Nutritional Adequacy of Commercially Available Blenderized Tube Feeds in Pediatric Patients

Abstract

Commercial blenderized formula for children dependent on feeding tubes is becoming increasingly popular. We aimed to determine if these formula provide complete nutrition for children. We compared the nutrient composition of popular commercial blenderized tube feeds to the Dietary Reference Intake (DRI) for age. We analyzed 3 brands: Compleat Pediatric, Real Food Blends, and Nourish. For children consuming a standard volume, all blenderized tube feeds met macronutrient requirements. None met all the fiber and micronutrient requirements with important deficiencies in vitamin D, calcium, B vitamins, and iron. Deficiencies were common in nonfortified feeds like Real Food Blends. There were micronutrients above the tolerable upper limits, especially in young children, in fortified feeds like Compleat and Nourish. No currently available commercial blenderized tube feeds provide complete nutrition for children compared to DRI for age. Physicians should be aware of possible deficiencies and/or toxicities associated with their long-term use.

Keywords

gastrostomy tube feeds pediatric nutrition blenderized diets enteral nutrition

Introduction

Globally, more than 3 million people receive tube feedings per year. Blenderized diets for children dependent on feeding tubes are becoming increasingly popular.¹ and there has been a surge in the development of commercial blenderized tube feeding (CBTF) products in the last 5 to 10 years. Caregivers desire whole-food alternatives to milk-based products.² Furthermore, blenderized diets may improve gastrointestinal conditions that are common in tube-fed children including constipation, gastrointestinal reflux and vomiting.^2,3 However, safe preparation and storage of homemade blenderized diet can be difficult and these diets can be expensive and time-consuming.⁴ In addition, there are nutritional differences between conventional enteral formulas, which are fortified to provide complete nutrition in children, and blenderized diets and pediatricians should be aware that these formula may not be interchangeable. Furthermore, homemade blenderized tube feedings may lead to nutritional deficiencies and weight loss in patients receiving this type of diet.^5,6 Commercial blenderized tube feedings (CBTF) are a convenient alternative to homemade preparations. Several CBTF are marketed for use in children 1 to 18 years old who have special nutritional needs to support healthy growth.⁷ As more patients use CBTF, physicians should be informed of these formulas, their benefits, and limitations at different stages of growth and development.

Literature on CBTF is sparse and physicians report receiving inadequate training to provide dietary advice to patients,⁸ especially those with special needs like tube-fed children. Dieticians report concerns over nutritional adequacy when prescribing CBTF to children.⁹ Moreover, there are limited dieticians to provide advice and monitoring in community practice.¹⁰ The range of CBTF available adds to prescriber and caregiver confusion when using these formulas. Therefore, we aimed to determine if common CBTF provide complete nutrition for pediatric patients and thus provide a resource for physicians and dieticians prescribing these formulas.

Methods

We conducted an observational study on the nutritional composition of commonly used CBTF. We included 3 popular brands of CBTF with 10 varieties Compleat Pediatric Organic Blends (Nestle HealthCare Nutrition, Inc, Bridgewater, New Jersey)—plant-based and chicken, Real Food Blends (Real Foods Blends, Nutricia, White Plains, New York)—turkey, salmon, quinoa, beef, egg, and chicken, and Nourish (Functional Formularies, Nutritional Medicinals, LLC, West Chester, Ohio)—original and peptide. Each formula’s nutritional composition was collected from the manufacturers’ product guide and verified with manufacturers’ nutritional representatives.^11-13

We analyzed each product’s nutritional content compared to the Dietary Reference Intakes (DRIs), where available. The DRIs are developed by the Institute of Medicine (IOM) and comprise 4 main categories: Estimated Average Requirements (EAR), Recommended Dietary Allowance (RDA), Adequate Intake (AI), and Tolerable Upper Limit (UL).^14,15

CBTF provides a caloric concentration from 1.1 to 1.5 kcal/mL. We compared standard volumes of CBTF using 1 liter for 1- to 8-year-olds, 1.2 liters for 9- to 13-year-olds and 1.5 liters for 14- to 18-year-olds.¹⁶ Nutrient content of each CBTF including energy, carbohydrates, protein, fat, fiber, 13 vitamins, and 12 minerals were recorded for the desired volume and caloric intake for age. Per US Dietary requirement, fiber calculations were based on 14 g/1000 kcal. Nutrient content was expressed as a percentage of the DRI and those less than 100% of DRI were deemed to not meet requirements for age and those above 100% of the UL were deemed to be in excess.

