16-­‐05-­‐22 Help! My client wants to make
homemade tube feeds.
Ali Boyle, MHA, RD!
BC Children’s Hospital!
Financial Interest Disclosure (over the past 24 months)
!
No relevant financial relationships with !
any commercial interests!
About me
•  Ali Boyle, BSc, RD, MHA!
•  BC Children’s Hospital, Department of
Gastroenterology, Hepatology and Nutrition!
–  Complex Feeding and Nutrition Service!
•  Contact: !
–  aboyle3@cw.bc.ca!
–  aliboyle@gmail.com !
1 16-­‐05-­‐22 Overview
•  History Lesson: Enteral Feeding!
•  Case Story: Patient Centered Care!
•  Evidence Review: Homemade Blenderized Tube
Feeding (HBTF)!
•  Practical Tips: Building Your Toolkit!
!
!
* Note: this is the “handout” version of the presentation therefore many of the pictures and
videos from the actual presentation have been removed. !
Evolution of Enteral Nutrition(1)
!
!
Ancient Egyp2an Times Enemas of wine, milk, broth etc. 16th and 17th Century Nasal and oral gastric tubes used !
1940’s & 1950’s Feeding pumps & commercially prepared formulas 1980’s -­‐ Present Medical nutri2on therapy prac2ce evolves Evolution of Enteral Formulas(1,2,3)
•  Prior to 1940’s: Milk, broth, eggs, meat, wine/whiskey etc.!
•  1940’s & 1950’s: Modified macronutrients and
micronutrients added and commercial formulas
introduced!
•  1960’s &1970’s: Commercial formulas improve and start
to become standard practice!
•  Present: !
–  > 100 commercial formulas, often believed to be clinically
superior(4)!
–  Renewed interest in homemade formulas!
!
2 16-­‐05-­‐22 Renewed Interest in HBTF
•  Nutritional sciences continue to develop!
•  Increase in health information on the internet!
–  Patient networking on social media!
Dietitians Perspectives on HBTF
Dietitians of Canada Pediatric and Nutrition Support Network
survey on experience and knowledge related to HBTF (2013)*!
-  88 respondents!
-  14 % of respondents felt comfortable using HBTF!
-  Additional education and tools were requested to increase
practitioner confidence with this practice area!
!
* Unpublished. Available through DC Pediatric and Nutrition Support Network Chairs.!
Dietitians Perspectives on HBTF
Survey Study Assessing Attitudes and Experiences of
Pediatric Registered Dietitians Regarding Blended Food
By Gastrostomy Tube Feeding (2015)(5)!
–  Survey to American Academy of Nutrition and
Dietetics – Pediatric Practice Group !
–  Younger RDs more interested in providing HBTF
compared to older RDs!
–  Older RDs were more familiar with HBTF but less
likely to use!
3 16-­‐05-­‐22 Evidence Based Nutrition
“The conscientious, explicit, and
judicious use of current best evidence,
primarily from clinical trials, in making
decisions about the care of individual
patients.” – British Medical Journal(6)!
Patient Centered Care
“ Providing care that is respectful of
and responsive to individual patient
preferences, needs, and values and
ensuring that patient values guide all
clinical decisions.” – Institute of
Medicine(7) !
Case Story: Patient History
•  15 month old with complex medical history including: !
–  Tetralogy of fallot !
–  Necrotizing enterocolitis !
–  Oral aversions!
–  Difficulties tolerating enteral feeds with multiple
formulas !
4 16-­‐05-­‐22 Case Story: Request to start HBTF
•  Despite medical complexities, parents request to trial a
HBTF!
•  Parents have researched HBTF !
–  Motivated to start!
–  Requesting dietitian support!
!
WHAT TO DO???!
Case Story: Help!
•
•
•
•
Review research!
Practice guidelines!
Seek mentorship !
Grey literature!
TAKING THE PLUNGE FORWARD ….!
!
Case Story: Transitioning to HBTF
•  RD educated parents on nutrition and food safety!
–  Started one food at a time (based on infant feeding
guidelines 6 years ago)!
–  HBTF recipe created!
•  Parents educated RD on blending techniques and
practicalities of feeding!
5 16-­‐05-­‐22 Case Story: Patient Outcomes
•  Improved nutritional status!!
