The Registered Dietitian Nutritionist’s Guide to Homemade Tube Feeding

PRACTICE APPLICATIONS

Topics of Professional Interest

The Registered Dietitian Nutritionist’s Guide to Homemade Tube Feeding

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OMEMADE TUBE FEEDING IS a tube feeding in which smooth or liquid food is used in addition to or in place of formula. Homemade tube feeding can also be referred to as blenderized tube feeding, blended formula, and puréed by gastrostomy tube diet. Patient and clinician interest in homemade tube feedings has increased during the past decade, and its use is becoming increasingly more common among adult and pediatric patients. Gastric feedings are documented in literature dating back to the 18th century using a tube made of whale bone and a mixture of foods and wine. Over time, advances were made in feeding tubes, modes of delivery, and foods delivered via feeding tube. The first commercial tube feeding formulas were introduced in the 1950s. Since that time, the practice of administering blended food by feeding tube declined steadily, as commercially prepared formula use increased.1 Recently, there has been an increased interest in returning to more whole foods for the nutrition of tube-fed patients. Many clinicians are hesitant to recommend or support homemade tube feeding due to potential risk of microbial contamination, variability of nutritional composition, and increased clinician time.2,3 A review of the literature shows that there is a lack of evidence on the safety and use of homemade tube feeding. However,

This article was written by Cassandra Walia, MS, RD, CD, CNSC, a clinical dietitian specialist, Megan Van Hoorn, RD, CD, CNSC, a clinical dietitian specialist, Angela Edlbeck, MS, RD, CSP, CD, a clinical dietitian specialist, and Mary Beth Feuling, MS, RD, CSP, CD, an advanced practice dietitian, all with the Children’s Hospital of Wisconsin, Milwaukee. http://dx.doi.org/10.1016/j.jand.2016.02.007 Available online 17 March 2016

ª 2017 by the Academy of Nutrition and Dietetics.

with appropriate patient selection, recipe creation, sanitation, and followup, homemade tube feeding can be a viable alternative to commercial formulas. This article focuses on homemade tube feeding in the pediatric setting, as this is the authors’ area of expertise. However, these strategies for creating homemade tube feeding recipes and monitoring homemade tube feeding can be applied to the adult population.

ADVANTAGES AND DISADVANTAGES There are many advantages and disadvantages to homemade tube feeding, and the safety and efficacy of homemade tube feeding is patient dependent (Figure 1). Some studies have shown increased oral intake and increased interest in food after implementation of homemade tube feedings.5 This may be related to improvement in gastrointestinal symptoms, such as gagging and retching. The cost of tube feeding may be increased or decreased, depending on the patient’s insurance coverage for commercial formula. Foods used for homemade tube feeding and supplies such as blenders are unlikely to be covered by insurance; thus, if commercial formula was covered by insurance, the patient’s out-of-pocket cost will increase with homemade tube feeding. However, if commercial formula was not covered by insurance, the cost of homemade tube feeding may be similar to or lower than commercial formula, depending on formula type and the homemade tube feeding ingredients used (Table 1). Homemade tube feeding is not an all-or-nothing approach. Instead, patients can fall anywhere along a continuum of 1% blended food to 100% blended food. Depending on the patient’s nutrient needs, medical conditions, and family support, homemade tube feeding can take shape anywhere along this continuum.

PATIENT SELECTION Before initiating homemade tube feeding, it is important to discuss the patient with the medical team to ensure that homemade tube feeding is a safe feeding method for the patient. Factors to consider are listed in Figure 2. First and foremost, the patient’s medical status must be considered. Patients should not be started on homemade tube feeding until they are deemed medically stable by a physician. Some medical conditions may make homemade tube feeding more difficult. For example, patients with multiple food allergies may need a commercial formula in addition to homemade tube feeding to meet their nutrient needs, or immunocompromised patients will require particular attention to food safety. Similarly, patients with specific genetic or metabolic disorders might not be suitable candidates for homemade tube feeding, given their complex dietary regimens. However, homemade tube feeding has been safely provided to patients with metabolic disorders.12 Clinical judgment is essential in determining the viability of homemade tube feeding for patients with specific medical conditions. In pediatric patients, similar to oral feedings, homemade tube feeding can provide partial nutrition (<25%) beginning around 6 months of age, after correction for prematurity. The amount of food in the homemade tube feeding recipe can gradually increase to 100% of nutrition by 12 months of age. Candidates for homemade tube feeding should have at minimum a 14-French gastrostomy tube (not orogastric, nasogastric, nasojejunal, or jejunostomy tube), as smaller diameter tubes are more likely to clog.5,13 Patients should tolerate bolus feedings by syringe. Feedings via pump are not recommended, as the tubing can become clogged, leading to extended feeding times or missed feedings and feeding pumps are intended to be used only for