This study was determined institutional review board exempt at University of Miami.

Results

All CBTF met the DRI for fats, protein, and caloric needs for age. Each formula had inadequacies expressed as a percentage of the DRI met. Several micronutrients were also above the UL. There was no information on B7, chloride, and iodine for Real Food Blends.

Macronutrients

Both the Compleat Pediatric varieties (plant-based and chicken) provided a macronutrient distribution in accordance with the 2020-2025 US Dietary Guidelines, 42% and 44% for carbohydrates, 15% both for protein and 43% and 41% for fats respectively. Nourish originally met the US Dietary Guidelines, with carbohydrates 50%, protein 14% and fat at 36% of calories. Nourish peptide, however, provided macronutrients that varied in distribution from the guidelines: 25% of calories from carbohydrates, 14% of calories from protein, and 61% of calories from fat. Real Food Blends varieties also provided variable macronutrient distribution. Carbohydrate content was below the recommended ranges at 29%-37%. Protein was within range, at 11%-18% of calories. Calories from fat were above the US Dietary Guidelines, ranging from 50% to 57% of calories. Please refer to Table 1 for a summary.

Table 1.

Macronutrient Composition by Percentage of 1.0 L of Commercial Blenderized Formula for Children, Compared to 2020-2025 US Dietary Guidelines.

	Compleat pediatric plant-based	Compleat pediatric chicken	Real food blends turkey	Real food blends salmon	real food blends quinoa	Real food blends chicken	Real food blends beef	Real food blends egg	Nourish original	Nourish peptide	2020-2025 dietary guidelines for macronutrients2-3 years	2020-2025 dietary guidelines for macronutrients4-18 years
% Calories - Carbohydrate	42	44	29	31	37	33	37	32	50	25	45-65	45-65
% Calories—Protein	15	15	18	14	13	16	13	11	14	14	5-20	10-30
% Calories -Fat	43	41	53	55	50	51	50	57	36	61	30-40	25-35

Abbreviation: RFB, Real Food Blends.

Source: Adapted from U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2020-2025 Dietary Guidelines for Americans. 9th Edition. https://www.dietaryguidelines.gov/. Published December 2020. Accessed November 28th, 2023.

Fiber

Compleat Pediatric plant-based only met AI for fiber for 1- to 3-year-olds. Compleat Pediatric chicken did not meet fiber requirements for all ages. For Real Food Blends, salmon, chicken, beef, and egg did not meet fiber requirements for all ages. Real Food Blends turkey only met requirements for 1- to 8-year-olds while quinoa met fiber requirements for all ages. Nourish original and peptide met fiber requirements in all ages.

Micronutrient Comparison

One to Three Years Old (1 L/Day)

Compleat Pediatric plant-based and chicken did not meet the DRI for sodium, potassium, and chloride. Vitamins A, B3, folate, manganese, and zinc were above the UL in both varieties. See table 2 for comparison.

Table 2.

Nutritional Composition of 1.0 L of Commercial Blenderized Tube Feeds for Children Aged 1 to 3 Years, in Units and as % Dietary Reference Intakes (DRI).

Abbreviations: RDA, Recommended Dietary Allowance; TUL, Tolerable Upper Limit; RFB, Real Food Blends; ND, No Data Available.

Legend: Adequate, ,

Both Nourish original and peptide formulas did not meet DRI for potassium and chloride. However, quantities of vitamin A, folate, manganese, and zinc were above the UL. See table 2 for comparison.

