitians [n=10]; nurses [n=12]; paediatricians [n=12]; speech and language therapists [n=7)]) were recruited. Parents and children were interviewed; professionals participated in focus groups. Children (2-18y) represented included those on formula (n=11), blended-food (n=7), and mixed (n=2) diets. All had been tube-fed for at least 6 months. Neurological, genetic, and metabolic conditions were represented. RESULTS Participants identified a range of children's outcomes relevant to a gastrostomy, including physical health, gastrointestinal symptoms, sleep, and time spent feeding. The children described experiences of exclusion caused by being tube-fed. Time, sleep, and emotional health were regarded as most salient to understanding parents' gastrostomy outcomes. Participants believed type of diet would most likely effect gastrointestinal symptoms, time spent feeding, sleep, and physical health. INTERPRETATION Findings indicate a number of refinements to, and allow further specification of, the current 'initial' core outcome set for tube-fed children. Findings also have implications for choice of outcomes measures. Further qualitative research with children and young people is needed. What this paper adds Sleep is a key outcome for children and parents. Gastrointestinal symptoms and physical health were regarded as outcomes most likely to be affected by type of diet. Well-being and participation were identified as key distal outcomes. Gastrostomies are complex interventions. Further specification of the core outcome set is possible.
Collapse
Affiliation(s)
- Jane Maddison
- Social Policy Research Unit, University of York, York, UK
| | - Johanna Taylor
- Martin House Research Centre, Department of Health Sciences, University of York, York, UK
| | - Mark O'Neill
- Martin House Research Centre, Department of Health Sciences, University of York, York, UK
| | - Janet Cade
- Nutritional Epidemiology Group, University of Leeds, Leeds, UK
| | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Karen Horridge
- South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | | | - Lorna K Fraser
- Martin House Research Centre, Department of Health Sciences, University of York, York, UK
| | | |
Collapse
|
44
|
Spurlock AY, Johnson TW, Pritchett A, Pierce L, Hussey J, Johnson K, Carter H, Davidson SL, Mundi MS, Epp L, Hurt RT. Blenderized food tube feeding in patients with head and neck cancer. Nutr Clin Pract 2021; 37:615-624. [PMID: 34462968 PMCID: PMC9292291 DOI: 10.1002/ncp.10760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Patients with headand neck cancer (HNC) are at high risk for malnutrition before and during chemoradiation treatment. Many will also require tube feeding to address declines in energy intake, weight, and quality of life (QOL) caused by the impact of treatment on gastrointestinal (GI) symptoms. Blenderized tube feeding (BTF) may ameliorate these adverse conditions. Methods In this open‐label, prospective pilot study, 30 patients with HNC who required feeding tube placement were recruited to switch from standard commercial formula after 2 weeks to a commercially prepared BTF formula. Weight, body mass index (BMI), GI symptoms, and QOL scores were tracked for 6 weeks from the first week of feeding tube placement. Results Of the 16 patients who completed the 6‐week assessment period, weights and BMI scores for 15 patients trended upward. For most patients, QOL and oral intake increased and GI symptoms decreased over the 6‐week period, particularly during weeks 3 and 4, when the impact of treatment is particularly exacting on patients with HNC. Conclusion BTF effectively mitigated weight loss, GI symptoms, QOL scores, and total energy intake in this group of patients with HNC who received tube feeding for 6 weeks.
