Blenderized Tube Feeding

What is a Blenderized Tube Feeding?

Blenderized tube feeding (BTF), is whole or pureed foods that are blended and delivered through a feeding tube. BTF can be homemade or commercially prepared and can be used on its own or in combination with formula.  BTF has been shown to decrease reflux, gagging and retching.(1) It has also been shown to improve bowel function, contribute to gut health and decrease hospitalizations.(2) Homemade BTF can be individualized to accommodate food allergies and intolerances, as well as specific nutrient, fluid, or fiber requirements. BTF recipes can be made to different thicknesses and can incorporate typical foods regularly eaten in the household including a family’s cultural foods. For those who prefer not to make their own recipes, a convenient alternative to homemade BTF that can provide similar health benefits is commercially prepared BTF. Commercially prepared BTF can be used on its own or in combination with homemade BTF or commercial formula.

Is BTF Right for My Child?

Talk with your medical team to make sure BTF is right for your child. Here are some considerations.

• Age: In the first year of life, breastmilk or infant formula provides the best nutrition for your infant.  At 6 months of age, infants can start transitioning toward BTF by incorporating blended foods one by one, mimicking developmentally appropriate eating patterns.
• Type of feeding tube: Gastric feeding tubes work best for BTF.  Nasogastric and Jejunal tubes have a high risk of clogging and may not be recommended for BTF unless under the supervision of your medical team.
• Delivery: Gravity or bolus feeds work best for BTF.  A feeding pump can be used but may be more prone to clogging.
• Duration of feeds: Homemade BTF is safe for feedings that last up to 2 hours. Some commercial BTF products may be safe for a longer feeding time. Manufacturer guidelines for each product should be followed.
• Medical conditions:  Certain medical conditions may not be appropriate for BTF. Your medical team may also want to evaluate your child’s growth before making a transition to BTF.

Why Choose BTF?

• Family inclusion at mealtimes: Your tube fed child can share in the same meal as the rest of the family. The feeding tube can be seen as just another mouth to feed at the dinner table.
• Intolerance to commercial formula: Gagging, retching, constipation, and other symptoms of intolerance to commercial formula may improve with BTF.(1)
• Variety: Homemade BTF can allow you to create recipes that meet your child’s specific needs and include different foods at each mealtime. Food allergies and intolerances to ingredients found in commercial formulas can also be avoided.
• Transition to an oral diet:  BTF allows for smells and tastes of foods which may help children with oral aversion to try new foods when transitioning from a feeding tube to an oral diet.
• Gut Health: The wide variety of foods that can be used in homemade and commercially prepared BTF can increase the diversity of bacteria living in your child’s gastrointestinal tract and contribute to overall gut health.(3)

Homemade vs. Commercially Prepared BTF

Here are some considerations to help you decide if preparing your own recipe or using a commercially prepared BTF product is best for your child and household.

Preparing a Homemade BTF Recipe

Gather your Tools: Here are some tools that you will need to prepare a homemade BTF recipe.

Food Safety

Always use safe kitchen and food handling practices. Follow these 4 steps to ensure safe food preparation:

• Clean: Wash hands, surfaces, and utensils. Wash fruits and vegetables, but do not wash meats, poultry, eggs, or seafood.
• Separate: Don’t cross-contaminate. Use one cutting board for produce or other foods and a separate cutting board for raw meat, poultry, eggs, and seafood. Use separate plates for raw and cooked foods.
• Cook: Cook foods to a safe minimum internal temperature.
• Chill: Refrigerate foods promptly.

For more information, including specific safe minimum internal temperatures when cooking or reheating food, please reference Safe Food Handling - Food Fact for Consumers from the U.S. Food and Drug Administration.

Choosing Foods for Your Homemade BTF

Homemade BTF allows for a variety of foods to be incorporated into a recipe. Work with a dietitian to determine a recipe with balanced nutrition that is specific to your child’s needs. Here are some tips for choosing foods for your recipe.

