Administering a blended diet via an enteral feeding tube, both in addition to and instead of commercial enteral feed, the gold standard, is a practice that continues to grow throughout the UK (Epp et al, 2017; British Dietetic Association (BDA), 2021; Köglmeier et al, 2023). The Dietitians Interested in Special Children professional group has estimated that up to 20% of its members' paediatric home enteral feeding caseload receive some form of blended diet, as reported in the BDA Practice Toolkit (BDA, 2021). In countries without universal healthcare such as the USA, blended diet may be even more common as accessibility and affordability could be prioritised when commercial enteral feed is not funded for tube-fed individuals. The US Healthcare Nutrition Council (2020) explained that ‘patients may have a difficult time finding providers to supply the enteral products they need, due to coverage and reimbursement issues’. Blended diet administered through feeding tubes remains a mainstay in many Southeast Asian countries, especially those of the lower-middle income tier; it has also been reported in some mid-income tier countries such as Thailand and Brazil (Wong et al, 2018).
The purpose of this review is to provide the reader with a foundation of knowledge on blended diet, provide an understanding of the motivation behind this practice, identify potential risks and benefits, highlight current guidance, and suggest practical advice in relation to the nursing role in blended diet management in both adult and paediatric tube-fed individuals in the UK community and hospital settings. Literature searches were conducted via PubMed and PubMed Central using keywords ‘blended diet’, ‘blenderized diet’ (American spelling) / ‘blenderised diet’ (British spelling), ‘blenderized tube feeding’ / ‘blenderised tube feeding’, and ‘enteral feeding’. The search was not restricted to a specific publication date range in order to include research on early practices and their justifications and findings.
The literature describes how blended diet has been suggested to present perceived risks and concerns for both the tube-fed individual and healthcare team. These include risk of gastrointestinal intolerance and allergic reactions (McCormack et al, 2023), nutritional insufficiency, tube blockages, and infection compared with using commercial enteral feed, as well as risk of litigation against the professional due to their support of practice that is not evidence-based (BDA, 2021). The BDA issued an updated policy statement in November 2019, writing that:
‘It is unclear if the previously suggested risks of BD [blended diet] are occurring with significant frequency in comparison to those using CEF [commercial enteral feed].’
Conversely, research has suggested that giving blended diet to some tube-fed individuals can have physiological benefits including reduced vomiting and reflux; reduction in abnormal bowel habits (BDA, 2019); improved level of alertness and overall wellbeing; reduced dependence on medication; improved skin, nail and hair condition (Köglmeier et al, 2023); and improved growth (McCormack et al, 2023). In addition to physical benefits, social and emotional benefits have been reported by the parents and carers of tube-fed children and young people (BDA, 2021). Parents may experience empowerment as parents, an improved wellbeing of the child, and an increased sense of normalisation (Soscia et al, 2021). A frequent driving force that care teams, tube-fed individuals, and families have communicated to the author's home enteral feeding team is to satisfy the need to ‘nourish with real food’ and allow the tube-fed individual to feel more included in mealtimes.
Current guidance
The above-mentioned policy statement (BDA, 2019) resulted in the BDA issuing updated recommendations (BDA, 2021) for dietitians including:
- Commercial enteral feed to remain the first line choice for the majority of tube-fed individuals, particularly those who are fed over the short term in hospital
- Acknowledge that commercial enteral feed products are not tolerated by a small group of long-term tube-fed individuals; the use of blended diet may provide clinical benefit in this tube-fed individual group
- Dietitians are now able to suggest blended diet as an option where they believe there to be potential physiological, social or emotional benefits to the tube-fed individuals and their family
- For adults and children over 12 months old, blended diet can be used either as a sole source of nutrition or in combination with commercial enteral feed.
The BDA Practice Toolkit recommends:
‘The Dietitian should work with other professionals and agencies to facilitate the implementation of BD in all care settings attended by the individual.’
Respite care, school and college are given as examples, but staff in other settings – such as, the acute hospital ward – may also choose to liaise with the dietitian to discuss appropriateness of blended diet if it is felt to be potentially beneficial in that setting.
Outside the UK, expert practice recommendations by the American Society for Parenteral and Enteral Nutrition can be found in the consensus statement by Epp et al (2023), the Australasian Society of Parenteral and Enteral Nutrition (2021) offers clinical consensus in its ‘Blended tube feeding in enteral feeding: Consensus Statement’, and further searches could be done by country to identify potential consensus statements or practice recommendations perhaps less readily available, for example, the South African National Enteral Nutrition Practice Guidelines for Adults, which briefly mentions blended diet (National Department of Health – Republic of South Africa, 2016). The above mentioned consensus statements highlight similar recommendations to the UK ones, although in varying amounts of detail.
