Nutrition

12/15/21, 6:33 PM Blenderized Enteral Nutrition Diet Study: Feasibility, Clinical, and Microbiome Outcomes of Providing Blenderized Feeds
zed Feeds Through…
Journal of Parenteral and Enteral Nutrition / Volume 42, Issue 6 / p. 1046-1060
Original Communication Free Access
Blenderized Enteral Nutrition Diet Study: Feasibility, Clinical, and Microbiome

Outcomes of Providing Blenderized Feeds Through a Gastric Tube in a Medically
Complex Pediatric Population
Kelsey Gallagher RD, Annika Flint PhD, Marialena Mouzaki MD, MSc, Andrea Carpenter RD,
Beth Haliburton RD, Louise Bannister RD, MSc, Holly Norgrove RN, Lisa Hoffman OT … See all authors 
First published: 16 January 2018

https://doi.org/10.1002/jpen.1049
Citations: 35
Financial disclosure: This study was supported by the John Garfield Campbell Fund. Blenders were donated
by Vitamix®®. A. Stintzi and D. Mack acknowledge support from the Government of Canada through
Genome Canada, the Ontario Genomics Institute (OGI-067), CIHR grant numbers GPH-129340, MOP-11487
and ECD-144627, the Ontario Ministry of Economic Development and Innovation (REG1-4450), Crohn's and
Colitis Canada (CCC), and the Faculty of Medicine of the University of Ottawa.
Conflicts of interest: None declared.
Abstract
Background
Chronically ill children often require feeding via gastrostomy tubes (G-tubes). Commercial
formula is most commonly used for enteral feeding; however, caregivers have been
requesting blenderized tube feeds (BTFs) as an alternative. The objective of this study was to
evaluate the feasibility of using BTFs in a medically complex pediatric population and assess
their impact on clinical outcomes, as well as the microbiota.
Methods
Twenty pediatric participants were included. Participants were G-tube dependent and
receiving ≥75% of their daily energy requirements from commercial formula. Over 4 weeks,
participants were transitioned from commercial formula to BTF and were monitored for 6
https://aspenjournals.onlinelibrary.wiley.com/doi/10.1002/jpen.1049 1/27
12/15/21, 6:33 PM Blenderized Enteral Nutrition Diet Study: Feasibility, Clinical, and Microbiome Outcomes of Providing Blenderized Feeds Through…
months for changes in nutrient intake, gastrointestinal symptoms, oral feeding, medication
use, and caregiver perceptions. Changes to intestinal microbiota were monitored by 16S
rDNA-based sequencing.
Results
Transition onto BTF was feasible in 17 participants, and 1 participant transitioned to oral
feeds. Participants required 50% more calories to maintain their body mass index while on
BTFs compared with commercial formula. BTF micronutrient content was superior to
commercial formula. Prevalence of vomiting and use of acid-suppressive agents significantly
decreased on BTFs. Stool consistency and frequency remained unchanged, while stool
softener use increased. The bacterial diversity and richness in stool samples significantly
increased, while the relative abundance of Proteobacteria decreased. Caregivers were more
satisfied with BTFs and unanimously indicated they would recommend BTFs.
Conclusion
Initiation and maintenance of BTFs is not only feasible in a medically complex pediatric
population but can also be associated with improved clinical outcomes and increased
intestinal bacterial diversity.
Clinical Relevancy Statement

