Blenderized Diet

I have been honored and touched to hear from so many parents and medical professionals, over the years, who have found the information and videos on Blenderized Diets that I have provided on Ainsley's blog to be helpful. What is a Blenderized Diet? It is simply real food blended to fit through a feeding tube. If you are a "regular person" you might be surprised to learn this method of feeding is somewhat controversial for people that are tube-fed, canned formula is typically prescribed in nearly all cases. If you are a person experienced in the area of gastrostomies then you know that it is true and that may well be why you are here on Ainsley's blog. Although Ainsley is no longer tube fed I believe wholeheartedly in this method of feeding for children (and adults) who require a gastrostomy. I believe getting a variety of foods in our diets is important for good health. Logically it makes sense to me that doesn't change just because a person is fed through a tube. 

Since we started using this method of feeding back in 2007 it has gained credibility and is far more common. However there are still are pros and cons of a Blenderized Diet vs. formula, which should be considered. Our thoughts are discussed in greater detail below but in a nutshell: I believe a Blenderized Diet is worth the extra work whenever it is possible. Personally we experienced an improvement in Ainsley's health when we switched from canned formula to a Blenderized Diet. She stopped vomiting (though she did still have silent reflux which led her to get a Nissen Fundoplication, her color looked better, she had more energy and she was more willing to try to eat food. I've heard many parents' stories over the years, and I have never heard a parent who switched say their child did better on formula than they do on a Blenderized Diet. Not once ever. That says a lot. That's not to say that there aren't good reasons to use formula. As much of an advocate as I am for a Blenderized Diet for g-tubes there were times after starting a Blenderized Diet that we were too busy and happily resorted to canned formula (okay, with a smidge of guilt).  As a parent of a medically complex special needs child I GET IT. If you are happy with formula don't take offense. I am simply telling our story and experience hoping that it might help others who are interested in it. I must say clearly that I am not a dietitian or doctor and I do recommend you consult yours to discuss whether a Blenderized Diet for g-tube is right for you or your child.

On this page I've attempted to consolidate the information that was contained in my posts, broken down into sections to make it easier to find for the people who want it. If a blenderized diet is right for your situation I wish you success! Please post a comment below letting us know how it goes. 

First A Little Background

Ainsley had a breathing tube inserted immediately after birth she was unable to eat. Because the endotracheal tube was in her mouth and throat a naso-gastric tube was inserted through her nose down through her esophagus into her stomach, to delivered all of her "food" (breastmilk and formula). We were optimistic that she would be able to breath on her own but after 3 attempts at removing the intubation tube it became clear that Ainsley would need to have a tracheostomy placed so she could breathe. That was done when she was 5 weeks old and we naively assumed  she would then start eating. We knew very little about anything medical back then. They sent Ainsley for a VSS, videofluoroscopic swallow study. This is a test where the patient, in this case baby, drinks formula with barium in it so that the formula can be viewed with radiology to evaluate the drinking process. If the child aspirates then that will be visible. We were told that Ainsley micro-aspirated during the test and so it wasn't safe to feed her orally and that started the beginning of our long journey with dysphagia.

Being a stubborn person who does not give up easily I was sure she would eventually eat on her own so when we finally left the hospital two months later Ainsley was still sporting the nasogastric or NG tube rather than a surgically placed gastrostomy. I continued to pump breast milk, thinking she would surely get the hang of eating eventually. I knew nothing about feeding difficulties and assumed that it was the natural way of the world that all beings eat and so would she.  I had no idea how complex the situation was, more on that later. I breastfed my other two children and was determined to do so with my third child. After all, with her medical concerns she she needed the benefits most of all. First, she had missed out on so much physical contact, being stuck in a hospital crib most of the time for the first 2 months of her life, with wires and tubes coming off her every which way and in a hip dysplasia brace, it was very difficult to ever hold her. Second, although she was healthy, that first year her body had a lot of recovery to do with all the interventions and surgeries she would go though. I wanted her to have the best nutrition possible and in my mind that meant breastfeeding.

Ainsley had a great suck reflex. During the time she was in the hospital she sucked on a pacifier non-stop and that is quite a trick with an endotracheal tube in the way. The nurses had their own tricks. Propping the pacifier, using a preemie pacifier. They figured out a way because as long as she was sucking she was happy. When we got home I noticed she would root for the breast and with doctor approval we eventually tried desperately to breastfeed. It was not to be and I'll spare you those painful details here. After giving it everything I had I stopped pumping completely when Ainsley was close to a year old and had to concede that it was never going to happen for her.  By that time I was getting very little milk anyway and she was mostly on formula.

