# The Impact of Blenderized Tube Feeding on Gastrointestinal Symptoms, a Scoping Review
## 4 Discussion  
The sentence \"What is old is new again\" is particularly true when considering BTF. While is it ancient like old Egyptians, the popularity and necessity of this type of nutrition reduced with the emergence of commercial formulas in the middle 20 th century. As technology advanced over the 1960s and 1970s, SCF (for definition, sterile products) began to replace home-prepared food because of their known nutrient composition and lack of possible microbial contamination [8]. However, lately, the interest in these individualized formulas has increased, especially as a request made by caregivers (a way of feeding perceived more \"normal\" by the family) [10]. Thirty years ago, the estimated annual prevalence of HEN in the USA was 415 per million people [26]. The practice of HEN has faced extensive growth over time, especially in the pediatric population, where the estimated overall prevalence is 3.47 per 100,000 inhabitants from 0 to 18 years of age [27]. This increase is driven by the rising prevalence of feeding and swallowing difficulties connected to improved survival rates of children with complex disabilities and rare genetic conditions [28; 29; 30; 31; 32]. In addition to SCF intolerance, one reason of the emerging interest and use of BFT is the inability to obtain commercial formulas in some peculiar settings [33]. To date, in some developing economies, such as Iran, for most hospitals, the traditional blended formulas remain the most widely used option due to higher affordability [34]. Conversely, in the Medicare and Medicaid context, food-based products are a second choice, preferred in case of allergy or intolerance to semi-synthetic formulas [26]. Although SCF guarantees an adequate supply of nutrients, with a low risk of contamination and device obstruction, intolerance has been reported [10]. The improvement of this latter concern is reported in multiple studies both in pediatric and adult populations [8; 9; 17]. Many aspects have contributed to the re-emergence of BTF. Paramount, for example, is the improvement in feeding tolerance (reduction in reflux, retching/gagging, constipation). This, indeed, greatly improved psychosocial aspects related to feeding, like normalizing mealtimes, allowing patients to participate in food preparation, and allowing caregivers to fulfill the fundamental role of feeding their child [8]. The BLEND study by [PERSON] et al. found a clear improvement in the QoL of families in which BTF was adopted [22]. However, some critical points are to be considered by clinicians before initiating BTF. The patient should be medically stable on a home enteral nutrition regimen, tolerate bolus feedings, and have access to the necessary equipment to prepare and store food. The gastrostomy site should be mature and well-maintained, and the gastrostomy tube should be \(\geq\)14 French to reduce the risk of tube occlusion [8]. Nonetheless, there are some concerns about BTF. Food-borne illness, related to the preparation of a \"whole food formula\", is a possible \"side effect\" that commonly leads clinicians to prefer commercial formula and represents a reason of concern for patients/caregivers, particularly for critically ill or immunocompromised patients, such as neonates [35]. Regardless, no available studies demonstrate a connection between higher levels of bacterial contamination and increased infection rates in BTF [36]. Additionally, a 2020 study by [PERSON] et al. shows that, when a correct way of preparation of BTF is applied, 88% of samples meet the criteria for safe food consumption [37]. With regard to contamination concerns, many authors suggest the use of accepted methods of safe food handling [37], adequate hygiene measures, and the use of comprehensive guidelines for preparation, storage, and transportation of BTF [38; 39].