Literature on blenderized tube feeds (BTFs) is limited. Improved feeding tolerance in enterally
fed patients using BTFs is reported but mostly anecdotal. Variability in BTF macronutrient
composition is reported; however, reports on nutritional adequacy when dietitians instruct on
feed composition is lacking.
This is the first prospective evaluation of transitioning patients from commercial formula to
BTF. This study demonstrates nutritional adequacy and an increase in bacterial diversity and
richness on BTFs, while also taking a novel look at its impact on caregivers. This study will aid
healthcare providers in gaining a clearer understanding of when to offer BTFs as an alternative
to formula. The study shows what physiological and psychosocial benefits BTFs may provide
patients and families.
Background
Chronically ill children with swallowing difficulties, neurological impairment, and/or
developmental delays often require feeding via a gastrostomy tube (G-tube). Prior to the 1970s,
pureed food was administered via G-tube as a blenderized tube feed (BTF).1, 2 Currently,
nutritionally complete commercial formulas are primarily used.3, 4 Recently, BTFs have gained
increased interest among the G-tube dependent population, as BTFs are perceived as
“healthier” and “more natural” compared with commercial formulas.5-7
A recent cross-sectional study reported that >50% of adults followed in a Home Enteral
Nutrition clinic were using BTFs.6 In a survey of American pediatric registered dietitians (RDs),
almost a third of respondents (69/243) were interested in additional information on how to use
BTFs in clinical practice.7 The literature on the impact of BTFs on gastrointestinal (GI)
symptoms, dysbiosis, and overall patient health is limited.8 The objective of this study was to
assess the feasibility of transitioning medically complex pediatric patients to BTFs.
Common abbreviations (in alphabetical order)
AI
adequate intake
AMDR
acceptable macronutrient distribution range
BLEND
blenderized enteral nutrition diet
BMI
body mass index
BTF
blenderized tube feed
CCHS
Canadian Community Health Survey
G-tube
gastrostomy tube
GI
gastrointestinal
MAC
mid arm circumference
MAMC
mid arm muscle circumference
NHANES
National Health and Nutrition Examination Survey
OTUs
operational taxonomic units
RDA
recommended dietary allowance
RDs
registered dietitians
SD
standard deviation
SickKids
The Hospital for Sick Children
TSF
triceps skinfold
Methods
The Blenderized Enteral Nutrition Diet (BLEND) study aimed to provide nutritionally adequate
BTFs to medically complex patients, to determine feeding tolerance, and to assess parental
perspectives of this feeding approach.
From May 2014 to July 2015, 20 pediatric outpatients, ages 1–16 years, were enrolled from
ambulatory clinics at The Hospital for Sick Children and followed prospectively for 6 months.
Approach for recruitment was based on caregiver interest in BTFs and eligibility, as described
below. Patients were recruited from gastroenterology, hepatology, and nutrition; cardiology;
complex respiratory; and complex care (pediatric medicine) clinics. Throughout the study,
decisions regarding medical management continued to be made by these respective clinics
independent of study participation.
Patients
Patients were considered eligible for recruitment if they were receiving ≥75% of their total daily
energy requirements from commercial formula via a G-tube (≥12 French). Participants were
excluded if they had a rapidly progressing degenerative disorder, were fed via Gastro-Jejunal
tube, had intestinal obstruction, had active burns, or were malnourished (weight below 85% of
ideal body weight for height).
Nutritional Guidelines
Participants had in-person visits with the study RD at enrollment, 6 weeks, 3 months, and 6
months after BTF initiation. At enrollment, the RD instructed parents on how to prepare and
administer BTFs. Participants were provided with a Vitamix® 7500 G-Series blender, BLEND
Resource Handbook and a personalized BLEND prescription based on Canada's Food Guide for
Healthy Eating (http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php). Each
BLEND prescription specified goal calories; daily number of servings required per food group,
including serving size; and fluid goals (Figure S1). BLEND prescriptions were determined by the
participant's intake at enrollment and estimated requirements (calculated using the Food and
Agriculture Organization/World Health Organization/United Nations University equation).9
Prescriptions were advanced as needed, based on tolerance and growth throughout the study.
Supplemental fluid was determined by calculating the participant's maintenance fluid

requirements,10 minus the total volume of fluid from other liquids and fluid contained in food
(75% of total food volume) (https://food-nutrition.canada.ca/cnf-fce/index-eng.jsp).
Given that many blended food items were unprocessed and low in sodium, a ¼ teaspoon of salt
(575 mg of sodium) was added daily to help meet dietary reference intake (DRI; http://www.hc-
sc.gc.ca/fn-an/food-guide-aliment/basics-base/quantit-eng.php). No additional vitamins or
minerals were prescribed. Participants were transitioned onto goal BTF (≥75% of total daily
energy) over 4 weeks.
Stool, buccal mucosa swabs, and gastric secretion samples were collected at scheduled clinic
visits for microbiota analysis. Stool samples were collected at enrollment and at 6, 10, and 22
weeks after initiation of BTF. Oral swab samples were collected at enrollment and
approximately 22 weeks after diet transition. Gastric samples were obtained at enrollment and
at 10 and/or 22 weeks post–diet transition. All samples were immediately flash frozen on dry
ice and stored at –80˚C until processing.
Anthropometrics and Diet Assessments

Anthropometric data including weight, length/height, triceps skinfolds (TSFs) and mid arm
circumference (MAC)11 were collected at all visits. Dietary intake was recorded at enrollment
using a 24-hour food recall and nutritional adequacy of BTF was assessed and analyzed at 3
and 6 months using 3-day food records (The Food Processor® Nutrition and Fitness Software,
ESHA Research). Adherence to the BLEND prescriptions was defined as a reported provision of
≥80% of the prescribed diet.
Perception of GI Symptoms
Medications were recorded at enrollment, and any changes were reported by the caregivers
during study phone calls and clinic visits. Questionnaires to assess caregivers’ perception of
their child's GI symptoms, stool frequency and consistency,12 oro-motor skills (using Crist
Pediatric Assessment for Severe Feeding Problems),13 and overall satisfaction with G-tube
feeds were completed at enrollment, and 3 and 6 months.
Caregiver Perceptions
At the end of the study, caregivers were asked to complete questionnaires regarding their
experience with BTF (Appendix 1).
Microbiota V6-16S Library Construction and Sequencing

Total metagenomic DNA was extracted from patient samples and V6-16S libraries were
constructed (Table S1) as previously described,14 with minor modifications described below.
V6-16S library amplicons were first visualized on an agarose gel, quantified and equal masses
of 45 barcoded libraries (300 ng each) were pooled together for subsequent polymerase chain
reaction (PCR) purification.
This was followed by size selection using Agencourt AMPure XP DNA beads and analysis using
an Agilent Bioanalyzer DNA high-sensitivity kit. The libraries were templated/sequenced using
an in-house Ion Chef/Ion Torrent PGM on 318 chips according to the manufacturer's protocol.
Microbiota Data Analysis