• Fruits with seeds such as pomegranate and berries may need to be strained out of your blend.
• Seeds that swell or expand over time such as flax or chia seeds can clog the feeding tube.
• Foods with thick skin such as garbanzo beans and corn may not blend to a smooth consistency and can clog the tube.
• Fibrous vegetables such as celery or leafy greens blend more easily when cooked.
• Foods with low moisture content such as eggs or lean meats can be used but may change the thickness of your blend.
• Fresh, frozen, canned, and bottled foods including pureed and infant foods, juices and broths can be used safely in your recipe.
• Raw eggs, meats, potato, and flour need to be cooked before being ingested.

Tips for Administration

There are many ways to safely start BTF. The important thing is to start slowly. Work with a dietitian to decide on the best way for your child to transition to BTF. Here is one way to start your child’s transition from commercial formula to BTF.

• Add a single food from your BTF recipe to your child’s formula feeding. Trial each food from your BTF recipe separately and work through your entire recipe. Your dietitian will guide you to decide how much blended food to start with and how fast to advance your trial.
• For infants and children who have never had food, begin with one food at a time every few days while watching for any reactions.
• Symptoms of intolerance to look for in your child when introducing BTF include nausea, vomiting, abdominal distention, constipation or diarrhea, and general discomfort. If any of these symptoms occur, talk with your medical team and dietitian before advancing any further.
• Once your child has tolerated each food separately, you are ready to trial a BTF feeding using your entire recipe. Notice the thickness and volume of your blend. You may need to adjust the foods or liquids in your recipe to make your blend to a thickness and volume that your child is able to tolerate.
• Your dietitian may advise you to replace a small amount of your child’s commercial formula with your BTF recipe at a single feeding time, gradually increasing the amount to all feeding times.  You will work to replace some or all commercial formula with your BTF blend.
• Schedule a follow up visit with your dietitian to help adjust your recipe and to monitor your child’s tolerance and growth.

Temperatures & Times to Remember

Commercially Prepared BTF Options

Commercially prepared BTF products are shelf stable at room temperature and can be a safe and convenient alternative to homemade BTF or commercial formula. The ingredients and nutrients vary between products. Always talk with your medical team before starting on a new product.

Nutrition Monitoring

It is important for your child on BTF to have routine follow up visits with your medical team. A registered dietitian familiar with BTF can ensure your child’s nutrition needs are met at every stage of development through careful monitoring of your child’s BTF plan. Your RD will analyze your BTF plan to check for a balance of nutrients, vitamins, minerals, and fluids and can provide guidance on modifying your BTF recipe and overall feeding plan.  Your RD will also monitor your child’s tolerance, ask about any adverse symptoms, and guide you to deliver BTF safely to your child.  Monitoring guidelines are yet to be established for pediatric patients on BTF however your medical providers will likely recommend routine monitoring using nutrition lab tests. Your dietitian will work with your medical providers to determine specific lab tests for your child and assist you with modifying your BTF plan accordingly.

• Pentiuk S, O’Flaherty T, Santoro K et al. Pureed by gastrostomy tube feeding improves gagging and retching in children with fundoplication. JPEN J Parenter Enteral Nutr. 2011; 35(3): 375-379
• Samela K, Mokha J, Emerick K, Davidovics ZH. Transition to a tube feeding formula with real food ingredients in pediatric patients with intestinal failure. Nutr Clin Pract. 2017 Apr;32(2):277- 281
• Hron B, Fishman E, Lurie M, Clarke T, Chin Z, Hester L, Burch E, Rosen R. Health Outcomes and Quality of Life Indices of Children Receiving Blenderized Feeds via Enteral Tube. J Pediatr. 2019 Aug;211:139-145.e1.

Authors:
Olivia Lampone, MS, RD, CD, CCTD
Nicole C. Lidyard, RDN, LD
Abigail Lundin, MS, RD
Kay Mullin, RDN, CDECS
Mayumi Nakamura, MPH, RD, CSP
Megan Van Hoorn, MS, RD, CSP, CD
Sharon Weston, MS RD LDN CSP FAND
Editor: Christine Waasdorp Hurtado, MD
July 2023

Supported by an educational grant from Functional Formularies.