Collapse
Affiliation(s)
| | - Teresa W Johnson
- College of Health and Human Services, Troy University, Troy, Alabama, USA
| | | | - Leah Pierce
- Montgomery Cancer Center, Montgomery, Alabama, USA
| | - Jenna Hussey
- School of Nursing, Troy University, Troy, Alabama, USA
| | - Kelly Johnson
- School of Nursing, Troy University, Troy, Alabama, USA
| | - Holly Carter
- School of Nursing, Troy University, Troy, Alabama, USA
| | - Stephen L Davidson
- Alabama Oncology Hematology Associates at The Montgomery Cancer Center, Montgomery, Alabama, USA
| | - Manpreet S Mundi
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota, USA
| | - Lisa Epp
- Endocrinology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Ryan T Hurt
- Medicine, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
45
|
Fass R, Boeckxstaens GE, El-Serag H, Rosen R, Sifrim D, Vaezi MF. Gastro-oesophageal reflux disease. Nat Rev Dis Primers 2021; 7:55. [PMID: 34326345 DOI: 10.1038/s41572-021-00287-w] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2021] [Indexed: 02/07/2023]
Abstract
Gastro-oesophageal reflux disease (GERD) is a common disorder in adults and children. The global prevalence of GERD is high and increasing. Non-erosive reflux disease is the most common phenotype of GERD. Heartburn and regurgitation are considered classic symptoms but GERD may present with various atypical and extra-oesophageal manifestations. The pathophysiology of GERD is multifactorial and different mechanisms may result in GERD symptoms, including gastric composition and motility, anti-reflux barrier, refluxate characteristics, clearance mechanisms, mucosal integrity and symptom perception. In clinical practice, the diagnosis of GERD is commonly established on the basis of response to anti-reflux treatment; however, a more accurate diagnosis requires testing that includes upper gastrointestinal tract endoscopy and reflux monitoring. New techniques and new reflux testing parameters help to better phenotype the condition. In children, the diagnosis of GERD is primarily based on history and physical examination and treatment vary with age. Treatment in adults includes a combination of lifestyle modifications with pharmacological, endoscopic or surgical intervention. In refractory GERD, optimization of proton-pump inhibitor treatment should be attempted before a series of diagnostic tests to assess the patient's phenotype.
Collapse
Affiliation(s)
- Ronnie Fass
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical System, Case Western Reserve University, Cleveland, OH, USA.
| | - Guy E Boeckxstaens
- Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - Hashem El-Serag
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Rachel Rosen
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Royal London Hospital, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Michael F Vaezi
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
46
|
|
47
|
Mezzomo TR, Fiori LS, de Oliveira Reis L, Schieferdecker MEM. Nutritional composition and cost of home-prepared enteral tube feeding. Clin Nutr ESPEN 2021; 42:393-399. [PMID: 33745611 DOI: 10.1016/j.clnesp.2020.12.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/28/2020] [Accepted: 12/18/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS To aid in dietary prescription and contribute to the promotion of food and nutritional safety of individuals, this study's objective was to compare the nutritional composition and cost of homemade preparations, blended preparations, and commercial enteral formula prescribed for adults and elderly people at hospital discharge. METHODS All hospitals in a Brazilian city that prescribed the three types of enteral formulations provide information about enteral formulations prescribed for home use. Enteral formulations were estimated in relation to energy content, macronutrients, micronutrients, and cost. RESULTS Homemade diets, blended and commercial enteral formulations showed, on average, normoproteic, normoglicidic and normolipidic features, with average daily costs (US$/2000 kcal) of US$ 29.77, 50.56 and 154.44, respectively. The cost was higher in the commercial enteral formulas (P < .001); vitamin and mineral content were poorer in homemade preparations. CONCLUSIONS The homemade and blended enteral preparations cost less, but were generally lower in micronutrients, calling for more adequate dietary prescription.
Collapse
Affiliation(s)
- Thais Regina Mezzomo
- Nutrition Course, International University Center UNINTER, Treze de Maio St, 538, 80510-030, São Francisco, Curitiba, Brazil; Master´s and Doctoral Graduate Program in Child and Adolescent Health, Federal University of Parana (UFPR), General Carneiro St., 181, Alto da Gloria, 80.060-900, Curitiba, Parana, Brazil.