Practical advice for managing blended diet
Although the initial suggestion to consider blended diet may be made by the tube-fed individual, their family or carers, or any health professional involved in their care, it is advised that the decision to start an individual on blended diet be made using a multidisciplinary approach (BDA, 2021). Key points to consider are the tube-fed individual's medical condition and any special dietary requirements; whether the tube-fed individual has previously eaten food orally or has been tube-fed since birth; whether the individual/family/carers have support available; the type of enteral feeding tube used; whether any additional ancillaries need to be made available; what storage and equipment is available; the home or care setting environment in which blended diet will be prepared, stored and administered; what the person preparing the blends' current level of understanding is with regard to nutrition and food hygiene; how the individual will transition onto blended diet from their current feeding plan; how blended diet will be administered; how blended diet will be monitored; how staff in education, respite care and acute settings will feed the individual and the training implication and delegation of practice to non-health professionals; any financial implications that the tube-fed individual, family or carer may experience if swapping onto blended diet; and finally the type of approach to blended diet the family intends to use in both the short and medium term (BDA, 2021).
Organisations should consider setting up a working group to scope out blended diet provisions in the community and acute settings. Staff working in these areas may be asked to be involved in establishing current practice, discussing how the suggested new practice may work, and raising questions or flagging potential barriers to blended diet provision in these settings. If they are not already in place, organisations and relevant stakeholders should establish policies for administration of blended diet both in the community and acute settings. If resources to support training and implementation of this practice are found to be limited, organisations should consider restricting implementation to only a few settings, as well as developing specific criteria to establish tube-fed individual priority categories. This allows the appropriate professionals (for example, the home enteral feeding team) to identify which tube-fed individuals may be unable to tolerate other feeding practices, and therefore would benefit from blended diet being supported in setting as soon as possible. Care teams, tube-fed individuals, and families should be made aware that the provision of blended diet is dependent on setting specific policy and food preparation facilities (BDA, 2019); settings may benefit from this being highlighted by their involved professionals.
Training
The following training should be considered for those involved in blended diet preparation, storage and administration.
Food hygiene training
This should be offered for anyone involved in preparing, storing, transporting and administering blended diet to prevent contamination and ensure that the food is safe (Mortenson, 2006; Novak et al, 2009; Brazel, 2014; Brown, 2014; Escuro, 2014; Zettle, 2016; Epp et al, 2019; Weeks, 2019). There may already be a process or team in place within the organisation to provide this training for staff. Tube-fed individuals, families or carers could be sign-posted to complete online food hygiene training, which is readily available at minimal or no cost. The Food Standards Agency does not provide a food hygiene course or certificates but has a link on its website for individuals to access their local authority, who may provide or recommend food hygiene courses in their locality (https://www.food.gov.uk/business-guidance/online-food-safety-training).
Blended diet training
Organisations should establish and provide blended diet training to ensure all those involved understand what blended diet is, what consistency prepared food needs to be, consideration of who will be responsible for cleaning the equipment, what the potential risks and benefits are, and can establish what needs to be in place prior to initiating. Training education and respite care staff can be challenging as some regions provide enteral feeding training by commercial enteral company employees, some of whom have been advised by their employers not to provide training on blended diet (BDA, 2021). In other areas, training is delivered by the specialist or community nurse employed by the health board/trust (BDA, 2021). It is considered good practice to involve the tube-fed individual/parent(s)/carer(s) or respite care staff in training education (BDA, 2021).
Gastrostomy training
The majority of enteral feeding tube manufacturer's information for use (IFU) guidance states that only enteral feeding products defined as foods for special medical purposes and water should be administered; the impact of not following the IFU would be that manufacturer warranty would not apply in the event of failure, so this should be considered; however, it should not be the only factor in the final shared decision (BDA, 2021). Administration of blended diet is likely to be easier and with reduced risk with some enteral feeding tubes in comparison with others (BDA, 2019). Training should be considered for the tube-fed individuals/carers/families who are supporting with tube care/replacement, in case of any tube issues. This training should be provided by the professionals usually responsible for all community or hospital tube care/replacement training in the locality (for example, enteral nutrition nurse specialists, or commercial enteral company employees).
Documentation training
During or following the process of designing documentation sheets in relation to blended diet, training should be organised by relevant stakeholders for staff who will be completing these records/schedules/logs. Audits may be required to ensure accuracy and completeness.