The sequencing reads were assigned to operational taxonomic units (OTUs) as previously
described,14 except that reads <140 bp or >200 bp were discarded from further analysis and
potential chimeras were removed with UCHIME15 using the default settings against the
GreenGenes database (v13.5) at 97% sequence identity. The demultiplexed/filtered reads were
deposited to the NCBI SRA database (PRJNA371603). Phyloseq16 was used to remove
singleton/doubleton OTUs, rarefy the samples to 50,000 reads, calculate α/β diversities, and
determine taxa relative abundances. Linear regressions were performed in R to detect changes
in α diversities or relative abundances over time, with a p<0.05 considered significant. OTUs
differentially abundant pre-BLEND (week 0) vs post-BLEND (∼week 22) were detected using
DESeq217 with fold changes >2 and an false discovery rate (FDR)-adjusted p<0.05 considered
significant.
Results
Demographics
Twenty children (75% female) with a mean (±SD) age of 3.4±2.2 years were enrolled in the
study. Genetic syndromes and congenital heart disease were the most common primary
diagnosis, each representing 35% of the population. The remaining participants had pulmonary
conditions (10%), neuromuscular conditions (10%), and neurological disorders (5%), or were not
yet diagnosed (5%).
The majority of participants (85%) had 12 French G-tubes, with the remaining having 14 French
G-tubes. All G-tubes had been in situ for over 3 months (mean = 2.2±1.9 years).
At enrollment, G-tube feed schedules varied; 50% were receiving bolus feeds, 35% continuous
feeds, and 15% a combination thereof. Hypercaloric formula (>1.0 kcal/mL) was provided to
25% of participants, while subjects on semi-elemental and elemental formula made up 15%
and 20% of the study population, respectively.
Feasibility
At study exit, 85% of participants (n = 17) had completed the study. Of those, 82% (n = 14)
received ≥75% of their daily energy from BTF. The remaining received between 31% and 64% of
their daily energy from BTF. Of the 3 participants that did not complete the study, 1 successfully
transitioned to 100% oral feeds 3 months following study entry, another discontinued due to
distance between hospital and home, making it too challenging to attend study follow-up
appointments, and the final patient's caregiver found the demands of a new job and BTF too
great.
Dietary Intake and Growth

In order to maintain a stable body mass index (BMI), the caloric intake required with BTF was
50% higher than that with formula feeds (Table 1). The proportion of patients with TSFs above
the fifth percentile increased from the beginning to the end of the study (76 vs 82%, p = 0.001).
Table 1.
Macronutrient Distribution: Enrollment Versus 6 Months
Enrollment 6 Months
Mean (SD) Mean (SD) P-Value
Energy Intake (kcal/kg) 74 (17.2) 111 (39.9) 0.0002
Protein (%kcal) 12 (0.6) 16 (0.8) 0.0014
Carbohydrates (%kcal) 47 (14.6) 42 (16.3) 0.0111
Fat (%kcal) 42 (14.9) 45 (19.9) 0.2097
Intake from protein increased from enrollment to study exit (2.3±0.2 g/kg/day vs 4.4 ±0.5
g/kg/day); however, percent energy from protein remained within the Acceptable
Macronutrient Distribution Range (AMDR) (12±0.6% vs 16±0.8, p<0.001) (Table S2)
(http://www.hc-sc.gc.ca/fn-an/nutrition/reference/table/index-eng.php).
Conversely, percent energy from carbohydrates decreased and fell below AMDR (47±14.6% vs
42±16.3, p = 0.011) at study exit, while fat intake remained similar and above AMDR at both
time points (42±15% vs 45±20, p = 0.210).
At study exit, participants on BTFs had a similar, if not greater, micronutrient intake when
compared with commercial formula, with the exception of vitamin D (Figure 1). While
participants received more vitamin D with commercial formula than BTF, neither met the
recommended dietary allowance (RDA) (75±37% DRI vs 45±34%, p = 0.009). Sodium and fiber
did not meet adequate intake (AI) at enrollment; however, the provision of both improved on
BTF.
Figure 1
Open in figure viewer PowerPoint

Micronutrient at enrollment vs 6 months compared with percent Dietary Reference Intake (DRI). BLEND, Blenderized Enteral
Nutrition Diet.
At study exit, 100%, 88%, 81%, and 63% of prescribed serving sizes of meat and alternatives,
milk and alternatives, vegetables and fruit, and grain products, respectively, were met.
GI Symptoms, Oral Intake, and GI Medication Use

The percentage of patients vomiting > once a week decreased from 76% to 53% at study exit (p
= 0.015). Improvement trends were seen in the prevalence of gagging and/or retching, which
decreased from 82% to 47% (p = 0.072). At enrollment, 82% of participants were safe to eat or
drink something by mouth. Of these participants, only 67% consumed something by mouth,
increasing to 80% at study exit. Stool frequency of > once per day was seen in 100% of
participants at enrollment and 94% at study exit; stool consistency did not change significantly.
The majority of participants were receiving acid-suppressive and promotility agents at

enrollment (88% and 53%, respectively). Between enrollment and study exit, the use of acid-
suppressive agents decreased from 88% to 76% (p = 0.007). There was no change in use of
promotility agents. The use of stool softeners increased with the use of BTF from 24% to 29% (p
= 0.022).
Caregiver Goals and Perceptions

