Effect of Added Free Water to Enteral Tube Feeds in Children Receiving Commercial Blends

Abstract

Objectives:To determine the impact of free water administration on clinical outcomes in medically complex patients, based on the hypothesis that patients receiving more thin liquids have worse outcomes related to increased risk of gastroesophageal reflux.Methods:This was a retrospective chart review of children initiated on commercial blenderized tube feedings from 2010 to 2019. The percentage of gastrostomy intake that was a thin liquid was determined, with thin liquids including free water or thin formula based on the International Dysphagia Diet Standardization Initiative (IDDSI) framework. Patients were categorized into those receiving low volumes of thin liquids (“percent thin” ≤20%) and those receiving higher volumes (“percent thin” >20%). Emergency room visits, hospital admissions, and chest X-rays during the year after starting the blend were compared.Results:Forty-five patients age 12 months to 18.7 years (median 3.7 years) were included. Twenty patients (44%) were receiving a blend with an IDDSI-categorized thin consistency and 25 patients (56%) were receiving a thicker blend. In addition to the blend, patients received a median of 320 mL per day of water (range 0–1000 mL). Patients receiving <20% thin liquids were less likely to undergo chest X-rays during follow-up than patients receiving larger amounts of thin liquids (10% in the minimal thin group versus 48% in the greater thin group, P = 0.03). In a multivariable logistic regression, this relationship remained significant after controlling for underlying pulmonary disease, aspiration, method of feed administration (bolus or continuous feeds), fundoplication status, and oral intake status.Conclusions:Our study demonstrates that patients on blenderized tube feeds receive widely variable amounts of added thin liquids, like water. The addition of water to tube feeds, while typically given for hydration, can modify feed viscosity and clinical outcomes, such as chest X-ray performance.

Gastrointestinal factors associated with risk of bronchiectasis in children

“…Prior studies have also shown increased pulmonary risk associated with enteral tubes, including hospitalization risk and increase in gastroesophageal reflux, which might suggest mechanisms by which bronchiectasis might occur 43,44 . Subjects in this study had enteral tubes placed for a variety of clinical indications, but given these ongoing risks, it is important to take advantage of more recent developments in blenderized tube feeding, the use of motility medications and, when necessary, transpyloric feeding status 45,46 . We cannot determine any causal relationship between enteral tubes and bronchiectasis with our retrospective study design and all decisions about safe feeding approaches must be made in the appropriate clinical context, but our findings do highlight the importance of GI involvement in the diagnosis and management of bronchiectasis in children.…”

Stir, Shake or Blend: A Comparison of Methods Used to Reduce Viscosity of Blenderized Tube Feedings

“…The viscosity of BTFs is a characteristic that makes this class of formulas unique as compared to conventional enteral formulas. Clear guidelines regarding thinning practices do not exist, and current practice is noted to include wide variations in the administration of additional water when BTFs are used (14). Furthermore, research investigating the use of BTFs and administration using ENFit connectors has indicated that there is a required increase in force needed to administer bolus feedings in 14 French (Fr) size gastrostomy tubes as compared to Legacy connectors (15).…”

“…Undiluted BTFs can be administered through an enteral feeding device, however, additional liquid may be added to the BTF through stirring, shaking, or blenderizing to promote improved flow (5,10,12,13). Of note, there are wide variations in practice and no formal guidelines to support the quantity of liquid and/or the method of mixing (blend, stir, shake) that should be followed when thinning feeds (14). Variation in practices could lead to excess thinning, thereby jeopardizing the clinical benefits related to the thicker viscosity.…”

Pediatric Aerodigestive Medicine: Advancing Collaborative Care for Children With Oropharyngeal Dysphagia

“…Viscosity, caloric content, and macro/micronutrient provision vary across home‐blended recipes and commercial blends; hence optimal application of different blends may vary. Adding free water can markedly decrease blend viscosity, decreasing the beneficial effect of thickening (47). Providing blenderized feeds requires active collaboration and monitoring between teams and families.…”