The Microbial Quality and Safety of Blenderised Enteral Nutrition Formula: A Systematic Review

Knowledge and clinical practice of ASPEN registered dietitian nutritionist members regarding blenderized tube feedings

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.

Trends and challenges in home enteral feeding methods for children with gastrointestinal disorders: an expert review on bolus feeding delivery methods

INTRODUCTION

New evidence supports the benefits of bolus feeding for children receiving home enteral feeding (HEN). Current home methods of bolus feeding have certain limitations, particularly in mobile or restless patients. Therefore, innovative delivery methods have been introduced to provide more flexible methods of reducing feeding time and formula handling.

AREAS COVERED

This manuscript presents an expert review of the updates in HEN for children and the results of an online user experience questionnaire about an innovative new cap-based bolus feeding system. A literature bibliographic search was conducted on Medline via PubMed up to September 2023 to collect relevant studies. We presented recent evidence demonstrating a dramatic increase in HEN use among children requiring EN and its benefits on patients' nutritional status and quality of life. In addition, the article examined the clinical and social benefits of bolus feeding and current challenges in delivery methods. We described the benefits of the new system and its user experience.

EXPERT OPINION

The uses and indications for bolus feeding in HEN are increasing among children. However, there are still some unmet needs regarding traditional delivery methods. Innovative techniques can improve flexibility, reduce feeding time, and improve user experience and quality of life.

Checklist to assess food safety when handling home enteral nutrition

BACKGROUND

Identifying food safety risks when handling enteral formulations at home is important to restore and maintain the health of patients. Therefore, this study developed and validated a food safety assessment checklist for handling home enteral nutrition (HEN).

METHODS

This methodological study developed a checklist based on a literature review and interviews with food safety professionals. The content validation, which was conducted by food safety and enteral feeding experts, assessed the relevance, clarity, and simplicity of the checklist using the content validity index of items (CVI-I), categories (CVI-C), and the entire instrument (CVI-EI). Each item was rated as either essential, necessary, or recommended according to the risk in relation to foodborne diseases.

RESULTS

The Food Safety for Handling Home Enteral Nutrition checklist (FSHEN checklist) that was developed includes 40 items and the following eight categories: physical structure; cleaning of facilities, equipment, furniture, and utensils; pests and waste; water supply; food handlers; ingredients and packaging; handling of enteral formulations; and the bottling and storage of enteral formulations. The CVI-EI was above the recommendation (≥0.93) for the three assessed criteria, as was the CVI-C in terms of clarity (≥0.95), relevance (≥0.98), and simplicity (≥0.84). A total of 52.5% of the items were rated as essential, 32.5% as necessary, and 15% as recommended.

CONCLUSION

The FSHEN checklist is relevant, clear, and easy to use. It can help health professionals and individuals working in the field to assess and prioritize items to improve food safety in the management of HEN.

Microbiological contamination present in enteral tube feeding prepared in hospitals and/or at home: a systematic review

CONTEXT

The safety of enteral formulas is important to restore and maintain the health of patients.

OBJECTIVE

A systematic review of the literature was conducted to assess the microbiological contamination present in enteral tube feeding prepared in hospitals and/or at home.

DATA SOURCES

A systematic search was conducted of the Medline, Scopus, BVS, CAPES/MEC, Embase, Science Direct, and SciELO databases and gray literature.

DATA EXTRACTION

Eligible studies that analyzed the contamination of enteral formulas manipulated in hospitals and/or at home were selected; a quality assessment tool was used.

DATA ANALYSIS

Twenty-three studies evaluated 1099 enteral formulations. Of these, 44.67% of enteral formulas (n = 491) exceeded the acceptable bacterial count. Samples of homemade enteral formulation preparations (86.03%; n = 191) had the highest bacterial counts, followed by mixed preparations (79.72%; n = 59), and commercial formulas (30.01%; n = 241). The number of samples of enteral formulations that exceeded the bacterial count at home was 70.79% (n = 160 at the hospital was 37.91% (n = 331). Total coliforms (82.68%; n = 406) and mesophilic aerobes (79.22%; n = 389) were the most common microorganisms. Samples with bacterial pathogens were also identified, with Bacillus cereus (4.07%; n = 20) and Listeria monocytogenes (3.66%; n = 18) being the most prevalent.

CONCLUSIONS

A high number of samples of enteral formulations exceeded the bacterial count, but the risk to patient's health when consuming enteral tube feeding prepared in hospitals or at home may be low. This is because the bacteria present in the samples are not considered potential causes of disease but rather indicators of hygiene conditions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42022367573.

