Article Text

Blended diets for tube-fed children and young people: a rapid review update
  1. Gemma Phillips1,
  2. Jane Coad2
  1. 1 Leicestershire Partnership NHS Trust, Leicester, UK
  2. 2 School of Health Sciences, University of Nottingham, Nottingham, UK
  1. Correspondence to Gemma Phillips, Leicestershire Partnership NHS Trust, Leicester, UK; gemma.phillips10{at}nhs.net

Abstract

Background Many children and young people with complex health and care needs use enteral feeding tubes to optimise their nutritional intake in the UK and other countries. Blended diets as an alternative to the exclusive use of commercial formula are becoming more commonly used, and there is evidence to support the benefits of using a blended diet on the child or young person and their wider family.

A rapid review was published in 2017 exploring blended diets as a valid alternative to commercial formula for enteral feeding for children and young people. An update was necessary to ensure that professional practice is informed by the latest evidence, which has expanded significantly since the publication of the original article.

Methods A rapid review method was used and the PRISMA checklist formed the basis of the protocol devised ahead of data collection. Key databases included: PubMed, MEDLINE, CINAHL, PsychINFO, Google Scholar.

Results 29 articles were included and four themes were identified from the collated data. (1) Symptom improvement and clinical outcomes, (2) nutritional content, (3) caregiver experiences and (4) blended diet practices. Findings showed that blended diets can have a positive impact on physical symptoms as well as social influences extending to families and carers.

Conclusion Nutritional content, food hygiene and viscosity of food blends are important considerations for professionals and families to ensure safe practice when using blended diets for enteral feeding.

  • Paediatrics
  • Child Health
  • Gastroenterology

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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WHAT IS ALREADY KNOWN ON THIS TOPIC

  • Blended diets are becoming more widely used for children and young people.

  • Benefits of using blended diets extend from improved physical symptoms, for example, reflux to social interactions with families and care givers.

  • National guidance now recommends a shared decision-making approach towards using blended diets.

WHAT THIS STUDY ADDS

  • This research highlights wider implications of blended diets, for example, reduced access to acute medical facilities and reduction in certain medications.

  • A combination of blended diet and commercial formula can be effective in reducing gastrointestinal (GI) symptoms.

  • Families report a lack of support and engagement from professionals to use a blended diet.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

  • Further research is required to determine how families can best be supported to use a blended diet.

  • Increased evidence of the benefits of a blended diet may enable them to be used to manage GI symptoms in this patient group.

Introduction

Blended diets are becoming more commonly used for children and young people in the UK who require enteral tube feeding.1 This relates toindividuals aged 0–25 years aligned with UK government legislation around special educational needs and disabilities2 and includes infants from weaning age (6 months). A blended diet is the use of everyday foods blended to a puree and given through an enteral feeding tube.3 This is in contrast to or in combination with commercial formula, a sterile and nutritionally complete liquid, which remains standard practice for enteral tube feeding in many countries including the UK.4

Reasons for choosing a blended diet vary given the heterogeneity of the tube feeding population. Many are looking for an alternative to commercial formula to address issues with tolerance, while others seek ‘natural’ foods or greater diversity in the diet.1 Studies have demonstrated the impact of blended diets on symptoms such as reflux and diarrhoea,5 a reduced need for gastrointestinal (GI) medications6 and a reduction in access to acute healthcare facilities.7

The original review by Coad et al 8 highlighted the value of a blended diet to families on the feeding relationship between children, young people and their relatives and carers. This may be pertinent to those using enteral feeding at home in the medium to long term, in contrast to acute settings where commercial formulas originated.

Until recently, blended diets had been met with caution with concerns over nutritional inadequacy, tube blockage and foodborne infection.3 However, adverse events reportedly occur less commonly than anticipated and may also occur with exclusive use of commercial formula, suggesting neither method superior.5

This article is an update of a rapid review published by Coad et al 8 considering blended diets as an alternative to commercial formula for enteral feeding in children and young people; the original review8 is widely referenced (42 citations) and has informed national guidance.3 An update is justified to ensure that guidelines and professional practice are informed by contemporaneous evidence.9 In addition, the landscape has changed since this original publication now that blended diets are no longer formally opposed and the evidence base has expanded significantly. Issues related to blended diets remain pertinent as anecdotally, blended diets remain less well supported than commercial formula and families report inequitable service provision across the UK.

This review collated the literature, summarising key themes, informing evidence-based practice around the use of blended diets.

Aim

To explore whether a blended diet is a valid alternative to commercial formula for enteral feeding for children and young people.

Method

A rapid review method was used; this method is defined as a form of knowledge synthesis that streamlines methods to produce evidence efficiently and is informed by Cochrane guidance.10

Guidance10 advises that a protocol is drafted ahead of data collection (online supplemental appendix 1), grey literature searching is limited and data is synthesised narratively.

Search strategy

Key databases were searched and included: PubMed, MEDLINE, CINAHL, PsychINFO, Google Scholar. Search terms from the original review were used in addition to alternative terms related to blended diets commonly cited in the literature (see online supplemental appendix 1). No date limits were set.

