Blended diets for gastrostomy fed children and young people: a scoping review

Nutritional management of the child with chronic kidney disease and on dialysis

While it is widely accepted that the nutritional management of the infant with chronic kidney disease (CKD) is paramount to achieve normal growth and development, nutritional management is also of importance beyond 1 year of age, particularly in toddlers, to support the delayed infantile stage of growth that may extend to 2-3 years of age. Puberty is also a vulnerable period when nutritional needs are higher to support the expected growth spurt. Inadequate nutritional intake throughout childhood can result in failure to achieve full adult height potential, and there is an increased risk for abnormal neurodevelopment. Conversely, the rising prevalence of overweight and obesity among children with CKD underscores the necessity for effective nutritional strategies to mitigate the risk of metabolic syndrome that is not confined to the post-transplant population. Nutritional management is of primary importance in improving metabolic equilibrium and reducing CKD-related imbalances, particularly as the range of foods eaten by the child widens as they get older (including increased consumption of processed foods), and as CKD progresses. The aim of this review is to integrate the Pediatric Renal Nutrition Taskforce (PRNT) clinical practice recommendations (CPRs) for children (1-18 years) with CKD stages 2-5 and on dialysis (CKD2-5D). We provide a holistic approach to the overall nutritional management of the toddler, child, and young person. Collaboration between physicians and pediatric kidney dietitians is strongly advised to ensure comprehensive and tailored nutritional care for children with CKD, ultimately optimizing their growth and development.

Blenderized food tube feeding in very young pediatric patients with special healthcare needs

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.

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.

Blended feeding in gastrostomy-fed children-A scoping review

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.

Blenderized tube feedings: Practice recommendations from the American Society for Parenteral and Enteral Nutrition

Prior to the 1970s, blending food and liquids and putting them through an enteral access device (EAD) was the most common form of enteral nutrition (EN). However, in the 1970s, blenderized tube feedings (BTFs) became less popular due to the emergence of modern commercial enteral formulas (CEFs). Recently, a cultural shift toward consuming a natural diet, consisting of whole foods, has led to a resurgence in the use of BTF. The increasing use of BTF in a variety of patient care settings identifies a need for practice recommendations that provide guidance for nutrition professionals and patients. Members of the American Society for Parental and Enteral Nutrition (ASPEN) Enteral Nutrition Committee identified salient clinical questions concerning BTF, conducted a comprehensive literature search, and subsequently developed practice recommendations pertaining to the use of BTF. This paper was approved by the ASPEN 2022-2023 Board of Directors.

Blended diets for tube-fed children and young people: a rapid review update

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.

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.

Blended diet for enteral tube feeding in young people: A systematic review of the benefits and complications

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.

Nutritional management of the infant with chronic kidney disease stages 2-5 and on dialysis

The nutritional management of children with chronic kidney disease (CKD) is of prime importance in meeting the challenge of maintaining normal growth and development in this population. The objective of this review is to integrate the Pediatric Renal Nutrition Taskforce clinical practice recommendations for children with CKD stages 2-5 and on dialysis, as they relate to the infant from full term birth up to 1 year of age, for healthcare professionals, including dietitians, physicians, and nurses. It addresses nutritional assessment, energy and protein requirements, delivery of the nutritional prescription, and necessary dietary modifications in the case of abnormal serum levels of calcium, phosphate, and potassium. We focus on the particular nutritional needs of infants with CKD for whom dietary recommendations for energy and protein, based on body weight, are higher compared with children over 1 year of age in order to support both linear and brain growth, which are normally maximal in the first 6 months of life. Attention to nutrition during infancy is important given that growth is predominantly nutrition dependent in the infantile phase and the growth of infants is acutely impaired by disruption to their nutritional intake, particularly during the first 6 months. Inadequate nutritional intake can result in the failure to achieve full adult height potential and an increased risk for abnormal neurodevelopment. We strongly suggest that physicians work closely with pediatric renal dietitians to ensure that the infant with CKD receives the best possible nutritional management to optimize their growth and development.

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

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.

Feeding children with neurodisability: challenges and practicalities

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.

An observational investigation of the faical microbiota and metabonome of gastrostomy fed children, on blended and formula diets

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.

YouTube as a Source of Information on Blenderised Tube Feeding

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.

Introduction of blended diet for enteral tube feeding in paediatrics: A case report

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.

Blenderized tube feeding for children: an integrative review

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.

Outcomes for gastrostomy-fed children and their parents: qualitative findings from the 'Your Tube' study

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.