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PRACTICE APPLICATIONS Advantages


















Disadvantages

Creation of a feeling of “meal time”4 Increased physical and emotional connection with caregivers Increased dietary diversity Opportunity for the patient and family to make choices about the patient’s nutrition4 Emotional support for caregivers and patients who are grieving the loss of normal oral feedings Decreased feeding intolerance including decreased gagging and retching5,6 Improved bowel function4,5 Decreased oral aversion5 Decreased cost











Increased preparation time7 Increased nutrition monitoring7 Increased risk of infection/ contamination6 Increased risk for macro- and micronutrient deficiencies and excesses Increased difficulty determining actual nutrient intake Increased complications with feeding delivery, such as clogged feeding tubes

Figure 1. Advantages and disadvantages of homemade tube feeding. commercially prepared formula. In addition, food safety becomes a concern with feeding duration of 2 hours or more at room temperature, the temperature where food-borne pathogens multiply most rapidly.

Volume tolerance needs to be taken into consideration when creating the homemade tube feeding recipe, as it can be difficult to meet 100% of nutrition needs from food in volumesensitive patients.

Table 1. Cost of food-based enteral formulas in comparison with standard pediatric enteral formula

Formula

Pack size

Price per Pack price, Price per unit, 100 calories, $ $ $

Homemade, conventionala

NA

NA

0.36 2.48 per daily recipeb (700 kcal)

Homemade, organica

NA

NA

4.29 per 0.61 daily recipeb (700 kcal)

Standard pediatric enteral formula: Pediasure (Abbott Nutrition8)

24 cans

49.00 2.04 per can (240 kcal)

Compleat Pediatric (Nestle Nutrition9)

24 tetrapacks 74.99 3.12 per tetra (250 kcal)

Real Food Blends10

12 pouches

6 pouches Liquid Hope (Functional Formularies11)

1.25

49.95 4.16 per pouch 1.26 (330 kcal) 47.94 7.99 per pouch 1.78 (450 kcal)

a

See Table 3 for recipe. Ingredient costs from peapod.com and vitacost.com.

b

12

0.85

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Depending on the type of homemade tube feeding desired by the family, additional equipment might be required. Refrigeration will be necessary for all recipes prepared in advance, and a freezer is required for recipes prepared more than 24 hours before feeding. If whole foods are used, a high-quality blender may be needed.14 Some blender companies provide discounts to patients using the blender for medical needs. Depending on the ingredients and storage methods used, additional equipment might be required, such as measuring cups and storage containers. Family motivation and literacy are also important to consider. Preparing homemade tube feeding can be very time consuming and requires a motivated family to make time every day to prepare homemade tube feeding. The family must also be able to read recipes, use standard measuring tools, and communicate concerns and issues with the health care team. They must be able and willing to attend the frequent follow-up appointments that will be required to monitor transition to homemade tube feeding.