Papers included in the original review were included in addition to those retrieved from the searches. All papers retrieved were screened with the exception of Google Scholar due to the quantity of articles retrieved (17 200). The Google Scholar search was sorted by relevance and the first 200 articles were screened as recommended by Haddaway et al 11 who advise that Google Scholar, while ineffective when used alone, is a ‘powerful addition’ to traditional search methods.

Eligibility criteria

Articles were from peer-reviewed journals only. It was necessary that studies had a focus on blended diets used for enteral feeding and were relevant to children and young people; studies exclusive to adults were included if the findings were transferable to children and young people.

Studies which were not original research (eg, literature reviews) were excluded and only studies published in English (including international studies) were included due to the time constraints of the review.

Data extraction and quality assessment

Endnote software was used to record the searches and remove duplicates. Searches and extracted papers were checked by both authors.

A data extraction tool was created to collate details of the studies and included the following data items:

  • Title.

  • Author.

  • Year of publication.

  • Country of study.

  • Sample.

  • Setting.

  • Aim.

  • Results.

  • Outcomes measured.

  • Conclusions.

  • Critical Appraisal Skills Programme (CASP) score.

CASP tools12 were used to assess the quality of studies included in the review as they are specific to health research and a range of research designs.13 CASP tools were adapted to include only closed questions (yes/no) and questions unrelated to quality were excluded. See online supplemental appendix 1 for detail on scoring.

See online supplemental appendix 2 for adapted CASP tools used within the review.

Evidence synthesis

The results are presented as a narrative synthesis identifying themes pertaining to the use of blended diets for children and young people.

Results

Figure 1 summarises the selection process for the review; searches were carried out on 12 July 2022 and 29 papers were included.

Themes were identified relating to outcomes for children and young people associated with the use of blended diets. These include the impact on physical symptoms and clinical outcomes, caregiver experiences and nutritional implications as well as microbial content of foods and practical considerations of giving blends.

Studies varied in quality based on assessment against the relevant CASP tool. Failure to address or consider the impact of confounding factors was the most common reason for low scores.

Online supplemental appendix 3 contains the extracted data.

Symptom improvement and clinical outcomes

A number of studies showed improved symptoms of reflux, retching and vomiting associated with a blended diet and is a commonly cited reason for starting a blended diet.6 7 14–17 Kernizan et al 6 reported that 91% of participants started a blended diet to manage reflux. All participants in a study by Gallagher et al 15 would recommend a blended diet due to reduced feeding discomfort.

Twelve (n=29) studies included exclusive use of blended diets, while 15 (n=29) reported on a combination of commercial formula and blended diets suggesting that both can be effective. Similarly, studies by Thornton-Wood,18 O’Connor et al 19 and Samela et al 20 specifically studied a commercial formula with 13% ‘food ingredients’ which also showed improvements, suggesting that a small amount of blended diet may be effective in achieving positive outcomes in upper GI symptoms. Improved upper GI symptoms were deemed important to children and parents in a study by Maddison et al 16 identifying core outcomes. The majority of studies included individuals with a range of conditions including genetic syndromes and intellectual disability; however, Zong et al 21 reported an improvement in diarrhoea specific to children with short bowel syndrome.

Kernizan et al 6 observed that 13 (n=35) individuals were able to reduce or discontinue medications previously necessary to manage upper GI symptoms; all participants remained on a blended diet after the study period unless transitioned to an oral diet. Furthermore, some participants were able to discontinue jejunal feeding (having transitioned to gastro feeding) once a blended diet was introduced.6

In addition to improved upper GI symptoms, Hron et al 7 showed a reduction in respiratory infections and fewer hospital attendances and admissions. These findings mirrored those reported by Klek et al 22 who observed a reduction in urinary infections, anaemia and fewer respiratory infections. One study also highlighted the increased bacterial diversity in stool samples following the introduction of a blended diet.15

Studies by O’Connor et al 19 and Samela et al 20 reported improved constipation while Batsis et al 14 and Thornton-Wood18 associated worsening constipation following transition to a blended diet. However, constipation was easily managed with additional fluids or polyethelene glycol.14

Thirteen studies linked the use of blended diets to improved clinical outcomes; however, a small number of participants in two of the studies experienced worsening symptoms.6 14 Similarly, Keighley et al 23 reported severe diarrhoea although similar symptoms were seen in the control group using commercial formula. These findings are in the minority although it is important that clinicians are aware of potential adverse symptoms which may occur although infrequently.

Nutritional content

Studies by Borghi et al,24 Sullivan et al 25 and Mokhalalati et al 26 investigated the nutritional content of blended diets in hospital settings and they showed variation in the nutritional content of blends. Mokhalalati et al 26 showed a 16–50% variability in nutritional content of food blends, taken from different hospital sites included in the study compared with 4–7% for commercial formula.

Borghi et al 24 state that blended diets require careful assessment, and a combination of blended foods and commercial formula may be effective to minimise risks of nutritional deficiency. Santos and Morais27 also reported on the effect of a blended diet on growth parameters and concurred that nutritional content of blended diets are inconsistent but did not negatively affect weight.

