Oral nutrition support in hospital and the community

National Collaborating Centre for Acute Care (UK)

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National Collaborating Centre for Acute Care (UK). Nutrition Support for Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. London: National Collaborating Centre for Acute Care (UK); 2006 Feb. (NICE Clinical Guidelines, No. 32.)

See 2017 Partial Update

July 2017: Links were updated in the footnotes to recommendations 1.3.4 and 1.8.15 by NICE. Recommendation 1.7.17 was updated and links added to National Patient Safety Agency documents.

July 2017: Links were updated in the footnotes to recommendations 1.3.4 and 1.8.15 by NICE. Recommendation 1.7.17 was updated and links added to National Patient Safety Agency documents.

Nutrition Support for Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition.

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8Oral nutrition support in hospital and the community

8.1. Introduction

Options for oral nutrition support should be considered for any patients taking inadequate food and fluid to meet their requirements, unless they cannot swallow safely or have inadequate gastrointestinal function. Oral options include dietary counselling to facilitate the addition of ingredients high in energy and/or protein (e.g. butter, cream, milk, sugar); adaptation of meal structures (e.g. 3 meals plus 3 snacks); the inclusion of ‘nourishing fluids (milky drinks, fruit juices and smoothies) and the use of proprietary oral nutritional supplements such as nutritionally complete pre-packed drinks or vitamin/mineral tablets.

Proprietary oral nutritional supplements can be prescribed for conditions laid down under Borderline substance guidance. Levels of electrolytes in oral and enteral feeds are governed by the EC Directive for Foods for Special Medical Purposes (1999/21/EC) The aim of oral nutritional supplements is to improve the patient’s overall food and fluid intake in order to improve clinical outcomes. It is important that the total intake from normal food plus the additional measures provides a balanced mix of energy, protein and micronutrients.

Dietary counselling and nutritional supplements may both be used to increase nutrient intake either individually or in combination. Dietary counselling has potential advantages in that it offers greater variety, can be tailored to individual needs and may be associated with lower costs to the health service. It has therefore been suggested that it should precede the use of nutritional supplements³⁴⁷. However, provision of complete oral nutritional supplements is simple and many are available on prescription although a number of studies have highlighted problems with compliance ¹⁸¹^,²⁴¹^,²⁷¹. It is not known whether these two methods of nutrition support are complimentary to one another.

We conducted a number of reviews to investigate the clinical and nutritional effects of one or more oral interventions along with a review to identify patients’ views on some of these interventions. Patient in all settings were included but there was insufficient evidence to make separate recommendations for each setting. However, it is likely that if oral nutritional interventions provide overall benefit for malnourished patients, these benefits will occur regardless of the setting in which the nutritional intervention is given. All diagnoses were also included in the reviews but only three areas were identified with enough specific studies to warrant separate sections in this chapter: surgery, pancreatitis and dysphagic patients.

8.2. Oral nutritional support versus standard care in malnourished patients

8.2.1. Studies considered for this review

Since effects of oral nutritional interventions are likely to be most evident in patients who are malnourished or at risk of malnutrition, we only aimed to review studies undertaken in such groups in both hospital and community settings (Table 27). Ideally, the studies included would have used the same or similar definitions for malnutrition and nutritional risk but unfortunately inclusion criteria were variable and in some cases unclear. Consequently, we included any study in which it appeared likely from either the reported criteria or the clinical setting that at least 50% of all participants would have had a BMI less than or equal to 21kg/m², unintentional weight loss of 5% in recent months, or had not been able to eat or unlikely to eat for more than five days.

8.2.2. Clinical evidence for oral nutritional supplements versus standard care in malnourished patients

The review identified 40 RCTs¹⁰^,¹⁹^,²³^,²⁶^,³¹^,³⁶^,⁶²^,⁷⁹^,^86–88^,¹¹⁸^,¹²¹^,¹⁵⁷^,¹⁸¹^,¹⁸⁷^,¹⁹⁵^,¹⁹⁷^,¹⁹⁹^,²⁰⁵^,²²⁶^,²²⁸^,²⁶⁰^,²⁶⁹^,²⁷⁰^,²⁷⁹^,²⁸²^,²⁸³^,²⁸⁵^,³⁰²^,³⁰⁶^,³²⁶^,³⁴⁴^,³⁴⁹^,^363–365^,³⁷³^,³⁷⁵^,³⁷⁹ that looked at the effectiveness of using an oral nutritional supplement. These included studies giving supplements alone and in combination with dietary counselling. The supplements investigated were a combination of proprietary complete supplements (complete supplements contain a balanced mixture of protein, energy, vitamins and minerals), homemade supplements and incomplete supplements (incomplete supplements do not contain a complete balance of nutrients).

8.2.3. Oral nutritional supplements alone versus standard care

Thirty two RCTs compared patients who received oral nutritional supplements with patients who received standard care/no intervention ¹⁹^,²⁶^,³⁶^,⁶²^,⁷⁹^,^86–88^,¹²¹^,¹⁵⁷^,¹⁸¹^,¹⁸⁷^,¹⁹⁵^,¹⁹⁷^,¹⁹⁹^,²⁰⁵^,²²⁶^,²²⁸^,²⁶⁰^,²⁷⁹^,²⁸³^,²⁸⁵^,³⁰²^,³⁰⁶^,³²⁶^,³⁴⁴^,³⁴⁹^,^363–365^,³⁷⁵^,³⁷⁹. There was no form of dietary advice in either arm. The most frequently reported outcomes were: death, anthropometric measurements (such as weight change), length of hospital stay, wound healing or complications, quality of life and functional status.

Twenty studies¹⁹^,³⁶^,⁶²^,⁷⁹^,⁸⁶^,⁸⁷^,¹²¹^,¹⁵⁷^,¹⁸⁷^,¹⁹⁷^,¹⁹⁹^,²²⁶^,²⁷⁹^,²⁸³^,³⁰⁶^,³⁴⁴^,³⁴⁹^,³⁶⁴^,³⁶⁵^,³⁷⁹ reported mortality. Although most of the studies showed lower mortality rates in the supplemented group no individual study showed a significant difference. However, a meta-analysis (Table 13) of these studies showed a significant reduction in mortality for the proprietary complete supplements with no significant difference for homemade or incomplete supplements (although only three small studies reported mortality this type of intervention).

Table 13

Summary of meta-analysis of oral nutritional supplements vs. standard care.

Nineteen studies provided information on weight change²⁶^,⁶²^,⁸⁷^,¹²¹^,¹⁵⁷^,¹⁸¹^,¹⁸⁷^,¹⁹⁵^,²⁰⁵^,²²⁶^,²²⁸^,²⁶⁰^,²⁷⁹^,³⁰²^,³⁰⁶^,³⁴⁹^,³⁶³^,³⁶⁵^,³⁷⁹. Eight showed a significant weight change in favour of the supplemented group⁶²^,¹⁸¹^,¹⁹⁵^,²²⁶^,²²⁸^,²⁶⁰^,²⁷⁹^,³⁷⁹, although in one of these it was only evident in a severely malnourished sub-group ²⁷⁹. The other studies showed no significant difference in weight change.