RECIPE PLANNING Before creating a recipe, discuss the family’s goals for homemade tube feeding. Some families might choose to switch to a commercial food-based enteral formula or add a small amount of baby food to current feeding plan, while other families may desire to have 100% of nutrition provided by foods and beverages. Some patients may require formula in addition to food in order to meet nutrient needs, especially in patients with high-calorie needs, low-calorie needs, volume intolerance, or specific medical conditions described here. It is also important to discuss the family’s food preferences and food restrictions before creating a recipe. Gather more information about forms of food to be used (puréed baby food jars vs whole foods), allergies, and food preferences (eg, vegetarian, organic, and local). Finally, be clear about the time, tools, and monitoring required for homemade tube feeding. Provide the family with a handout that outlines the advantages and disadvantages of homemade tube feeding (see reference 15 for an example). January 2017 Volume 117 Number 1

PRACTICE APPLICATIONS Medical Status: patient must be medically stable Medical Conditions: caution with multiple food allergies, metabolic disorders, or renal disease Age: Homemade tube feeding may provide partial (<25%) nutrition around 6 months of age and 100% nutrition starting at 12 months of age Growth: Consider delaying initiation if malnourished or not following a stable growth pattern Feeding Tube: Gastrostomy tube of 14-French diameter or greater is recommended Feeding Method: Bolus feeding by syringe is recommended Access to Equipment: Refrigerator, freezer, storage containers, and high-quality blender are recommended Family Resources: Consider motivation and health literacy of patient’s family Figure 2. Ideal patient selection for homemade tube feeding.

CREATING A HOMEMADE TUBE FEEDING RECIPE Step 1: Complete Nutrition Assessment Assess patient’s current nutrient intake and determine nutrient needs. Document estimated calorie, protein, fluid, and micronutrient needs. See the Academy of Nutrition and Dietetics’ Pediatric Nutrition Care Manual for pediatric specific nutrition recommendations.16

Step 2: Create a Recipe Draft Use nutrient analysis software to create and analyze the recipe. Start by using portion sizes from Table 2 based on patient’s estimated calorie needs. Begin by entering the patient’s main beverage, such as whole milk or formula, then move on to protein, grains,

vegetables, and fruit. When entering the recipe into the software, choose a variety of foods from each food group. For example, instead of using “green beans,” use “mixed vegetables.” Encourage the family to vary the fruits and vegetables used in the homemade tube feeding recipe.

Step 3: Compare Recipe to Estimated Needs Assess the recipe for adequacy of calories, distribution of macronutrients, micronutrient composition compared with dietary reference intakes for age, and essential fatty acid content. Add additional foods and supplements to meet nutrient and calorie needs as indicated. Oil or a combination of oils may be needed to meet essential fatty acid needs, a complete multivitamin with minerals can be added to meet

Table 2. Recommended portions of the five food groups for 1,000- to 3,000-kcal diet using MyPlate17 Dairy or dairy Grains, oz Vegetables,b Fruit,b a Goal, kcal substitute, cups Protein, oz (1-oz equivalent ) cups cups 1,000

2

2

3

1

1,200

21/2

3

4

11/2

1,400

1

2 /2

4

5

1

1 /2

1 /2

1,600

21/2

5

5

2

11/2

1,800

3

5

6

21/2

11/2

5 /2

6

1

2 /2

2

1

1 1 1

2,000

3

2,200

3

6

7

3

2

2,400

3

61/2

8

3

2

1

1

2,600

3

6 /2

9

3 /2

2

2,800

3

7

10

31/2

21/2

3,000

3

7

10

4

21/2

1-oz equivalent is measuring weight, not fluid ounces. See US Department of Agriculture17 for more information. Fruits and vegetables should be chopped or diced, then measured before blending.

a

b

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micronutrient needs, and individual supplements may be necessary to meet additional micronutrient needs, such as calcium and vitamin D. Table salt or salt alternatives, such as “lite” or “lowsodium” salts, can be added to the recipe in prescribed amounts to meet minimum sodium and potassium goals. Finally, add additional water to meet fluid needs. This water can be mixed into the formula as needed to provide the consistency necessary for tube feedings or can be given as boluses between tube feedings. See Table 3 for a sample homemade tube feeding recipe.