–  Significant reduction in vomiting!
–  Increased macronutrient and micronutrient intake!
–  Interest in oral feeding !
!
Case Story: Dietitian Perspectives
•  Improved nutrition for a n=1 case example!
–  Stimulate further research and hypothesis!
–  Contraindication to what I knew about enteral feeding!
•  Impact on practice!
–  A couple cases ≠ expert !
HBTF Evidence Review
•  No RCTs to compare commercial formulas to HBTF!
•  Small cohort studies !
•  Cross-sectional studies !
!
6 16-­‐05-­‐22 The Risks of HBTF
•
•
•
•
Food borne illness!
Nutritionally inadequate diets!
Hyperosmolar formula!
Tube occlusion !
Evidence Review: Food Borne Illness
•  Microbial, nutritional and physical quality of commercial
and hospital prepared tube feedings in Saudi Arabia
(2004)(8)!
•  Bacterial contamination of blenderized whole food and
commercial enteral tube feeding in the Philippines
(2001)(9)!
•  Bacterial contamination of hospital-prepared enteral
tube feeding formulas in Isfahan, Iran (2009)(10)!
Evidence Review: Nutritionally Inadequate
•  Scurvy related to the use of homemade tube feeding
formula (2015)(11)!
•  Nutritional analysis of blenderized enteral diets in the
Philippines (2004)(12)!
!
7 16-­‐05-­‐22 Evidence Review: Hyperosmolar Formula &
Tube Occlusion
•  Microbial, nutritional and physical quality of commercial
and hospital prepared tube feedings in Saudi Arabia
(2004)(8)!
•  Nutritional analysis of blenderized enteral diets in the
Philippines (2004)(12)!
!
!
The Benefits of HBTF
•
•
•
•
Improved formula tolerance!
Reduced gastrointestinal discomfort!
Enhanced nutritional variety!
Support the parent child feeding relationship !
Evidence Review: The benefits of HBTF
Pureed by Gastrostomy Tube Diet Improves Gagging and
Retching in Children With Fundoplication (2011)(13)!
–  Prospective cohort study!
–  N=33 children post fundoplication!
–  73 % reported a > 50% reduction in symptoms!
–  57% reported increased oral intake!
8 16-­‐05-­‐22 Evidence Review: The benefits of HBTF
Blended Tube Feeding Use in Adult Home Enteral
Nutrition Patients: A Cross-Sectional Study. (2015)(14)!
–  Prospective cross-sectional study!
–  Adults (>18), N=54!
–  Patients using HBTF reported less nausea, bloating,
diarrhea and constipation compared to commercial
formula!
Practical Tips for RD’s: Overview
•
•
•
•
•
•
•
•
Determining appropriate candidates!
Equipment and supplies needed!
Planning a HBTF “recipe”!
Preparing, blenderizing and storing HBTF!
Administration of a HBTF!
Hospitalized patients requesting HBTF!
Emergency planning!
Resources for families (and professionals)!
Appropriate HBTF Candidates
•  Based on limited available research guidelines and
clinical experiences!
•  Algorithm or decision-support tool to help clinicians and
patients understand criteria to support a successful
transition to HBTF!
•  Some patients may still choose to use HBTF despite
clinical readiness!
–  Communicate and document risks!
9 16-­‐05-­‐22 Appropriate HBTF Candidates(15)
HBTF Candidates Ra/onale Pa2ent is medically stable •  Medically unstable pa2ents oPen required commercial formula for beRer control of fluid and nutrient administra2on. •  Medically unstable pa2ents are oPen immunocompromised and HBTF have a higher risk of contamina2on. Pa2ent is > 6 months of age •  Health Canada, the Canadian Pediatric Society and Die22ans of Canada do not endorse the use of homemade infants formula (due to risk of inadequate nutri2on and contamina2on). Appropriate HBTF Candidates(15)
HBTF Candidates Ra/onale Medical Nutri2on Therapy needs can be met by HBTF •  In some cases, specialized enteral formulas cannot be replicated by HBTF. For example, formulas used for the management of metabolic or gastrointes2nal condi2ons. Pa2ent is gastrostomy fed •  Jejunostomy feeding requires con2nuous or intermiRent feeding which can be logis2cally challenging when HBTF cannot be leP at room temperature for > 2hours. •  Hypertonic formulas can increase dumping and the osmolarity of HBTF can be difficult to calculate. •  Smaller feeding tube diameter may become blocked. Appropriate HBTF Candidates(15)
HBTF Candidates Ra/onale Pa2ent tolerates bolus feeding •  Avoiding con2nuous feeds can reduce the risk of food borne illness. •  Feeds can be administered by syringe rather than feeding pump. The tube size is ≥ 12 French •  Small tube sizes can become occluded easily. Pa2ent and/or the care providers have the equipment and training to transi2on to HBTF •  HBTF prepara2on can require extra 2me, equipment and cost. •  Pa2ents benefit from educa2on on nutri2on and food safety prior to star2ng. 10 16-­‐05-­‐22 Equipment and Supplies
•  Kitchen space, refrigerator, measuring cups, sink, tube
feeding supplies!
