Enteral tube feeding is commonly used for children and young people (CYP) with conditions such as complex neurodisability that affect their eating and drinking. Some CYP are not able to swallow safely and are at risk of aspiration whereby food and fluids go into their lungs. Others cannot manage sufficient quantities to meet their nutritional needs, which can affect their growth and increase their risk of malnutrition (National Institute for Health and Care Excellence (NICE), 2017). In the UK, it has been common practice to use commercial prescription formulas administered through an enteral feeding tube. These products are designed to be the correct consistency to be given through a tube, do not require any preparation and are nutritionally complete in a directed volume.
In recent years, there has been a rise in the number of parents and carers of CYP choosing to use a blended diet. A blended diet consists of everyday foods blended to a purée consistency and given through an enteral feeding tube (Durnan et al, 2021). Blended diets can be different for each child or young person; some families use a blended diet exclusively, whereas others use it in combination with commercial prescription formulas. Some use a blended diet daily and other families will blend foods periodically when they have time to prepare foods or want to share a mealtime on a special occasion, for example. For this reason, a blended diet can be considered a continuum rather than a binary differentiation for tube-fed CYP (Durnan et al, 2021).
For some CYP experiencing poor tolerance of commercial prescription formulas, a blended diet offers an alternative that they can better tolerate. Blended diets have been shown to reduce symptoms such as reflux, vomiting and constipation or diarrhoea, which are prevalent among CYP with complex neurodisabilities that necessitate enteral tube feeding (Breaks et al, 2018). Similarly, these CYP often require a range of medications and many families are therefore keen to explore natural alternatives to optimise their child's bowel habits, for example. In addition, using homemade food blends is valued by CYP, parents and carers due to the social implications of sharing food and mealtimes as a family (Phillips and Coad, 2023). Enteral tube feeding often coexists with other medical interventions for these CYP, such as ventilation, multiple medications and physiotherapy regimens; normalisation of any aspect of their care is therefore particularly valued by these families.
The increasing use of blended diets has been met with caution due to perceived risks associated with this practice. These risks relate to the nutritional adequacy of blended diets, the risk of food-borne infection and tube blockage (Madden et al, 2019; Milton et al, 2020). These potential risks have made the use of blended diets a particularly contentious issue that has affected the support that CYP and their families receive to use them (Phillips, 2019). However, studies have shown that these risks are less common in practice and the benefits of using a blended diet may outweigh the potential risks (Durnan et al, 2021). Despite the growing number of studies investigating blended diets, there remains relatively little research to inform evidence-based professional practice. It can therefore be difficult for nurses and other health professionals to advise families and other carers, resulting in disparity in practice across the UK. The British Dietetic Association published a practice toolkit (Durnan et al, 2021) to provide best practice guidance for blended diets. However, using a blended diet is not universally accepted practice across the UK and more work is needed to overcome barriers preventing the adoption of blended diets nationally. It is therefore necessary that nurses and other health professionals are informed of the evidence to underpin their practice in this field.
This article collates the current available evidence related to blended diets and considers the implications for nursing practice.
Current evidence review
An updated rapid review of the evidence was recently published (Phillips and Coad, 2023); this was necessary to capture new research published since the original review (Coad et al, 2017). There has been a change in enteral tube feeding practice in the UK since health professionals are no longer advised to recommend families avoid using blended diets (Durnan et al, 2021) and the evidence base has increased.
Key databases were searched including PubMed, Medline, CINAHL, PsychInfo and Google Scholar. Articles from the original review were included in addition to those identified from the search after screening and 29 were included in the review (Phillips and Coad, 2023).
Results
A narrative synthesis of the articles identified four key themes, discussed below.
Symptom improvement and clinical outcomes
Many families opt to start a blended diet due to issues with their child's tolerance of commercial prescription formulas. Blended diets have been shown to reduce retching and vomiting. One study reported that every participant (caregivers) recommended a blended diet to reduce feeding discomfort (Gallagher et al, 2018). In another, all participants remained on a blended diet unless transitioning to a fully oral diet (Kernizan et al, 2020). As a result of this improved feeding tolerance, some medications commonly used to manage such symptoms may be reduced or no longer needed at all.