Despite starting therapy when she was 4 months old and working very hard on feeding and oral eating Ainsley was still getting virtually 100% of her nutrition through the tube. I'd heard that parents were feeding their children a Blenderized Diet though their feeding tubes on the Tracheostomy.com support forum (link here).  I wanted to try it but there were several obstacles.

• I was afraid, like anything new it seemed daunting and I had a LOT going on already.  
• I didn't know where to start.
• I'd been told that it required an expensive high power blender and I didn't want to spend $800 on a Vitamix just to find out I didn't like making her formula (prices have come down since then). 
• Ainsley was underweight. She coughed up a lot of trach secretions and that frequently led to vomiting. She already needed a higher than normal amount of calories due to the extra effort of breathing through a tiny tube, but when the formula wouldn't stay down it was impossible to keep her weight up. This meant that her dietitian and doctors weren't eager to try anything experimental. They felt that at least they knew how many calories were going in. This is a common concern of medical professionals which is why I eventually modified the blenderized diet in a way that would make Ainsley's medical team happy by creating a recipe that provided consistent calories and fluid volumes.

Creating A Plan

I had heard if there was one resource for making the transition to a blenderized formula it was The Homemade Blended Formula Handbook (link here) by Marsha Dunn Klein. I did purchase the handbook and found it helpful for two reasons.

• It showed me that it really could be done. The parent stories were inspirational. I loved hearing how kids' health were benefiting from the switch.
• I felt it helped the dietitian and doctor take me seriously and backed up the validity of this method of feeding because it was written by medical professionals. Take it to your appointment!

What this book is not, is a recipe book. It's not going to tell you exactly what to put into and how to make a blenderized formula. I know it's disappointing, but the reality is that it is not that simple.

Many kids that require the support of a feeding tube have special dietary concerns. That is another benefit of feeding your child a Blenderized Diet. You can adjust it to what works for him/her. If your child doesn't do well with certain foods or needs a dairy-free or gluten-free diet, for example, it is no problem to make those changes. They may need additional fiber to "keep things moving", or less fiber to prevent diarrhea. In addition some children have sensitivity to volume and more nutrient dense formula. The most important reason there is no "one size fits all blenderized formula recipe" is that the amount of calories and fluid a child needs varies, depending on age, size, metabolism and digestion.  It is very important that you tailor your formula to best fit your child's individual needs.

If you sense your doctor and/or dietitian may need persuading I suggest you start by doing a bit of research, come up with a formula recipe based on the caloric intake your child is currently on and put it in writing so they can look at it. I used a Microsoft Excel spreadsheet see the example below (Note: It looks funny because it was reformatted to .JPG). Note mine shows the amount of free water. At the appointment you can ask the dietitian to help you estimate the amount of free water and adjust as needed. Here is a flyer from Seattle Children's Hospital that might help.

Please keep in mind this example was Ainsley's formula at one time, years ago. Kids grow, we adapted her blenderized formula accordingly over time. The purpose of showing this is not for you to use it as your recipe but is so you can see how to organize the information that the doctors and dietitians will want to see: i.e. ingredients, free water content, calories, protein and fat.

* Note: After hearing from a reader who tried this recipe and found it to be different I want to point out I provided it to show the spreadsheet, not to recommend this recipe. When I cook I don't measure and I didn't use a measuring cup when making Ainsley's formula. 

• the bread I use is the rectangular size and dense, so if you square bread would an extra half piece
• the apple sauce is a heaping 1/3c, so more like 1/2 c
• same with the vegetables, so more like a full cup
• bananas vary in size, we use about 1/2 of a large banana

The blender would appear full of food to the 4c mark. And I only add milk at the end to make it pureeable. More or less liquid is needed depending on the water content of the cooked veggies. As noted on the spreadsheet she would get 4oz additional milk with each feeding with a small water flush.

Over the years we varied our recipes and methods as my confidence grew. I pureed ALL kinds of foods over the years. When Ainsley progressed with eating skills her "Blenderized Formula" was a puree of what she didn't finish at the table at each meal. Usually this was during the summer when I had more time to devote to our pursuit of eating skills. We adapted to whatever was best for our family situation at the time.

