Summary

In principle, the European Society for Clinical Nutrition and Metabolism (ESPEN) guideline for clinical practitioners recommends:

• Early diagnosis of OD to prevent malnourishment-related complications and assessment of the risk of aspiration
• Resorting to a general or if possible, a custom nutrition care plan for promoting recovery

ESPEN’s recent guideline on clinical nutrition in neurology provides recommendations on how to address malnourishment and use nutrition as therapy for patients of stroke.

As with most neurological disorders, patients of stroke are susceptible to micronutrient deficiency and dehydration due to Oropharyngeal Dysphagia (OD) and the risk of aspiration. Both are linked to more complications, slower recovery and higher chances of mortality.

Diagnosis of OD and considerations to be given for nutrition therapy

1. Swallowing disorders in patients of stroke are a major cause of malnutrition. Early diagnosis and treatment of dysphagia can help reduce its growing impact on the patient’s health and other looming risks.
2. Every stroke patient should be assessed for the risk of malnutrition within 48 hours of admission to hospital and before providing any oral intake. Further, Malnutrition Universal Screening Tool (MUST) or a similar tool should be used to determine if the patient can benefit from nutrition therapy.
3. It is recommended that a customized nutrition care plan be created for an undernourished stroke patient. A tailored diet can help prevent weight and fat loss, ensure matching his or her energy requirement, and promote faster recovery and improvement in the quality of a patient’s life.
4. Oral Nutritional Supplements (ONS) along with administered diet should be fed only to those stroke patients, who are assessed as malnourished.

Nutrition care for stroke patients with dysphagia and risk of aspiration

Neuropsychological impairment makes prolonged artificial nutrition necessary, which can give rise to aspirations and lead to life-threatening diseases like pneumonia.

A stroke patient, if diagnosed with dysphagia, should be further clinically assessed for the risk of aspiration.

• If the patient tests negative for both, texture-modified and thickened liquid foods can be fed
• However, if the patient tests positive, clinical assessment for dysphagia and aspiration should be regularly performed until the patient can start swallowing normally

Every patient on texture-modified and thickened liquid foods should undergo nutritional assessment and counselling. The assessment and counselling should be continued right till the patient is taken off such foods.

If the assessment demonstrates aspiration to thin liquids, free access to water alongside thickened liquids can be considered. Carbonated liquids may also be used if pharyngeal residue needs to be tackled.

Feeding methods

1. Patients who experience dysphagia for over a week after the stroke should be fed with enteral tube within 72 hours of the event of stroke.
2. Patients of acute stroke, who have impaired or low consciousness and are put on ventilation, must be treated with medical nutrition therapy. They should be fed through an enteral tube within 72 hours of the event of stroke if adequate nutrition cannot be supplied through oral route.
3. If oral food intake is not sufficient, a nasogastric tube should be used for enteral nutrition.
4. If enteral feeding is required for more than 28 days, a Percutaneous Endoscopic Gastrostomy (PEG) should be placed in a stable phase between the 14th and 28th day. If PEG has to be used for stroke patients with dysphagia, ‘Pull’ technique should be preferred over the ‘Push’ technique for PEG placement.
5. A PEG may be placed within a week if the stroke patient is mechanically ventilated for more than 48 hours.

Obstacles in feeding methods and recommended alternatives

If the nasogastric tube is accidentally or repeatedly removed by the patient, a nasal bridle or loop can be used to secure the nasogastric tube for enteral nutrition.

If by chance, the nasogastric tube is rejected by the patient, the nasal bridle or loop is not suited, and medical nutrition seems necessary for more than 14 days, then PEG feeding should be started early.

Nasogastric tube feeding is no obstacle in dysphagia rehabilitation, so therapy should be started as early as possible for all stroke patients.

It was observed in the studied cases that misplacement of the nasogastric tube often happened when the tube coiled up in the pharynx, which made dysphagia worse. In such a scenario or if dysphagia seems to worsen due to any other reason, the pharyngeal tube position should be controlled endoscopically instead of continuing the use of nasogastric tube.

Recommendations for ensuring ethical and fair nutrition treatment

1. In case of unfavourable prognosis, the patient’s will to live should be given ethical consideration.
2. In case of doubt, nasogastric feeding for semi-invasive nutrition should be used. However, artificial nutrition should be given a consideration every day. Tube feeding may be discontinued if indications stop.
3. In case the prognosis is uncertain, PEG insertion or tolerance of nasogastric tube should not be the criteria for considering rehabilitation of a stroke patient.
4. Small diameter nasogastric (8 French) feeding tubes should be used to prevent the risk of internal pressure sores. Tubes with bigger diameters should be used only if gastric decompression is required.