PRACTICE APPLICATIONS
Topics of Professional Interest
The Registered Dietitian Nutritionist’s Guide to
Homemade Tube Feeding
H
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 cen-
tury 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 pa-
tients. 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 liter-
ature shows that there is a lack of evi-
dence 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 dieti-
tian 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 follow-
up, 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 disad-
vantages to homemade tube feeding,
and the safety and efficacy of home-
made tube feeding is patient dependent
(Figure 1). Some studies have shown
increased oral intake and increased in-
terest in food after implementation of
homemade tube feedings.5 This may be
related to improvement in gastrointes-
tinal 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 commer-
cial formula was covered by insurance,
the patient’s out-of-pocket cost will in-
crease 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, pa-
tients can fall anywhere along a con-
tinuum of 1% blended food to 100%
blended food. Depending on the pa-
tient’s nutrient needs, medical condi-
tions, and family support, homemade
tube feeding can take shape anywhere
along this continuum.
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
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 pa-
tient’s medical status must be consid-
ered. Patients should not be started on
homemade tube feeding until they are
deemed medically stable by a physi-
cian. 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 immunocompro-
mised patients will require particular
attention to food safety. Similarly,
patients with specific genetic or meta-
bolic disorders might not be suit-
able 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 deter-
mining 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, af-
ter 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 jejunos-
tomy tube), as smaller diameter tubes
are more likely to clog.5,13 Patients
should tolerate bolus feedings by sy-
ringe. Feedings via pump are not rec-
ommended, as the tubing can become
clogged, leading to extended feeding
times or missed feedings and feeding
pumps are intended to be used only for
11
PRACTICE APPLICATIONS

Depending on the type of homemade

Advantages Disadvantages tube feeding desired by the family,

Creation of a feeling of “meal
Increased preparation time7 additional equipment might be
time”4
Increased nutrition monitoring7 required. Refrigeration will be neces-


sary for all recipes prepared in advance,
Increased physical and Increased risk of infection/
and a freezer is required for recipes
emotional connection contamination6 prepared more than 24 hours before
with caregivers
Increased risk for macro- and feeding. If whole foods are used, a

Increased dietary diversity micronutrient deficiencies high-quality blender may be needed.14

Opportunity for the patient and and excesses Some blender companies provide dis-
family to make choices about
Increased difficulty determining counts to patients using the blender for
the patient’s nutrition4 actual nutrient intake medical needs. Depending on the in-


gredients and storage methods used,
Emotional support for Increased complications with
additional equipment might be
caregivers and patients feeding delivery, such as required, such as measuring cups and
who are grieving the loss clogged feeding tubes storage containers.
of normal oral feedings Family motivation and literacy are

Decreased feeding intolerance also important to consider. Preparing
including decreased gagging homemade tube feeding can be very
and retching5,6 time consuming and requires a moti-

vated family to make time every day to
Improved bowel function4,5
prepare homemade tube feeding. The

Decreased oral aversion5 family must also be able to read rec-

Decreased cost ipes, use standard measuring tools, and
Figure 1. Advantages and disadvantages of homemade tube feeding. communicate concerns and issues with
the health care team. They must be
able and willing to attend the frequent
commercially prepared formula. In Volume tolerance needs to be taken
follow-up appointments that will be
addition, food safety becomes a into consideration when creating the
required to monitor transition to
concern with feeding duration of 2 homemade tube feeding recipe, as it
homemade tube feeding.
hours or more at room temperature, can be difficult to meet 100% of nutri-
the temperature where food-borne tion needs from food in volume-
pathogens multiply most rapidly. sensitive patients. RECIPE PLANNING
Before creating a recipe, discuss the
family’s goals for homemade tube
Table 1. Cost of food-based enteral formulas in comparison with standard
feeding. Some families might choose to
pediatric enteral formula
switch to a commercial food-based
Pack Price per enteral formula or add a small
amount of baby food to current feeding
price, Price per unit, 100 calories,
plan, while other families may desire to
Formula Pack size $ $ $ have 100% of nutrition provided by
foods and beverages. Some patients
Homemade, conventionala NA NA 2.48 per 0.36
may require formula in addition to
daily recipeb food in order to meet nutrient needs,
(700 kcal) especially in patients with high-calorie
Homemade, organica NA NA 4.29 per 0.61 needs, low-calorie needs, volume
daily recipeb intolerance, or specific medical condi-
(700 kcal) tions described here.
It is also important to discuss the
Standard pediatric enteral 24 cans 49.00 2.04 per can 0.85 family’s food preferences and food re-
formula: Pediasure (240 kcal) strictions before creating a recipe.
(Abbott Nutrition8) Gather more information about forms
Compleat Pediatric 24 tetrapacks 74.99 3.12 per tetra 1.25 of food to be used (puréed baby food
jars vs whole foods), allergies, and food
(Nestle Nutrition9) (250 kcal)
preferences (eg, vegetarian, organic,
Real Food Blends10 12 pouches 49.95 4.16 per pouch 1.26 and local). Finally, be clear about the
(330 kcal) time, tools, and monitoring required
Liquid Hope 6 pouches 47.94 7.99 per pouch 1.78 for homemade tube feeding. Provide
the family with a handout that outlines
(Functional Formularies11) (450 kcal)
the advantages and disadvantages of
a
See Table 3 for recipe. homemade tube feeding (see reference
b
Ingredient costs from peapod.com and vitacost.com. 15 for an example).