Parents and health professionals' experiences and perceptions of blended feeding in tube-fed children: a qualitative systematic review protocol

OBJECTIVE

The objective of this review is to identify and synthesize the best available evidence on parents' and health professionals' experiences and perceptions of blended feeding in tube-fed children in order to promote effective decision-making on its use.

INTRODUCTION

Blended feeding is not a new concept, despite the fact that commercial formulas have displaced its use in recent years. As feeding is viewed as an intimate experience between a parent and child, the choice of individualized blended feeds is something to be considered; however, professionals find there is a lack of evidence and discussion to support the use of blended feeding in practice. Therefore, the findings of this review may be beneficial, especially for professionals, and inform or promote more effective decision-making on the use of blended feeding.

INCLUSION CRITERIA

This review will consider studies that investigate parents and/or health professionals' experiences and perceptions of total or partial blended feeding in tube-fed children. Studies published in English that focus on qualitative data will be considered. There will be no restrictions on year or publication.

METHODS

The key information sources to be searched are: CINAHL Complete, MEDLINE, PsycINFO, Embase, Web of Science, WHO Library Database (GIM), and Google Scholar, along with several sources of gray literature. Two reviewers will independently screen titles and abstracts against the inclusion criteria, and will retrieve full text studies, assess methodological quality, and extract data. Findings will be pooled using meta aggregation, and a ConQual Summary of Findings will be presented.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO (CRD42020160357).

Psychosocial support for families of children with neurodisability who have or are considering a gastrostomy: the G-PATH mixed-methods study

Background

Evidence reviews recommend consistent and structured support for children with neurodisability and their caregivers in care pathways in which professionals recommend a gastrostomy feeding tube. To date, and to our knowledge, no research has shown how these recommendations have been implemented.

Objectives

The objectives were to describe different exemplar models of psychosocial support and provide an estimate of their resources and costs.

Design

This was a mixed-methods study involving (1) a web-based survey, (2) a qualitative, collective case study of psychosocial support provision in four services and (3) an estimate of costs and preference through a willingness-to-pay study.

Setting

Four service configurations in different locations in England and Scotland.

Participants

Participants were staff who responded to a survey (n = 67) and interviewees (staff, n = 58; parents/children, n = 29).

Findings

Psychosocial support was rarely formalised or documented; it was delivered by different members of the multidisciplinary team, rather than by designated staff, and it was often integrated into appointments dominated by clinical care. Parents expressed different needs for support but reported little opportunity to discuss emotional aspects. Psychologists were not routinely involved and, in general, families were underserved by psychosocial services. Professionals constructed families’ need for psychosocial support in terms of their own roles and the management of risk. Mechanisms for integrating and delivering support were identified, including models of care that linked community and tertiary health services and integrated health and education through pooled budgets. Although generally valued by both staff and parents, peer-to-peer parent support was not consistently offered. Barriers included concerns about confidentiality and appropriately matching parents. Parents participated as members of a feeding committee at one site. Three analytical constructs described the provision of psychosocial support: ‘hidden work’, expressing emotional vulnerability and negotiations around risks and values. The cost-of-support study found that there was a mean of 2.25 appointments (n = 8 parents or carers) over the previous 12 months. The cost of health-care professionals’ time spent on providing psychosocial support ranged from £0.00 to £317.37 per child per year, with an average cost of £76.42, at 2017 prices. In the willingness-to-pay study the median rank of enhanced support, involving the opportunity to see a psychologist and parental peers, was significantly higher than that of usual care (n = 96 respondents, both carers and professionals, who completed rating of the service; p < 0.001).

Limitations

It proved difficult to disseminate a national survey, which resulted in a small number of returns, and to cost the provision of psychosocial support, which we designated as ‘hidden work’, owing to the lack of recording in clinical systems. Moreover, estimates were based on small numbers.

Conclusions

Parent interviews and the willingness-to-pay study demonstrated a preference for enhanced psychosocial support. The study suggests that there is a need for services to formally assess families’ needs for psychosocial support to ensure that provision is planned, costed and made explicit in care pathways. Personalised interventions may assist with the targeting of resources and ensuring that there is an appropriate balance in focus on both clinical care and psychosocial support needs in relation to and following treatment.

Future work

More work is needed to develop tools to assess families’ needs for psychosocial support and the effectiveness of training packages to strengthen team competency in providing support.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 38. See the NIHR Journals Library website for further project information.