To identify caregivers’ motivation for initiating BTFs at enrollment, they were asked an open-
ended question about goal outcomes. The most common goals were to see an increase in oral
intake, provide “real food,” and improve reflux symptoms.
Caregiver perception of G-tube feeding changed during the study, particularly relating to
feeding discomfort and satisfaction. Measured on Likert scales of 1–10 (discomfort: 10 = severe
discomfort and satisfaction: 10 = extremely satisfied), caregivers perceived that their child was
in significantly less discomfort at 6 months (5 vs 2, p = 0.002) and were significantly more
satisfied with G-tube feeds (6 vs 9, p<0.001). The vast majority (89%; 16 of 18) of caregivers
agreed that their goals for participating in the study were met, and all respondents indicated
that they would recommend BTFs to other parents (Table 2).
Table 2.
Caregivers’ Perceptions at 6 Months
Theme Statements Strongly Agree or

Agree (n = 18)
Satisfaction The BTF were successful for my child 94%
Goals for participating in BTF study were met 89%
You would recommend BTF to other parents of tube feeding children 100%
Health & Your child appears happier on BTF 94%

Well-Being
Your child appears healthier on BTF 94%
Do your family members/other caregivers see BTF as being beneficial? 83%
Do your family members/other caregivers feel the effort to make BTF is 94%
worth it over using commercial formula?
Theme Statements Strongly Agree or

Time & BTF were expensive compared with a regular diet Agree
44% (n = 18)
Cost
BTF were time-consuming compared with preparing a regular meal 61%
Level of The decision to participate in the study was supported by your homecare 83%
BTF, blenderized tube feed
Bacterial Diversity and Species Richness Changes with BLEND

Sequencing yielded ≈10 million reads with a median of 142,254 reads per sample after OTU
picking (54, 30, and 34 samples for stools, gastric secretions, and buccal mucosa, respectively).
Analysis of α diversity revealed increased bacterial diversity (Shannon index) and richness
(Chao1 index) in stool samples post–diet transition (Figure 2AC, p<0.001). Furthermore, there
was a small but significant increase in the bacterial diversity of buccal mucosal samples (Figure
2B, p<0.05) but no increase in bacterial richness (Figure 2D). No significant changes in α
diversity were observed in the gastric secretions (data not shown). Q-Q plots confirmed sample
data was normally distributed for linear regression analysis (Figure S2).
Figure 2
Open in figure viewer PowerPoint
The blenderized diet increases the α diversity of microbiota in stool and oral samples in pediatric G-tube-fed patients over
time. A. Chao1 index of species diversity observed from patient stool samples over time (weeks); B. Chao1 index of species
diversity observed from patient oral samples over time (weeks); C. Shannon diversity of microbial richness from patient
stool samples as a function of time; D. Shannon diversity of microbial richness from patient oral samples over time. α
diversity indices were calculated using data rarefied to 50,000 reads per sample. Statistical significance of increased species
diversity and richness was calculated using linear regression with p<0.05 considered significant.
Principal coordinate analysis (PCoA) revealed that patient stool samples separated from both
gastric secretion and buccal mucosa samples but not one another (Figure S3). Separate PCoA of
the stool samples did not reveal any clear separation of pre-BLEND and post-BLEND samples
(data not shown). Furthermore, the samples did not separate by other covariates such as sex,
dietary fiber intake, patient, or sequencing library. No clear separation could be obtained for
either the gastric secretion or buccal mucosa samples with the covariates used in the stool
analysis (data not shown).
Changes in the Relative Abundance of Bacterial Phyla in Stool

Proteobacteria was significantly reduced in patient stool samples pre-BTF vs post-BTF at ∼6
months (Figures S4 and S5, p = 0.02). Although not significant (p = 0.08), there was also a trend
for the relative abundance of Firmicutes to increase over time (Figures S4 and S5). No
significant changes in relative abundance were observed for either the gastric secretion or
buccal mucosa samples during diet transition (data not shown). Few OTUs were differentially
abundant over the course of the BLEND diet transition in the stool samples, with only a
Eubacterium dolichum (3.6-fold decrease, p<0.05) and a Lachnospira sp. (6.5-fold increase, p =
0.05) reaching statistical significance.
Discussion
The BLEND study is the first prospective study addressing the feasibility of transitioning
medically complex children from commercial formula to BTFs. BTFs were introduced safely and
were well-tolerated. Despite this, in order to maintain BMI z-scores, a higher-energy diet was
required with BTFs. BTFs were associated with increased provision of protein, fiber, and sodium
compared with commercial formulas, as well as an increase in bacterial diversity and species
richness, in the context of decreasing Proteobacteria in stool.
It is unclear why participants’ daily energy intake increased 1.5-fold in order to maintain their
BMI on a BTF compared with that of commercial formula; however, our results are consistent
with the Tanchoco et al study where adults receiving BTFs required 1.2-fold more energy
compared with adults receiving commercial formula with no significant differences in weight
outcomes between arms.18 While further investigation is needed, possible explanations
include differences in the thermic effect of feeding19 as well as changes in food digestion and
absorption secondary to diet-related alterations in the intestinal microbiota composition.20 It
should be noted that body fatness, as measured with TSFs, did increase with use of BTFs,
suggesting that perhaps fewer calories may have been sufficient as well.
Literature on the nutrient composition of BTFs is limited. Adult studies from Brazil, Saudi
Arabia, and the Philippines found significant variability in macro- and micronutrient content of
hospital-administered BTFs.21-23 In our study, BTF prescriptions were provided and modified
in response to BMI change. With our dietitians modifying the number of servings per food
group and parents deciding which foods within these food groups to provide, we were able to
meet participants’ nutrient requirements. Similar results were reported in a Singapore case
series showing that pediatric participants receiving BTFs met DRI micronutrient
requirements.24 This suggests appropriately designed BTFs can meet nutrient requirements.
Data from the Canadian Community Health Survey (CCHS;