Blended diets vary considerably between individuals and families, influenced by their individual food choices and whether the blended diet is used exclusively or alongside commercial prescription formulas. Research shows that both can be effective in mitigating symptoms such as reflux and vomiting, which are commonly experienced by these individuals (Phillips, 2019). In addition, there has been an increase in the development of commercial prescription formulas containing ‘food ingredients’. These products have been shown to improve upper gastrointestinal tract symptoms (O'Connor et al, 2022) despite ‘food ingredients’ comprising only 13% of the feed; this suggests that a small amount of blended diet can be effective in managing symptoms.
In addition to the changes in gastrointestinal symptoms associated with blended diets, they have also been linked to a reduction in respiratory infections. A study by Hron et al (2019) showed that children using a blended diet had fewer respiratory infections and accessed hospitals less frequently.
Nutritional content
Several studies show variation in the nutritional content of some food blends provided in a hospital setting (Borghi et al, 2013). This is similar to foods taken by mouth, and it is therefore important that CYP have regular dietetic reviews to ensure their nutritional intake is adequate. Nutritional deficiencies have occurred in CYP using commercial prescription formulas or a blended diet, suggesting that neither method of feeding is better than the other (Breaks et al, 2018). A combination of blended diet and commercial prescription formulas may be effective in achieving sufficient nutritional intake. Research shows that although the nutritional content of blended feeds vary, it does not have a negative influence on weight gain (Santos and Morais, 2010).
Caregiver experiences
In addition to symptom relief for CYP, the use of blended diets also impacts relationships with carers and other family members. Anecdotally, blended diets allow families to share mealtimes, which is highly valued, particularly by families of long-term tube-fed CYP. Parents and carers in some research studies have reported improved general wellbeing and better skin, hair and nails following a transition to a blended diet (Phillips, 2019; Durnan et al, 2021).
However, families of CYP report a lack of support for blended diets (Phillips, 2019) and a limited awareness and knowledge of them in schools and hospitals (Soscia et al, 2021). This means that some CYP cannot access certain settings such as schools or are forced to compromise their use of a blended diet in order to attend (Breaks et al, 2018). Families are keen to receive better support from professionals (Trollip et al, 2020). Practical challenges for carers include providing blended diets when CYP are away from home and, in some instances, cost implications. These relate to the purchase of equipment, such as blenders, or food ingredients where commercial prescription formulas may be available to families free of charge or covered by health insurance (Boston and Wile, 2020; Soscia et al, 2021).
Blended diet practices
Microbial contamination of foods used for blended diets is a commonly anticipated risk and there is disparity in the findings of some studies (Jalali et al, 2009; Milton et al, 2020; Galindo et al, 2021).
Some studies show higher than acceptable amounts of bacteria in blends (Galindo et al, 2021) whereas others report that levels of bacteria tested fall within safe parameters (Milton et al, 2020). It is important to consider the clinical significance of these findings, which were not reported in some studies; for example, the occurrence of food-borne infection (Jalali et al, 2009). Similarly, studies have been carried out in different countries and potential confounding factors are difficult to identify.
Food hygiene training and refrigeration of food blends were shown to minimise the bacterial content and growth in food blends (Milton et al, 2020); these may be key to mitigating potential risks.
The viscosity of food blends is another commonly anticipated risk (Durnan et al, 2021). There is concern that thick blends, which may contain lumps if not completely blended, may occlude the feeding tube. A study by Madden et al (2019) showed that tubes block infrequently and can be cleared with a water flush, which is routine practice for enteral feeding. Blended diets have also been shown to take longer to pass through the tube due to their thickness and require increased pressure compared to commercial prescription formulas. It is important to consider the type of enteral feeding tube CYP have as some can be changed more easily and in the community. The diameter (French gauge) of the tube should be considered as food blends may need to be a thinner consistency for a narrower tube.
