USE OF HOMEMADE BLENDERIZED FORMULA IN GASTROSTOMY TUBE DEPENDENT PEDIATRIC PATIENTS WITH FEEDING INTOLERANCE: A RETROSPECTIVE ANALYSIS A Thesis Presented in Partial Fulfillment of the Requirements for the Degree Master of Science in the Graduate School of The Ohio State University By Ashley Lynn Bronston, B.S. Graduate Program in Allied Medical Professions The Ohio State University 2016 Master’s Examination Committee: Dr. Marcia Nahikian-Nelms, Advisor Dr. Wendelin Burdo-Hartman Dr. Colleen Spees Dr. Jill Clutter i Copyright by Ashley Lynn Bronston, B.S. 2016 ii Abstract BACKGROUND: The use of blenderized foods for tube feedings is becoming more popular in response to exploring alternative options to commercial formulas.1 Such formulations have been documented to improve gastrointestinal symptoms, including gagging and retching.2,3 However, research that demonstrates the safety and efficacy of homemade blenderized formulas (HBF) is limited with regard to nutritional adequacy, weight maintenance, quality of life and gastrointestinal (GI) symptom alleviation. METHODS: This study was a retrospective chart review. Patients were identified from a pilot study conducted in 2014-15. Data extracted for each patient included demographic characteristics, diagnoses, anthropometric measurements, an initial commercial formula prescription, a dietitian supervised transition plan, 5-day dietary histories of homemade blenderized recipes, scores from the Pediatric Quality of Life Inventory questionnaires (Gastrointestinal Symptoms Module), and notes derived from the caregiver interviews. Nutritional adequacy was assessed using the Nutrition Data System for Research (NDSR) to assess formula volume, energy, macronutrients, and micronutrients.4 The nutritional adequacy of each HBF recipe was evaluated by comparing HBF delivery of energy and 27 key nutrients (including fiber) to the participant’s dietary recommendations, based on age and gender. Weight was monitored and compared throughout study visits using the ii Cerebral Palsy Gross Motor Function Classification System (CP GMFCS) Level 5-Tube Fed Growth Charts. The presence or absence of gastrointestinal symptoms was documented at each outpatient visit. Finally, health related quality of life was evaluated using the Pediatric Quality of Life Inventory (PEDsQL) – Gastrointestinal Symptoms Module. INCLUSION CRITERIA: Four youth, between the ages of 2 and 18 years, diagnosed with a neurodevelopmental disability, were on enteral feeding via gastrostomy tube > 3 months, and identified with persistent GI symptoms. RESULTS: Subjects presented with a mean of 3.5 GI symptoms. All subjects reported some degree of symptom alleviation during the intervention and post intervention, 75% of GI symptoms were resolved. The mean weight loss was 2.53 pounds + 4.14. On average, caregivers answered only 5 of the 14 domains on the PEDsQL due to the subjective nature of some questions. HBF was superior in the provision of nutrients for Subjects 1 and 2. In Subject 3, commercial formula was identified as the more nutritionally adequate formula, but only by two nutrients. The commercial formula and HBF in subject 4 was nutritionally comparable, with both delivering 20 nutrients according to their clinical recommendations. CONCLUSIONS: HBF alleviated most GI symptoms for the subjects in this study, especially symptoms related to diarrhea, retching and vomiting. Weight and nutrient intake must be closely monitored for potential variability. Inferences cannot be drawn from the PEDsQL for quality of life due to the high percentage of incomplete questions iii by caregivers. Homemade blenderized formula may be nutritionally comparable to commercial formula prescriptions, but require close monitoring and intervention by a Registered Dietitian Nutritionist (RDN). iv Acknowledgments To my hard working mentor, Dr. Marcia Nahikian-Nelms: You inspire me day in and day out with your tireless efforts, clinical expertise, kind demeanor, and priceless knowledge. I will be forever grateful that our lives crossed paths. A big thanks to my Nationwide Children’s Hospital cheerleaders: Carol Williams and Wendelin Burdo- Hartman. Both of you have guided me through this experience and have kept me on track. Thank you for supporting me! Also, thank you Dr. Jill Clutter and Dr. Colleen Spees for being a part of this team. To my family, thank you for repeatedly reassuring me that I would graduate on those late night phone calls. This was a hard road, but I would not have done it without your love and support. To my high school friends: you have given me the support I needed, in order to become who I am today. To my Mansfield Field Hockey girls: our years together went by way too quickly. I will never forget the love I felt when we were all crowded in my living room to find out into which program I was accepted. MUFH will always have a piece of my heart. Finally, this experience would not have been the same without my beloved Med Diet family. In two years, most of us went from strangers to best friends. You are what I love most about Columbus. The memories we created here will never be forgotten. I love you all! v Vita May 16, 1992 ................................................ Born – Princeton, New Jersey June 2010 ...................................................... Bordentown Regional High School May 2014 ...................................................... B.S. Dietetics & Sports Nutrition, Mansfield University May 2016 ...................................................... Combined MS/DI Program in Medical Dietetics, The Ohio State University Field of Study Major Field: Allied Medicine vi Table of Contents Abstract ............................................................................................................................... ii Acknowledgments ............................................................................................................... v Vita ..................................................................................................................................... vi List of Figures ................................................................................................................... xii Chapter 1: Introduction ....................................................................................................... 1 Background and Significance of the Problem ................................................................ 1 Problem Statement .......................................................................................................... 2 Purpose of Study ............................................................................................................. 2 Research Objective ......................................................................................................... 3 Research Questions ......................................................................................................... 3 Chapter 2: Literature Review .............................................................................................. 8 Introduction ..................................................................................................................... 8 Prevalence of Undernutrition in Developmental Disabilities ......................................... 9 Enteral Nutrition ........................................................................................................... 12 Commercial Formulas ................................................................................................... 15 Homemade Blenderized Formulas (HBF) .................................................................... 19 Commercial Whole Food Formulas .............................................................................. 27 Liquid Hope™ .......................................................................................................... 27 Real Food Blends™ .................................................................................................. 28 Compleat Pediatric® ................................................................................................. 29 Pediatric Nutrient Requirements ................................................................................... 30 Cerebral Palsy Specific Nutrition Needs ...................................................................... 34 Conclusion .................................................................................................................... 35 Chapter 3: Methodology ................................................................................................... 36 vii Research Design ............................................................................................................ 36 Research Questions ....................................................................................................... 37 Participant Selection ..................................................................................................... 38 Eligibility ...................................................................................................................... 39 Instruments .................................................................................................................... 39 Data Collection ............................................................................................................. 42 Data Analysis ................................................................................................................ 44