http://www23.statcan.gc.ca/imdb/p2SV.pl?Function=getSurvey&SDDS=3226) highlight
similarities and differences between the diet of our participants and the average Canadian
child. In our study, protein intake on BTFs was higher (16±0.8%) than that of the average
Canadian child 1–8 years old (14.3–15.2%). Despite this, protein intake with BTFs was
comparable to the National Health and Nutrition Examination Survey looking at children ≤8
years of age.25 Proportion of energy from fat was not different between commercial formula
and BTF, but both exceeded the AMDR and the CCHS data. Provision of micronutrients was
similar to the average Canadian child and BTF participants. Most notably, BTFs provided
superior amounts of fiber and comparable amounts of vitamin D (CCHS). Practitioners caring
for children on BTF should ensure adequate intake and/or supplementation with vitamin D to
prevent deficiencies.
In G-tube-fed patients, symptoms secondary to generalized GI dysmotility and

Gastroesophageal Reflux Disease (GERD) are a frequent barrier to the provision of adequate
nutrition.1, 26 While the role of BTFs in symptom management is not well-understood, some
evidence suggests BTFs can help improve feeding tolerance. A questionnaire administered by
Hurt et al found that of the 54 G-tube fed adults surveyed, 30% chose BTFs to improve feeding
tolerance.6 Furthermore, when surveying a group of pediatric dietitians, Johnson et al found
that BTFs were started in an effort to meet parental demands, which included improvements in
feeding tolerance and oral intake.7 Pentiuk et al demonstrated improvements in GI symptoms
on BTFs, reporting that ≥50% of pediatric study participants had a 76%–100% reduction in
gagging and retching on BTFs.27 This was consistent with the results of our study that
suggested a decrease in gagging and retching as well as frequency of emesis. While stooling
frequency and consistency was similar throughout the study, stool softener use increased on
BTF. This may be related to the type of fiber used in the BLEND prescriptions (eg, soluble vs
insoluble),28 the rapidity with which a higher-fiber diet was introduced to participants, fluid
intake, and perhaps the changes in intestinal microbiota composition, which may impact
colonic motility.20, 28 Change in stool consistency was not noted and was only assessed initially
on the commercial formula and at study exit, rather than on BTFs prior to stool softener
initiation. Therefore, changes in stool consistency, specifically due to dietary changes, may not
have been captured.
The relationship between the gut microbiota composition and human health has been the
focus of intense study in recent years. Indeed, numerous human diseases have been
associated with decreases in bacterial richness and diversity.29-31 Thus, the overall increase in
α diversity seen in our study may suggest that the use of the BTF diet could be beneficial in
improving G-tube-fed patient health and well-being. GI diseases display an expansion of
Proteobacteria leading to a microbial dysbiosis in the gut.32 Our study found that
Proteobacteria decreased in stools over time and highlights the potential health benefits of a
varied BTF diet in helping to maintain a healthy gut microbiota. Furthermore, analysis of the
stool samples showed a decrease in E. dolichum and an increase in Lachnospira sp. The E.
dolichum genome is enriched for genes involved in simple sugar uptake and metabolism.33
Over the course of the study, the percent energy from carbohydrates decreased below AMDR,
and thus the reduction in relative abundance of E. dolichum might therefore correlate with this
finding. Lachnospira sp are involved in colonic dietary fiber fermentation and have been
characterized to degrade pectin.34, 35 The BTFs had increased dietary fiber, which may explain
the shift to increase fiber fermentation bacteria such as Lachnospira sp.
In our study, one of caregivers’ main motives for trialing BTFs was to increase oral intake. The
number of participants that progressed from eating nothing to eating something by mouth in
our study approached significance, with 1 patient transitioning to 100% oral feeds. This is
consistent with the report of Pentiuk et al,27 where participants’ oral intake increased by 57%
on BTF. Improved oral intake may be influenced by decreased GI symptomatology; changes in
appetite signaling mediated by changes in intestinal microbiota composition,4, 36 and
increased motivation of caregivers to offer oral feeds. More studies are needed to investigate
the association between BTFs and oral intake in children with complex medical history.
There were several limitations to this study. Participants were not randomized, and all families
expressed prior interest in BTFs, introducing reporter bias. Regarding outcome measures, given
our inclusion criteria required that participants were medically stable and had a normal growth
velocity we did not complete nutrition panels on patients, as this is not part of our standard of
care. Despite this, if a patient is not growing well, clinicians should consider completing a
nutrition panel when switching to BTFs. Not completing a nutrition panel was a limitation and
should be considered for future larger-scale studies. Our study did not have a commercial
formula control group that would better inform whether changes to GI symptoms, medications,