Sixteen of the nineteen included studies with enough data to incorporate into a meta-analysis ²⁶^,⁶²^,⁸⁷^,¹²¹^,¹⁵⁷^,¹⁸¹^,¹⁹⁵^,²²⁶^,²⁶⁰^,²⁷⁹^,³⁰²^,³⁰⁶^,³⁴⁹^,³⁶³^,³⁶⁵^,³⁷⁹ The meta-analysis showed that those taking proprietary complete supplements⁶²^,⁸⁷^,¹²¹^,¹⁸¹^,²²⁶^,²⁶⁰^,²⁷⁹^,³⁴⁹^,³⁶³^,³⁶⁵^,³⁷⁹ had significant weight gains whereas homemade or incomplete supplements²⁶^,¹⁵⁷^,¹⁹⁵^,³⁰²^,³⁰⁶ only showed a non-significant weight change in favour of supplements.

Change in BMI as an outcome was reported in 6 studies⁶²^,¹⁸¹^,¹⁹⁵^,²⁸⁵^,³⁷⁵^,³⁷⁹. Two ⁶²^,³⁷⁹ documented significant change favouring the supplemented group, one reported that the majority of participants in both groups showed improved or maintained BMI but did not document the change²⁸⁵, one reported a significant increase in BMI of men that were supplemented compared to male controls but no significant differences for women³⁷⁵ and the last two showed no significant difference in any groups¹⁸¹^,¹⁹⁵. Other anthropometric measurements such as Triceps skin fold (TSF), Mid-arm muscle circumference (MAC), were not reported consistently in studies although where significant differences were shown they favoured the intervention groups.

Twelve studies provided data on length of stay ⁷⁹^,⁸⁷^,¹²¹^,¹⁵⁷^,¹⁸¹^,²⁷⁹^,²⁸³^,³⁰²^,³²⁶^,³⁴⁹^,³⁶⁴^,³⁷⁵. One showed a significant reduction in the supplemented group⁷⁹, four showed no significant difference between groups¹⁸¹^,²⁷⁹^,²⁸³^,³²⁶, and seven did not report the significance. Our meta-analysis (Appendix Six: Meta-Analyses Oral versus Standard Care) showed no significant difference overall for either complete proprietary supplements or non-complete/homemade supplements.

Functional outcomes reported differed from study to study but where benefit was identified, it favoured the supplemented group.

Energy and/or protein intake was higher in the supplemented group in some studies³⁶^,¹²¹^,¹⁸¹^,¹⁸⁷^,²⁰⁵^,²²⁸^,³⁰²^,³²⁶^,³⁶³ and where significant benefit was identified it was in favour of the intervention. No study demonstrated a better intake in the control for this outcome.

Complications were reported in eight studies³⁶^,⁷⁹^,¹²¹^,¹⁸¹^,²⁸³^,³⁰²^,³²⁶^,³⁴⁹. All showed fewer complications in the supplemented group, the difference was significant in four studies³⁶^,¹⁸¹^,²⁸³^,³²⁶.

8.2.4. Oral nutritional supplements plus dietary counselling versus standard care

Three studies compared oral supplements plus dietary counselling with standard care ³¹^,²⁶⁹^,²⁷⁰. All three of these showed a weight gain in the supplement plus dietary counselling group compared to the standard care group, the gain was significant in two of these studies²⁶⁹^,²⁷⁰. Two studies reported data on energy intake with one showing no difference between the groups³¹ and the other showing a significant increase in the supplemented group²⁷⁰.

8.2.5. Oral nutritional supplements plus dietary counselling versus dietary counselling

The review identified five RCTs¹⁰^,²³^,¹¹⁸^,²⁸²^,³⁷³ that compared oral supplements plus dietary counselling with dietary counselling alone (although dietary counselling is not necessarily standard care). There was no significant difference in mortality for the three studies reporting this outcome ¹⁰^,²³^,¹¹⁸. The same three studies also reported weight change with only one of them showing a significant difference²³, this was in favour of the supplemented group.

Length of stay was reported for two studies²³^,³⁷³, both reported shorter lengths of stay in the control group than the supplemented group but neither showed a significant difference. Beattie et al²³ also reported complications, the supplement group had significantly fewer than the control group.

8.2.6. Meta-analysis summary of oral supplements vs. standard care

Our meta-analysis (Appendix Six: Meta-Analyses Oral versus Standard Care) looked into four commonly reported outcomes for oral nutritional supplementation. It demonstrated that their use leads to statistically significant increases in weight and statistically significant reductions in complications and mortality. There was no significant effect on length of hospital stay although some caution is required when interpreting both weight change and length of stay data. In one study ²⁶, we had to approximate mean weight change from median weight change, and estimate the standard deviation using the weighted mean of standard deviations in the other studies. Similar approaches were needed for lengths of stay data in four studies⁷⁹^,¹²¹^,²⁷⁹^,³⁴⁹.

8.2.7. Cost effectiveness of oral nutritional supplements

We found one UK and one French study that compared the cost of oral nutrition support with standard care using data extracted from specific RCTs (Studies on the use of support in surgical patients rather than generally malnourished patients are dealt with separately – see section 8.6). Both studies were performed on patients in the community although in one case patients had just been discharged from hospital and in both cases hospital admissions or readmissions were costed outcomes.

The UK study was a cost-effectiveness analysis ⁸⁷ was based on an RCT to determine whether nutritional supplementation reduced health care costs and improved quality of life in older malnourished patients post-discharge. They found no significant difference in quality of life of patients although, the short course of the intervention (8 weeks) made it relatively unlikely that improvements would be evident. Patients in the oral supplement arm had significantly increased cost (£3034 vs. £1854) due to longer lengths of stay for those who needed readmission to hospital, even though the increases in length of stay were not significant. The reasons for the increased length of stay were neither clear nor discussed in the paper. However, although it is possible that they were a result of the intervention, a misbalance between trial arms (although baseline characteristics of the patients were similar) or chance within the small study with varied diagnoses seems more likely.

The French study also evaluated the resource and cost implications of using supplements in older patients⁹. It was based on a prospective comparison of patient cohorts with one cohort in a region with high rates of oral nutritional supplement prescription compared to another cohort in a region with low prescription rates. Patients in the high frequency arm had a significantly improved MNA scores, reduced numbers of admissions (in contrast to Edington 2004) but no significant reduction in costs. There was no significant difference in mortality and other patient outcomes, such as quality of life were not recorded.

In addition to the above, we also examined an unpublished report ⁹¹ that estimated the cost impact of oral nutritional supplements from an NHS perspective using two separate analyses related to lengths of stay or complication rates. These were extracted by meta-analysis from selected RCTs. The report found relatively few studies in the community on which to base any estimates of cost impact and the majority of relevant RCTs identified in hospital settings, were in surgical patients and did not necessarily focus on patients that were malnourished. Both the length of stay and complication rate showed that the use of oral nutritional supplements led to reduced in hospital costs. However, specific additional costs associated with administering and monitoring the supplements were not included, the bed day costs used did account for associated nursing time etc. However, the studies did not claim to be full cost-benefit analyses and they do not account for potential additional NHS costs of care related to added weeks of life in any seriously ill patients and, furthermore, the differences in length of stay reported in this study do not concord with either our meta-analysis or that in the Cochrane review ²³¹ (neither of which show significant reductions in length of stay with oral nutritional supplements).

We also estimated the cost-effectiveness of oral nutrition support in older inpatients in our model of their use within the context of a malnutrition screening programme (Section 4.6.1). This suggested that screening followed by intervention using oral nutritional supplements would be cost-effective using the base case assumptions although the results were sensitive to relatively small changes in some of the model’s parameters.

