Monitoring keeps nutrition support safe and effective and identifies complications. It also checks that the goals agreed are being met.
Closer monitoring is needed when establishing blended diet or transitioning from commercial enteral formula, particularly during the first twelve months.
Once established, a person on blended diet needs the same monitoring as anyone else receiving home enteral tube feeding.
This part covers what to agree before starting and what to monitor.
Monitoring can frequently fall between services, without agreement on who requests it and acts on the result.
1. Agree a time-bound monitoring plan before starting
Set the parameters and review intervals in advance, ideally as part of a multidisciplinary discussion with the individual, their family or carers. A baseline should be recorded before starting blended diet.
UK home enteral feeding reviews tend to take place every three to six months, but people may need more support in the first few months of starting blended diet. Discuss what is realistic within the resource available. Agree and record who is responsible for each element of monitoring.
The dietitian is the expert in enteral tube feeding and should lead the monitoring plan.
2. Monitor weight and body composition
This may include weight, height or length using actual or proxy measures, BMI, mid-arm circumference and triceps skinfold.
In children and young people, growth trajectory should be monitored as well as weight and height. Consider the measurements alongside clinical symptoms and appropriate functional measures rather than on their own.
Blended diet can be used for either weight gain or loss depending on food ingredients chosen.
3. Do not increase biochemical monitoring as routine
Blended diet is not in itself an indication for more biochemical monitoring in comparison to commercial enteral formula as long as a wide variety of foods from each of the food groups is used (point 5).
Follow local schedules and panels for biochemical monitoring in home enteral feeding as these vary regionally.
Clinical concern should prompt investigation.
4. Monitor gastrointestinal symptoms
Adverse gastrointestinal symptoms are a common reason why people choose to try blended diet.
A baseline discussion before starting is essential if improvement is to be monitored. Most improvement in upper gastrointestinal symptoms appears within the first three months.
Where symptom management was the main reason for trialling blends and nothing has improved, consider whether to continue, taking account of any other benefits the person and family value (point 7).
Conversely, gastrointestinal symptoms can be triggered by the introduction of blended diet, for example by introduction of a food intolerance or by adding too much fibre to the diet too quickly.
Ideally tube-fed individuals and their families and carers should be taught to monitor these symptoms themselves.
5. Monitor the overall balance of the person’s diet
Tools such as 24-hour recall and three-day food diaries are useful ways for the dietitian to assess the variety of the diet. They help identify potential gaps and are more practical than analysing each individual blend.
Dietary analysis is important in restrictive diets where the same recipes are used repeatedly.
6. Monitor the tube for patency and stoma site for health
As with all enteral tube feeding, tube patency and stoma site health should be routinely monitored, and tube integrity, complications and replacements recorded at each review.
7. Capture the outcomes that matter to the person and family
Social and emotional benefits and improvements in appearance, general health, sleep, comfort, alertness and family life could be missed in a routine clinical appointment focused on gastrointestinal symptoms.
Discuss before starting what matters to the person and their family and how it will be measured.
Patient reported outcome measures should form part of the monitoring plan and be assessed at each review. These may include quality of life, psychosocial impact, confidence, and perceived burden or stress.
A validated tool, such as the Paediatric Quality of Life Inventory used in UK research, or a simple rating agreed with the family can be used.
8. Monitor more intensively during initiation and at care transitions
More frequent contact is usually needed in the first weeks and months.
Once blends are established, monitoring should step down to that of anyone else receiving home enteral tube feeding, in line with local home enteral feeding guidance.
Additional support will be needed when planning for transitions (Part 12).
9. Allow the choice to use a hybrid approach or stop blends
Moving onto blended diet does not have to mean replacing commercial enteral formula entirely.
Many people use blends alongside commercial enteral formula, and in adults this appears to be the more common pattern.
Circumstances change and the amount of time and energy available for blending can fluctuate.