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|Home Tube Feeding with Blenderized Foods|
Theresa A. Fessler, MS, RDN, CNSC
Think about the wide variety of foods most people eat every day. Now imagine “eating” these same foods using your feeding tube. With today’s high-performance blenders this is possible, and many home enteral nutrition (HEN) consumers and caregivers are using blenderized foods instead of, or as a supplement to, standard canned enteral nutrition (EN) products.
Why Blenderize Food?
Lisa Epp, RD, LD, CNSC, is the home nutrition support coordinator at Mayo Clinic in Rochester, Minnesota. Epp has been working with HEN consumers for more than eleven years; for the past seven years, she has been working with those who use blenderized tube feeding, the popularity of which, she notes, has been growing since 2011. Epp states that in their program they see about 650 adults and 150 children per year who are just starting on tube feeding, and findings from a preliminary Institutional Review Board (IRB) approved study show that about 50 percent of them use blenderized foods at least some of the time.
There are several reasons some HEN consumers use blenderized foods. Some have allergy or intolerance to certain ingredients that are present in most standard EN products, such as corn, cow’s milk, or soy proteins. Others desire more variety, and/or healthy, unprocessed natural foods for a diet lower in sugar and with phytonutrients and fibers. Most conventional EN formulas contain corn syrup, maltodextrins, sugar, soy, corn oils, and casein and soy proteins. While they provide all the known essential vitamins, minerals, and protein, they do not provide the wide variety of phytonutrients and fibers present in natural foods (see sidebar page 8). [Editor’s note: It is unknown whether this variety provides any health advantage in people on tube feeding.
Homemade blenderized foods can be less expensive than commercial products, which is an important factor for people whose insurance does not cover EN formulas. Some who are concerned about the environment like blenderized foods because there are fewer cans and cartons to throw out. Many HEN consumers enjoy sharing meals with their families and experiencing the sight and smell of foods while they prepare and use blenderized meals. Epp recalls one of the HEN consumers she has worked with saying, “Blending real food has brought the joy of cooking and eating back into my life.” Epp also mentions that people report improved bowel regularity.
Reports written by consumers found on the Internet and shared by word of mouth indicate that tube-fed children tolerate blenderized foods better than standard EN formulas. According to an article published in the Journal of Parenteral and Enteral Nutrition (2011), clinician researchers in Cincinnati studied thirty-three children who had fundoplication surgery and who had gagging and retching with gastric (G-) tube feedings using standard EN formula. As reported by the children’s parents, seventy-three percent of the children had at least a fifty percent decrease—and fifty-two percent had a seventy-six to one hundred percent decrease—in gagging and retching after switching to pureed foods in their G-tubes.
Choosing and Preparing Food
Blenderizing foods is easier than you might think and many foods can be used. High-speed and commercial-quality blenders such as Vitamix® or Blendtec™ work best for more complete liquification of foods. Foods should be cut into chunks and placed in a blender along with enough liquid to allow blending to a smooth consistency. You may need to strain the blend to remove small chunks or seeds.
Foods that are popular for blending include sweet potatoes, bananas, quinoa, avocado, oats, nut and seed butters, chicken, yogurt, kefir, various grains, and milk (cow’s, soy, almond, coconut, etc). Other liquids include water, broths, and juices. Some foods have more potential to clog tubes, such as string beans, blueberries, and flaxseeds. Eggs can become lumpy if not thoroughly cooked prior to blending. Epp states that brown rice, fruits, vegetables, lentils, toasted breads, and crackers work well for blending, and that olives, white pasta, white rice, breads, muffins, and bagels tend to gum up in the blender.
General food safety principles are very important, especially if the person using tube feeding has compromised immune function. As with any food preparation, hand washing is essential, and fresh vegetables and fruits and dried legumes should be carefully cleaned to remove any soil, microorganisms, and other contaminants. Dried legumes should be inspected for small pebbles prior to cooking.
Raw foods can be used, but foods that normally require cooking (such as meats, brown rice, potatoes) should be cooked just as they would if they were being eaten by mouth. Blenders and syringes need to be thoroughly cleaned right after each use. Unused blends should be promptly covered and refrigerated for up to twenty-four hours.
Feeding the Blenderized Formula
Blenderized foods can be administered the same ways as regular canned formula—by gravity, bolus, or pump. However, most often they are infused into G-tubes (including PEG-tubes and low-profile devices) slowly with a 60 mL syringe, by using gentle pressure on the syringe plunger (called bolus feeding). All methods work well with tubes of 14 French size or larger. Although very uncommon, some people use nasogastric (NG-) tubes in the home setting; using blenderized food is difficult or not possible with small-bore NG-tubes.
As with any tube feeding, the person being fed should be seated upright or have their upper body elevated at least 30 degrees to help prevent reflux. Tubes need to be flushed with warm water before and after each feeding and whenever medications are administered. Water flushes are critically important to clean out the tube and prevent clogging. If any lumps are seen in the blend, pour it through a strainer.
Although it is less common, some people with G- or J- (jejunal) feeding tubes administer their blends with feeding bags and a pump. This will typically only work with thinner blends, which usually requires more fluid be added to the mixture and thus would not be appropriate for those with fluid restrictions or high calorie needs. According to Epp, a blenderized diet administered by pump via J-tube has been successful for some children with low calorie needs who can use a thinner blend; however, she cautions, for those with higher calorie needs, it’s too difficult to get the goal volume in when using pump feeds.
With pump feeding, the blend should be infused within two hours to avoid spoilage. If the blend is left in feeding bags too long, ingredients may separate out in layers, increasing risk for clogging and inconsistent intake of nutrients. Some manufacturers of feeding pumps have specifically stated that their pumps are not to be used with anything but commercial formula.