Assessing heavy metal levels in pediatric enteral nutrition formulas available in the Turkish market: Implications for consumer health

In this study, we assessed the levels of lead (Pb), cadmium (Cd), mercury (Hg), and inorganic arsenic (iAs) in 27 pediatric enteral nutrition (EN) formulas from five international brands available in the Turkish market. Analysis was conducted using inductively coupled plasma mass spectrometry (ICP-MS). Non-carcinogenic and carcinogenic risk assessment was performed using hazard quotient (HQ), hazard index (HI), carcinogenic risk (CR), Toxicological contribution % of Provisional Tolerable Weekly Intake (PTWI) models. Our objective was to evaluate heavy metal exposure in EN formulas, specifically focusing on Cd, Pb, iAs, and Hg levels according to recommended amounts for different age groups based on their energy requirements. Average concentrations of iAs in polymeric (PC), oligomeric (OC), and monomeric (MC) EN formulas were as follows: PC: 2.13 ± 0.16 ( Collapse

Key Words

• Carcinogenic risk
• Enteral nutrition formula
• Hazard quotient
• Health risk assessment
• Heavy metal

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MESH Headings

• Female
• Child
• Humans
• Male
• Cadmium/analysis
• Enteral Nutrition
• Lead
• Metals, Heavy/analysis
• Mercury/analysis
• Risk Assessment

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Affiliation(s)

Gursel Isci Department of Nutrition and Dietetics, Faculty of Health Sciences, Agri Ibrahim Cecen University, 04100, Agri, Turkey.
Betul Orucoglu Department of Nutrition and Dietetics, Faculty of Health Sciences, Afyonkarahisar Health Sciences University, 03100, Afyonkarahisar, Turkey.
Merve Ekici Department of Nutrition and Dietetics, Faculty of Health Sciences, Agri Ibrahim Cecen University, 04100, Agri, Turkey; Department of Nutrition and Dietetics, Institute of Health Sciences, Acıbadem Mehmet Ali Aydınlar University, 34758, Istanbul, Turkey.

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Homemade blenderized tube feeding improves gut microbiome communities in children with enteral nutrition

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.

The Impact of Blenderized Tube Feeding on Gastrointestinal Symptoms, a Scoping Review

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.

Microbiological quality of hospital-prepared blenderised tube feeding

BACKGROUND

Contaminated blenderised tube feeding (BTF) causes numerous infections in patients with deficient immune systems. The microbial quality of BTF should be thoroughly monitored to reduce the risks of microbial agents and prevent food safety problems such as food poisoning and food-borne illnesses. The aim of this study was to survey the contamination rate of BTF samples prepared in the teaching hospitals in Mashhad, Iran.

METHODS

This study was conducted on 24 samples of BTF prepared in four teaching hospitals in Mashhad city; the samples were collected randomly. Then specific culture media were used for detected and counted Listeria monocytogenes, Salmonella spp., Staphylococcus aureus, Clostridium perfringens, Bacillus cereus, coliforms and Escherichia coli. The final confirmation of the isolates was performed using polymerase chain reaction.

RESULTS

The total bacterial count was determined in the BTF samples and compared with the Food and Drug Administration medical food standards; 91.6% of the samples had 5.2 ± 0.1 log CFU/ml microbial bacterial contamination considering the standard range. The mean prevalence of contamination in these samples was measured for coliforms 4.9 ± 0.17 log CFU/ml, B. cereus 3.6 ± 0.16 log CFU/ml, S. aureus 3.7 ± 0.15 log CFU/ml and C. perfringens 4.7 ± 0.08 log CFU/ml (p < 0.05). Moreover, E. coli 11 (45.8%), Salmonella spp. 9 (37.5%) and L. monocytogenes 17 (70.8%) samples were detected.

CONCLUSION

Given the high consumption of BTF and the transmission of food contamination to hospitalised patients, it is essential to improve the hygienic conditions at the site of BTF preparation to prevent re-contamination.

MICROBIOLOGICAL QUALITY OF ENTERAL FORMULATIONS HANDLED AT HOME: A SYSTEMATIC REVIEW

BACKGROUND

Studies have shown an increase in the number of patients who use enteral nutrition at home, and the benefits of this type of nutritional care. However, little is known about the risk of bacterial contamination of enteral formulations prepared at home. Therefore, the aim of the study was to assess the microbiological quality of home-prepared enteral formulations.

METHODS

This study is a systematic review, registered in PROSPERO. The search for articles was carried out in databases and gray literature. Eligible studies which microbiologically analyzed homemade enteral preparations (HEP), blended enteral preparations (BEP), and commercial enteral formulas (CEF) that were prepared at home were selected. The types and quantities of microorganisms, sources of contamination in the handling area, and the consequences of contamination (signs and symptoms) were the subjects extracted from the studies.

RESULTS

Five studies evaluated 217 enteral formulations. It was found that 72.81% of the enteral formulations exceeded the acceptable bacterial count in the case of at least one of the analyzed microorganisms. This result corresponded to 93.58% (n=73) of the HEP; 81.96% (n=50) of the BEP; and 44.87% (n=35) of the CEF. The presence of ten different microorganisms was identified in the enteral formulations, and total coliforms and mesophilic aerobics were the microorganisms found in the greatest quantity in the samples.

CONCLUSION

The three types of home-prepared enteral formulations showed unsatisfactory microbiological quality, indicating poor hygiene conditions during food handling. This article is protected by copyright. All rights reserved.