and oral medications were a function of BTFs or time. Additionally, our small sample size and
varied primary diagnoses preclude us from making general assumptions regarding the
applicability of such an intervention; however, this study provides the basis for larger
randomized trials to address the feasibility and impact of using BTFs for medically complex
children.
Conclusion
Despite its limitations, this study achieved its objective, to demonstrate the feasibility and
safety of introducing BTFs in a medically complex pediatric cohort. Given that BTFs have
already entered into clinical practice, it is imperative that clinicians can provide accurate
information on BTFs. While additional studies are needed, this research is the first step in
providing a body of evidence-based knowledge. Using a BLEND prescription, this study
demonstrates that BTFs are well-tolerated and provides a nutrient profile that is similar to that
of the average Canadian child and to commercial formulas. BTFs give families an opportunity to
participate in their child's care by preparing their meals and choosing the content of their diets.
Statement of Authorship
Kelsey Gallagher, RD, drafted the initial manuscript, aided with the conception and design of
the study, designed the data collection instruments, gathered, coordinated and supervised
clinical data collection, coordinated and supervised data analysis and approved the final
manuscript as submitted. Contributor agreed to be accountable for all aspects of the work in
ensuring that questions related to the accuracy or integrity of any part of the work are
appropriately investigated and resolved.
Marialena Mouzaki, MD, MSc, aided with the conception and design of the study, carried out
the initial analyses, reviewed and revised the manuscript and approved the final manuscript as
submitted. Contributor agreed to be accountable for all aspects of the work in ensuring that
questions related to the accuracy or integrity of any part of the work are appropriately
investigated and resolved.
Andrea Carpenter, RD, aided with the conception and design of the study and critically revised
the manuscript for important intellectual content and approved the final version to be
published. Contributor agreed to be accountable for all aspects of the work in ensuring that
questions related to the accuracy or integrity of any part of the work are appropriately
Beth Haliburton, RD, helped with data analysis, aided with the conception and design of the
study and revised the manuscript for important intellectual content and approved final version
to be published. Contributor agreed to be accountable for all aspects of the work in ensuring
that questions related to the accuracy or integrity of any part of the work are appropriately
Louise Bannister, RD, aided with the conception and design of the study and revised the
manuscript for important intellectual content and approved final version to be published.
Contributor agreed to be accountable for all aspects of the work in ensuring that questions
related to the accuracy or integrity of any part of the work are appropriately investigated and
resolved.
Holly Norgrove, RN, designed data collection tool, involved in acquisition of data, revised the
manuscript for important intellectual content, and approved final version to be published.
resolved.
Lisa Hoffman, OT, aided with the conception and design of the study and revised the
manuscript for important intellectual content and approved final version to be published.
resolved.
Margaret Marcon, MD, conceptualized and designed the study and reviewed and revised the
manuscript, revised the manuscript for important intellectual content and approved final
version to be published. Contributor agreed to be accountable for all aspects of the work in
ensuring that questions related to the accuracy or integrity of any part of the work are
appropriately investigated and resolved.
Appendix
Supporting Information 
Filename Description
jpen1049-sup-0001-SuppMat.pdf 3 MB Supporting Material
Please note: The publisher is not responsible for the content or functionality of any supporting
information supplied by the authors. Any queries (other than missing content) should be directed to
the corresponding author for the article.
References 
1 Campbell SM. An anthology of advances in enteral tube feeding formulations. Nutrition in Clinical
Practice. Aug 2006; 21(4): 411- 415.
Wiley Online Library | PubMed | Google Scholar
2 Harkness L. The history of enteral nutrition therapy: from raw eggs and nasal tubes to purified
amino acids and early postoperative jejunal delivery. Journal of the American Dietetic Association. Mar
2002; 102(3): 399- 404.
Crossref | PubMed | Web of Science® | Google Scholar
3 Brown B, Roehl K, Betz M. Enteral nutrition formula selection: current evidence and implications
for practice. Nutrition in Clinical Practice. Feb 2015; 30(1): 72- 85.
Wiley Online Library | PubMed | Web of Science® | Google Scholar
4 Marchand V, Motil KJ, Nutrition NCo. Nutrition support for neurologically impaired children: a
clinical report of the North American Society for Pediatric Gastroenterology, Hepatology, and
Nutrition. Journal of Pediatric Gastroenterology and Nutrition. Jul 2006; 43(1): 123- 135.
5 Escuro A. Blenderized tube feeding: suggested guidelines to clinicians. Practical Gastroenterology.

