This interview originally appeared on Pediatric Feeding News, a website run by speech pathologist and feeding therapist Krisi Brackett. I had the pleasure of working briefly with Krisi during my internship period at UNC Children’s Hospital.

1. Most therapists are familiar with the idea of using a blenderized tube feeding diet. Could you briefly describe what it means and talk about who you feel is a good candidate?

Blenderized tube feedings are made of whole foods that have been pureed using a blender and delivered through a patient’s feeding tube. This feeding method has recently been gaining in popularity despite the availability of commercially prepared, nutritionally complete formulas. There are many reports of clinical improvement in children whose parents have decided to make the switch to a blenderized diet, which is why many parents are becoming interested in the alternative feeding technique.

Blenderized tube feeds are largely used to manage the gagging, retching, vomiting, and reflux that frequently accompanies gastrostomy (G-) tube placement or Nissen fundoplication, but many other parents also use these types of feeds to increase overall feeding tolerance, improved growth, and to speed the transition to oral feeding in children that are able to do so.

The best candidates for this feeding method are children with G-tubes who are experiencing retching, gagging, or vomiting from their current formula but who are growing appropriately. Some evidence exists supporting the use of blenderized feedings in children with severe reflux, food allergies, constipation, developmental delays, and oral aversions.

There are many steps to take in determining whether a child is appropriate for this feeding method. The most important criteria are: the child is older than 6 months, is medically stable and not immunocompromised, has a G-tube and not a J-tube, has a tube at least 14 french in diameter, and does not require a continuous feed. There are many other factors that are important in determining eligibility, but these are the most crucial. If any one of these requirements is not met, the child should not be considered a candidate for a blenderized diet.

2. I’m interested in the study that showed a blenderized diet could help with GI tolerance and reduce retching and vomiting, is this something you have seen? Is there just 1 study that showed this?

This 2011 study was conducted at the Cincinnati Children’s Hospital Medical Center (CCHMC), where the clinical team found that blenderized diets helped increase feeding tolerance and reduce gagging, retching, and vomiting in patients with feeding tubes. This was the first major study to demonstrate the benefits of a blenderized diet, however there are other clinical teams that have published their successful results.

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For example, the feeding team at the Pasadena Child Development Feeding Team (PCDA) in California have noted greater volume tolerance and improvements in reflux and constipation in their pediatric patients after switching from commercial formula to blenderized tube feeding. They also suggested that the use of a blenderized diet facilitates the transition from tube feeding to oral feeding, as children often consume the same foods through the tube as they are being offered by mouth. Additionally at CCHMC, dietitians in the pulmonary division have used the blenderized diet to help improve formula tolerance in their pediatric patients with cystic fibrosis who have had a feeding tube placed to ensure adequate nutritional intake.

While the blenderized diet is not yet the standard of practice for feeding children with G-tubes, there are many clinical teams and pediatric dietitians who are using the blenderized diet with great success. I imagine more studies will come out in the next few years that demonstrate the potential benefit of this method.

3. As a registered dietitian, what do you feel are the nutritional benefits to a homemade blenderized diet? What the advantages to using this diet?

The major benefit to using this diet is the potential for improvement in formula tolerance, especially in children who may eventually be orally fed. Gagging, vomiting, reflux, and poor bowel function (diarrhea/constipation) are common side effects from using commercial formulas, and a blenderized diet that has been customized to the child’s nutritional needs can make an enormous difference in the child’s health, growth potential, and quality of life.

Beyond the medical benefits of a blenderized diet, there are some psychological benefits as well. Many families enjoy providing their child with a blenderized diet, as preparing and administering a blenderized feed allows the parent to take a more active role in feeding their child. A reduction in symptoms can vastly improve the quality of the parent-child interaction during feeding, and allows the child to focus on learning, playtime, and social skill building when they are not distracted by G.I. discomfort.

Some parents prefer to feed their children a whole foods or “natural” diet. Being able to feed a tube-fed child the same foods their siblings eat is an important consideration for many parents, who feel more comfortable having more control over their child’s diet rather than relying on a processed commercial formula. There are dozens of reasons a parent might want to use a blenderized diet with their child, and many of them are not related to clinical symptoms of formula intolerance.

4. What are the disadvantages of using a blenderized diet?

The biggest disadvantage is the potential for nutritional inadequacy when designing a blenderized recipe. While a whole foods diet is a great option for children, it’s possible that a poorly designed recipe will not provide adequate amounts of specific nutrients that are required for the child’s growth and development. Adding a children’s multivitamin can help here, but there’s a lot of room for error when it comes to designing and producing a nutritionally adequate blenderized formula that meets 100% of the child’s needs. The recipe may be incorrectly analyzed, or the parent may make a mistake during the preparation process, possibly leaving out an ingredient by accident, or substituting a recipe with items that are not nutritionally equivalent to the ones used in the provided recipe.

