A Historic Perspective on Homemade Blended Formulas

By Marsha Dunn Klein OTR/L, MEd, FAOTA

I would like to share some perspectives on homemade blended formulas for tube fed children. Many of you may know that Suzanne Evans Morris and I wrote the Homemade Blended Formula Handbook in 2007. I would like to share a historical perspective on how HBF has evolved since that time.

How did Homemade Blended Formula Handbook come to be?

Suzanne and I met a family whose child was tube fed. Prior to having her baby, Mom could not wait to feed and make food for her baby. She described herself as a Vegan and spent lots of time at health food stores and in her garden thinking about and preparing special foods for her family, preparing everything homemade and with love.  Imagine her disappointment when her baby struggled to eat her carefully pumped breast milk, vomited many times a day, got a feeding tube with no oral foods in sight! Mom was told to feed her a particular commercial formula and lost the dream of feeding her baby all those lovingly prepared meals.

Mom’s frustration grew and as her baby was almost two years old.  Mom went to the pediatrician and asked “Can I just put food in the tube?  Why do I have to feed this canned stuff?  When I read the label, I do not see real food words and I also see lots of sugar?” He had no experience at all with any kind of real food in tubes but said, “I think it is a reasonable question; I will support you, but let’s connect you with a pediatric dietitian.” The dietitian also said, “Well, I have never done this, but it seems like a reasonable question, so let’s go slowly, try this together and monitor your daughter closely.” I will always be impressed with that pediatrician and that dietitian.  They listened to this concerned parent and were willing to support her on this journey.

They monitored weight, constipation and vomiting and introduced each new food, liquid or spice for 4-6 days at a time to be sure each ingredient they offered was working well. They went extremely slowly.  Over the course of a year and a half, this sweet little girl was finally fed a completely homemade blend with lots of variation. Canned formula decreased as the homemade blend increased. Vomiting stopped, reflux stopped, and medications for reflux were discontinued. And most importantly, Mom saw her daughter increase her enthusiasm for oral eating.  

Mom, the pediatrician, and the dietitian were so excited about the changes that they started a support group for families in the area interested in using foods in the tubes.  The internet became a very easy ways to share information and experiences and the online support groups expanded. Suzanne and I interviewed many families around the US, Australia, Canada and the UK and complied the information in the Homemade Blended Formula Handbook to share the experiences of these many families who were convinced that, for them, the change to blended foods was remarkable.  We wrote that book with careful input from two dietitians and an integrative medicine pediatrician for those particular parents and teams who really wanted support exploring this journey. This was really a grassroots parent effort as the medical profession had not yet experienced putting foods in tubes, and quite frankly were quite skeptical. 

Why parents wanted to make homemade formula?

HBF was not for everyone.  But the parents who wanted to find out more about real foods in tubes wanted to nourish their children with foods that were their own choices that looked more like foods on the family table. They had heard dietitian tell them to feed a rainbow and wanted to nourish their children with variety and with the love of creating the meals for them. 

What changes did parents see when they changed to HBF?

The first thing most parents shared was their joy at being able to make nutritional decisions for their own child and having choices.  For so many parents, feeding was a way to show love. Parent after parent told us of changes in stools, less constipation, or less diarrhea, reduced or eliminated reflux, reduced gagging or vomiting and increased volume tolerance, improved weight and, as a bonus, increased interest in foods.

What were the concern about HBF?

There were those in the medical profession who had worried about suggesting HBF. These were reasonable questions, which was why we recommended a collaboration with a dietitian and pediatrician. 

•How will the parent get food in the tube without clogging it?

Parents shared all their tips and tricks for not clogging the tube and many purchased a high-powered commercial blender that made the food smooth enough. Vitamix® and Blendtec® even created special discount programs for families using them to make HBF.

•How will we know the parent is offering a balanced diet?

In general, the parents most interested in taking the time, energy and expense to do homemade blends had a strong interest in nutrition and were willing to take the time to make this work. The dietitian guide supported the balance diet.  

