Whole food tube feed is safe. This is what the research says!

Over the past 10 years, there has been a major development in the research field when it comes to whole-food based, homemade tube feed. Research studies have been driven by carers of people who receive food through gastrostomy tubes, because it is the carers who want their loved ones to enjoy food that provide good health without tolerance challenges.

 

As early as 2015, Hurt et al (1) conducted a study of adult gastrostomy users in the US, which showed that when using whole-food based, homemade tube feeding, patients maintained body weight, had significantly less nausea, vomiting, discomfort, diarrhea and constipation compared to conventional tube feeding (n = 54, 22-87 years), and in 2019, Hron et al (2) found that whole-food based, homemade tube feeding also reduced nausea and vomiting, pain and diarrhea compared to conventional tube feeding in a pediatric population in the US (n = 70 1-18 years), and the reduction in symptoms was significant.

 

In 2018, Gallagher et al (3) showed that initiating and maintaining whole-food based, homemade tube feeding is not only feasible in a medically complex pediatric population of chronically ill children, but may also be associated with improved clinical outcomes and increased gut bacterial diversity. Twenty pediatric participants were included. Participants were dependent on gastrostomy feeding and received ≥75% of their daily energy needs from conventional tube feeding. Over the course of 4 weeks, participants were transitioned from conventional tube feeding to whole-food based homemade tube feeding and were monitored for 6 months for changes in nutrient intake, gastrointestinal symptoms, oral food intake, medication use and caregiver perceptions. Changes in gut microbiota were monitored by 16S rDNA-based sequencing, showing an increase in gut biotic diversity with whole-food based homemade tube feed.  The micronutrient content was also superior to conventional tube feed formulas. The prevalence of vomiting and the use of acid suppressants decreased significantly on whole-food based homemade tube feed. Carers were more satisfied with whole-food homemade tube feed and unanimously indicated that they would recommend it.

 

The idea that regular food is dangerous or insufficient is outdated.

From 2022, research has increased further. More and more people have realized the benefits of whole-food based home cooking and moved away from the idea that regular food is dangerous or insufficient. Bakewell (4) sums it up nicely in the introduction to his article in 2023: "The decision to start blending home-cooked food for gastrostomy-fed children can feel controversial. Blending homemade food for administration through a gastrostomy tube, while logical in many ways, has been limited by a lack of food safety and efficacy data compared to decades of experience for better or worse with conventional tube solutions. As a result, professionals have stopped recommending blended food for routine use, even as they encourage healthcare professionals to support homemade tube feeding. Despite this, we are seeing an increasing number of families now choosing to feed their tube-fed children homemade food, and standardized support may not be available to all."

Bakewell therefore praises the YourTube study by Lorna et al (5), a prospective, multi-centre cohort study of 180 gastrostomy-fed children in the UK (104 people on home-cooked food and 76 people on sterile conventional feeding tubes at baseline) and says this has provided evidence on the food safety and efficacy of home-cooked food.

 

The biggest proof is already in the pudding - homemade food shows reduced symptom burden that persists over time

In the Your-tube study, Lorna et al found that children receiving whole food tube feed have a good food safety profile, adequate nutritional intake and a lower burden of gastrointestinal symptoms than children fed conventional tube feeding. Lorna also found that the nutritional intake of those on homemade tube feeds had higher intake of calories per kilogram, and a greater intake of fibre. They also showed that both homemade and conventionally tube-fed children have values above the dietary reference values for most micronutrients.

The most important finding, however, was that their results confirmed that homemade tube feed was associated with a significantly improved quality of life shown by the Gastrointestinal Symptom Score. This showed a lower symptom burden, and the improvement was seen at baseline, 12- and 18-month follow-up. The improvements shown by Lorna's baseline data, which was maintained at follow-up, reported significantly fewer symptoms of abdominal pain, constipation, diarrhea, bloating, vomiting and acid reflux in children who received home-cooked food. There was no difference between those who were followed up for 12 and 18 months, i.e. the improvement in symptoms persisted throughout the period.