12 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 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 vegetables, and fruit. When entering micronutrient needs, and individual
FEEDING RECIPE the recipe into the software, choose a supplements may be necessary to meet
variety of foods from each food group. additional micronutrient needs, such as
Step 1: Complete Nutrition For example, instead of using “green calcium and vitamin D. Table salt or
Assessment beans,” use “mixed vegetables.” salt alternatives, such as “lite” or “low-
Encourage the family to vary the fruits sodium” salts, can be added to the
Assess patient’s current nutrient in-
and vegetables used in the homemade recipe in prescribed amounts to meet
take and determine nutrient needs.
tube feeding recipe. minimum sodium and potassium goals.
Document estimated calorie, protein,
Finally, add additional water to meet
fluid, and micronutrient needs. See
fluid needs. This water can be mixed
the Academy of Nutrition and Die-
tetics’ Pediatric Nutrition Care Manual
Step 3: Compare Recipe to into the formula as needed to provide
for pediatric specific nutrition
Estimated Needs the consistency necessary for tube
Assess the recipe for adequacy of cal- feedings or can be given as boluses
recommendations.16
ories, distribution of macronutrients, between tube feedings. See Table 3 for
micronutrient composition compared a sample homemade tube feeding
Step 2: Create a Recipe Draft with dietary reference intakes for age, recipe.
Use nutrient analysis software to and essential fatty acid content. Add
create and analyze the recipe. Start by additional foods and supplements to
using portion sizes from Table 2 based meet nutrient and calorie needs as IMPLEMENTING HOMEMADE
on patient’s estimated calorie needs. indicated. Oil or a combination of oils TUBE FEEDING RECIPE
Begin by entering the patient’s main may be needed to meet essential fatty When initiating a homemade tube
beverage, such as whole milk or for- acid needs, a complete multivitamin feeding recipe, it is important to
mula, then move on to protein, grains, with minerals can be added to meet consider the patient’s experience with
food. If the patient has never consumed
food by mouth or gastrostomy tube,
Table 2. Recommended portions of the five food groups for 1,000- to 3,000-kcal introduce new foods as you would an
diet using MyPlate17 infant with one new, single ingredient
food every 3 to 4 days to assess for
Dairy or dairy Grains, oz Vegetables,b Fruit,b tolerance. The homemade tube feeding
a
Goal, kcal substitute, cups Protein, oz (1-oz equivalent ) cups cups recipe should be introduced slowly and
commercial formula should be
1,000 2 2 3 1 1 decreased accordingly. See Figure 3 for
an example transition schedule. The
1,200 21/2 3 4 11/2 1
1 1 1
transition from commercial formula to
1,400 2 /2 4 5 1 /2 1 /2 homemade tube feeding will take time;
1,600 21/2 5 5 2 11/2 however, if the transition takes an
excessive amount of time, it puts the
1,800 3 5 6 21/2 11/2
1 1
patient at increased risk for nutrition
2,000 3 5 /2 6 2 /2 2 deficiencies.
2,200 3 6 7 3 2 Reiterate the importance of food
safety, sanitation, and proper formula
2,400 3 61/2 8 3 2
1 1
storage to help prevent microbial
2,600 3 6 /2 9 3 /2 2 contamination. Encourage the family to
2,800 3 7 10 31/2 21/2 have commercial formula available for
times of illness (when continuous
3,000 3 7 10 4 21/2
feedings might be needed), for trav-
a
1-oz equivalent is measuring weight, not fluid ounces. See US Department of Agriculture17 for more information. eling, and for emergencies (such as
b
Fruits and vegetables should be chopped or diced, then measured before blending. power outages) or other instances

January 2017 Volume 117 Number 1 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 13
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 % of Goald

Calories 696 99e

Protein 39 g 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.
b
Bayer.
c
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.

when preparation or delivery of The Homemade Blended Formula Hand-
homemade tube feeding is not feasible. book is a great comprehensive resource
for clinicians and families and includes
information on foods that tend to
PRACTICAL GUIDELINES FOR blend well.19
HOMEMADE TUBE FEEDINGS Food safety needs to be considered in
Depending on the homemade tube the preparation, storage, and delivery
feeding recipe and blender used, some of homemade tube feeding. Discuss
foods might blend better than others. food safety basics with the family and
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

14 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 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 nutri-
tionist (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 communi-
cation between the RDN and family is
necessary, as the recipe is imple-
mented 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 recom-
mended to ensure the foods selected
by the family are meeting the patient’s
nutrient needs.
The potential nutrition risks of
homemade tube feeding include inad-
equate 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,
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 feed-
ing. 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 pa-
tients 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 food-
based 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 pa-
tients, but may not be appropriate as
sole source nutrition for pediatric pa-
tients. Compleat Pediatric and
Compleat Pediatric Reduced Calorie
formulas9 are commercially prepared
food-based enteral formulas designed
to meet the needs of pediatric pa-
tients. 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 dur-
ing traveling or time away from the
home.
CONCLUSIONS
Homemade tube feeding is becoming
more popular among patients and cli-
nicians. 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 recom-
mendations for homemade tube
feeding. Future research should focus
on prospectively studying the safety
and efficacy of homemade tube
feeding.

January 2017 Volume 117 Number 1 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 15
PRACTICE APPLICATIONS
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Vieira R, Theodoro de Souza T, Linetzky
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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.
16 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
Bobo E. Blenderized formula for tube
feeding. Frontier 2013;(Fall):4.
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January 2017 Volume 117 Number 1