Nutrition

Dietitians and doctors all agree that when real food is "an option" it is nutritionally superior to canned formula.  I cannot imagine how I would feel if I survived off cans of Ensure. Surely I wouldn't experience better health because it is "nutritionally optimal" compared to actual food. This was the main motivation behind why I went to the extra trouble, there is just no way any canned formula is as good as the real thing. In the beginning an additional motivator was that I hoped a BD would control GERD. It did to an extent and Ainsley went from vomiting several times a day to no vomit, just retching. Several months later we discovered that she still had severe airway swelling from silent reflux despite PPI's (?). Concerned about lung damage due to potential aspiration of stomach content we decided on a Nissen Fundoplication(?) and afterward reflux was no longer an issue needing control with a BD but we kept with it. Why? Because I wanted better nutrition and more natural "food" for Ainsley.

The main "food" ingredients in canned formula taken right off the label are: water, corn malodextrin (ie. corn starch), milk protein concentrate (ie. whey powder), sugar, high oleic safflower oil, soy oil, medium chain diglycerides(?), and vitamins.  With those ingredients canned formula may be adequate but how can it possibly be optimal or even good? I don't say this to make anyone angry or feel guilty if a blenderized formula doesn't work for them but because I believe this so firmly that I feel I must speak up. I personally believe that switching to a Blenderized Diet is likely one of the single most important things a tube fed persona can do to improve their health.

That being said, canned formula has benefits. It's consistent in calories and nutrients and it's food-safe. Mostly it's convenient. Over the years we sometimes used canned formula for those reasons.  If I was going to be somewhere without adequate refrigeration, if ran out of ingredients for the formula and couldn't get to the store, if Ainsley was in the hospital for a surgery, if something happened and I didn't have time, or even if I just didn't have the energy one day.  Later on when she was eating orally we would sometimes use formula, knowing that the majority of her calories came from actual food she ate.

Some people like to vary the ingredients in their blenderized formula for superior nutrition. We all know that eating a variety of healthy foods is best. I think that's a great end goal. Later on after I became more confident and knowledgeable about how particular food pureed would change some of the ingredients for variety, I might include leftovers, or even whatever Ainsley didn't finish at dinner. You name it we pureed it: Thanksgiving dinner, curried tofu, birthday cake, salmon, salad, even left over McDonalds. But in the beginning I started out I found it was easier to make a consistent recipe. The way I looked at it was that getting the same fruits and vegetables every day is still better than getting the same canned formula.  The beauty of a blenderized formula is that you can tailor the ingredients and method to match your own philosophies about nutrition.

Make It Easy

There are as many ways to make a blenderized formula as there are ways to eat. Do you love to cook complex dishes from scratch for your children? If so my method may not be for you. I have read about families that make a blenderized formula using kefir they made from their own goats' milk! (No kidding, pun intended!) Some parents blend each meal separately. While that is great, and if you have the energy to blend three times a day and want to, then why not?! But my mission is to explain how to make it easy for those who might not otherwise have the confidence to try.  Life with a child with medical issues is hard enough. While making your own formula is a bit of extra work compared with popping a can my goal was and is to show people how to make their own formula with the least amount of effort knowing that the majority of us do not want to raise our own goats or anything close to that.

Methods

I have tried different methods of making a blenderized diet.

• Using baby foods and a stick blender
• Using a baby foods and a regular blender
• Using whole foods with a high speed blender

Blenderized Formula Using A Regular Blender

A regular blender is NOT the same as a HIGH SPEED blender such as a Vitamix or Blendtec. No matter how many times I heard that I could not get that through my thick head. A Cuisinart or KitchenAid are fine normal blenders but it's like comparing a Ford to a Ferarri. Not the same.

You can however, use a regular home blender if you are using finely pureed baby foods as your ingredients because the blender then doesn't have to be capable of pureeing whole foods. This method is not as easy as using a high-speed blender but is a good way to get started without a large cash investment. This is the way I started because I wasn't sure if I would like making my own formula.

Blenderized Formula Using A Stick Blender

I don't like to clean blenders. So while I was using the baby food ingredients I used a stick blender. It was easier to clean, I could see the formula very easily and be sure it was well blended and it's an inexpensive tool. I used a Braun that I got from a Christmas gift exchange, I think it cost about $20 (it didn't come with all those attachments). A stick blender is portable. I took it with me on our trip to Disneyland. I did get a little grief from airport security (even though it was packed in luggage) but it made it through and was a lot easier than packing a blender. Again, this method is a great way to get started and see if making a blenderized diet is for you before going to the next level. Here is a video showing me preparing a blenderized formula using a stick blender.