I remember one parent who when questioned about the balanced diet replied. “I have twins. One is oral and one has a tube. You are worried that my tube fed child diet may not be getting a nutritious enough diet, but how do you know my oral child gets proper nutrition? You aren’t asking me about her.  In fact, my tube fed child’s diet is way better that my picky oral toddler’s diet because I can just put it in the tube!”

•How will we know the food is prepared in a clean environment?

This is an issue for preparation of oral or tube food. All food should be prepared in a clean environment

What about the child who cannot tolerate volume?

Parent experience was that volume increased over time as the gut worked better.  The sensation of the more weighted blended foods seemed to allow the food to stay down better and helped the stomach capacity increase.      

What is in a name?

Suzanne and I named this homemade blended formula to celebrate the personal nature of the homemade blend.  Through the years, we have rethought this and, as you can see from the chart below, there have been lots of attempts to redefine this blended food. 

In 2017, Melissa Davis RD and I wrote HBF updates for Nutrition Focus and recommend we changing the terminology to BLENDED TUBE MEALS as a way to describe that these were for the tube and were meals, not formulas, and they were blended with love for a child.

The introduction of many Commercial food-based formulas

Since this grassroots effort of so many families, the medical profession came on board and the idea of food in the tube flourished and research expanded. Today there are lots of food-based formulas such as Nourish®, Compleat Pediatric®, Kate Farms®, Real Food Blends®, and Whole Story Meals®. And an entrepreneurial Mom, Julie Bombacino, started the company Real Food Blends inspired by feeding her own child homemade blends. She offered pouched blended meals that can be easy for traveling and can offer nice variation for the diet. Parents today have many more choices than they had in 2007 and children and families have benefited from this.

Research supported the experiences of parents

The anecdotes from our original group of parents in fact withstood the scrutiny of research.  The research supported family findings.

• Increased fiber: (Fessler, 2016; Mortensen, 2016)
• Bowel regularity: (Hurt et al., 2015; Fessler, 2016); Thorton-Wood, 2019; Trollip et al., 2020; Gallagher et al., 2018; Alabbas & Dumant, 2022)
• Reduced gagging and retching: (Pentiuk et al., 2011; Thorton-Wood, 2019; Alabbas & Dumant, 2022; Batsis et al, 2020; O’Flaherty et al, 2011 )
• Reduce vomiting: (Hurt et al., 2015; Thorton-Wood, 2019; Trollip et al., 2020; Gallagher et al., 2018; Alabbas & Dumant, 2022; Batsis et al, 2020)
• Improved feeding tolerance: (Johnson et al., 2015), (Fessler, 2016), (Fessler, 2015)
• Decreases reflux and does not impact stomach emptying: (Hirsch, 2021; Gallagher et al., 2018)
• Increase oral intake: (Pentiuk et al., 2011) 
• Decrease in oral aversion: (Pentiuk et al., 2011) 
• Decreased bloating: (Hurt et al., 2015)
• Improved dietary diversity: (Fessler, 2016; Fessler, 2015; Weeks, 2019; Boston and Wile, 2020, Shrager et al., 2023)
• Decreased cost: (Fessler, 2016; Mortensen, 2016; Walia et al., 2016; Fessler, 2015)
• Overall positive outcome: (Johnson et al, 2015), (Pentiuk et al., 2011; Soscias et al., 2021; Trollip et al., 2020; Gallagher et al, 2018)
• Psychologically positive for parents (Alabbas & Dumant, 2022)
• Increased intestinal bacterial diversity (Gallagher et al., 2018)

Some important lessons

HBF was not for everyone.  It should be recommended and supported by teams.

Our team had to reconsider how to start.  There were too many families who went out, bought the big expensive blender and then were so overwhelmed be building recipes. (Remember, many of these families had never fed these children orally, let alone figure out how to put all the nutrition in the tube.) 

Parents wanted THE RECIPE, but there was not one recipe for everyone.  Each child and family were different. Some families learned to make one exact recipe and gave that over and over and then worried “where is the variation?”.

Our team learned that they could help a family tip toe in the direction of HBF by going slower, watching the child’s reaction, and gaining confidence along the away.