2014; 38(12): 58- 66.
Google Scholar
6 Hurt RT, Edakkanambeth Varayil J, Epp LM, et al. Blenderized tube feeding use in adult home
enteral nutrition patients: a cross-sectional study. Nutrition in Clinical Practice. Dec 2015; 30(6): 824-
829.
Wiley Online Library | CAS | PubMed | Web of Science® | Google Scholar
7 Johnson TW, Spurlock A, Pierce L. Survey study assessing attitudes and experiences of pediatric
registered dietitians regarding blended food by gastrostomy tube feeding. Nutrition in Clinical Practice.
Jun 2015; 30(3): 402- 405.
Wiley Online Library | PubMed | Web of Science® | Google Scholar
8 Novak P, Wilson, KE, Ausderau, K, Cullinane, D. The use of blenderized tube feedings. ICAN: Infant,
Child, & Adolescent Nutrition. 2009; 1(1): 21- 23.
Google Scholar
9 Energy and protein requirements. Report of a joint FAO/WHO/UNU Expert Consultation. World
Health Organization Technical Report Series. 1985; 724: 1- 206.
PubMed | Google Scholar
10 Holliday MA, Segar, WE. The maintenance need for water in parenteral fluid therapy. Pediatrics.
1957; 19(5): 823- 832.
CAS | PubMed | Web of Science® | Google Scholar
11 Frisancho AR. New norms of upper limb fat and muscle areas for assessment of nutritional
status. The American Journal of Clinical Nutrition. 1981; 34(11): 2540- 2545.
Crossref | CAS | PubMed | Web of Science® | Google Scholar
12 Chumpitazi BP, Self MM, Czyzewski DI, Cejka S, Swank PR, Shulman RJ. Bristol Stool Form Scale
reliability and agreement decreases when determining Rome III stool form designations.
Neurogastroenterology and Motility. Mar 2016; 28(3): 443- 448.
13 Crist W. Pediatric assessment scale for severe feeding problems: validity and reliability of a new
scale for tube-fed children. Nutrition in Clinical Practice. 2004; 19(4): 403- 408.
Wiley Online Library | PubMed | Google Scholar
14 Mottawea W, Chiang CK, Muhlbauer M, et al. Altered intestinal microbiota-host mitochondria

crosstalk in new onset Crohn's disease. Nature Communications. Nov 23 2016; 7: 13419.
15 Edgar RC, Haas BJ, Clemente JC, Quince C, Knight R. UCHIME improves sensitivity and speed of
chimera detection. Bioinformatics. Aug 15 2011; 27(16): 2194- 2200.
16 McMurdie PJ, Holmes S. Phyloseq: a bioconductor package for handling and analysis of high-
throughput phylogenetic sequence data. Pacific Symposium on Biocomputing. 2012: 235- 246.
Google Scholar
17 Love MI, Huber W, Anders S. Moderated estimation of fold change and dispersion for RNA-seq
data with DESeq2. Genome Biology. 2014; 15(12): 550.
18 Tanchoco CC, Castro CA, Villadolid MF, et al. Enteral feeding in stable chronic obstructive
pulmonary disease patients. Respirology. Mar 2001; 6(1): 43- 50.
Wiley Online Library | CAS | PubMed | Google Scholar
19 Reed GW, Hill, JO. Measuring the thermic effect of food. The American Journal of Clinical Nutrition.
1996; 63(2): 164- 169.
PubMed | Web of Science® | Google Scholar
20 David LA, Maurice CF, Carmody RN, et al. Diet rapidly and reproducibly alters the human gut
microbiome. Nature. Jan 23 2014; 505(7484): 559- 563.
21 Borghi R, Dutra Araujo T, Airoldi Vieira RI, Theodoro de Souza T, Waitzberg DL. ILSI Task Force on
enteral nutrition; estimated composition and costs of blenderized diets. Nutricion Hospitalaria. Nov–
Dec 2013; 28(6): 2033- 2038.
22 Mokhalalati JK, Druyan ME, Shott SB, Comer GM. Microbial, nutritional and physical quality of
commercial and hospital prepared tube feedings in Saudi Arabia. Saudi Medical Journal. Mar 2004;
25(3): 331- 341.
23 Sullivan MM, Sorreda-Esguerra P, Platon MB, et al. Nutritional analysis of blenderized enteral
diets in the Philippines. Asia Pacific Journal of Clinical Nutrition. 2004; 13(4): 385- 391.
24 Han WM. Does switching from milk to pureed foods for gastrostomy tube improve micronutrient
intake? Clinical Nutrition. 2014; 33(S106).
Google Scholar
25 Fulgoni VL,3rd. Current protein intake in America: analysis of the National Health and Nutrition
Examination Survey, 2003–2004. The American Journal of Clinical Nutrition. May 2008; 87(5): 1554S-
1557S.
26 Savage K, Kritas S, Schwarzer A, Davidson G, Omari T. Whey- vs casein-based enteral formula and
gastrointestinal function in children with cerebral palsy. Journal of Parenteral and Enteral Nutrition. Jan
2012; 36(1 Suppl): 118S- 123S.
27 Pentiuk S, O'Flaherty T, Santoro K, Willging P, Kaul A. Pureed by gastrostomy tube diet improves
gagging and retching in children with fundoplication. Journal of Parenteral and Enteral Nutrition. May
2011; 35(3): 375- 379.