IMPLEMENTING HOMEMADE TUBE FEEDING RECIPE When initiating a homemade tube feeding recipe, it is important to consider the patient’s experience with food. If the patient has never consumed food by mouth or gastrostomy tube, introduce new foods as you would an infant with one new, single ingredient food every 3 to 4 days to assess for tolerance. The homemade tube feeding recipe should be introduced slowly and commercial formula should be decreased accordingly. See Figure 3 for an example transition schedule. The transition from commercial formula to homemade tube feeding will take time; however, if the transition takes an excessive amount of time, it puts the patient at increased risk for nutrition deficiencies. Reiterate the importance of food safety, sanitation, and proper formula storage to help prevent microbial contamination. Encourage the family to have commercial formula available for times of illness (when continuous feedings might be needed), for traveling, and for emergencies (such as power outages) or other instances

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PRACTICE APPLICATIONS Table 3. Sample homemade tube feeding recipe including nutrient analysis using Nutritionist Proa for an 18-month-old child requiring 700 kcal/d Recipe 1 cup mixed cooked vegetables 3

/4 cup mixed fruit

2 oz cooked meat 16 oz whole milk 1

/4 cup cooked brown rice

1 teaspoon flax seed oil 1 teaspoon corn oil 1

/8 teaspoon table salt

1

/2 Flintstones Complete chewable multivitaminb

1 mL Enfamil D-Vi-Solc 12 oz water Additional water as needed to meet desired consistency Nutrient

Value

Calories

696

Protein

39 g

% of Goald 99e 300

Linoleic acid

3.9 g

130

Linolenic acid

2.6 g

236

Dietary fiber

10.7 g

178

Vitamin D

700 IU

117

Calcium

717 mg

102

Iron

12 mg

177

Zinc

11.8 mg

394

Sodium

28.1 mEq

140

Potassium

36.3 mEq

363

Macronutrient

% of Calories

Protein

22.7

Carbohydrate

45.4

Total fat

31.9

a

Version 5.4.0, 2016, Axxya Systems. Bayer. Enfamil. d Sodium goal of >2 mEq/kg. Potassium goal of >1 mEq/kg. Essential fatty acid goals calculated using 3 g linoleic acid/day and 1.1 g linolenic acid/day.18 All other goals determined using age-specific Dietary Reference Intake. e Calorie needs determined using patient history of age-appropriate growth on 700 kcal/d. b c

when preparation or delivery of homemade tube feeding is not feasible.

PRACTICAL GUIDELINES FOR HOMEMADE TUBE FEEDINGS Depending on the homemade tube feeding recipe and blender used, some foods might blend better than others. 14

The Homemade Blended Formula Handbook is a great comprehensive resource for clinicians and families and includes information on foods that tend to blend well.19 Food safety needs to be considered in the preparation, storage, and delivery of homemade tube feeding. Discuss food safety basics with the family and

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refer them to reputable websites for additional information. Some websites to consider include: www.foodsafety. gov, www.fightbac.org, and www.cdc. gov/foodsafety. The homemade tube feeding recipe can be adjusted to meet a variety of patient and family requests. For example, instead of creating one January 2017 Volume 117 Number 1

PRACTICE APPLICATIONS Transition schedule from 700 mL commercial enteral formula to homemade tube feeding: 1. 600 mL formula, 240 mL water, 1 cup vegetables 2. 550 mL formula, 240 mL water, 1 cup vegetables, 3/4 cup fruit 3. 500 mL formula, 240 mL water, 1 cup vegetables, 3/4 cup fruit, 2 oz meat 4. 450 mL formula, 240 mL water, 1 cup vegetables, 3/4 cup fruit, 2 oz meat, 1/4 cup rice 5. 400 mL formula, 240 mL water, 1 cup vegetables, 3/4 cup fruit, 2 oz meat, 1/4 cup rice, 1 teaspoon flax seed oil 6. 350 mL formula, 240 mL water, 1 cup vegetables, 3/4 cup fruit, 2 oz meat, 1/4 cup rice, 1 teaspoon flax seed oil, 1 teaspoon corn oil 7. 0 mL formula, 240 mL water, 1 cup vegetables, 3/4 cup fruit, 2 oz meat, 1/4 cup rice, 1 teaspoon flax seed oil, 1 teaspoon corn oil, 16 oz 2% milk 8. 0 mL formula, 360 mL water (¼12 oz), 1 cup vegetables, 3/4 cup fruit, 2 oz meat, 1/4 cup rice, 1 teaspoon flax seed oil, 1 teaspoon corn oil, 16 oz 2% milk 9. 0 mL formula, 360 mL water (¼12 oz), 1 cup vegetables, 3/4 cup fruit, 2 oz meat, 1/4 cup rice, 1 teaspoon flax seed oil, 1 teaspoon corn oil, 16 oz 2% milk, 1/2 Flintstones Complete chewable multivitamina 10. 0 mL formula, 360 mL water (¼12 oz), 1 cup vegetables, 3/4 cup fruit, 2 oz meat, 1/4 cup rice, 1 teaspoon flax seed oil, 1 teaspoon corn oil, 16 oz 2% milk, 1/2 Flintstones Complete chewable multivitamin, 1 mL D-Vi-Solb, 1/8 teaspoon table salt Figure 3. Transition schedule from 100% commercial formula to 100% homemade tube feeding. See Table 3 for homemade tube feeding recipe. aBayer. bEnfamil.