Real Food turkey blend was below the DRI for some B vitamins, vitamin D, electrolytes, and iron. There was excess in vitamins A, B3, and zinc. Real Food salmon did not meet the DRI for many vitamins, electrolytes, and iron. However, levels of vitamin B3, manganese, and selenium were above the UL. Real Food quinoa had some B vitamins, vitamin D, electrolytes, and selenium below the DRI, with folate, zinc and manganese levels above UL. Real Food chicken did not meet the DRI for vitamins B12 and D and for electrolytes and iron. Vitamins A, B3, E, and manganese levels were above UL. Real Food beef had vitamin D and electrolytes levels under the DRI with excesses of vitamin B3, manganese, and zinc. Real Food egg did not meet the DRI for many vitamins B, D E and K and for electrolytes. See table 2 for comparison.

Four to Eight Years Old (1 L/Day)

Compleat Pediatric plant-based and chicken did not meet the DRI for electrolytes with vitamin A and folate above the UL. See table 3 for comparison.

Table 3.

Nutritional Composition of 1.0 L of Commercial Blenderized Tube Feeds for Children Aged 4 to 8 Years in Units and as % Dietary Reference Intakes (DRI).

Abbreviations: RDA, Recommended Dietary Allowance; UL, Tolerable Upper Limit; RFB, Real Food Blends; ND, No Data Available.

Legend: Adequate, , .

Nourish original and peptide blends were below the DRI for some B vitamins, electrolytes and selenium, whereas vitamin A and manganese levels exceeded the UL. See table 3 for comparison.

Real Food turkey, beef, and egg did not meet the DRI for some vitamins, electrolytes, and iron. Vitamins A and B3 in the turkey variety and manganese in the beef variety were above the UL. Real Food salmon and chicken both had many vitamins, electrolytes, zinc, and iron under the DRI, while vitamins A and B3 were above the UL. Real Food quinoa did not meet the DRI for some vitamins, electrolytes, and selenium. Manganese levels were in excess of the UL. See table 3 for comparison.

Nine to Thirteen Years Old (1.2 L/Day)

Compleat Pediatric plant-based and chicken did not meet the DRI for electrolytes. No micronutrients rose above the UL for both varieties. See table 4 for comparison.

Table 4.

Nutritional Composition of 1.2 L Commercial Blenderized Tube Feeds for Children Aged 9 to 13 Years in Units and as % Dietary Reference Intakes (DRI).

Abbreviations: RDA, Recommended Dietary Allowance; UL, Tolerable Upper Limit; RFB, Real Food Blends; ND, No Data Available.

Legend: Adequate, , .

Nourish original and peptide had many vitamins, electrolytes, and selenium below the DRI. Nourish original had excess vitamin A. See table 4 for comparison.

Real Food turkey was deficient in some vitamins, many electrolytes, and iron. Excesses were found with vitamins A and B3. Real Food salmon did not meet the DRI for many vitamins, electrolytes, copper, zinc, and iron, with excess in B3 above the UL. Real Food quinoa was deficient in several vitamins, electrolytes, and selenium but sufficient in manganese. Real Food chicken was deficient in vitamins, electrolytes, zinc, and iron. Vitamins A and B3 levels were above the UL. Real Food beef did not meet the DRI for various vitamins and electrolytes. Real Food egg had insufficient levels of many vitamins, electrolytes, and zinc See table 4 for comparison..

Fourteen to Eighteen Years Old (1.5 L/Day)

Compleat Pediatric plant-based did not meet DRI for vitamin B3 and electrolytes, and chicken was deficient in electrolytes. See table 5 for comparison.

Table 5.

Nutritional Composition of 1.5 L of Commercial Blenderized Tube Feeds for Children Aged 14 to 18 Years in Units and as % Dietary Reference Intakes (DRI).

Abbreviations: RDA, Recommended Dietary Allowance; UL, Tolerable Upper Limit; RFB, Real Food Blends; ND, No Data Available.

Legend: Adequate, , .

Nourish original and peptide were both deficient in some B vitamins and potassium. See table 5 for comparison.

