For dietitians working through the introduction of blended diet with an individual and their family. The approach depends on how the person is fed now. Part 8 sets out the practice points behind these approaches.
Individuals with limited previous food exposure
For individuals who have been tube-fed since infancy or have had limited exposure to foods, introduce foods gradually before progressing to larger blend volumes. Consider introducing fruit and vegetables, then starchy carbohydrates and then protein foods.
Common food allergens, such as egg, nuts, dairy, fish, wheat and soya, should be introduced in line with national guidance. Once a variety of foods from these groups has been tolerated, progression to the next stage can be considered.
Individuals established on bolus feeding
Step 1: Introduce a small amount of blended diet
- Choose one feed time to start with.
- Replace part of the usual feed with a small volume of blended diet.
- Set the starting volume from your assessment and the person’s feeding history.
- Top up with commercial enteral formula to maintain the usual feed volume.
Example
- Usual feed = 200ml commercial enteral formula
- Blended diet = 50ml
- Commercial enteral formula top-up = 150ml
If there are nutritional or clinical concerns, consider trialling small blend volumes between usual feed times before replacing a bolus feed.
Step 2: Increase the blend volume
- Gradually increase the amount of blended diet at the same feed time.
- Reduce the volume of commercial enteral formula accordingly.
- Continue until the blended diet replaces the full bolus feed volume.
- If new foods are also being introduced, it may be helpful to alternate increases in blend volume with the introduction of additional foods.
- The rate of progression should be guided by tolerance, feeding history, medical complexity and feeding route. Progression may take days to weeks depending on the individual.
Step 3: Replace additional feeds
- Once the first blended meal is well tolerated, replace a second feed with blended diet.
- In most cases, this can be a direct volume swap.
- Continue replacing feeds according to the individual’s goals and nutritional requirements.
Individuals receiving continuous pump feeding
Step 1: Introduce a blended meal
- Aim to provide blended diet during an existing break in the feeding plan.
- If no suitable break exists, adjust the feeding schedule to create one.
- Consider leaving a gap between the blended meal and restarting the pump feed.
- Set the starting volume from your assessment.
- If blended diet contributes significantly to nutritional intake, reduce commercial enteral formula accordingly, preferably by reducing the duration of pump feeding while maintaining the prescribed feeding rate.
- If the blended meal is given during an established feeding break, formula volumes may not need to be reduced immediately.
Step 2: Increase the blend volume
- Gradually increase blended diet volume according to individual tolerance.
- Reduce commercial enteral formula provision accordingly.
- Aim for a meal volume that is tolerated and supports nutritional requirements.
- As above, alternate increases in volume with the introduction of new foods, and let tolerance set the pace.
Step 3: Introduce additional blended meals
- If the goal is to reduce or discontinue continuous pump feeding:
- Repeat the process to introduce further blended meals.
- Reduce pump feeding hours accordingly.
- Increase meal volumes gradually where required.
Infants from around six months
Introduction checklist
Before starting, agree goals, expectations, progression and monitoring arrangements with the family. Confirm caregivers can prepare and administer blends safely. Blended diet should ideally be introduced when the infant is medically stable, and in line with UK complementary feeding guidance.
Step 1: Introduce a small volume of blended food
- Begin with approximately 5 to 10ml of a smooth single-ingredient food, mixed with the infant’s breast milk, formula or enteral feed where appropriate.
- Commercial stage 1 baby foods may be a practical starting option for anyone new to blended diet or without suitable equipment.
- The existing feeding plan will usually remain unchanged initially.
Step 2: Increase volume and variety
- Introduce new foods one at a time, gradually.
- Increase volumes according to tolerance.
- Volume tolerance often improves with time. Where weight gain is a concern, energy-dense foods can add energy without adding volume.
- Monitor for gastrointestinal symptoms, feed intolerance and allergic reactions.
- Progress towards a varied diet from all food groups, including common food allergens, such as egg, nuts, dairy, fish, wheat and soya, from around six months and before twelve months.
Step 3: Adjust milk or formula feeds
- Continue breast milk, infant formula and/or enteral feed alongside blended diet as required.
- Reduce breast milk, formula or enteral feed in line with age-appropriate complementary feeding. At 6 to 7 months, milk volume stays largely unchanged. From 7 to 9 months, once the infant has two to three meals a day, milk feeds usually fall to three or four a day. By 10 to 12 months, meals and snacks are the main energy source, though milk is still an important contributor. Reduce sooner if weight is rising faster than expected for the infant’s growth centile.
- Where a breast milk or formula top-up feed follows a blended meal, reduce that top-up first, before adjusting the wider feeding plan.
Step 4: Introduce additional blended meals
- Once a blended meal is tolerated, repeat the process for additional meals.
- Introduce further blended meals gradually, replacing breast milk, formula or enteral feeds as agreed within the nutrition care plan.
- A hybrid approach combining blended diet and commercial enteral formula may be used where this best meets nutritional and practical needs.