 

Whole-food tube feed has been a valid dietary treatment since 2017 - now healthcare personell must step up and support their patients.

To stay up to date, healthcare professionals often rely on major review articles to keep them up to date in their practice. Some might be curious if any major review articles have been published in recent years, and we can assure that many see the need for this. Phillips et al (6), in 2023, pointed out that research on homemade tube feed is a valid alternative to conventional tube feed for children and young people, and that this was published as early as 2017 (7).

At the same time, Philips recognized that an update was needed to ensure that healthcare professionals were informed of the latest evidence, which has expanded significantly since the publication of the original article. As homemade tube feeding is a good alternative to the exclusive use of conventional tube feeding and increasingly used, Phillips says there is evidence to support the benefits of using homemade food for the child or young person and their family, and they wanted to look at this. They therefore included 29 articles and four themes were identified from the data collected: (a) symptom improvement and clinical outcomes, (b) nutritional content, (c) carer experiences and (d) homemade dietary practices. Findings showed that homemade tube feed can have a positive impact on physical symptoms as well as social influences extending to families and carers. The conclusion was positive: Nutritional content, food hygiene, and viscosity of homemade tube feeds are important considerations for professionals and families to ensure safe practices when using homemade tube feeds for enteral feeding. In addition, this article provides further evidence of the positive impact of homemade tube feeding on gastrointestinal symptoms and major benefits such as reduced respiratory infections and fewer hospitalizations.

 

Families report needing reassurance and support from healthcare professionals that regular homemade tube feed is good enough, so they can achieve reduced need for medication and hospitalization

In addition to showing that the symptom burden of homemade food is lower than that of conventional tube feed, Phillips adds more in their study, and adds the following knowledge to the field: Families report a lack of support and commitment from professionals to use homemade food in the feeding tube. And until recently, homemade tube feeding had been met with caution by healthcare professionals with concerns over nutritional inadequacy, clogging of feeding equipment and food borne infection. However, such side effects occur less frequently than expected and can also occur with the use of conventional tube feeding, suggesting neither is method superior. So it's useful to consider the other benefits highlighted in this article, namely that homemade tube feeding has shown positive effects on symptoms such as reflux and diarrhea, reduces the need for gastrointestinal medication and reduces admissions to acute medical wards.

 

So, what can we say about the use of homemade tube feeding so far?

Research is always looking for more research to be able to say anything for sure, and since 2015 we have seen many studies pointing more and more in the direction of healthy people who can tolerate food in their stomachs being able to safely use homemade food in their feeding tubes. And if we think logically about the use of whole-food based tube feed and compare it with food that people who can chew and swallow eat themselves, it's not difficult to understand that regular food is obviously preferable to a lifetime of maltodextrin, protein powder, oil and a vitamin and mineral supplements every day.

But we need healthcare professionals to reassure and help families struggling with tolerance issues from conventional enteral formulas, to make the transition to homemade tube feed easily and safe, and that we certainly don't put a spanner in the works because of our own fears about whether regular food is safe and healthy!

Normal hygiene measures apply both in your kitchen and mine, as with a person consuming food through a feeding syringe - but be careful not to confuse normal food hygiene with the fact that home-made food is unsafe or less good than commercial feeding tube formulas that do not provide variation in the diet and can lead to major tolerance problems in a vulnerable group.

If healthcare professionals can help people live with less nausea, vomiting, discomfort, diarrhea and constipation compared to conventional tube feeding, they should absolutely help people in need of changing the diet.

 

Dietary guidelines are crystal clear - a varied, whole food-based diet is best - this also applies to people who eat in a slightly different way.

