Is it safe to use blended food with J-tubes?
This is a question that I receive fairly often from clinical dietitians who are unsure whether or not blenderized tube feeding is an option for their J-tube fed patients. I am also asked this question by people who have jejunostomy tubes themselves or have a family member (adult or child) with a J-tube. It seems to me that there is a lack of information and guidance in regards to the use of blended food with J-tubes, so I decided to share my expertise in this area on my blog.
As a registered dietitian, my tendency is to refer to published research in order to determine whether there is evidence to support a particular practice. In the case of this question, there is very little data on jejunostomy tube feeding and blended diets, but having worked with tube fed patients now for over 16 years, I feel that my expert opinion and practical experience have value so I will be sharing them in this post. Of course, I will also be sharing some relevant scientific evidence as well, but there are not a lot of studies to reference when it comes to blended diets via J-tubes. I am grateful that I have this blog where I can share my opinion and my experiences related to this question, however, if you have a different opinion or different experiences with the use of blended food and jejunostomies, I would love to hear from you so please leave me a comment. Please keep in mind that my blog does not constitute medical advice and I don’t recommend the use of blended food for tube feeding without the support of your medical team.
First off, let me quickly explain what a J-tube is, so that we’re all on the same page. J-tube is medical slang. The “J” stands for jejunostomy. Let’s break that down- “jejun” is derived from the word “jejunum”, the second section of the small intestine. The small intestine is the part of the bowel that is between the stomach and the colon. “Ostomy” basically means a hole. So a jejunostomy feeding tube is essentially a hole to the small intestine. Sometimes a J-tube just refers to the end point of the feeding tube. So, a tube that goes into a person’s nose and ends up in the jejunum is also a J-tube, but technically the proper name for that type of tube is a nasojejunal feeding tube. One last tube worth mentioning is a transgastric jejunostomy tube. That’s a tube that goes through the abdomen into the stomach but carries on through the stomach and ends up in the jejunum. If you’re not sure whether you have a J-tube, the simplest way to know is to understand where your tube tip is located. If it’s in your small bowel, it’s a J-tube, no matter what type of tube it is, or where it starts. Remember, a G-tube is different….that’s a stomach tube. The G stands for “gastric”, a latin root word for stomach.
Blenderized Tube Feeding by J-Tube
Let’s get back to the question….Is it safe to use blended food with J-tubes? In my experience - YES. There may be exceptions depending on a variety of factors (such as cases where there is a malabsorption issue requiring elemental formula), but in general, blended food can be safely used for J-tube feeding. In fact, I expect that blenderized tube feeding by J-tube is likely to become more common as blended food is perceived by an increasing number of healthcare practitioners as a viable tube feeding option, and tube fed individuals (or their families) are asking for a more natural tube feeding option regardless of their tube type.
When it comes to J-tubes. I will say that a blended diet has got to be very carefully designed so that meals contain plenty of nutrition in a reasonable volume. Why? Well, there are some significant differences between the stomach and the jejunum. Probably the biggest difference is the fact that the stomach is designed to be a reservoir so it can handle large volumes of food. When a person is tube fed via a gastric feeding tube (into their stomach), they can usually handle fairly high infusion rates, meaning that they can take in quite a lot of food at one time. For example, it’s quite normal for adults with G-tubes to have meals infused by pump rates upwards of 250 mL/hour. When using a syringe, feedings are even more quickly infused. Some adults syringe feed over 500 mL of blended food in just 15 minutes or so, for example. Since the stomach is designed to handle large volumes, there’s usually no issue with these practices. Remember- people who eat by mouth generally have no difficulty eating or drinking large amounts of food in short periods of time. We are adapted for this. With J-tubes, you need to look at this differently.
Can Blended Food Be Digested If It Skips the Stomach?
The jejunum normally doesn’t receive food directly. Normally it would be receiving food that is released from the stomach after it has been mixed with certain digestive fluids (hydrochloric acid, pepsin, gastric lipase) and mixed around to reduce the food particle sizes. The good news is that blended food fed through a J-tube is already in a liquid form with very small particle sizes so it really doesn’t matter that the food skips the stomach. Most digestion happens in the small bowel anyway. In fact most of the majority of enzymes needed for digestion are not produced by the stomach, rather they are secreted by the pancreas into the small bowel. Also, let’s not forget about bile, a powerful emulsifier for breaking down fats. Guess where bile is secreted? The small bowel! My point is that there is absolutely enough digestion going on in the small bowel to properly allow digestion and absorption of blended food by J-tube feeding.
What About Bacteria?
Now, some people fear that without the acidic environment of the stomach, there is a risk of too much bacteria getting into the small bowel if you are J-tube feeding blended food. After all, blended food naturally has some bacteria in it (not a bad thing necessarily). Well, in my opinion, as long as you are following basic food safety guidelines, you do not need to concern yourself with this. In fact, I’m not convinced that the acidic stomach environment is all that helpful in the prevention of foodborne illness, ask anyone who eats by mouth who has ever had food poisoning! Remember, our gastrointestinal tract is already inhabited by huge numbers of bacteria so why should our food need to be sterile? This question can certainly be considered on an individual basis, but in general I stand by my opinion that this concern regarding bacteria in blended food has very little scientific basis. Plus, no studies have ever linked blended food to food borne illness in tube fed people.