Blenderized Formula Using a High Speed Blender

If you don't intend to puree your own foods then there really is no need for a high speed blender but if you are it is a requirement. Many people swear by a Vitamix (link here). They have been around forever and last. I believe they've come down in price and if you are using them for tube feeding the company offers a discount on refurbished units. At the time they were about $800 so when Costco had a demo of the Blendtec blender(link here) and I saw it in action I was impressed and bought one knowing I could return it if it didn't work out. It cost about $400, so half the price. I am someone who generally prefers to buy the best. I'd heard so many times that that Vitamix was the best and you had to have one. I was expecting to return the Blendtec but I didn't and I think that speaks for itself.  I haven't actually used a Vitamix so I can't say for sure, but there has been nothing I wanted to do with my Blendtec that I was unable to. I actually preferred the look of the Blendtec and the fact that it was shorter and thus able to slide under the kitchen cabinets. Saving some $$$ was great too. I think either blender is a good choice.

Here is a video showing how to make formula using our high speed blender.

Shortcuts

Over the past year or so I've learned a few shortcuts that I will share with you.

The first is how I prep the bananas. Since I only use a half a banana in the recipe I find using frozen bananas works best. People are often surprised to hear you can freeze bananas. You can. In fact they are great to have on hand for making smoothies. Here's how.

The second tip is simply making a mixture of cooked vegetables to use as an ingredient in your blenderized formula. I often add a little sea salt to them but I didn't do that in this video.

The third is to have an easy source of protein available. I found Trader Joe's sells pre-cooked chicken breast that is very convenient. I have also used ground turkey or chicken and even ground lamb or beef which I simply simmer in a small quantity of water in a pot and kept in a container in the refrigerator. In the end it cost about the same as the "Just Chicken" and since it has no additives or preservatives I figure I may as well make it easy on myself and buy it ready made.

Fresh vs. Frozen

Many people think fresh vegetables are more nutritious than frozen. In reality vegetables that are immediately frozen can be more nutritious than fresh vegetables that have been shipped here and there and were sitting in your frig for awhile. The advantage of frozen is that you can always have the vegetables you need on hand and it is very easy to calculate calories because the nutritional information is right there on the package and you know exactly how much you are putting into your mix. If you prefer fresh by all means use fresh. With a high speed blender you can even use raw. Personally I love Trader Joe's. They sell frozen organic vegetables that aren't very expensive.  Because they are frozen I always have them ready in the freezer when I need them. The great thing about a Blenderized Diet is that the choice is up to you depending on your philosophies about nutrition.

Organic vs Non-Organic

It's almost not worth saying, but I will since someone will otherwise ask. These days almost everything is available in organic form. Some people swear by the health benefits of an organic diet. (Of course organic foods often taste better and are also better for the environment.) Personally I don't get too hung up about everything having to be organic. I buy organic when it's available, convenient and cost effective. Use as many organic ingredients as you'd like. If your budget doesn't allow for organic food, non-organic is still far better than canned formula. 

 

Substitutions

There may be times that you want to make substitutions in your recipe. As I've already said, the beauty of a blenderized formula is that it can be easily modified. I have found it generally works to substitute similar quantities of similar foods. For example:

• Instead of white bread you may use whole grain bread (though the texture will be slightly different), pasta, rice or potatoes. Even baby rice cereal. You may need to add additional liquid because these other ingredients do not absorb liquid like bread does.
• Instead of chicken breast you may use ground chicken, turkey, ground beef, steak, fish, canned tuna or salmon, pork or lamb. Even beans though they contain far less protein per ounce.
• Instead of the apple sauce and/or bananas you may use raw apple, frozen berries, pineapple, or other fruit, either fresh, frozen or canned.  Keep in mind that fruits vary a lot in their water content and that will affect the thickness of your blend.
• Instead of a precooked vegetable mixture you may want to make your vegetables daily. Or you may prefer to use raw vegetables. On days that I've run out of my precooked mixture I have simply microwaved some baby carrots and frozen veggies with a tablespoon of water and added them hot to my formula. Sometimes I even use raw lettuce. Spaghetti sauce or even tomato paste. The one consideration is to be mindful of the change in fiber content so your mixture doesn't swing radically in its fiber content.
• Instead of 1% cows milk you can substitute whole milk for more fat and calories, or even half and half for quick bulking up. You may also wish to substitute cows milk with rice, almond or soy milk. 
• Instead of orange juice you may prefer to use some other kind of juice, cranberry, apple, a juice cocktail. I've even used boxed pureed soup.