•  Equipment to blend:!
–  Commercial grade blender!
•  Blendtec: 1-800-253-6383!
•  Vita-mix: 1-800-VITAMIX!
–  Or: regular blender and a strainer or fine sieve!
–  Or: commercial strained infant foods!
!
!
The HBTF “Recipe”
One set HBTF formula recipe A HBTF recipe template Pros •  Consistent daily nutrient •  Increased nutrient variety intake •  Increased flexibility with planning •  Some families may find it HBTF blends easier to follow and plan for Cons •  Can lack nutrient variety •  Variability in nutrient and calorie •  May not match family meals concentra2on of blends which requires the prepara2on of different foods Planning a HBTF(15)
1.  Determine nutritional needs and patient goals!
2.  Prepare a recipe template:!
•  Canada’s Food Guide!
•  Homemade Blended Formula Worksheets!
3.  Create sample recipes using the recipe template!
4.  Complete a nutrient analysis of several recipe blends. And
assess factors such as: !
•  Macronutrient distribution!
•  Micronutrients !
•  Free water!
11 16-­‐05-­‐22 Planning a HBTF – Example(15)
Grains: ½ cup cooked quinoa, ½ cup cooked brown rice, 1 slice of
whole wheat bread!
Vegetables and Fruit: ½ cup carrots, ½ cup broccoli, ½ cup banana,
½ cup plums!
Milk/Alternatives: 2 cups milk!
Meat/Alternatives: 1/4 cup chickpeas, 1 ounce roast beef!
Fat: 1 Tbsp Canola oil!
Other: 1 Tbsp cooking molasses 1/3 tsp table salt !
!
Provides: 1050 kcal/day (15 % protein, 53 % carbohydrate, 32 % fat)!
!
Preparing HBTF(18,17,18)
•  Proper hand washing !
•  Wash and sanitize cooking surfaces prior to use!
•  Wash all fruits and vegetables. Use cooked fruits and
vegetables for people with weakened immune systems!
•  Cook meat, fish, eggs and poultry to appropriate
temperatures!
•  Cool heated food within 2 hours!
Blenderizing HBTF
•  Follow recipe guidelines!
•  Blend to a liquid consistency (at least 2-3 minutes)!
•  Use a strainer or sieve when lumps or seeds remain in
formula after blending!
!
12 16-­‐05-­‐22 Storing HBTF(17)
•  Store formula in a refrigerator (<4° C, 40° F) for up to 48
hours!
•  Store formula in a freezer (-18° C, 0° F) for up to 1 month!
•  Label:!
–  Date of preparation!
–  Ingredients!
–  Date of expiration!
Administering HBTF
•  Syringe Feeding!
–  Large syringes (60 ml) fastest!
–  Smaller syringes (20 or 35 ml) for thicker blends!
•  Feeding pumps!
–  Made for commercial formula!
–  Lumps can set off the alarm!
•  Avoid having HBTF formula at room temperature for > 2
hours!
!
Hospitalized Patients Requesting HBTF
BC Children’s Hospital!
q Inpatient hospital policy!
q Patient/Caregiver waiver forms!
q Practice guidelines for clinicians!
!
13 16-­‐05-­‐22 Emergency Planning
•  Ensure there is a back-up plan for a power outage or
natural disaster as well as for hospitalization. !
–  Back up commercial formula available!
–  Strained baby foods !
–  Water !