Several European countries, such as Denmark and Norway, have recently published dietary guidelines that applies for their population (9, 10). Both countries health authorities state the importance of a plant based and varied diet to function well here and now, but also to stay healthy and prevent chronic disease, and the Norwegian guidelines explain «It is not one food group that is the solution to a healthy diet, it is how we put the food together and variety in what we eat». The advises are in line with Worlds Health organizations dietary advise, namely eat varied food from all the food groups, and eat whole-food based most of the time (11). The Norwegian dietary guideline also add a different perspective to their advice, namely «Eat with joy», and explained that «it is important to remember that food and meals are about more than nutrients and calories. It's about taking time for a meal and enjoying the meal. Food is identity, culture, tradition and joy.  Moreover, social mealtime together is important for eating. Especially for children, it can mean a lot that you get together for a meal together and set aside enough time to eat». It is safe to say that there is a lot more joy from a delicious homemade food and the smell of whole food tube feed rather than a bottle of conventional tube feed being served with tolerance issues as main company. We therefore praise the researchers that confirms that taking back regular whole food to the table is a safe and good option, and we are happy to say; Dinner is served! 

 

References:

(1) Hurt et al. 2015 Blenderised tube feeding use in adults home enteral nutrition patients: A cross sectional study. Nutr Clin Pract. 2015 Dec;30(6):824-9. doi: 10.1177/0884533615591602. Epub 2015 Jul 6. Available from: Blenderised Tube Feeding Use in Adult Home Enteral Nutrition Patients: A Cross-Sectional Study - PubMed (nih.gov)  

(2) Hron et al. 2019 Health outcomes and quality of life indices of children receiving blenderised feeds via enteral tube. J Pediatr 2019 Aug:211:139-145.e1. doi: 10.1016/j.jpeds.2019.04.023. Epub 2019 May 23. Available from: Health Outcomes and Quality of Life Indices of Children Receiving Blenderised Feeds via Enteral Tube - PubMed(nih.gov)  

(3) Gallagher et al. 2018 Blenderised Enteral Nutrition Diet Study: Feasibility, Clinical, and Microbiome Outcomes of Providing Blenderised Feeds Through a Gastric Tube in a Medically Complex Pediatric Population. JPEN J Parenter Enteral Nutr. 2018 Aug;42(6):1046-1060. doi: 10.1002/jpen.1049. Epub 2018 Jan 16. Available from: Blenderised Enteral Nutrition Diet Study: Feasibility, Clinical, and Microbiome Outcomes of Providing Blenderised Feeds Through a Gastric Tube in a Medically Complex Pediatric Population

(4) Bakewell C et al. 2023 Advancing the conversation around blended diets for gastrostomy-fed children, Archives of Disease in Childhood 2024;109:605-606. Available from: Advancing the conversation around blended diets for gastrostomy-fed children

(5) Lorna K et al. 2023 Safety, resource use and nutritional content of home-blended diets in children who are gastrostomy fed: Findings from 'YourTube' - a prospective cohort study Archives of Disease in Childhood 2023; 109 628-635 Available from: Findings from 'YourTube' - a prospective cohort study Archives of Disease in Childhood 2023

(6) Phillips G et al. 2023 Blended diets for tube-fed children and young people; a rapid review update.Arch Dis Child 2023;108:1014-1018. Available from: Blended diets for tube-fed children and young people; a rapid review

(7) Coad J et al. 2017 Blended Foods for tube-fed children: a safe and realistic option? A rapid review of the evidence. Arch Dis Child 2017;102:274-8. Available from: Blended Foods for tube-fed children: a safe and realistic option? A rapid review of the evidence.

(9) Helsedirektoratet, Norwegian Directorate of Health. Dietary guidelines 2024 Oslo: Norwegian Directorate of Health; updated Thursday 15 August 2024. Available from: Kostrådene - Helsedirektoratet

(10) Fødevarestyrelsen, The official dietary guidelines, 2022, Denmark  https://foedevarestyrelsen.dk/kost-og-foedevarer/alt-om-mad/de-officielle-kostraad/kostraad-til-dig

(11) World Health Organization (WHO) 2020, Factsheet Healthy diet- https://www.who.int/news-room/fact-sheets/detail/healthy-diet