8.2.7.1. Conclusions

Overall, although the studies identified were small with marked heterogeneity in study populations and outcomes, they do show improved outcomes for malnourished patients given oral nutritional supplements. These benefits were somewhat inconsistent but our meta-analysis (Appendix Six: Meta-Analyses Oral versus Standard Care) shows that the use of oral nutritional supplements in such patients leads to statistically significant improvements in body weight along with reductions in complications and mortality. Economic modelling of the use of oral nutritional supplements within the context of a screening programme undertaken in elderly hospital patients also suggests probable cost-effectiveness in terms of cost per QALY <£20,000. However, available RCTs provide too little information and are too underpowered to define these costs with confidence,

8.2.8. The influence of care setting for oral nutritional supplementation

As stated in the introduction to this section, too few RCTs on the effects of on oral nutrition support in the community were identified to make separate recommendations for different patient settings. Furthermore, we did find some evidence which suggests that caution is needed in extrapolating to typical malnourished groups in the community from the evidence within hospital studies. Three RCTs ⁸⁷^,¹⁹⁵^,³⁷⁹ examined the benefits of oral nutrition support in typical elderly malnourished patients in community settings (rather than community studies on more unusual populations such as those with locally advanced cancer or alcoholic liver disease). These studies suggested a benefit from supplements in terms of increased weight but did not confirm the net mortality benefit in this setting that was identified by our meta-analysis. However, overall the paucity of evidence from community studies make it very difficult to be confident in any real differences related to setting and/or patient population, and more detailed larger studies are required.

8.2.9. Patient’s satisfaction with nutritional supplements

A literature search conducted to identify patient’s views on nutrition support retrieved four studies which looked at patients’ preferences for nutritional supplements ⁸⁵^,¹⁴²^,²²²^,³²⁴.

In one US study ³²⁴ 20 patients and 20 staff members of a large teaching hospital rated a variety of brands of liquid nutritional supplements. Each participant sampled four brands of vanilla product and four brands of an alternate flavour (either chocolate or strawberry, based on their personal preference). The first round of sampling was blinded (participants did not know the brand of the supplements) and in the second round the brand was disclosed. The results of the study indicated that staff member ratings of acceptability were lower (in some cases significantly lower) than ratings given by patients. In general, staff member acceptability ratings did not change significantly once the brand name was known. Patient acceptability ratings appeared to be impacted to a much greater degree by knowing brand name; significant increases were seen in four ratings.

Another study ⁸⁵ also looked at differences in preferences of oral nutritional supplements between patients and dietitians. There were significant differences between patients and dietitians in their evaluation of 7 of their 13 products.

The palatability of sip-feed nutritional supplements and other high-energy foods to older medical inpatients was assessed in one study ¹⁴². 49 malnourished subjects rated the taste of a previously selected sip-feed supplement and five other high-energy foods: cheese biscuit, plain potato crisps, chocolate, cherry-flavored cereal bar and stout beer. Subjects rated the taste of sip-feeds as favourable as all other offered foods, with the exception of stout beer which had a lower rate.

Another study ²²² examined whether sip-feeds are less preferred and less likely to be selected than other energy-dense foods in healthy elders; and whether eating alone further reduces intake relative to eating in a social setting.

Twenty-one healthy older adults (aged 60–79) were included. Subjects rated six different flavours of sip-feed (three fruit juice flavours: apple, orange and fruit punch and three milkshake flavours: vanilla, strawberry and chocolate) and then rated the pleasantness of the taste of the flavour against five other energy-dense familiar foods/drinks (cheese cracker, cereal bar, potato chip, chocolate button, and beer). Two drinks, two salty foods, and two sweet foods were offered to the participants. Intake was measured when participants ate alone or in a group. Pleasantness ratings were made on a 7-point Likert scale, where 1 represented ‘extremely unpleasant’ and 7 represented ‘extremely pleasant’.

The results from the study showed that the mean pleasantness of sip-feeds was above neutral (rating of 4) in all but one case (chocolate). Sip-feeds were rated as the third most pleasant (5.0 +/− 0.3). The participants’ favourite flavours of sip-feeds compared well with other more familiar foods and were selected as part of a snack. Snack intake increased by 60% when consumed in a group setting compared with eating alone.

8.2.9.1. Conclusions

Patients found oral nutritional supplements an acceptable form of nutrition support.

8.3. Dietary advice versus standard care

8.3.1. Studies considered for this review

One systematic review ¹⁷ and one RCT ¹¹³ investigated the impact of dietary advice. The purpose of dietary advice given by a dietitian or healthcare professional was to provide instruction on modifying food intake (e.g. food fortification, meal plan adaptation) to improve nutritional intake. ‘No dietary advice’ as used in this context meant patients received no other specific oral intervention.

Two of the sub-group comparisons were of interest; dietary advice versus no advice and dietary advice plus supplements (if required) versus no advice and no supplements.

8.3.2. Clinical evidence for dietary advice versus no dietary advice

The review considered 5 RCTs including 888 older people, cancer and Crohn’s disease patients (Table 28). However, only three of these studies reported outcomes of interest; mortality, hospital admission, nutritional status and clinical function. No significant difference was found for mortality at six months (two studies), hospital admission (one study), weight change and BMI (one study) or measures of clinical function (one study).

8.3.3. Clinical evidence for dietary advice plus oral nutritional supplements (if required) versus no dietary advice and no oral nutritional supplements

The Baldwin et al. review ¹⁷ also compared patients receiving dietary advice plus oral nutritional supplements (if required) with those receiving no advice and no oral nutritional supplements (Table 28). Seven RCTs including 665 cancer, surgical and chronic obstructive pulmonary disease patients were contained within the review although, only two provided data on the outcomes of interest which were mortality and change in nutritional status. The separate small RCT ¹¹³ also looked at this comparison although it also included a third, normal weight group of patients, which we did not include in our analysis.

No significant differences for any of the outcomes were found in either the systematic review ¹⁷ or the small RCT ¹¹³.

8.3.4. Patient’s satisfaction with dietary advice

We performed a literature search to assess patient’s views on dietary advice which identified two studies: one conducted in Canada ³⁵⁶ and the other in Australia ¹⁰⁶. The studies included hospitalised patients for a minimum stay of 5 days ³⁵⁶ (n=55) and acute hospital patients ¹⁰⁶ (n=49). Patients consumed a therapeutic diet and used dietary counselling during their hospital stay. A survey questionnaire was used to evaluate patients’ satisfaction with four components of dietary counselling. One study ³⁵⁶ looked at the following components:

knowledge: “patient’s perception of the dietitian’s knowledge of his or her medical condition, dietary therapy, and food composition of meals served in the hospital.”
cognitive communication skills: “dietitian’s use of simple language in verbal and written communications and in answering patient’s questions”
affective communication skills: “interpersonal qualities of the dietitian (e.g., courtesy, warmth, and attentiveness) that help build a positive relationship with the patient”
facilitation skills: “dietitian customization of the diet, inclusion of the patient in decision making, and dispensation of advice to the patient about adapting the diet after discharge from the hospital”
The other study ¹⁰⁶ assessed the following elements:
Staff interpersonal skills: These included staff communication skills and understanding of patients’ needs.
Nutrition supplements: Temperature, taste, smell and appearance of nutritional supplements
Perceived health benefits of nutrition care: Effect of dietary advice on patient’s health
Staff presentation skills: These included whether staff were polite, courteous and friendly.