‘Real Food’ Formulas
•  Compleat (and Compleat Pediatric)
https://www.nestlehealthscience.ca/en/brands/compleat!
–  Nestle Nutrition!
–  Chicken, carrots, peas, tomatoes, cranberry juice,
canola oil, corn syrup, milk protein, micronutrients !
•  Evynn’s Advantage http://evynnsadvantage.com/!
–  Canadian Company!
–  Not yet on the market, aiming for fall 2016!
‘Real Food’ Formulas
•  Functional Formularies – http://functionalformularies.com/ !
–  Liquid Hope (adult) and Nourish (pediatric)!
–  Plant based, dairy free, soy free, gluten free, corn free,
GMO free!
–  Not yet approved by Health Canada!
•  Real Food Blends - http://www.realfoodblends.com/!
–  Variety of meal blends!
–  Not yet approved by Health Canada!
14 16-­‐05-­‐22 Resources for Families: Books
!
•  The Homemade Blended Formula Handbook, by
Marsha Dunn Klein and Suzanne Evans Morris, 2007,
Mealtime Notions LLC !
•  Complete Tubefeeding: Everything You Need to Know
about Tubefeeding, Tube Nutrition and Blended Diets,
by Eric Aadhaar O’Gorman, 2012!
Resources for Families: Websites
!
•  The Oley Foundation – Blenderized diet pros and cons.
http://oley.org/?page=MakeYourOwnFoodTF!
•  Feeding Tube Awareness Foundation – Blenderized
diet.
http://www.feedingtubeawareness.org/BlenderizedDiet.html!
•  Food for Tubies – online resource group.
http://www.foodfortubies.org/!
Additional Readings for Dietitians
q
Novak P, Wilson K, Ausderau K, Cullinane D. The Use of Blenderized Tube Feedings. ICAN: Infant,
Child, & Adolescent Nutrition. 2009 1: 21-23. !
q
Parrish, C. Enteral Formula Selection: A Review of Selected Product Categories. Practical
Gastroenterology. 2005. Series #28.!
q
Escuro AA. Blenderized Tube Feeding: Suggested Guidelines to Clinicians. Practical Gastroenterology.
2014. Series #136.!
q
O’Flaherty T, Santoro K, Pentiuk S. Calculating and Preparing a Pureed-by-Gastrostomy-Tube (PBGT)
Diet for Pediatric Patients with Retching and Gagging Post Fundoplication. ICAN: Infant, Child, &
Adolescent Nutrition. 2001.!
q
Walla C, Van Hoorn M, Edibeck A, Feuling MC, The Registered Dietitian Nutritionist’s Guide to
Homemade Tube Feeding. Journal of the Academy of Nutrition and Dietetics. 2016.!
15 16-­‐05-­‐22 References
1.
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4.
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M, Figula K, Kowalczyk T, Kulig J. Commercial Enteral Formulas and Nutrition Support Teams Improve
the Outcome of Home Enteral Tube Feeding. Journal of Parenteral and Enteral Nutrition. 2001: 35 (3):
380-385.!
Campbell SM. An Anthology of Advances in Enteral Tube Feeding Formulations. Nutrition in Clinical
Practice. 2006, 21: 411-415. !
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the Outcome of Home Enteral Tube Feeding. Journal of Parenteral and Enteral Nutrition. 2001: 35 (3):
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Johnson TW, Apurlock A, Pierce L. Survey Study Assessing Attitudes and Experiences of Pediatric
Registered Dietitians Regarding Blended Food by Gastrostomy Tube Feeding. Nutrition in Clinical
Practice. 2015: 30 (3): 402-405.!
Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is
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Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality
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Mokhlalalati JK, Druyan ME, Shott SB, Comer GM. Microbial, nutritional and physical quality of
commercial and hospital prepared tube feedings in Saudi Arabia. Saudi Med J, 2004; 25 (3). !
Sullivan MM, Sorreda-Esguerra P, Santos EE et al. Bacterial contamination of blenderized
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Jalali M, Sabzghabaee AM, Badri SS, Soltani HA, Maracy MR. Bacterial contamination of
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!
!
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Pentiuk S, O’Flaherty T, Santoro K, Willging P, Kaul A. Pureed by Gastrostomy Tube Diet
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!
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