| | - Lize Stangarlin Fiori
- Postgraduate Program in Food and Nutrition, Department of Nutrition, Federal University of Parana (UFPR), Lothario Meissner Ave., 632, Jardim Botanico Campus, 80.210-170, Curitiba, Parana, Brazil
| | - Letícia de Oliveira Reis
- Nutrition Course, Positivo University, Prof. Pedro Viriato Parigot de Souza St, 5300, Campo Comprido, 81280-330, Curitiba, Brazil
| | - Maria Eliana Madalozzo Schieferdecker
- Postgraduate Program in Food and Nutrition, Department of Nutrition, Federal University of Parana (UFPR), Lothario Meissner Ave., 632, Jardim Botanico Campus, 80.210-170, Curitiba, Parana, Brazil
| |
Collapse
|
48
|
Chandrasekar N, Dehlsen K, Leach ST, Krishnan U. Exploring Clinical Outcomes and Feasibility of Blended Tube Feeds in Children. JPEN J Parenter Enteral Nutr 2021; 45:685-698. [PMID: 33305384 DOI: 10.1002/jpen.2062] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 12/02/2020] [Accepted: 12/07/2020] [Indexed: 02/06/2023]
Abstract
Commercially produced complete nutritional formulas (CFs) are commonly delivered to children requiring enteral nutrition via gastrostomy. However, a cultural shift toward consuming a more natural diet consisting of whole foods has caused the use of blenderized tube feeds (BTFs) to grow in popularity among parents and carers in recent years. There are advantages and disadvantages of both BTF and CF use. There is evidence that suggests that BTFs can significantly improve tube-feeding tolerance and reduce gastrointestinal symptoms associated with tube feeding, such as gagging, retching, and constipation, thereby resulting in an improved quality of life (QoL) for enterally fed children and their caregivers. BTFs have also been implicated in increasing the diversity of the gut microbiota in enterally fed children. However, concerns have been raised that BTFs may be inferior to CFs in energy and nutrition sufficiency. Issues such as microbial contamination, tube blockages, and difficulties in preparation and administration may also complicate the use of BTFs. Additionally, like CFs, BTFs can vary significantly in nutrition composition, and dietitian involvement with BTF use is crucial. The current literature on the clinical outcomes of BTF use is limited, and further research is needed before recommendations can be made on BTF use in children. A literature review was conducted to compare clinical outcomes between BTFs and CFs and evaluate the feasibility of BTF use in children.
Collapse
Affiliation(s)
- Neha Chandrasekar
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Kate Dehlsen
- Department of Nutrition and Dietetics, Sydney Children's Hospital, Randwick, New South Wales, Australia.,Department of Paediatric Gastroenterology, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Steven T Leach
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Usha Krishnan
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia.,Department of Paediatric Gastroenterology, Sydney Children's Hospital, Randwick, New South Wales, Australia
| |
Collapse
|
49
|
The Ethics of Feeding the Aspirating Child in an Age of Increasing Patient Complexity. J Pediatr Gastroenterol Nutr 2020; 71:586-588. [PMID: 33093363 DOI: 10.1097/mpg.0000000000002919] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
|
50
|
Bennett K, Hjelmgren B, Piazza J. Blenderized Tube Feeding: Health Outcomes and Review of Homemade and Commercially Prepared Products. Nutr Clin Pract 2020; 35:417-431. [PMID: 32362020 DOI: 10.1002/ncp.10493] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The popularity of homemade blenderized tube feeding (HBTF) continues to increase among enteral nutrition (EN) consumers and healthcare providers alike, citing improved feeding tolerance over standard commercial enteral formulas, among other health outcomes. Within the past 5-10 years, there has been a surge in the development of commercial blenderized tube feeding (CBTF) products. CBTF products promote similar benefits from whole foods like those used in HBTF while being a nutritionally-consistent, easy to use, and shelf-stable option for EN consumers. Research is improving but is still limited for HBTF and virtually nonexistent for CBTF products. This review aims to summarize current health outcomes of HBTF, compare HBTF with CBTF, evaluate CBTF products, and provide considerations for future research and practices.
Collapse
|