Implications for nursing practice
As evidence-based clinicians, it is important for nurses to stay up-to-date with research underpinning the care they provide to patients (Nursing and Midwifery Council (NMC), 2018a). The NMC mandates that nurses undertake a minimum of 35 hours of continuing professional development activities to revalidate their registration. This is to ensure that all nurses are able to provide effective and safe care to patients (NMC, 2021). Increasing knowledge of blended diets is pertinent due to the shift in practice over recent years. Blended diets were previously advised against due to a lack of evidence to underpin practice in this area, making their use particularly contentious at the outset as more families began to choose this method of feeding. Over the past 5 to 10 years, there have been more studies exploring the safety and effectiveness of blended diets and the wider social implications. Although assessment of risk is key to safe and effective nursing, there has been a shift away from risk assessment of blended diets towards shared decision-making to best meet the individual child or young person's needs (Durnan et al, 2021).
Nurses are pivotal members of the multidisciplinary team who can support CYP and their families in making informed choices about enteral feeding. Communication is a core nursing skill. Nurses are well placed to facilitate collaborative working between families and other health, education and social care professionals involved in the care of CYP to best meet their needs.
Despite developments in the evidence informing blended diets, barriers to their use remain. For some children, continuing with commercial prescription formulas results in symptoms such as vomiting that prevent them from attending school. Similarly, prohibition of blended diets in the school environment can result in the same outcome. It is essential that all CYP, particularly those with complex needs and disabilities, are supported to attend school to receive an education to which they have a right (Azpitarte and Holt, 2024).Tube-fed CYP often have special educational needs and disabilities; these CYP are significantly disadvantaged in education compared with their peers and far less likely to meet certain educational standards (Azpitarte and Holt, 2024). It is therefore paramount that these CYP do not face additional challenges in accessing education.
Some parents describe blended diets as a ‘game changer’ with regard to managing symptoms which, in turn, allows their CYP to engage in other activities such as therapy and education and has huge implications for their overall health and wellbeing (Coad and Durnan, 2023). Even parents of CYP who are able to tolerate commercial prescription formulas derive benefits from using a blended diet to make food choices in the same way as parents who send in a packed lunch to school for an orally fed CYP (Thomas, 2017). For some families, the merit of a blended diet is the ability for their tube-fed CYP to have ‘proper food’ (Coad and Durnan, 2023). The NMC Code (2018b) highlights that nurses must ‘listen to people and respond to their preferences and concerns’; therefore, understanding how blended diets can benefit some CYP and their families is necessary.
For nursing practice to continue to meet the evolving needs of people accessing NHS services, nurses must challenge barriers and promote positive change underpinned by the latest evidence (Thomas, 2017). Families report encountering barriers to using blended diets and a lack of support for them specifically in schools and hospitals (Soscia et al, 2021). This creates frustration as families must continually justify and explain their reasons for using a blended diet for their child. Families require support and engagement from health professionals and feel that increased knowledge and awareness of blended diets is prudent (Trollip et al, 2020). Nurses are ideally placed to raise this awareness among other health professional colleagues as well as non-healthcare staff involved with tube-fed CYP.
A key nursing role is the training of parents and other formal or informal carers. Nurses are responsible for delegating tasks to others within their capabilities and ensuring that they can perform the task to the necessary standard (NMC, 2018b). It is commonly the role of nurses to train and assess carers in settings such as schools, respite centres and nurseries to deliver enteral tube feeds and therefore blended diets if this is necessary. Given changes in practice around blended diets, it may be necessary for additional or revised protocols and frameworks to be produced. This is to ensure consistency in the delivery of care for CYP using blended diets, which can optimise patient safety, a key priority for all nursing care (Thomas, 2017). A clearly documented multi-agency care plan can be used to outline an assessment of any potential risks and how they can be mitigated, as well as the individual responsibilities of everyone involved in CYP's care (Thomas, 2017). The use of protocols and frameworks can provide guidance for nurses that they must apply to the individual needs of CYP. Evidence-based guidance can also reassure staff that they have the support of the organisation in managing the risks and delegating tasks; the absence of such guidance has anecdotally caused anxiety and concern for nurses in the past.
Conclusion
The use of blended diets for enteral feeding is increasing; evidence shows a range of benefits related to this method of feeding. As with all aspects of healthcare, blended diets are not without risks and these must be mitigated to ensure the delivery of safe and effective care. CYP, their families and carers require the support of nurses and the wider multidisciplinary team to make informed decisions related to the use of blended diets and deliver them safely and effectively.