The result from the studies indicated that staff facilitation skills, knowledge ³⁵⁶ and interpersonal skills ¹⁰⁶ were the most important factors of patient satisfaction with dietary advice.

8.3.4.1. Conclusions

Staff facilitation skills were the most important determinant of patients’ satisfaction with dietary advice.

8.3.6. Cost-effectiveness evidence for dietary advice

No study reporting cost or cost-effectiveness of dietary advice was found.

8.3.7. Conclusions

We were unable to demonstrate any evidence of effect for dietary advice but studies were too small and heterogeneous to allow any conclusions. Many also failed to report outcomes of interest and there is no relevant economic evidence

8.4. Oral nutritional supplements versus dietary advice

8.4.1. Studies considered for this review

We looked for studies that compared one type of oral nutrition support with another, for example three meals per day versus six meals per day, snacks or dietary advice to improve nutritional status versus oral nutritional supplement, oral nutritional supplement versus placebo multivitamin pills, in malnourished patients or patients at risk of malnutrition (Table 29). One systematic review and one RCT met the inclusion criteria. The systematic review compared the effects of dietary advice to no advice or other oral interventions ¹⁷, and the RCT compared dietary advice with oral supplements and also standard care ²⁸⁵.

8.4.2. Clinical evidence for dietary advice or snacks versus oral nutritional supplements

We identified one systematic review ¹⁷ which included 4 RCTs covering 173 older, HIV and cystic fibrosis patients, and one additional RCT ²⁸⁵ that included 111 colorectal cancer patients undergoing radiotherapy treatment, compared dietary advice or snacks with oral nutritional supplements. The Ravasco RCT ²⁸⁵ included patients regardless of nutritional status but did provide some results for 42 patients considered malnourished. The reported outcomes were mortality, hospital admission, nutritional status, nutritional intake and clinical function.

There was no significant difference in mortality at three months (5 studies), hospital admission (1 study), or measures of clinical function at three months (1 study investigating older people living at home). Energy intake at three months was significantly greater in the oral nutritional supplement group compared to the dietary advice group (4 studies) and although there were variable effects on weight change, the systematic review reported significantly greater gains in the sip fed patients.

8.4.3. Cost-effectiveness evidence

No study reporting cost or cost-effectiveness was found.

8.4.4. Conclusions

Oral nutritional supplements may be more effective in increasing energy intake and increasing weight than dietary advice but studies have been too small to determine whether there are any differences in terms of mortality or clinical outcome, and there is little or no information on cost effectiveness.

Since oral nutritional supplements presumably produce clinical benefits through increased nutrient intake, a similar increase in nutrient intake achieved by dietary means, should lead to similar clinical benefits. It therefore seems logical that, until further evidence is available, people with weight loss secondary to illness should either be managed by referral to a dietitian or by staff using protocols drawn up by dietitians with referral as necessary.

8.5. Recommendations for clinical practice

8.5.1. Indications for oral nutrition support

Healthcare professionals should consider oral nutrition support³³ to improve nutritional intake for people who can swallow safely and are malnourished³⁴ or at risk of malnutrition³⁵. [A]

Healthcare professionals should ensure that the overall nutrient intake of oral nutrition support offered contains a balanced mixture of protein, energy, fibre, electrolytes, vitamins and minerals. [D(GPP)]

Oral nutrition support should be stopped when the patient is established on adequate oral intake from normal food. [D(GPP)]

8.6. Oral nutrition support in surgical patients

8.6.1. Introduction

Many surgical patients are malnourished prior to their operation. During the period leading up to diagnosis, the underlying problem (especially if gastrointestinal) may cause deterioration in nutritional status and in some patients, coincidental illness or psycho-social issues also contribute. To add to these nutritional risks, many investigations used to diagnose surgical problems, require patients to be ‘nil by mouth’.

Following surgery, any pre-operative problems can worsen. Many patients have some degree of intestinal failure, usually due to ileus and most also have variable catabolic responses with increased or changed nutrient demands. Some have abnormal nutrient losses via drains, stomas etc.

In view of the above, there are always some surgical patients with an undoubted need for temporary nutrition support (e.g. those with prolonged but potentially reversible intestinal failure due to post-operative complications such as sepsis, anastamotic leaks, or GI fistulae, will need it until recovery). There will also be occasional patients who end up with irreversible intestinal failure due to extensive gut resection etc., and these may need long-term enteral tube feeding or parenteral nutrition (see Chapter 11). In the majority of surgical cases, however, the need for nutrition support is less definite. Nevertheless, they might benefit from its elective use. Pre-operative nutrition support might reduce risks of infection or poor wound healing, whilst early postoperative intervention might limit the nutritional risks arising from the standard practice of keeping patients ‘nil by mouth’ for several days (with a view to protecting gastro-intestinal anastomoses and allowing any ileus to resolve). Furthermore, there is some evidence that early post-operative engagement of the GI tract might reduce the metabolic effects of injury and limit infections caused by the spread of gut organisms to other parts of the body. We therefore reviewed studies of oral nutrition support around the time of surgery.

8.6.2. Methodology

We conducted literature searches to identify studies on the ‘elective’ use of nutrition support around the time of surgery. The studies identified were grouped to examine the possible benefits under the following circumstances:

Pre-operative oral nutrition support versus no additional pre-operative supplementary nutrition (i.e. normal hospital diet, placebo drink, fasting or simple IV fluids)

Pre- and post-operative oral nutrition support vs. no additional nutrition support (i.e. normal hospital diet, placebo drink, fasting or simple IV fluids)

Pre-operative oral nutrition support versus postoperative oral nutrition support

Early post-operative oral nutrition (<24 hrs after surgery) versus no additional post -operative nutrition (i.e. normal post-operative fasting with simple IV fluids until clinically-judged return of GI function)

They were also grouped according to the type of surgery undertaken.

8.6.3. Elective pre-operative oral nutrition support versus no pre- operative nutrition support

Studies considered for this review

We identified 2 RCTs²⁰⁹^,³²⁶ which examined pre-operative oral nutritional supplements versus no pre-operative nutrition support (Table 32).

8.6.3.1. Clinical evidence

One study³²⁶ reported a decrease in postoperative complications following pre-operative nutritional supplementation while the other ²⁰⁹ reported increased problems.

8.6.4. Elective pre- and post-operative oral nutrition support vs. no nutrition support

Studies considered for this review

Two RCTs ²⁰⁹^,³²⁶ were identified (Table 32).

8.6.4.1. Clinical evidence

One RCT ³²⁶ reported a decrease in the total number of postoperative minor complications in patients receiving pre- and post-operative nutrition support (p<0.05) and the fed group also lost significantly less weight than controls (p<0.05), however, the other RCT ²⁰⁹ found no significant differences between intervention and control groups. Different systems of classification of complications were used for the studies.

8.6.5. Elective pre-operative oral nutrition support versus post-operative oral nutrition support

Studies considered for this review

Two RCTs ²⁰⁹^,³²⁶ were identified (Table 32).

8.6.5.1. Clinical evidence

No significant differences were found in any of the outcomes.

