# The Impact of Blenderized Tube Feeding on Gastrointestinal Symptoms, a Scoping Review
## 4 Discussion
A review based on the adult population showed that BTFs are inappropriate for use in medically complex patients or those at risk for malnutrition, since BTF seems to be associated with lower nutrient adequacy, possibly leading to a decline in weight status, BMI, and upper arm circumference [40]. This aspect could be of concern in more fragile pediatric patients. Overall volume tolerance should also be factored in. Given the patient's level of volume sensitivity, the patient could not meet the daily caloric and nutrient intake needed with BTF alone, which is crucial in children's growth [8]. The BLEND3 study found thatchildren needed 1.5-fold calories when on BTF in comparison to SCF to sustain growth. It is still controversial why a caloric increase is necessary for BTF. Possible explanations include differences in thermic effects of feeding, miscalculation of the caloric value of foods, or changes in food digestion on BTF. However, further investigation is needed to clarify this point [36]. The most relevant evidence emerging from this research study is that all included papers unanimously converge in defining an improvement in both upper and lower GI symptoms during BTF both in the pediatric and adult populations regardless of their medical conditions. GI symptoms, including diarrhea and abdominal distension, frequently occur in patients receiving EN, and diverse causes, such as antibiotics, infections, or even enteral nutrition, may contribute [41]. All included studies showed comparable results, indicating an improvement of HEN tolerance between patients using BTF. Notwithstanding, experimental studies, particularly RCTs, are lacking. Adequate methodological quality is only sometimes achieved in the included studies in this review. In fact, dietetic prescription, as well as concomitant possible antibiotic administration, are not always described owing to observational biases. To note, blinding is more difficult to achieve in studies on feeds as less feasible. Additionally, due to small cohorts, statistical power is lacking. Despite all the limitations, this review highlights the possible improvement of BTF on clinical outcomes. It fits into a stream of studies covering most aspects of HEN, including future strategies to improve environmental sustainability of HEN [42]. Results of studies on nutritional value, quality of life, and microbial contamination of BTF are not always consistent, as they do not always show that BTF is more beneficial than SCF. Notably, BTF is not a good alternative in patients requiring jejunumy in order to prevent metabolic complications. Since this feeding route requires the administration of feeds through a feeding pump, BTF is not recommended [1, 43, 44, 45]. To conclude, there is a strong consensus agreement on most the appropriate HEN formula among experts. ESPEN guideline recommends the use of SCF as the first choice, unless there is the presence of a specific justification for BTF [1]. The absence of standardized BTF formulas may potentially increase the risk of malnutrition due to deficiencies of micronutrients [9, 44] that are fundamental for effective metabolism and biochemical processes [46, 47]. Hence, the importance of an appropriate interdisciplinary management of BTF, especially by an expert dietitian. A 3-day food diary may be filled in to estimate the adequate supply of macro- and micronutrients and to prevent weight loss.