The formula may vary some in thickness but that is okay. If your child has motility issues, you will probably want to stick to a consistent recipe.

Making the Transition

It's best when making a change to do so gradually so the child's digestive system can adjust. No matter the age of your child it is prudent to start slow as you would, say, with a newborn.

When a baby is first introduced to food it is done gradually and systematically. You add one food at a time in very small quantities for 2-3 days and watch carefully for an allergic reaction. I highly recommend you keep notes of what you do. What we did went something like this......We started out with baby rice cereal first since most people are not allergic to rice, using white rice rather than brown rice cereal mainly because brown rice cereal possibly could contain too much fiber for a first food. Kids with tubes are often more sensitive and you don't want to risk upsetting the tummy.  I made sure to blend it well into the formula so it wouldn't clog the tube. Blending it into an entire days worth of formula would be best so there is less of change to the diet. I would then reduce the formula intake for the day by the same number of calories contained in the new food, which was very little at this point. This process takes awhile but is an important step.

Then we made a recipe of pureed baby foods based on a handout from our hospital(available here). We were able to calculate the amount of calories for a serving and then reduced the canned formula by the same number of calories. We then mixed the formula together so that the new formula is diluted in the normal formula. Of course once open the formula must be refrigerated. If all went well for a day or two then we did the same process increasing the blenderized formula to two servings spread throughout the days feedings. Then 3 and 4 until we'd completely switched over.

Once Ainsley was on a blenderized formula we started modifying the ingredients. When I got the high-speed blender I started adding leftovers like London Broil, curried tofu, salmon, whatever I had on hand. At various times I included blueberries, tomato paste, turmeric (considered an anti-inflammatory), even garlic and spices.  How does all this taste? (Yes I always tasted it). Well it depends on the ingredients. Kids do burp up the taste of their food so I wanted it to taste okay. The recipe that I eventually settled upon reminds be a bit of an Orange Julius, fruity but with a twist. Not that I'd want to drink one by mouth.  I know mom's from my trach support group who would blend up breakfast, lunch and dinner separately for their kids, even letting their child pick some of the foods (this is a great idea for a child that is able to eat some orally). Later on when Ainsley progressed to some oral eating we tried this, hoping the blends would be more palatable when the meals were mixed one at a time. So you can go that route too if you can't get past the idea of  the "taste" of mixing all those foods together.

Getting It In

Once you've made the formula you have to get it in through the g-tube. Ainsley's g-tube was an 18fr. We always use a bolus tube extension set because they are wider. Many people use feeding pumps. We wanted to be technology free and worked our way toward bolus gravity feedings early on, even before going to a blenderized diet. I haven't used a feeding pump to feed a blenderized diet. We made our recipe thick on purpose to make it easier to bolus feed, but Ainsley received milk and water in addition to the blend. If I were to want to use a feeding pump I would combine it all together at the end. The blenderized formula is very fine so I would not anticipate a problem unless there was settling of the heavier molecules. As with any food, make sure you are conscious of food safety and do not leave the formula out for long periods of time. (I wouldn't hang a bag overnight.)

Here is an older video of me giving Ainsley a bolus tube feeding just to give you an idea of how did a feeding.

What About Clogs?

No not the type you wear in Holland. Bits of food stuck in the tube. People have asked me about this. In the beginning we had a couple times when a whole raw carrot didn't get blended well enough and got stuck in the extension (never the g-tube). I simply stopped the feeding, disconnected the extension set and blew the food out of it and then removed the bit of carrot and restarted the feeding. Since then I've discovered that if the mixture is fairly thick during the initial blend you get a much finer puree. Then I add liquid at the end to get the formula to the consistency I want. I since haven't had any clogs.

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As I've already said, the beauty of a Blenderized Diet is that with the help of your doctor and/or dietitian you can create a formula and feeding method that is perfect for your child and you. Unfortunately I cannot advise you of how to do that beyond the information I've provided here, which I hope has been helpful.

In addition you may find it helpful to join the Yahoo Blenderized Diet Support Group (link here) where you can talk to other people who are using this feeding method.

I wish you the best of luck!