28 Slavin J. Fiber and prebiotics: mechanisms and health benefits. Nutrients. Apr 2013; 5(4): 1417-
1435.
29 Walters WA, Xu Z, Knight R. Meta-analyses of human gut microbes associated with obesity and
IBD. FEBS Letters. Nov 17 2014; 588(22): 4223- 4233.
30 McMurtry VE, Gupta RW, Tran L, et al. Bacterial diversity and Clostridia abundance decrease with
increasing severity of necrotizing enterocolitis. Microbiome. 2015; 3: 11.
31 Le Chatelier E, Nielsen T, Qin J, et al. Richness of human gut microbiome correlates with metabolic
markers. Nature. Aug 29 2013; 500(7464): 541- 546.
32 Shin NR, Whon TW, Bae JW. Proteobacteria: microbial signature of dysbiosis in gut microbiota.
Trends in Biotechnology. Sep 2015; 33(9): 496- 503.
33 Turnbaugh PJ, Backhed F, Fulton L, Gordon JI. Diet-induced obesity is linked to marked but
reversible alterations in the mouse distal gut microbiome. Cell Host & Microbe. Apr 17 2008; 3(4): 213-
223.
34 Zhang H, DiBaise JK, Zuccolo A, et al. Human gut microbiota in obesity and after gastric bypass.
Proceedings of the National Academy of Sciences of the United States of America. Feb 17 2009; 106(7):
2365- 2370.
35 Rode LM, Genthner BR, Bryant MP. Syntrophic association by cocultures of the methanol- and
CO(2)-H(2)-utilizing species eubacterium limosum and pectin-fermenting lachnospira multiparus
during growth in a pectin medium. Appl Environ Microbiol. Jul 1981; 42(1): 20- 22.
Google Scholar
36 Cani PD, Lecourt E, Dewulf EM, et al. Gut microbiota fermentation of prebiotics increases
satietogenic and incretin gut peptide production with consequences for appetite sensation and
glucose response after a meal. The American Journal of Clinical Nutrition. Nov 2009; 90(5): 1236- 1243.
Citing Literature 
Download PDF
© 2021 American Society for Parenteral and Enteral Nutrition
About Wiley Online Library

Privacy Policy
Terms of Use
Cookies
Accessibility
Publishing Policies
Help & Support

Contact Us
Training and Support
DMCA & Reporting Piracy
Opportunities
Subscription Agents
Advertisers & Corporate Partners
Connect with Wiley

The Wiley Network
Wiley Press Room
Copyright © 1999-2021 John Wiley & Sons, Inc. All rights reserved

Nutrition

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Nutrition

Uploaded by

Copyright:

Available Formats

12/15/21, 6:33 PM Blenderized Enteral Nutrition Diet Study: Feasibility, Clinical, and Microbiome Outcomes of Providing Blenderized Feeds

zed Feeds Through…

Journal of Parenteral and Enteral Nutrition / Volume 42, Issue 6 / p. 1046-1060

Original Communication Free Access

Blenderized Enteral Nutrition Diet Study: Feasibility, Clinical, and Microbiome

First published: 16 January 2018

Conflicts of interest: None declared.

Clinical Relevancy Statement

Common abbreviations (in alphabetical order)

Supplemental fluid was determined by calculating the participant's maintenance fluid

Anthropometrics and Diet Assessments

Microbiota V6-16S Library Construction and Sequencing

Microbiota Data Analysis

Dietary Intake and Growth

Mean (SD) Mean (SD) P-Value

Energy Intake (kcal/kg) 74 (17.2) 111 (39.9) 0.0002

Protein (%kcal) 12 (0.6) 16 (0.8) 0.0014

Carbohydrates (%kcal) 47 (14.6) 42 (16.3) 0.0111

Fat (%kcal) 42 (14.9) 45 (19.9) 0.2097

Open in figure viewer PowerPoint

GI Symptoms, Oral Intake, and GI Medication Use

The majority of participants were receiving acid-suppressive and promotility agents at

Caregiver Goals and Perceptions

Theme Statements Strongly Agree or

Satisfaction The BTF were successful for my child 94%

Goals for participating in BTF study were met 89%

Health & Your child appears happier on BTF 94%

Your child appears healthier on BTF 94%

Do your family members/other caregivers see BTF as being beneficial? 83%

Theme Statements Strongly Agree or

BTF were time-consuming compared with preparing a regular meal 61%

BTF, blenderized tube feed

Bacterial Diversity and Species Richness Changes with BLEND

Open in figure viewer PowerPoint

Changes in the Relative Abundance of Bacterial Phyla in Stool

Data from the Canadian Community Health Survey (CCHS;

In G-tube-fed patients, symptoms secondary to generalized GI dysmotility and

jpen1049-sup-0001-SuppMat.pdf 3 MB Supporting Material

5 Escuro A. Blenderized tube feeding: suggested guidelines to clinicians. Practical Gastroenterology.

Wiley Online Library | PubMed | Web of Science® | Google Scholar

14 Mottawea W, Chiang CK, Muhlbauer M, et al. Altered intestinal microbiota-host mitochondria

2011; 35(3): 375- 379.

© 2021 American Society for Parenteral and Enteral Nutrition

About Wiley Online Library

Help & Support

Connect with Wiley

You might also like