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

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

NICE Clinical Guidelines - National Collaborating Centre for Acute Care (UK)

Version: February 2006

Oral nutrition support in hospital and the community

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.

Introduction and methods

Malnutrition is common - many people who are unwell in hospital or the community, are likely to eat and drink less than they need. This impairment of food and fluid intake may be short-lived as part of an acute illness, or prolonged if there are chronic medical or social problems. If impaired food intake persists for even a few days, a patient can become malnourished to a degree that may impair recovery or precipitate other medical problems. This is especially true if the patient was malnourished before they became unwell due to other longstanding medical or psycho-social problems, or a generally poor diet. To compound any disease related reduction in food intake, many patients also have no help with obtaining or preparing meals when they are ill at home, while those in hospital may have further problems relating to poor standards of catering, inappropriate or interrupted meal times, incorrect food consistencies, and inappropriate eating aids and/or staff to help them eat and drink for themselves. The ‘Better Hospital Food’ and the ‘Protected Mealtimes’ plans are welcome government initiatives which try to improve the provision of hospital meals and snacks.

What to give in hospital and the community

Individual patients’ nutritional needs vary with their current and past nutritional history and the nature of their condition. It is therefore essential to estimate nutritional requirements before instigating nutrition support. Since either inadequate or excessive macronutrient or micronutrient provision can be harmful, recommendations on appropriate levels would ideally be based on large studies comparing the effects of different levels of feeding on clinical outcomes e.g. complications, length of stay, and mortality. However, relatively few such studies have been published and hence the recommendations in this part of the guideline were proposed by a number of GDG members who have expertise in this area and a knowledge of other widely accepted levels of feeding including those recommended by BAPEN and the PEN Group. These accepted levels evolved over several decades from studies of metabolic rate and nitrogen balance along with measurements of electrolyte and micronutrient status in both healthy volunteers and patients. Nevertheless, members of the GDG have concerns about some aspects of current practice, particularly the potential over provision of nutrition in early feeding of severely ill or injured patients (see Section 6.6).

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