Safety in settings
Consider the following points in line with relevant policies/guidelines for the setting (eg, school, hospital, respite centre). Policies may include descriptions on which staff are responsible for what task:
- How often the feeding equipment, microwave and fridge are cleaned, and which cleaning fluids to use on which equipment (eg, equipment in direct contact with foodstuffs will be cleaned differently to the microwaves/fridges/work surfaces). This should be in line with Control of Substances Hazardous to Health (COSHH) regulations (https://www.hse.gov.uk/coshh/index.htm). Cleaning schedules and logs should be made available
- How often fridge temperature checks are required and who will be responsible for this. Temperature schedules and logs should be made available
- Whether child locks are required to prevent children from accessing the fridge or microwave
- Whether the electrical equipment has had PAT (portable appliance testing) checks and safety checks are undertaken as/when required
- Whether recipes are nut-free to reduce allergen risk. Staff may need to highlight this to the tube-fed individual, their families and/or their carers to ensure the safety of everyone in the setting
- Having parents/carers sign an agreement on a suitable alternative of feed in case blended meals are inappropriate/unavailable at the time of administration
- That pre-prepared foods that are sent in with the tube-fed individual should already be blended to the appropriate consistency, transported using insulated containers that are suitable for freezing food and microwaving, and need to be used within 24 hours of preparation. The food should also be individually portioned and labelled to show date and time prepared, frozen, defrosted, and the name of the tube-fed individual. Staff may need to highlight this to the tube-fed individual, their families and/or their carers to ensure the safety of the tube-fed individual
- For the organisation to consult a catering dietitian for a full nutrition analysis of each blend to ensure they are suitable to meet the tube-fed individual's nutritional requirements. Not many ready-made blended diet options are available in the UK, but this may also be an option to be considered by the tube-fed individual, their families and/or their carers. Ready-made blends generally do not require any preparation, have a nutritional analysis available, do not require reheating, can generally be stored at room temperature when sealed, can be frozen if smaller portions are required at a time, and generally have a shelf life of 12 months.
Contraindications to blended diet
- Where intensive care or high-dependency unit admission is required (Epp et al, 2019)
- Where there is a contraindication to bolus feeding – blended diet should not be provided via feeding pump in order to prevent or minimise bacterial growth that may occur in cooked foods kept at room temperature for longer than 2 hours (BDA, 2021).
- In those requiring post-pyloric feeding (Duperret et al, 2004; Mortenson, 2006; Novak et al, 2009; Johnson et al, 2013; Brazel, 2014; Zettle, 2016; Walia et al, 2017; Johnson et al. 2019; Milton et al, 2020).
- In those requiring nasogastric tube (NGT) or trans-gastric feeding (Walia et al, 2017). NGTs are both thinner and longer than gastrostomy tubes and would require higher pressure to deliver blended diet, which may result in splitting of the tube (Mundi et al, 2019). If this were to happen above the epiglottis, this could lead to aspiration. A thinner tube also requires a less viscous dilution, which may negate some of the positive effects on reflux, retching and vomiting
- In children under 6 months of age
- In those who are immunocompromised and therefore considered more vulnerable to foodborne infections. Adjustments may need to be made to reflect a more careful selection of foods to be included in the blend. This is unless further processing – such as cooking – will mitigate the risk (BDA, 2021)
- In those with a history of, or current diagnosis of, bowel obstruction
- In those ‘nil by tube’ as deemed required by their lead consultant/physician
- Inequality of tube-fed individuals; potentially other parents/carers may also want to start bringing meals into setting, so the setting needs to ensure adequate resources are available to provide the same service to all.
Conclusion
Administering blended food via enteral feeding tubes has been growing in popularity in recent years (Epp et al, 2017; BDA, 2021; Köglmeier et al, 2023). Research has suggested that this practice can have physiological, social and emotional benefits (BDA, 2019; 2021; Soscia et al, 2021; Köglmeier et al, 2023; McCormack et al, 2023). It is unclear if the previously suggested risks of blended diet are occurring with significant frequency (BDA, 2019). Current guidance recommends that the decision to start an individual on blended diet be made using a multidisciplinary approach (BDA, 2021).
Key points to consider prior to initiating blended diet are establishing local community and acute provisions; considering the tube-fed individual's medical condition; whether there are any blended diet contraindications; the tube-fed individual's previous exposure to allergens; their type of enteral feeding tube; the ancillaries, storage and equipment available; the home or care setting environment in which blended diet will be prepared, stored and administered; the current level of understanding with regard to nutrition and food hygiene in those involved with the individual's blended diet; the plan for transition onto blended diet along with administration method and monitoring plan; any financial implications that the tube-fed individual, family or carer may experience if swapping onto blended diet; and finally how staff in education, respite care and acute settings will feed the individual with the relevant training implication (BDA, 2021).
KEY POINTS
- Administering blended food via enteral feeding tubes has grown in popularity, with research suggesting that it can have physiological, social and emotional benefits
- It is unclear if the previously suggested risks of blended diet are occurring with significant frequency
- Current guidance recommends establishing local community and acute provisions, and then considering training, safety and blended diet contraindications before implementing this practice
- Safety considerations will include food hygiene practices, ensuring that blends meet the individual's nutritional needs, and suitable alternatives
- Contraindications include patients who are more at risk from foodborne infection, such as individuals needing post-pyloric enteral feeding
CPD reflective questions
- Consider the area where you work and the types of training highlighted in the article: are these already available, and if so where from? What gaps in your knowledge can you identify?
- Reflecting on patients you have recently cared for, would blended diet have been an option for them? What contraindications or constraints were there?
- What safety considerations apply to your work setting relating to storage and administration of blended diet?