homemade tube feeding recipe for the whole day and dividing it into bolus feedings, some patients and families may prefer to create three recipes per day to represent breakfast, lunch, and dinner. The registered dietitian nutritionist (RDN) will work closely with the family and their homemade tube feeding recipe to meet their specific needs.

MONITORING AND EVALUATION Initially, patients on homemade tube feeding will need to be monitored more frequently. Frequent communication between the RDN and family is necessary, as the recipe is implemented to ensure that the mixture is meeting the patient’s and family’s needs. The patient might also need more frequent visits to ensure adequate growth and nutrient intake. Three-day food records are recommended to ensure the foods selected by the family are meeting the patient’s nutrient needs. The potential nutrition risks of homemade tube feeding include inadequate or excessive intake of protein, fluid, iron, and other micronutrients, and electrolytes. Consider screening labs if you suspect a nutrient deficiency or excess based on the nutrition assessment. Laboratory tests to consider include complete blood count and chemistry profile, including electrolytes, January 2017 Volume 117 Number 1

vitamin D, selenium, zinc, and iron studies. Additional labs should be considered on a case by case basis. Over time, the family, patient, and RDN will become more familiar with the patient’s homemade tube feeding. Once the patient demonstrates adequate nutrient intake and growth and tolerance of the homemade tube feeding recipe, follow-up can occur less frequently. Eventually, these patients can be followed using the same protocol as tube-fed patients receiving commercial formula.

COMMERCIAL FOOD-BASED ENTERAL FORMULAS There are a variety of commercially prepared food-based enteral formulas available for purchase. Some formula brands have Medicare-approved codes for billing purposes.20 We only recommend the purchase of foodbased enteral formulas that are approved by the US Food and Drug Administration. Some formulas, such as Real Food Blends,10 are intended to be used as supplements to commercial formula or food in order to meet nutrient needs. Other formulas, such as Liquid Hope,11 can be used as the sole source of nutrition for adult patients, but may not be appropriate as sole source nutrition for pediatric patients. Compleat Pediatric and Compleat Pediatric Reduced Calorie

formulas9 are commercially prepared food-based enteral formulas designed to meet the needs of pediatric patients. These products are shelf-stable and convenient. If they are not covered by insurance, these formulas may be an increased financial burden to the family compared with standard formula or homemade tube feeding (Table 1), but could be beneficial during traveling or time away from the home.

CONCLUSIONS Homemade tube feeding is becoming more popular among patients and clinicians. Many RDNs are hesitant to support or recommended homemade tube feedings, as they are unfamiliar with the process of creating and monitoring nutritionally complete homemade tube feeding recipes. These guidelines will help RDNs feel more comfortable with recommending and supporting the use of homemade tube feeding. The current literature on homemade tube feeding is largely based on expert opinion, and more research is needed to create evidenced-based recommendations for homemade tube feeding. Future research should focus on prospectively studying the safety and efficacy of homemade tube feeding.