Real Food turkey and chicken did not meet DRI for vitamins, electrolytes, zinc, and iron. The turkey and chicken variety contained excess vitamin A and B3, respectively. Real Food salmon had deficiencies in several vitamins, electrolytes, copper, zinc, and iron. Real Food quinoa did not meet DRI for many vitamins, electrolytes, and selenium. Manganese level was above the UL. Real Food beef had various vitamins and electrolytes below the DRI. Finally, Real Food egg did not meet DRI for many vitamins A, electrolytes, and zinc. See table 5 for comparison.

Discussion

We analyzed 3 brands of CBTF made using whole-food products. Some were plant-based and others were made using eggs, meats, or fish. Compleat Pediatric and Nourish contain synthetic micronutrient additives, whereas Real Food Blends is not fortified. No brand met the DRI for all micronutrients with marked variability amongst the 3 brands and among different varieties of each brand.

Compleat Pediatric is marketed for 1- to 13-year-olds but provides almost complete nutrition for 1- to 18-year-olds. Patients using Compleat Pediatric exclusively may be at risk for electrolyte deficiencies. Furthermore, Compleat Pediatric also did not meet daily requirements for fiber in most children. In younger children there were micronutrients above the UL, like vitamins A and B3, folate, manganese, and zinc. Nourish is targeted to children 4 to 8 years old but provides near adequate nutrition for children from 1 to 18 with some deficiencies in potassium, chloride, and B vitamins in some age groups. Notably, Nourish provided excess vitamin A, folate, and manganese above the UL in young children.

Tube-fed children consuming primarily Real Food Blends for prolonged periods would be at highest risk for a deficiency. Real Food Blends’ website does not indicate a target age range, but it does state that Real Food Blends does not provide complete nutrition to children and is meant to complement other feeds. There are several varieties of Real Food Blends that did not meet the DRI for important nutrients like B vitamins, calcium, sodium, vitamin D, iron, and fiber. A registered dietitian or physician trained in nutrition can incorporate Real Food Blends into a nutritionally complete meal plan. Real Food Blends may be an attractive choice for parents seeking all natural blended whole foods without artificial micronutrient additives. Blended whole foods, free of artificial additives, may increase tolerance and improve gastrointestinal symptoms such as gastrointestinal reflux, constipation, and diarrhea.¹⁷ To date, no studies have compared tolerance of different CBTF.

Children are especially vulnerable to micronutrient deficiency states during crucial periods of growth and development. In addition, children reliant on CBTF may have other complex medical conditions and medication regimens that require special attention to micronutrient intake. Insufficient fiber intake can exacerbate constipation,¹⁸ a common complaint in tube-fed children. However, although all CBTF reviewed were fiber-deficient, each had greater fiber content than standard pediatric formulas. Patients exclusively on CBTF with high gastric output, ostomy losses, or diarrhea may be at a higher risk for sodium, potassium, and chloride deficiency. Furthermore, children have increased needs for calcium and vitamin D due to increase in bone mass during periods of growth, and insufficient intake can lead to disorders of bone mineralization.¹⁹ Children with a history of intestinal resection or cholestasis may be vulnerable to the effects of fat-soluble vitamin deficiency. Vitamin A deficiency can lead to night blindness, whereas vitamin E deficiency can result in neurological deficits and vitamin K deficiency can cause bleeding diatheses in already susceptible patients like those with end stage liver disease.²⁰ Iron and folate deficiency cause anemia, but iron deficiency can also lead to long-term sequelae like impaired cognitive development in children.²¹ Thiamine and selenium deficiency both lead to cardiovascular manifestations.^22,23 with potentially devastating neurological complications resulting from severe thiamine deficiency.²³

Children with malabsorptive syndromes with excessive losses or increased demands for micronutrients, and fluid restricted patients consuming less than the recommended daily volume of CBTF are prone to micronutrient deficiencies related to CBTF. Prescriber awareness of these potential deficiencies can avoid deficiency states by appropriately screening and supplementing at-risk patients. Physicians may prescribe supplements or advise mixing different types of CBTF or adding homemade blends to provide balanced nutrition. Where possible, primary care physicians should work with a dietitian or physician nutrition specialist to monitor CBTF-dependent children.