I spent a good portion of my career working on a general surgery hospital unit where it was not uncommon to have adult patients admitted for gastrectomy surgery (where their stomach is surgically removed for medical reasons) or other surgeries where their small bowel is moved into a position where their stomach is bypassed. The post-operative plan was always to have these patients eat by mouth. Their diets would progress in the days after surgery from liquids to solids and once they were able to consume adequate amounts, they would go home on a fairly normal diet with a few restrictions and eventually resume their usual diet over the next few months or so. Although their food was going directly from their esophagus into their small intestine, they still ate real food. They were not expected to eat sterile food or only drink special formula for the rest of their lives. In fact, we would advise them to avoid sugary foods, so something like a tube feeding formula would not have been recommended. I encourage clinicians to think critically as to why it would be ok for oral eaters to have real food skip the stomach and go directly into the jejunum, yet it’s not ok for tube fed people? This is a question worth consideration a the very least.
The Privilege of Enteral Formula Access
This leads me to something else worth discussion. Commercial tube feeding formula is not available in every community in every corner of the world. Availability of commercial formula is a privilege. Not everyone has access. Through my website and social media I have heard from dietitians and tube fed people from all over the world. In many developing countries, there is no commercial formula! So, imagine if blended food wasn’t available and a child or adult needs to receive J-tube feeding. What would people in the places in the world without commercial formula do? Starve? No, they use liquid foods and blended food (if they are able to have a blender and electricity) and make do as best as they can. You may be imagining remote places of our world, but think again…a dietitian colleague at the major hospital in Vancouver, Canada where I work recently told me about a homeless adult patient living on the streets of Vancouver and doing J-tube feeding by syringe using any liquid foods he could get from shelters and community support programs. He could not afford to buy tube feeding formula and even if he could, he would have a very hard time storing it. Anyway, I mention this because we can never assume that formula is an option for everyone with a J-tube.
Blended Food and J-Tube Feeding in Research
Specifically in regards to blended food, there are a few studies where subjects used blended food for tube feeding by J-tube. Dr. S Klek conducted a study where he and his co-authors reviewed a database of tube fed adults in Poland. 7 patients in this study were receiving homemade blended food via J-tubes. Interestingly, this study was looking at effects of switching home tube fed adults from homemade blends to formula as part of efforts to improve their overall care in the community. Previously, most tube fed people in Poland were apparently sent home from hospital with feeding tubes without any guidance or ongoing support and could not afford formula. So, they were left to their own devices to blend meals. My primary reason for mentioning this study is that it shows that there are people using blended food for tube feeding by jejunostomy, just in case there are people reading this and still doubtful that it can be done.
Other blenderized tube feeding research where subjects had J-tubes is a study by Bridget Hron that was published in the Journal of Pediatrics in 2019. Of the 42 children receiving blended food for tube feeding, 5 had GJ-tubes and 2 had J-tubes. This study compared tube fed kids on formula to those on blended diets and found that emergency room visits and hospital admissions were dramatically less in the blended diet group. Again, my primary reason in presenting this study is to show documented proof that blended diets are most certainly being used for J-tube feeding. So, I don’t think it’s accurate to say that there is no data on the use of blended food for J-tube feeding as this study can certainly be pointed to as evidence that it is used and outcomes were positive.
Can Blended Food Be Used For Tube Feeding By J-Tube?
Let’s get back to the question at hand. In my opinion, YES, blended food can be used for tube feeding. I have had patients use blended food by J-tube and it went well. My first experience involved a patient under my care at the hospital where I work. This was an adult man who had an esophageal fistula requiring esophageal surgery and a 6 month period of “nothing by mouth” and J-tube feeding. He did not want to survive exclusively on standard tube feeding formula for 6 months. He very much wanted to use real food such as blended soups and smoothies. Ultimately he did a combination of food and formula. Interestingly he tolerated blended food far more easily than formula. When infusing formula by pump he would feel uncomfortable if the rate exceeded 120 mL/h. When infusing blended food, he felt good at rates as high as 500 mL/h. That’s a massive difference and likely can be attributed to the fact that his blends contained no added sugar, while the tube feed formula used at the time was 1.5 calories per mL and contained so much sugar that it equated to 11 sugar cubes per box. He would have needed 5 boxes daily if he used only formula- 55 sugar cubes daily! Eventually he stopped using formula and only used blended food by pump.
Blended Food By Jejunostomy Tube
Hopefully I have helped those reading this post understand why I support exploring the option of blended food for people who have J-tubes. Keeping in mind the general risks and benefits of blended diets is important, of course, so check out my blog post on that topic if you want to learn more. In an upcoming post I will explain how to use blended food by J-tube and why a combo of food and formula, and a slower transition might be necessary. So, stay tuned and leave me a comment if you have any questions or thoughts/experiences to share.
Remember, if you are interested in learning how to safely prepare blended meals for tube feeding (whether by G-tube or J-tube) check out the Natural Tube Feeding Blended Diet Online Course.
Thanks for reading!