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

Systematic review: exploring outcomes of commercial and homemade blenderized tube-feeding regimens on feeding tolerance in pediatric patients

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.

Safety, resource use and nutritional content of home-blended diets in children who are gastrostomy fed: findings from 'YourTube' - a prospective cohort study

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.

Blended diet in enteral feeding: current guidance

The practice of administering blended food via enteral feeding tubes has been growing in popularity in recent years. Concerns have been raised as this practice was perceived to increase risk of gastrointestinal intolerance, allergic reactions, nutritional insufficiency, tube blockages, and infection compared with using commercial enteral feed (CEF), the gold standard, as well as risk of litigation against the professional due to their support of practice that is not evidence-based. However, research has shown that the physical, social and emotional benefits from receiving blended diet may outweigh the previously suggested risks. Guidance has been updated to encourage discussions around blended diet while informing the tube-fed individuals, families and carers of potential risks, potential benefits, barriers, considerations for training, safety and contraindications.

Pediatric Formulas: An Update

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.

The Management of Dietary Fiber Intake in Children With Chronic Kidney Disease - Clinical Practice Recommendations From the Pediatric Renal Nutrition Taskforce

The benefits of dietary fiber are widely accepted. Nevertheless, a substantial proportion of children fail to meet the recommended intake of dietary fiber. Achieving adequate fiber intake is especially challenging in children with chronic kidney disease (CKD). An international team of pediatric renal dietitians and pediatric nephrologists from the Pediatric Renal Nutrition Taskforce (PRNT) has developed clinical practice recommendations (CPRs) for the dietary intake of fiber in children and adolescents with CKD. In this CPR paper, we propose a definition of fiber, provide advice on the requirements and assessment of fiber intake, and offer practical guidance on optimizing dietary fiber intake in children with CKD. In addition, given the paucity of available evidence and to achieve consensus from international experts, a Delphi survey was performed in which all the clinical practice recommendations were reviewed.

Blenderized tube feeding in pediatrics - current evidence, guidelines, and considerations

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.

'YourTube' the role of different diets in gastrostomy-fed children: Baseline findings from a prospective cohort study

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.

A clinical consensus paper on jejunal tube feeding in children

BACKGROUND

Feeding problems are common in children with complex medical problems or acute critical illness and enteral nutrition may be required. In certain situations, gastric tube feeding is poorly tolerated or may not be feasible. When feed intolerance persists despite appropriate adjustments to oral and gastric enteral regimens, jejunal tube feeding can be considered as an option for nutrition support.

METHODS

A multidisciplinary expert working group of the Australasian Society of Parenteral and Enteral Nutrition was convened. They identified topic questions and five key areas of jejunal tube feeding in children. Literatures searches were undertaken on Pubmed, Embase, and Medline for all relevant studies, between January 2000 and September 2022 (n = 103). Studies were assessed using National Health and Medical Research Council guidelines to generate statements, which were discussed as a group, followed by voting on statements using a modified Delphi process to determine consensus.

RESULTS

A total of 24 consensus statements were created for five key areas: patient selection, type and selection of feeding tube, complications, clinical use of jejunal tubes, follow-up, and reassessment.

CONCLUSION

Jejunal tube feeding is a safe and effective means of providing nutrition in a select group of pediatric patients with complex medical needs, who are unable to be fed by gastric tube feeding. Appropriate patient selection is important as complications associated with jejunal tube feeding are not uncommon, and although mostly minor, can be significant or require tube reinsertion. All children receiving jejunal tube feeding should have multidisciplinary team assessment and follow-up.

Experiences and perceptions of multidisciplinary paediatric teams of blended tube feeding in children

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.

The evolution of nutrition management in children with severe neurological impairment with a focus on cerebral palsy

Nutritional management of children with severe neurological impairment (SNI) is highly complex, and the profile of this population is changing. The aim of this narrative review was to give the reader a broad description of evolution of the nutritional management of children with SNI in a high resource setting. In the last decade, there has been an emphasis on using multiple anthropometric measures to monitor nutritional status in children with SNI, and several attempts at standardising the approach have been made. Tools such as the Feeding and Nutrition Screening Tool, the Subjective Global Nutrition Assessment, the Eating and Drinking Ability Classification System and the Focus on Early Eating and Drinking Swallowing (FEEDS) toolkit have become available. There has been an increased understanding of how the gut microbiome influences gastrointestinal symptoms common in children with SNI, and the use of fibre in the management of these has received attention. A new diagnosis, 'gastrointestinal dystonia', has been defined. The increased use and acceptance of blended food tube feeds has been a major development in the nutritional management of children with SNI, with reported benefits in managing gastrointestinal symptoms. New interventions to support eating and drinking skill development in children with SNI show promise. In conclusion, as the life expectancy of people with SNI increases due to advances in medical and nutrition care, our approach necessitates a view to long-term health and quality of life. This involves balancing adequate nutrition to support growth, development and well-being while avoiding overnutrition and its associated detrimental long-term effects.

Clinical guideline highlights for the hospitalist: The use of blended diets in children with enteral feeding tubes

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.