Another major downside to the blenderized diet is cost, including money, time, and effort. Most insurance companies do not cover the cost of food and supplies in a blenderized diet, even if they cover a child’s commercial formula, so most parents will have to pay out of pocket for this diet. It can get expensive over time, and good blenders are a big investment. It also takes significantly more time, energy, thought, and  overall effort to create and produce a nutritionally appropriate blenderized diet on a daily basis. Many parents do not have the time or energy to spend preparing a blenderized feed, and a commercial formula is a far easier option for busy parents.

5. What equipment do you need? Are there specific size tubes needed for this?

It’s recommended that the child’s tube size be at least 14 french in diameter or larger to prevent clogging. Typically, the parent will need a high quality blender and 60 mL syringes to push the food through the tube, as well as access to a refrigerator to store the extra formula until it’s ready to be used. I recommend using a Blendtec or Vitamix blender; these blenders are more expensive but they blend extremely well, greatly reducing the risk of clogging, and they last a long time. These companies offer medical discounts to parents of children who need to be tube-fed. While it’s an investment, I believe it’s one worth making to guarantee a high quality blenderized formula.

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If parents can’t afford a blender, or do not have access to one, they can actually use commercial baby foods as a substitute for whole foods. These incorporate into the fluid base quite easily and don’t require a blender to mix at all. In fact, this is typically the way many dietitians will start adding “solid” foods to a child’s formula before a blender is even required.

6. What options would a patient have that need continuous feeds or J feeds? Can you put a homemade tube feed through a pump or does it require bolus feeds? Can you do the diet part time and use commercial supplements some of the time?

Unfortunately, J-tube feeds are not compatible with the blenderized diet and cannot be used. Some parents report using the blenderized feed with a continuous feed but this is not recommended due to concerns over food safety and the challenge of keeping the homemade formula at a cold enough temperature to prevent bacterial contamination. One of the benefits of a blenderized feed is many children are able to better tolerate this type of feeding in boluses, but if the child absolutely cannot take a bolus, he or she is likely not a good candidate for the blenderized diet.

Many parents use commercial supplements as a base for their homemade formula. This ensures adequate vitamins and minerals, while the added food has been shown to improve tolerance even when using formula as the base. Alternatively, parents can use formula part time, for example if the child needs an overnight continuous feed or needs to be fed outside the home, and blenderized food at the other times.

7. Is it possible to make a homemade formula that is 30cal/ounce or 45 cal /ounce like commercial formulas?

While this is possible to do, it’s quite difficult to create a formula with that level of volume precision. When I design blenderized tube feeding recipes, I prefer to use a daily calorie target rather than a calorie per volume target, as it’s much easier to ensure that the formula is providing enough calories for the whole day in one batch and spread the recipe across various bolus times.

The calorie estimate will not be as precise as a commercial formula, but most recipes can be fairly well estimated to meet the child’s calorie needs, and the calories provided can be adjusted based on the child’s growth rate. After all, a child’s estimated needs are just that: an estimate. A dietitian will always adjust the amount of calories provided daily with any formula if the child’s growth rate becomes inappropriately fast or slow. She or he can easily do the same with the child’s blenderized recipes.

8. Do you have recommendations for resources for families and for therapists who want to support caregivers? I am assuming it is a requirement that a family work with a dietician?

Working with a dietitian is very important, and I’d even say it’s a requirement. Determining a child’s ideal number of calories, protein, carbohydrates, and fat, along with the many essential micronutrients, is something pediatric dietitians have been trained to do and this information is vital in developing an appropriate food-based formula. Further, a dietitian can track the child’s growth and symptom changes, and make adjustments to the formula contents and quantity as necessary.

Finally, a blenderized tube feeding is a big commitment, and doing it on your own is very challenging. A dietitian can be a great supportive resource during the transition to the new diet, as well as helping to ensure that the diet is nutritionally sound, safely prepared, and appropriate for the individual child’s needs.

There are many additional resources that a parent can use in conjunction with working with a qualified dietitian. One great book is called “The Homemade Blended Formula Handbook” by Marsha Dunn Klein and Suzanne Evans Morris. The book is designed as a reference and “how to” for parents and professionals who together are making the choice to try a homemade blended diet for tube feeding.

Another helpful website is http://www.blenderizeddiet.com. There are tons of resources available on this page for both parents and dietitians who want to learn more about the diet and methods for developing recipes. There are also support groups, which are so helpful for parents who are just starting out and have questions that can be answered by other parents who are experienced in blenderized diets.

Ultimately, your best option is finding a registered dietitian who is knowledgable about blenderized diets and is willing to work with you to design an appropriate diet for your child.