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PRACTICE APPLICATIONS References 1.

2.

3.

4.

5.

6.

Harkness L. The history of enteral nutrition therapy: From raw eggs and nasal tubes to purified amino acids and early postoperative jejunal delivery. J Am Diet Assoc. 2002;102(3):399-404. Borghi R, Dutra Araujo T, Ianni Airoldi Vieira R, Theodoro de Souza T, Linetzky Waitzberg D. ILSI task force on enteral nutrition; estimated composition and costs of blenderized diets. Nutr Hosp. 2013;28(6):2033-2038. Johnson TW, Spurlock A, Pierce L. Survey study assessing attitudes and experiences of pediatric registered dietitians regarding blended food by gastrostomy tube feeding. Nutr Clin Pract. 2015;30(3):402-405. Pattinson A, Lammert L, Epp L, et al. Use of blenderized tube feeding in patients on home enteral nutrition. JPEN. 2015;39(2): 238. Pentiuk S, O’Flaherty T, Santoro K, Willging P, Kaul A. Pureed by gastrostomy tube diet improves gagging and retching in children with fundoplication. JPEN. 2011;35(3):375-379. Johnson TW, Spurlock A, Galloway P. Blenderized formula by gastrostomy tube. Top Clin Nutr. 2013;28(1):84-92.

7.

Bobo E. Blenderized formula for tube feeding. Frontier 2013;(Fall):4.

8.

Abbott. Pediasure. http://abbottstore.com/ pediasure?source¼anu. Accessed July 31, 2015.

www.chw.org/teaching-sheets/2014/03/howto-blend-foods/. Published March 20, 2014. Updated 2014. Accessed October 9, 2015. 15.

Children’s Hospital of Wisconsin. Homemade tube feeding: The basics. Children’s Hospital of Wisconsin teaching sheets website. http://www.chw.org/teachingsheets/2014/03/homemade-tube-feedings/. Published March 6, 2014. Updated 2014. Accessed October 9, 2015.

9.

Nestle Health Science. Compleat Pediatric. http://www.nestlenutritionstore.com/product/ Specialized-Nutrition/COMPLEAT-PEDIATRIC. html. Accessed July 31, 2015.

10.

Real Food Blends. Meals for tube fed people. https://real-food-blends.myshopify. com/?_ga¼1.136241145.993005815.141780 5819. Accessed July 29, 2015.

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Academy of Nutrition and Dietetics. Nutrition Care Manual. https://www.nutrition caremanual.org/. Published 2015. Updated 2015. Accessed September 1, 2015.

11.

Robin Gentry McGee’s Functional Formularies. Liquid hope. http://shop.functional formularies.com/main.sc. Accessed July 29, 2015.

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Kopesky J. Use of blenderized G-tube feeds in the management of glutaric aciduria type 1. Abbott Nutrition Metabolic Conference, April 30-May 2, 2015, San Diego, CA.

US Department of Agriculture. Daily food plans and worksheets. ChooseMyPlate. gov Website. www.choosemyplate.gov/ tools-daily-food-plans. Published 2015. Updated 2015. Accessed October 9, 2015.

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Cox J, Melbardis I. Parenteral nutrition. In: Samour P, King K, eds. Pediatric Nutrition. 4th ed. Sudbury, MA: Jones & Bartlett Learning; 2012:434.

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Mortensen MJ. Blenderized tube feeding clinical perspectives on homemade tube feeding. PNPG Post. 2006;17(1):1-3.

19.

Dunn Klein M, Evans Morris S. Homemade Blended Formula Handbook. Tucson, AZ: Mealtime Notions; 2007.

14.

Children’s Hospital of Wisconsin. How to blend foods. Children’s Hospital of Wisconsin teaching sheets website. http://

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Escuro AA. Blenderized tube feeding: Suggested guidelines to clinicians. Pract Gastroenterol. 2014;38(12):58. 60-66.

DISCLOSURES STATEMENT OF POTENTIAL CONFLICT OF INTEREST No potential conflict of interest was reported by the authors.

FUNDING/SUPPORT There is no funding to disclose.

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