Alternatively, younger children are more vulnerable to toxicity or drug interactions with excessive micronutrient intake in artificially fortified CBTF. The risk of vitamin A toxicity is well described in young children consuming excess vitamin A.²⁴ Vitamin B3 and folate toxicity are rare from enteral intake, however folate intake above the UL can mask vitamin B12 deficiency.²⁵ Furthermore, hepatotoxicity has been reported with excess vitamin B3 from fortified supplements.^26,27 Mn toxicity can occur in patients on excessive doses of parenteral manganese,²⁸ but is uncommon with manganese intake enterally. Excessive enteral zinc consumption can cause copper deficiency in susceptible patients.²⁹

Excess micronutrient intake may also interact with medications,³⁰ altering their absorption.³¹ This is especially important for tube-fed children with other chronic illnesses on a plethora of medications. Fortunately, excess micronutrients are usually excreted in urine or stool and do not cause toxicity.³² Micronutrient intakes at or below the UL can be tolerated for extended periods, but prolonged high intake increases the risk of toxicity. Moreover, pediatric patients consuming CBTF and on micronutrient infusions in parenteral nutrition, such as intestinal failure patients, may receive excessive amounts of vitamins and minerals with a higher risk of adverse effects. To date, there are no studies assessing if excess micronutrients provided in CBTF are associated with clinical toxicity.

This study has limitations. We only reviewed common CBTF at a time when new CBTF are emerging regularly. We relied on manufacturer data and did not consider bioavailability of nutrients in CBTF or distinguish between naturally occurring micronutrients present in food versus nutrient additives. Furthermore, we compared the content of CBTF with DRI which is not without issues when considering daily intake for children at various stages of growth and development and with various chronic diseases. Standard polymeric formulas are nutritionally complete at daily volumes for age as identified by manufacturers. These formulas have more uniformity in ingredients, whereas commercially blenderized formulas have great variability in macronutrients, micronutrients, and functional components. The CBTF products are classified as “medical foods” by the Food and Drug Administration,³³ thus are exempt from labeling requirements and efficacy studies to assess nutrient content.

Our study has several strengths. We reviewed several popular brands to guide physicians when prescribing CBTF. We reviewed several micronutrients for each age group to inform physicians for a wide range of patients, even those with less common medical conditions or on medications that might put them at risk for rare deficiencies or toxicities. For simplicity of comparison for practitioners, we compared DRI to standard volumes, however several factors will influence each child’s exact fluid, caloric and thus micronutrient need. Thus, these results are best used clinically to compare each CBTF to each patient’s daily intake to predict potential deficiency risk over time.

Conclusion

No currently available CBTF provide complete nutrition for children requiring tube feeds when compared with DRI for age. Prescribers should be aware of children at risk for deficiencies and possible toxicities associated with their long-term use. When choosing a nutritionally complete CBTF, fortified formulas like Compleat Pediatric and Nourish brands performed better, with more variability seen with Real Food Blends. CBTF met the DRI for most important macro- and micronutrients for toddlers but there were more frequent deficiencies in adolescents, especially in nonfortified blenderized tube feedings. Especially important were deficiencies in fiber, vitamin D, calcium, folate, and iron. Fortified formulas were more likely to have excess micronutrients above the UL for small children. Further studies assessing serum vitamin and mineral levels and associated signs and symptoms in children on CBTF would increase our knowledge on the safety and efficacy of these formulas in children.

Author Contributions

ACF contributed to conceptualization, methodology, formal analysis, writing—original draft, writing—reviewing and editing, visualization, supervision and project administration. AP and CG contributed to formal analysis, investigation, data curation, visualization and writing—review and editing. All authors approved the final manuscript as submitted and agreed to be accountable for all aspects of the work.

Footnotes

Acknowledgements

The authors thank Olivia Rapson, Rebecca Lake, RD, and Fabiana Caldera Boscan, RD, for their contribution to data collection for the manuscript.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Amanda C. Fifi

Christy Gardner

Aishwarya Palorath

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