8.6.6. Elective post-operative oral nutrition support versus standard care

8.6.6.1. Post-operative oral nutrition support in GI surgery (at the time of or after return of GI function)

Studies considered for this review

Five RCT’s ²³^,¹⁸¹^,²⁰⁹^,²⁸³^,³⁰²^,³²⁶ compared patients undergoing abdominal surgery who received standard care/no intervention with patients who received oral supplements at or after the return gastrointestinal function judged clinically (Table 33). One study included patients undergoing elective and emergency GI surgery ³⁰², four studies included patients undergoing elective GI surgery only ¹⁸¹^,²⁰⁹^,²⁸³^,³²⁶ and one study included patients undergoing elective GI and vascular surgery ²³. Three of these studies ²³^,²⁸³^,³⁰² are also included in the oral vs. standard care section for malnourished patients in general (section 8.2).

8.6.6.2. Clinical evidence

Post-operative oral supplements led to significant increase in BMI and mid-arm circumference in 1 study ¹⁸¹ and weight gain in 3 studies ¹⁸¹^,²⁸³^,³⁰². In one study¹⁸¹ the intervention group had significantly less complications than the control group (p< 0.05), although in another³²⁶ the difference was only significant for minor complications. Four studies reported no significant difference for wound infections ²³^,²⁰⁹^,²⁸³^,³⁰².. The only study that reported pneumonia ²⁸³ showed a lower incidence in the supplemented group (p<0.02). Quality of life was significantly higher in the intervention group in one study ²³. Postoperative anxiety was reported in one study and showed no significant difference ²⁰⁹. There were no significant changes in length of stay ²⁰⁹^,²⁸³^,³⁰² or mortality ²³^,²⁰⁹^,²⁸³ in the studies reporting these outcomes.

8.6.7. Post operative oral nutrition support in orthopaedic Surgery (at the time of or after return of GI function)

A systematic review (8 RCT’s) ¹⁴ and 2 additional RCT’s ⁴⁹^,¹⁶¹ provided data on the effects of elective post-operative oral nutrition support in patients following orthopaedic surgery for hip fracture (Table 34). The systematic review reported on mortality, complications, and unfavourable outcomes but potential biases resulting from inadequate sample size, allocation and concealment make the results difficult to interpret.

Pooled data from for 3 RCTs ⁷⁹^,¹⁴¹^,³³⁰ contained in the systematic review demonstrate that oral nutritional supplements led to a statistically significant reduction in adverse outcomes in the supplemented groups including reduced complications (borderline significance). However, none of the studies in the systematic review demonstrated a difference between study groups for functional outcomes and the 2 separate RCTs ⁴⁹^,¹⁶¹ did not show any differences in reported outcomes.

8.6.8. Early post-operative oral nutrition (<24 hrs after surgery) versus post-operative ‘nil by mouth’

Routine practice in most centres is for post-surgical patients to be kept nil by mouth until there are clinical signs of returning GI function e.g. for two to three days after a major abdominal operation. This delayed nutrient intake could have significant consequences on nutritional state and potential recovery but conversely, very early oral intake might cause problems with nausea and vomiting, or leakage from vulnerable anastomoses. We therefore conducted a review to investigate any benefits or harm related to delaying the start of food and fluid intake in post-surgical patients.

8.6.8.1. Studies considered for this review

We identified one systematic review ²⁰⁶ that looked at early post-operative feeding (oral or enteral) versus post-operative ‘nil by mouth’. The oral studies from this review were included as relevant in this section (enteral tube studies were included in section 9.4.5 on post-operative enteral tube feeding) to give a total of 20 RCTs identified in which patients were given oral feeding within 1–24 hours post operatively compared to no nutrition (i.e. intravenous dextrose and/or clear fluids only) until clinical evidence of returning bowel function ³²^,⁵¹^,⁷³^,¹⁰⁴^,¹²⁷^,¹²⁸^,¹³⁷^,¹⁴⁰^,¹⁴⁴^,¹⁹²^,²¹⁴^,²⁵⁸^,²⁶⁸^,²⁷²^,²⁸⁶^,²⁹¹^,³⁰⁸^,³³¹^,³³⁴^,³⁶⁹. Data were extracted on seven outcomes: vomiting, anastomotic dehiscence, pneumonia, death, intra-abdominal abscess, wound infection and hospital length of stay (LOS) (Table 35, Table 36, Table 37). Where appropriate we pooled the data for these outcomes but we were unable to pool data for LOS as the studies reported this in different units and information needed to convert these units was lacking. Studies fell into two groups, those including patients undergoing general abdominal surgery for gastrointestinal problems, vascular problems of trauma, and those including patients undergoing gynaecological or obstetric surgery. One study of early oral intake in pancreatitis patients who did not undergo surgery is reported separately.

8.6.8.2. Clinical evidence

Abdominal surgery patients

We identified eight studies. Six included patients undergoing lower GI surgery ³²^,¹⁰⁴^,¹⁴⁴^,²⁵⁸^,²⁹¹^,³³⁴, one included patient undergoing lower GI and transabdominal central vascular reconstruction ¹⁴⁰ and one included emergency or elective intra-peritoneal surgery of all types²⁸⁶ (Table 35). A combined analysis of these eight studies showed that patients in the early feeding group had a statistically higher incidence of vomiting compared to patients in the later feeding group. There were no statistically significant differences in any of the other outcomes in this pooled analysis (Table 14 and Appendix Seven). LOS was reported in six studies ³²^,¹⁰⁴^,¹⁴⁰^,¹⁴⁴^,²⁹¹^,³³⁴ with no statistically significant differences between groups.

Table 14

Outcomes reported in studies of patients undergoing GI surgery.

Caesarean and gynaecological surgery

We identified twelve studies in this group: seven studies included patients undergoing caesarean section ⁵¹^,¹²⁷^,¹²⁸^,¹³⁷^,¹⁹²^,²⁶⁸^,³⁶⁹ and five studies ⁷³^,²¹⁴^,²⁷²^,³⁰⁸^,³³¹ included patients undergoing gynaecological surgery (Table 36, Table 37). Although pregnancy does not fall within the scope of the guideline the GDG decided to include patients who have undergone caesarian section as these patients are no longer pregnant at the start of oral feeding.

We initially analysed the two surgical groups (caesarean and gynaecology) separately. The results of the analyses showed no significant differences between the groups in vomiting, pneumonia and wound infection in either surgical group. The P value from test for heterogeneity was greater than 0.1 for all outcomes in either surgical group. LOS was reported in 10 studies. The early feeding group spent fewer days in hospital (p< 0.001) in two ¹²⁸^,²⁶⁸ out of six studies⁵¹^,¹²⁷^,¹²⁸^,¹⁹²^,²⁶⁸^,³⁶⁹ on caesarean section and four⁷³^,²⁷²^,³⁰⁸^,³³¹ out of four studies on gynaecological surgery (p<0.05).

In an analysis there were no statistically significant differences in any of the outcomes extracted (Table 15 and Appendix Seven: Meta-Analyses Oral versus Nil Post Operative Nutrition Support).

Table 15

Outcomes of studies of patients undergoing caesarean and gynaecological surgery.

8.6.8.3. Cost effectiveness evidence in surgical patients

We identified two studies and two cost analyses which examined the effects of perioperative oral nutrition support. An RCT (n=152), based in the UK compared four arms (preoperative, postoperative, perioperative and no nutritional supplementation) in patients undergoing elective major to moderate lower GI surgery ³²⁶. There were significantly fewer minor complications in the intervention arms and no significant differences with respect to major complications. Costs were lower by £300 per patient although this was not significant. The results favour intervention but the trial was inadequately powered to detect differences in cost.