Some health professionals and consumers are concerned about possible problems using blenderized formulas with the new EN connector devices that are to be a standard of practice in the next year or so. This past summer, these new “ENFit” connectors were tested using conventional tube feeding formula, applesauce, a very thick EN formula (used in Japan), and a commercial blenderized formula. Researchers measured the amount of pressure needed to push the formulas (and applesauce) through a 60 mL catheter-tip syringe and a 60 mL syringe fitted with an ENFit connector. They also measured the gravity flow of the formulas after they had been refrigerated. They found no significant differences in either the pressure required or the gravity flow rate using a catheter tip syringe or a syringe with an ENFit connector. More information on this research can be found in the July/August issue of the LifelineLetter.
Creating Healthy, Balanced Meals
One can find many blenderized diet recipes, but consultation with a registered dietitian/nutritionist (RD/RDN) is crucial to ensure that a diet is appropriate for the individual’s specific nutrition needs; otherwise, one is at risk of under- or overdosing on various nutrients. RDs will calculate calorie, protein, water, and micronutrient needs based on age, height, gender, laboratory information, medical diagnoses, post-surgical status (if applicable), activity levels, weight, and, for children, growth goals. RDs can evaluate food and fluid choices and monitor a person’s nutritional progress.
Some people who have poor digestion or malabsorption will not be able to use blenderized foods. Others might need to restrict fiber. If you are transitioning from conventional canned EN formula to blended foods, it is recommended you try one new food for several days and monitor tolerance before adding another new food. However, if you were eating a variety of foods just prior to starting EN, this will not be necessary.
Use of blenderized feeding can range from adding one fruit or vegetable blend daily to a regimen of standard commercial EN formula, to a diet that consists only of blenderized foods. One way to make a balanced meal is to portion out foods in amounts that would otherwise have been eaten by mouth, add liquid, and blenderize. Another way is to blend a specific number of portions each day from the different food groups: carbohydrates (grains and starchy vegetables), protein, vegetable, fruit, dairy (or dairy substitutes), and fats and oils.
According to Epp, they use the USDA MyPlate system at Mayo clinic (visit www.choosemyplate.gov). The SuperTracker program on the MyPlate Web site can help guide healthy choices and serving sizes. For those who wish to create nutritionally complete recipes, or just find general nutrient information, the free USDA National Agricultural Library’s Nutrient Data Web site or other published nutrient databases can be helpful.
Prepackaged Blenderized Formulas
For convenience and variety, some HEN consumers use prepackaged commercial blenderized formulas, either alone or in addition to their homemade blended diets or standard HEN formulas. Nestle® Compleat® and Compleat® Pediatric have been available for years. These formulas contain some ingredients found in conventional formuals as well as a blend of real food ingredients from tomatoes, peaches, green beans, carrots, cranberry juice concentrate, and chicken, milk, and pea proteins. Compleat® formulas now contain no corn or soy ingredients.
Consumer demand has resulted in some new prepackaged blenderized natural food products.
Real Food Blends, LLC was founded by Julie Bombacino, the mother of a young boy who required tube feeds and who did not tolerate standard EN formulas. Currently there are four Real Food Blends™ meal varieties: orange chicken, carrots, and brown rice blend; salmon, oats, and squash blend; quinoa, kale, and hemp blend; and beef, potatotes, and peas blend. None of these contain corn syrup, dairy, soy, or nuts. Other ingredients include grape, orange, and pomegranate juice concentrates; grapeseed, flaxseed, and extra virgin olive oils; cinnamon, sunflower seeds, and water.
Liquid Hope® is an organic, vegan whole foods meal replacement blend produced by Functional Formularies®. Robin Gentry McGee invented this formula while providing care for her father who used HEN. Ingredients include (all organic) garbanzo beans, green peas, carrots, whole grain brown rice, whole grain brown rice protein, flax and borage oils, sprouted quinoa, sweet potato, broccoli, almond butter, kale, garlic, turmeric, rosemary, ginger, wakame (seaweed), and added vitamins. Liquid Hope contains no genetically modified foods (non-GMO), no added sugars, and no dairy, soy, corn, or gluten.
Prepackaged blenderized food formulas are more expensive than standard formulas, and the cost will not be covered by Medicare unless the physician documents in the patient’s medical record a medical reason that a standard EN formula is not tolerated. The Medicare term is “blenderized natural foods with intact nutrients” and the billing code is B 4149. Medical reasons for coverage are intolerance, or adverse or allergic reaction to a standard EN product. Examples include corn, soy, or casein allergy; or severe constipation, vomiting, or diarrhea.
For help with the expense of blenders, check out the manufacturers’ Web sites or call the companies (for Vitamix, Blendtec, Oster®, and other brands of blenders); some reduce prices for those using the blenders for medical use. If you are just starting out with blenderized foods, it is wise to use a regular or less expensive blender at first, to make sure blenderized diets will work for you before purchasing a very expensive one.
The practice of home tube feeding with blenderized foods is not common, but interest is growing and more consumers are choosing this method of nutrition support. It is up to each consumer, along with his or her medical care team, to decide what is best. Consumers and caregivers should discuss options with the HEN user’s health care professionals before changing an HEN regimen. Registered dietitians who specialize in HEN can be helpful in choosing appropriate foods, however not all RDs/RDNs are familiar with blenderized tube feeding diets. For HEN consumers whose health condition allows, and who desire a variety of fresh healthy foods instead of or as a supplement to their current tube feeding regimen, blenderized foods are an option to consider.
Updated September 2016. Original article appeared in the November/December 2014 LifelineLetter.