WIth the support and guidance of the team dietitian, some families introduced baby food purees as Appetizer Tastes. The parent continued the formula regime that was working for the child and added small baby food “tastes” through the tube (ex 5 mLs, 10, mLs, 30 mLs etc) as an “appetizer” either just before a tube meal, or sometimes between tube meals.  This way, the family did not need to buy a special blender or learn complicated recipes.  They could just see how the child did with food variation, changes, and expand the food flavors and amounts as the child showed a tolerance. As families found a handful of baby foods that worked well, our dietitian would help the family then offer combinations of these foods as a meal and adjust the tube feeding accordingly. 

These were smaller more achievable changes for families and allowed the team to observe how the child responded to smaller changes. Gradually some families created one blended meal a day, others made two, and others made three with the formula supplementing the blends. This slower introduction to the blended tube diets seemed to work so much better. Some families transitioned to all homemade blends and others stayed with baby foods.  We realized there were lot of ways to feed oral babies and there needed to be lots of ways to offer tube nutrition.  And these days, with a variety of food-based tube formulas, there can be so many combinations of canned formulas, baby food purees or pouches and homemade foods. We learned the lesson that we needed to help it work of each child, and each family. We found that for many children the benefits seen with blended food variations could be readily seen even with appetizers or one or two meals a day.  Some families stayed canned formula with added Appetizer Tastes, others at one or two meals a day and others aiming for completely homemade blends.  The journey depended on how the child did with each change and how the family could incorporate these changes into their family routine.  

Get Permission Approach

Check out this wonderful resource!

Homemade Blended Formula Handbook

https://amzn.to/4d7thTg

References

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Bobo, E. (2016). Re-emergence of Blenderized Tube Feedings: Exploring the Evidence.  Nutr Clin Practice. 31(6):730-73.

Boston, M. & Wile, H. (2020). Caregiver Perceptions of Real-Food Containing Tube Feeding: A Canadian Survey. Canadian J of Diet Practice ad Research. Vol 81(4).

Brown, T., Zelig, R. & Radler, D.R. (2020). Clinical Outcomes Associated with Commercial and Homemade Blenderized Tube Feeding: A Literature Review. Nutr Clin Practice. 35(3):442-453. doi: 10.1002/ncp.10487. Epub 2020 Apr 22.PMID: 32319708 Review.

Carter, H., Johnson, K., Johnson, T.W. & Spurlock, A. (2018).  Homemade Diet versus Diet Industrialized for Patients Using Alternative Feeding Tube at Home – An Integrative Review. J Am Assoc Nurse Practice. Mar;30(3):150-157.

Chandrasekar, N., Dehlsen, K., Leach, S.T., & Krishnan, U. (2021). Exploring Clinical Outcomes and Feasibility of Blended Tube Feeds in Children. JPEN  Parental Enteral Nutr. May;45(4):685-698. doi: 10.1002/jpen.2062. Epub 2021 Feb17.PMID: 33305384 Review.

Davis, M.& Dunn Klein, M. (2017). A Look at Blended Tube Meals: Part 1-An Update. Nutrition Focus, 31(3), May/June.

Davis, M. & Dunn Klein, M. (2017). A Look at Blended Tube Meals: Part 2-An Update. Nutrition Focus, 31(4), July/August.

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Gallagher. K., Flint, A., Mouzaki, M., Carpenter, A., Haliburton, B., Bannister, L., Norgrove, H. (2018).  Blenderized Enteral Nutrition Diet Study: Feasibility, Clinical, and Microbiome Outcomes of Providing Blenderized Feeds Through a Gastric Tube in a Medically Complex Pediatric Population.  JPEN J Parental Enteral Nutr. 42(6):1046–1060.

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Pentiuk, S., O’Flaherty, T., Santoro, K., Willging, P., Kaul, A. (2011). Pureed by Gastrostomy Tube Diet Improves Gagging and Retching in Children with Fundoplication. JPEN J Parenter Enteral Nutrition; 35(3):375–379.

Schmitz, É.P.C.R., Silva, E.C.D., Lins Filho, O.L., Antunes, M.M.C. & Brandt, K.G. (2021). Blenderized Tube Feeding for Children: An Integrative Review. Rev Paul Pediatrics; Sep 1;40. 

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