Another study¹⁹⁸ looked at the effect of postoperative oral supplements on complication rates and hospital costs in adult orthopaedic patients, using a cross-over trial. Despite low compliance with the intervention there was a significant reduction in the complication rate in the oral supplemented group (16.6 % vs. 35.1%, p=0.005). There were cost savings from the reductions in both length of stay and specific treatment interventions (£2,068 vs. £2,199) although it was not stated whether this difference was statistically significant.

An unpublished UK-based decision analysis ²⁶⁶ evaluated preoperative assessment, dietary advice and oral intervention (mixture of fortification and/or supplements) versus no preoperative assessment or intervention in patients undergoing GI surgery. Data was elicited from the expert opinion of a sample of NHS consultants. Incremental cost per patient (excluding cost savings due to complications averted) was estimated to be between £17 and £48. They found that preoperative assessment and ONS would be cost saving if averting a complication saves three or more bed-days.

An unpublished report ⁹¹ estimated the cost impact of oral nutritional supplements from an NHS perspective using two alternative methods: firstly by costing length of stay (as reported in selected RCTs) and secondly by costing complications (reported in those same RCTs). The RCTs included were mainly in surgical patients but did not all focus on patients that we would categorise as being at risk of malnutrition. For each of the trials, and using both methods, they estimated in hospital cost savings from oral nutritional supplements and although any specific additional costs associated with administering and monitoring the supplements were not included, the bed day costs used did account for associated nursing etc. The studies did not claim to be full cost-benefit analyses and they did not account for the potential additional NHS costs of care in added weeks of life for critically ill patients.

Only one study was found that evaluated the costs (and consequences) of early post-operative oral nutrition versus nil by mouth ⁶. It was performed in Japanese patients undergoing oncological colorectal surgery and reported that early post-operative feeding significantly reduced length of stay and hence medical costs with no significant differences in complication rates. However, the difference in length of stay in this study was much greater than that observed in studies within the clinical review and patients did not appear to be randomized. This, in combination with small sample size and considerable variation in the types of surgery included within different arms, gave a large potential for bias. Furthermore, the costs appear to be expressed as medians and hence might not reflect true differences in mean cost and the feeding protocol was based on rice gruel, which may not be replicable in a UK setting.

8.6.9. Conclusions - oral nutrition support in surgical patients

Some surgical patients need nutrition support either pre- and or post-operatively due to the severity of their existing malnutrition or the presence of post–operative complications and hence prolonged delay in recovery of normal food intake. These patients should receive support by the simplest method possible using oral supplements, enteral tube feeding or PN alone or in combination as necessary.

For patients who are not malnourished, there is little evidence that pre-operative oral nutrition support is of benefit although trials are small and underpowered. A cost-benefit model does suggest that pre-operative oral support might be cost saving for some patient groups but the models were sensitive to assumptions about the number of complications averted. Similarly, there is also no evidence that the early introduction of oral intake following general abdominal surgery is of value although there is also no evidence of harm other than a slight increased incidence of nausea and vomiting. In caesarean or gynaecological surgery patients early oral intake is generally well tolerated and may lead to earlier discharge. Larger trials are needed to confirm these points.

There is some evidence that post-operative oral nutritional supplements, introduced at or after recovery of GI function may reduce some complications in general surgery patients and patients with hip fracture requiring orthopaedic surgery but once again, studies have been small and underpowered. Nutritional principles suggest that giving post-operative oral supplements to more malnourished patients might lead to greater benefits but larger, targeted trials are also needed to prove this point.

8.7. Recommendations for clinical practice

Oral nutrition support for surgical patients

Peri-operative oral nutrition support should be considered for surgical patients who can swallow safely and are malnourished³⁶. [B]

Healthcare professionals should consider giving post-caesarean or gynaecological surgical patients who can swallow safely, some oral intake within 24 hours of surgery. [A]

Healthcare professionals should consider giving post-abdominal surgery patients who can swallow safely, and in whom there are no specific concerns about gut function or integrity, some oral intake within 24 hours of surgery. The patient should be monitored carefully for any signs of nausea or vomiting. [A]

8.8. Oral nutrition support in pancreatitis patients

Only one study included patients who had clinical features of acute pancreatitis and did not have any surgical procedure ¹⁹⁶ (Table 38). Fifty patients were included in the study. Patients in the early feeding group (n=50) were given liquids, such as tea, water and juice, orally without restrictions immediately after admission. Patients in the late feeding group had a nasogastric tube placed in the stomach for suction. Continuous suction was applied and maintained until the tube was removed.

Results were available for mortality and LOS. There were three deaths in the early feeding group and two deaths in the late feeding group. There were no statistically significant differences in LOS.

8.8.1. Conclusion

There is insufficient data to conclude on the benefits of early feeding for pancreatitis patients.

8.9. Oral multivitamin and mineral supplementation in malnourished patients

8.9.1. Introduction

Oral multivitamin and mineral supplements should help individuals who are eating poorly to meet their vitamin and mineral requirements and in some circumstances, apparently healthy people may also have sub-optimal multivitamin/mineral status. In the National Diet and Nutrition Survey, many older individuals living at home and a great many living in residential care were found to have biochemical deficiencies of vitamins or minerals despite the fact that their food supply appeared to contain sufficient amounts. This raises the possibility that vitamin/mineral supplementation might be of value to patients with malnutrition and they might even be of value to individuals who are not overtly malnourished or ill, although the latter fall outside the scope of this guideline.

8.9.2. Clinical evidence

Our review identified RCTs that studied the effects of multivitamins/minerals on patients who were potentially malnourished. The studies included individuals who were hospitalised, living in older persons care homes or were HIV infected patients.^124–126^,¹⁵⁹^,²⁷⁵^,³⁶⁴. The studies were categorised into two groups according to the type of supplement provided i.e. multivitamin and mineral supplement v placebo ^124–126 (Table 30) or multivitamin supplement only v placebo ¹⁵⁹^,²⁷⁵^,³⁶⁴ (Table 31).

8.9.3. Multivitamin and mineral v placebo/standard care

8.9.3.1. Studies considered for this review

Four studies were included in this category ⁸^,^124–126^,¹⁶⁹ (one study was reported in two papers ¹²⁴^,¹²⁶). Three studies included older patients in nursing homes and one study included HIV infected patients.

8.9.3.2. Older patients in nursing homes

Two studies with identical methodology included older patients in nursing homes. One was a large multi-centre study¹²⁵ and the other reported in two papers¹²⁴^,¹²⁶ was a study in one of the centres in the multi-centre study but provided additional data. Patients in both studies were randomised into four groups: vitamin group (Vitamins A, C and E) mineral group (zinc, selenium), vitamin and mineral group (vitamins A, C, E and zinc and selenium) and a placebo group (calcium phosphate). Immunological data were reported in the large multi-centre study ¹²⁵.

Clinical Evidence

No differences were observed in delayed hypersensitivity responses. A sub-group of patients received influenza vaccine towards the end of the two-year supplementation period and the humoral response to the vaccine strain was assessed before and after vaccination. Results overall for the three influenza vaccines showed an improvement in antibody titre in trace element and trace element/vitamin groups relative to placebo or vitamins alone, but the mineral group had significantly higher numbers of serologically protected patients compared to the vitamin, vitamin/mineral, and placebo groups, for one of the three vaccines (p<0.05). The authors concluded that zinc and selenium supplementation improves the humoral response, and that vitamin supplementation led to a weaker response, but chance variation is another explanation.