Energy and protein requirements for children with CKD stages 2-5 and on dialysis-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce

Dietary management in pediatric chronic kidney disease (CKD) is an area fraught with uncertainties and wide variations in practice. Even in tertiary pediatric nephrology centers, expert dietetic input is often lacking. The Pediatric Renal Nutrition Taskforce (PRNT), an international team of pediatric renal dietitians and pediatric nephrologists, was established to develop clinical practice recommendations (CPRs) to address these challenges and to serve as a resource for nutritional care. We present CPRs for energy and protein requirements for children with CKD stages 2-5 and those on dialysis (CKD2-5D). We address energy requirements in the context of poor growth, obesity, and different levels of physical activity, together with the additional protein needs to compensate for dialysate losses. We describe how to achieve the dietary prescription for energy and protein using breastmilk, formulas, food, and dietary supplements, which can be incorporated into everyday practice. Statements with a low grade of evidence, or based on opinion, must be considered and adapted for the individual patient by the treating physician and dietitian according to their clinical judgment. Research recommendations have been suggested. The CPRs will be regularly audited and updated by the PRNT.

'Your Tube': the role of different diets in children who are gastrostomy fed: protocol for a mixed methods exploratory sequential study

INTRODUCTION

Increasing numbers of children require having all, or part, of their nutritional intake via gastrostomy. More parents are using home-blended meals to feed their children, with many reporting beneficial effects such as improved gastro-oesophageal reflux, less constipation and less distress in their child.This study aims to identify the important outcomes of tube feeding in this population, compare the safety, outcomes and resource use of those on a home-blended diet compared with a formula diet and assess feasibility of long-term follow-up of children recruited to this study.

METHODS AND ANALYSES

This is a mixed methods study of children (aged 6 months to 18 years) who are gastrostomy feed dependent recruited via general, community and specialist paediatric and dietetic services. Workstream1 (WS1): a qualitative study involving semistructured interviews with parents (n~20) and young people (n~5-10), and focus groups with health professionals (n~25), will provide evidence of appropriate outcome measures and the feasibility/acceptability of proposed data collection methods for WS2. It will gather data on: desired outcomes of gastrostomy feeding, variability in diets and reasons; use of oral feeding; perceived benefits of the alternative diets, resources associated with gastrostomy feeding and safety issues. Data will be analysed using thematic analysis. WS2: a cohort study of 300 children who are gastrostomy fed. Data will be collected at months 0, 9 and 18 from parents, children (if appropriate) and clinicians using standardised measures and questionnaires developed specifically for the study. Data collected will include gastrointestinal symptoms, health and other outcomes (child, parent), dietary intake, anthropometry, healthcare usage, safety outcomes and resource use. Outcomes in the home-blended and formula groups will be compared using appropriate multiple regression analyses.

ETHICS AND DISSEMINATION

The study has been approved by a research ethics committee (REC reference: 19/YH/0028). Results will be disseminated through publications and presentations for professionals and families.

STUDY REGISTRATION NUMBER

ISRCTN13977361.

A laboratory-based evaluation of tube blocking and microbial risks associated with one blended enteral feed recipe

BACKGROUND

Concerns associated with blended enteral feeds include the risk of blocked tubes and microbial contamination, although the available evidence is limited. The present laboratory-based investigation aimed to examine these risks in a blended feed providing a nutritionally adequate intake for a hypothetical patient.

METHODS

A one-blended feed recipe was made using three different methods (professional, jug and stick blenders) and three storage procedures. Feed samples were syringed via 10-, 12- and 14-French (Fr) enteral feeding tubes and both blockages and the time taken were recorded. Feed samples were diluted, plated on agars, incubated and bacterial colony-forming units (CFU) counted. After storage at -80 °C, identification was undertaken using 16S rRNA polymerase chain reaction sequencing.

RESULTS

Two blockages occurred during 27 administrations of feed made using a professional blender, although they were resolved with a water flush. No blockages occurred with the 14-Fr tube and administration was quicker with wider tubes (P < 0.00001). There was no significant difference between the total bacterial CFU of feeds prepared using different methods (P = 0.771) or stored differently. The genus of bacteria identified included Enterococcus, Bacillus, lactose-fermenting Enterobacteriaceae, Pseudomonas and Staphylococcus. Pathogens, such as Clostridium spp., Salmonella spp. and Vibrio spp., were not identified by phenotypic tests used. Sequencing identified Escherichia coli, Shigella spp., Streptococcus lutetiensis and Staphylococcus epidermidis.

CONCLUSIONS

The present study found no risk of tube blockages when one blended feed recipe made using three methods was delivered via a 14-Fr tube. There is concern about bacterial contamination, although this was not influenced by the methods of preparation or storage used in the present study.