Caregiver experiences

Six studies included in the review focused on caregiver experiences of using blended diets.6 15 28–31

Phillips29 acknowledged the social implications of a blended diet on family mealtimes and the general well-being of the child as well as a lack of support for blended diets. Soscia et al 30 reflected these findings reporting a lack of awareness in schools and hospitals. Trollip et al 31 further support these claims highlighting a desire for increased education, engagement and support from health professionals. Challenges identified by Boston and Wile28 related to being away from home; however, participants felt that challenges associated with using a blended diet were mitigated by the improvements in their child’s well-being.29 30

In addition to the practical challenges, Soscia et al 30 recognised cost implications of blended diets. In this study, participants were sampled from Canada where commercial formula is covered by health insurance while a blended diet is funded by families. Participants in a study by Trollip et al 31 reported that the cost of a high-quality blender can be prohibitive.

Blended diet practices

Microbial content

Microbial content of food blends is a commonly cited anticipated risk associated with blended diets and the focus of studies by Galindo et al,32 Jalali et al,33 Milton et al 34 and Sullivan et al 25; however, there is disagreement in the findings between some studies.

Galindo et al 32 reported that 82% of the samples exceeded acceptable bacterial counts, while Milton et al 34 reported that 88% of the samples met the safe limits set by the food safety code. Jalali et al 33 reported the bacterial content of the food blends sampled but did not draw conclusions on the clinical significance of these findings.

Galindo et al 32 concluded that familial income and food training had a significant impact on hygiene conditions, which may account for the findings. Demographic data was not collected in the study by Milton et al, 34 so it is not possible to make a comparison. However, the studies were carried out in Brazil32 and the USA,34 respectively, which may be associated with unreported confounding factors.

In addition to familial income and food training as mitigating factors on bacterial load, Milton et al 34 reported little change in bacterial growth after 48 hours, suggesting that refrigerating foods limits microbial growth. These may be important considerations to minimise potential risks associated with blended diets.

Tube blockage and viscosity

Thickness of food blends and potential for tube blockage are anticipated risks associated with blended diets. However, Madden et al 35 showed that only 2 of 27 administrations of food blends resulted in a blocked tube and these were easily cleared with a water flush. Food blends took longer to give (50–65 s via 14FG tube) than commercial formula (27 s via 14FG tube). These findings are in contrast to those from a study by Sullivan et al 25 who reported that food blends were too viscous to administer via feeding tubes.

Both studies25 35 recognised the additional force required to give blended foods compared with commercial formula. Mundi et al 36 also investigated the force required to give feeds and concluded that the force required via EnFit connectors, which are now widely used internationally, is less than connectors used previously.

Limitations

Limitations of the included studies were identified using the CASP checklists (see online supplemental appendix 3 for CASP scores). For quantitative studies, the use of validated data collection tools could increase the quality of the research. In addition, consideration and reporting of potential confounding factors such as the provision of commercial formula by healthcare services or insurance may be significant. In qualitative studies, reporting on the transferability of the findings and the impact of the researcher’s role would enhance the quality.

Conclusion

Evidence collated in this review builds on the findings from the original review,8 which identified that families felt that blended diets can be more effective than formula feeding and highlighted associated social benefits.

In addition, this review provides further evidence on the positive impact of blended diets on GI symptoms and extended benefits such as reduced respiratory infections and hospital admission. Evidence in this review demonstrated that a combination of commercial formula and blended diet can be effective in achieving these outcomes. Since this evidence was collated, Walker et al 37 published a study in accordance with this review showing a reduction in children requiring medication for GI symptoms, improved oral intake and a non-statistically significant improvement in growth parameters following introduction of a full or partial blended diet.

This updated review provides further evidence of how blended diets can be effective and considerations for families and professionals when using blended diets which can be summarised in the following key points:

  • Blended diets have been associated with improved GI symptoms as well as reduced respiratory infections and hospital admissions for children and young people.

  • A combination of commercial formula and blended foods can be effective.

  • Challenges related to using blended diets remain; these include cost, using a blended diet away from home and obtaining adequate support from professionals.

  • Bacterial content and viscosity of food blends are factors that can be mitigated although remain important considerations for those using blended diets.

This review will further evidence practice and policy to facilitate the use of blended diets by those who may benefit.

Further studies are necessary to explore the impact and outcomes of using blended diets as well as the experiences of patients, their families and professionals working with them. Research is needed to understand how blended diets can be implemented into our health and care services across both acute and community settings. A robust evidence base will support safe, effective and equitable practice by underpinning evidence-based practice and enabling the development of standardised guidelines and policy.38

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

Ethics statements

Patient consent for publication

Ethics approval

Not applicable.

References

Supplementary materials

Footnotes

  • Contributors GP and JC conceived the study. GP carried out the searches, data collection and drafted the article. JC contributed to the study design and data synthesis. Both authors provided critical feedback to shape the review and the manuscript and provided final approval. GP is the guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.