Infectious morbidity, respiratory and urogenital infections were reported in both of these studies. In the smaller study ¹²⁴^,¹²⁶ (n=81) patients in the mineral and (mineral/vitamin) groups had significantly fewer respiratory and urogenital infections( p<0.01). In the larger multicentre study ¹²⁵ (n=725) no significant difference between the groups was observed. However, there are some limitations with this last result. A subgroup of 140/725 patients in this study received influenza vaccine to assess immunological outcomes. Infections were reported for the total number of patients and not extracted for the group that received the vaccine. These two trials ^124–126 also reported mortality and both found no significant differences between the groups.

In a further small study in the UK ⁸, a two month period of supplementation with a complete vitamin/trace element mixture was not associated with any significant alteration in antibody response to influenza vaccination.

8.9.3.3. HIV-infected patients

Studies considered for this review

A single study was identified ¹⁶⁹ which included 481 HIV-infected patients randomised to receive either a high dose multiple micronutrient or a placebo for a period of 48 weeks. Patients were examined clinically 12-weekly and tested for CD4 cell count 24-weekly.

Clinical Evidence

There were no statistically significant differences in overall mortality or changes in CD4 cell count.

8.9.4. Multivitamin v placebo/standard care

8.9.4.1. Studies considered for this review

Three studies were included in this category ¹⁵⁹^,²⁷⁵^,³⁶⁴ and although there was a variation in the content of the intervention supplement, most were composed of vitamins C,+/− A, B and E. One included older long-stay stroke patients ²⁷⁵ and one included acute medical or surgical patients ³⁶⁴ (Table 31). The other study ¹⁵⁹ included older medical patients who received in addition to the intervention/placebo either a glucose energy or placebo drink.

8.9.4.2. Clinical Evidence

One study ²⁷⁵ reported changes in absolute number of lymphocytes and T cells sub-types. This showed a significant increase in the intervention group (p<0.05). Mental test score and Barthel score (activity score) were reported in one study ¹⁵⁹ with no significant differences between the groups. Change in body weight was reported in two studies¹⁵⁹^,²⁷⁵. In one there was no significant change whilst in the other ²⁷⁵, the supplemented group lost weight compared to placebo p<0.05). There were no significant differences reported for mortality or length of stay ¹⁵⁹^,³⁶⁴ although the findings in the Vlaming study did suggest that length of stay may be shorter in multivitamin supplemented acute hospital patients and if this were the case, it would be a very important finding since the intervention is relatively low cost and probably harmless. More research is therefore needed with a large multi—=centre trial to clarify this point.

(Note: The most commonly reported outcome was biochemical assessment of plasma vitamins and minerals. This data was not extracted.)

8.9.4.3. Cost-effectiveness evidence

We did not find any relevant economic studies.

8.9.5. The National Diet and Nutrition Survey

The National Diet and Nutrition Survey presented findings on biochemical indices of nutritional status and nutrient intake in older people living in nursing homes. Results from the survey indicate that although the food supply appears to contain sufficient amounts of vitamins and trace elements, in general the status of vitamins and minerals is poor in this population, suggesting that intake and absorption from food was inadequate. The reasons for this are not clear, but possibilities include the presentation and timing of the food, the need for assistance in eating, changes in absorptive function of the gut, and general medical condition.

8.9.6. Conclusions

There is no evidence to support the routine use of vitamin and mineral supplements in either acute hospitalised patients or older residents of nursing homes. However, in view of the National Diet and Nutrition Survey findings, large scale trials are needed and a vitamin/mineral supplement may be beneficial in older people when there is concern about the adequacy of total food intake.

8.9.7. Rationale for recommendation

The National Diet and Nutrition Survey has shown biochemical deficiency of vitamins and or minerals is common in older people, particularly those in residential care. Studies to determine whether there is definite benefit of providing vitamin supplements to patients have been inadequate, but balanced micronutrient supplements providing the reference nutrient intake for all vitamins and trace elements, have been shown to improve biochemical deficiencies.

8.9.8. Recommendations for clinical practice

8.9.8.1. Oral multivitamin and mineral supplement

If there is concern about the adequacy of micronutrient intake, a complete oral multivitamin and mineral supplement providing the reference nutrient intake for all vitamins and trace elements should be considered by healthcare professionals with the relevant skills and training in nutrition support who are able to determine the nutritional adequacy of a patient’s dietary intake. [D(GPP)]

8.10. Nutrition support in patients with dysphagia

8.10.1. Introduction

Dysphagia is the term used to describe any impairment of eating, drinking and swallowing. It is …’ not a disease in itself, but rather a symptom of one or more underlying pathologies…’ ¹⁹⁴.. Patients with dysphagia are seen in both hospital and community settings, with varying degrees of severity and impact on individuals’ lives. Around 50% of older people with dysphagia living in either nursing homes or attending clinics reported that they ate less, whilst 44% reported weight loss and 41%, anxiety or panic attacks during mealtimes⁹⁰. There is therefore a close link between dysphagia and nutritional compromise. Indeed, one study showed that by offering swallowing therapy to dysphagic patients post stroke, they could improve nutritional parameters ⁹⁵. The cause of dysphagia can be either a single medical problem (e.g. acute cerebral conditions, progressive neurological disorders and trauma, disease or surgery to the mouth, pharynx, larynx or oesophagus ²⁰⁴). It can also occur or worsen with conditions such as sepsis, respiratory impairment and cognitive disorders.

If the dysphagia is not diagnosed, it can lead to inadequate food and fluid intake, impaired nutritional status and problems such as chest infections, sepsis, and pneumonia. Avoidance of eating may also lead to social isolation and ultimately dysphagia has a ‘high morbidity, mortality and cost’⁶⁹^,²⁵⁵. As a result, particularly since it is not always obvious that a patient has dysphagia, the condition must be assessed and managed by a knowledgeable and skilled team.

8.10.2. Prevalence of dysphagia

The prevalence of oropharyngeal dysphagia is estimated to be 60% in nursing home residents and 12–13% of patients in hospital⁶⁹. The prevalence for the general population over 50 years is cited as 16–22% ¹⁹⁴., Specific examples of conditions which may present with dysphagia include 27 – 100% of stroke patients ¹⁹⁴ depending on the time assessed post stroke, adults with learning disabilities (36% of people with learning difficulties in hospital and 5.3% of those in the community present with dysphagia¹⁵⁶ and between 48–100% of patients with Motor Neurone Disease (MND)¹⁹⁴. However, there is considerable variation in prevalences cited, probably due to variation in the timing and completeness of assessments (e.g. in stroke the incidence of presentation with aspiration risk is 51% on admission, 27% at day 7, 6.8% at 6 months, and 2.3% after 6 months)³²⁹.

8.10.3. Identifying patients with dysphagia

Patients with dysphagia may present with a range of symptoms which can be divided into obvious and less obvious indicators (Table 16)

Table 16

Obvious and less obvious indicators for dysphagia.

Patients with any of the obvious or less obvious indicators for dysphagia should be referred for assessment by healthcare professionals with specialist training in diagnosis, assessment and management of swallowing disorders. A variety of skills is needed including those of speech and language therapists, gastroenterologists, radiologists and specialist nurses. Healthcare professionals should be aware that patients with acute cerebral conditions, degenerative disorders (e.g. MND, dementia), trauma, disease, or who have undergone surgery or radiotherapy to the upper aero-digestive tract, are at high risk of developing dysphagia.

8.10.4. Nutritional intervention strategies

There are a number of possible treatment strategies that may help to maintain or improve the nutritional status of patients with oro-pharyngeal dysphagia. These include modification of the consistency, temperature and/or taste of liquids and food. Factors to be considered before any modification is undertaken are listed in table 21 but more detailed guidance can be found in specialist documents (e.g. National descriptors for Texture Modification in Adults, 2002⁴⁴) In some situations, however, modification of texture and consistency may compromise hydration status, nutritional intake, and swallowing safety\efficiency for patients³⁷¹ and so help from appropriately trained healthcare professionals should always be sought and all oral and non-oral options must be considered¹¹⁰.

8.10.5. Methods

We searched for systematic reviews and RCTs investigating either the effectiveness of modified foods and fluids or the use of and enteral tube feeding in dysphagic patients. No studies or systematic reviews were found, probably because RCTS are not feasible in this patient group. The GDG therefore appointed a sub-group of experts to develop our recommendations which were ratified by the whole GDG through informal consensus.

8.10.6. Rationale for Recommendations

Due to the complex nature of dysphagia and the range of its presentations our recommendations offer a framework upon which to make decisions that are based on individual patients’ symptoms rather than specific diagnoses. The recommendations must take into account the appropriateness of intervention in individual cases and all ethical/legal issues (section 5.3) and decisions should always involve the patient, family and clinical teams. Dysphagia specialists should advise the clinical teams.

8.11. Recommendations for clinical practice

8.11.1. People with dysphagia

People who present with any obvious or less obvious indicators of dysphagia listed in Box 5 should be referred to healthcare professionals with relevant skills and training in the diagnosis, assessment and management of swallowing disorders. [D(GPP)]

Box 5

Indicators of dysphagia.

Healthcare professionals should recognise that people with acute and chronic neurological conditions and those who have undergone surgery or radiotherapy to the upper aero-digestive tract are at high risk of developing dysphagia. [D(GPP)]

When managing people with dysphagia, healthcare professionals with relevant skills and training in the diagnosis, assessment and management of swallowing disorders should consider:

the risks and benefits of modified oral nutrition support and/or enteral tube feeding
the factors listed in Box 6. [D(GPP)]

Box 6

Factors to be considered before modification of nutrition support and hydration in people with dysphagia.

People with dysphagia should have a drug review to ascertain if the current drug formulation, route and timing of administration remains appropriate and is without contraindications for the feeding regimen or swallowing process. [D(GPP)]

Healthcare professionals with relevant skills and training in the diagnosis, assessment and management of swallowing disorders should regularly monitor and reassess people with dysphagia who are having modified food and liquid until they are stable. [D(GPP)]

8.12. Research recommendations

What are the benefits of patients (in hospital or the community, including older people) identified as high risk of malnutrition by a screening tool such as the ‘Malnutrition Universal Screening Tool’ (‘MUST’) being offered either oral nutritional supplements compared to a) dietary modification and or food fortification, or b) dietary modification and or food fortification and dietary counselling in terms of determining complications, survival, length of hospital stay, quality of life and cost effectiveness?

This is an essential recommendation for research since there is insufficient evidence on the benefits of intervention used for oral nutrition support in particular the benefits of often first line treatment for example food fortification and or dietary counselling. It is essential to know this so that the indications on who to treat can be further supported

What are the benefits to patients in hospital identified as at high risk of malnutrition by a screening tool such as the ‘Malnutrition Universal Screening Tool’ (‘MUST’) being offered either a) complete oral nutritional supplements b) combined micro and macronutrient supplements or c) micronutrient supplementation in terms of survival, hospital admissions, quality of life and cost effectiveness?

This is an essential recommendation for research since there is insufficient evidence on the benefits of intervention using oral nutrition support and/or micronutrients but indications that such interventions might decrease complications, mortality and lengths of stay. Results will clarify indications on who to treat and the best means of doing so.

What are the benefits to patients in primary care identified as high risk of malnutrition by a screening tool such as the ‘Malnutrition Universal Screening Tool’ (‘MUST’) being offered either oral nutritional supplements compared to being offered; a) combined micro and macronutrient supplement or b) micronutrient supplementation alone or c) standard care (no specific dietary intervention) in terms of survival, hospital admissions, quality of life and cost effectiveness?

This is an essential recommendation for research since there is insufficient evidence on the benefits of intervention used for oral nutrition support. It is essential to know this so that the indications on who to treat can be further supported.

Do patients with oro-pharyngeal dysphagia (as assessed by a trained practitioner) who are given thickened liquids compared to standard/unthickened liquids benefit in terms of improved mood, increased nutritional intake, reduce dehydration, less aspiration incidents, mortality and avoidance of the need for enteral feeding?

This is an essential area for research. Thickening liquids(and foods) is a major cost consideration with no evidence to support it and increasing evidence to show it causes more harm than good for example dehydration.

Do patients with oro-pharyngeal dysphagia (as assessed by a trained practitioner) who are given pureed food compared to standard/soft food benefit in terms of improved nutritional intake, the safety and efficiency of swallow, the number of aspiration incidents and avoidance of the need for enteral feeding?

This is an essential area for research. Thickening liquids or modifying foods for example liquidised foods) has cost implications with no evidence to support it and increasing evidence to show it causes more harm, for example dehydration, than good.

Footnotes

33: Oral nutrition support includes any of the following methods to improve nutritional intake: fortified food with protein, carbohydrate and/or fat, plus minerals and vitamins; snacks; oral nutritional supplements; altered meal patterns; the provision of dietary advice.
34: Malnourished: BMI <18.5 kg/m², unintentional weight loss >10% within the last 3–6 months, a BMI<20 kg/m² and unintentional weight loss >5% within the last 3–6 months.
35: At risk of malnutrition: eaten little or nothing for more than 5 days and/or likely to eat little or nothing for the next 5 days or longer or poor absorptive capacity, and or high nutrient losses and or increased nutritional needs from causes such as catabolism.
36: Malnourished: BMI <18.5 kg/m², unintentional weight loss >10% within the last 3–6 months, a BMI<20 kg/m² and unintentional weight loss >5% within the last 3–6 months.

Apart from any fair dealing for the purposes of research or private study, criticism or review, as permitted under the Copyright, Designs and Patents Act, 1988, no part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page.

The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use.

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National Collaborating Centre for Acute Care (UK). Nutrition Support for Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. London: National Collaborating Centre for Acute Care (UK); 2006 Feb. (NICE Clinical Guidelines, No. 32.) 8, Oral nutrition support in hospital and the community.
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Introduction
Oral nutritional support versus standard care in malnourished patients
Dietary advice versus standard care
Oral nutritional supplements versus dietary advice
Recommendations for clinical practice
Oral nutrition support in surgical patients
Recommendations for clinical practice
Oral nutrition support in pancreatitis patients
Oral multivitamin and mineral supplementation in malnourished patients
Nutrition support in patients with dysphagia
Recommendations for clinical practice
Research recommendations

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