Enteral nutrition management in stroke patients: a narrative review

Introduction

Over the past 30 years, stroke has been the leading cause of death in China. Although prevention and treatment strategies have improved significantly, the incidence of stroke has continually increased from 219 to 247 per 100,000 people in the period between 1989 and 2017 (1,2). The mortality rate of stroke is high compared with the recent mortality rates of other diseases (3). Approximately 16.3–25% of patients who experience stroke are malnourished at admission (4,5), and as the length of hospital stay increases, this rate increases to 56.3–62% (6). The increase in the malnutrition rate is significantly correlated with the prolongation of admission time and the decrease in functional improvement during rehabilitation (7), which affects the prognosis and mortality of the disease (8). In this study, we aimed to summarize the enteral nutrition (EN) management of stroke patients according to recent evidence.

Prof. Omorogieva Ojo and Prof. Joanne Brooke have reviewed EN for stroke patients in 2016 (9), while Chinese guidelines and expert consensuses were absence due to language restriction. To our knowledge, this is the first narrative review that summarizes and compares the latest EN guidelines and expert consensus for stroke patients in China with those of other countries. We summarize the latest developments in the EN guidelines and expert consensus for stroke patients in different countries, and is committed to promoting standardized enteral management of stroke patients. We present the following article in accordance with the Narrative Review reporting checklist (available at https://dx.doi.org/10.21037/apm-21-2922).

Methods

To construct this narrative review, non-systematic searches of the PubMed database were conducted to retrieve relevant English-language articles, and the CNKI and Wanfang database were searched for relevant Chinese-language articles using the following keywords: stroke, guideline, EN, clinical nutrition, practice, and management. Articles deemed relevant to both authors, including animal studies, observational and prospective randomized clinical studies, reviews, meta-analysis, guidelines, and expert consensuses, were included.

Risk factors of malnutrition in stroke patients

The risk of malnutrition was reported as 25.8% when screening within 1.3 days after stroke in UK (10). According to different evaluation criteria the prevalence of malnutrition was 28.7% (11) to 42% (12) at admission, 76% at discharge (12) for Japanese stroke patients. Using the Mini Nutritional Assessment (MNA) (13) criteria, 5% of Netherland stroke patients were malnourished at admission and 14% were at risk of malnutrition. Ten days after stroke, the data surged to 26% and 39% respectively (6). A multi-center prospective survey in China found that the incidence of malnutrition at first stroke patients was about 3.8% when they were admitted to the hospital, and the incidence was about 7.5% at 2 weeks after admission (14). The malnutrition rate ranges due to different evaluation criteria, population, stroke type.

It has been reported that over 90% of stroke patients are plagued by oral intake restriction, which is mainly caused by dysphagia (15,16). The incidence of dysphagia ranges from 8.1% to 80% (17,18), and is the most common complication in patients with stroke and the main cause of malnutrition, especially in elderly patients (19,20). A previous study showed that in patients with acute ischemic stroke (IS), 20.7% have dysphagia, and half have persistent dysphagia at hospital discharge (21). Dysphagia lasts approximately 1 month in 15% of stroke patients and may affect 11–50% at 6 months, which contributes to an increased risk of malnutrition (6,21-24). In recent years, studies have shown that malnutrition and dysphagia are risk factors for each other (25,26). Patients with severe malnutrition risk were less likely to achieve full oral intake (26).

It has been reported that 30.5% of stroke patients require tube feeding (TF) (27), and 30% need TF at discharge (28). The differences in dysphagia incidence are related to the severity of stroke (27), hematoma type, and volume (15).

The risk of malnutrition in patients without dysphagia increases if long-term energy intake insufficiency is accompanied by insufficient protein intake, suggesting that monitoring nutritional intake is necessary. The loss of consciousness (29,30), poor oral hygiene (31), depression (32), reduced mobility (30), and limb and face weakness are associated with a high risk of malnutrition. During hospitalization, age, IS, National Institutes of Health Stroke Scale (NIHSS) score at admission, geriatric nutritional risk index (GNRI) at admission (33). Barthel Index feeding were associated with the nutritional status at discharge (12). Post-stroke depression often reduces a patient’s appetite and impairs the recovery of the patient’s ability to perform daily activities (7). Research shows that body muscle synthesis in healthy older adults is reduced by 30% and muscle strength is reduced by 16% after only 10 days of bed rest (34), which may further affect gastrointestinal motility and reattainment of full oral intake (31). In addition to dysphagia and inadequate food intake, the increased metabolic needs of patients undergoing stroke recovery also increase the risk of malnutrition. In addition, increasing age (35) and malnutrition at the time of admission (36) are also factors that increase the risk of malnutrition.

The occurrence of chronic disease and a history of medication usage at admission are significantly associated with an increased risk of malnutrition, especially in elderly patients. The presence of diabetes at admission and a history of stroke increase the risk of malnutrition by 58% and 71%, respectively (4). Deficiencies in vitamins A, B, C, D and E are significantly related to cerebrovascular disease, and also increase the risk of stroke and cognitive impairment in elderly patients (5,37). A meta-analysis revealed that malnutrition at admission, dysphagia, previous stroke, diabetes mellitus, TF, and a reduced level of consciousness were probably correlated with an increased risk of malnutrition; however, other factors such as alcohol consumption, hypertension, male sex, depression, pneumonia, and infection need to be re-evaluated (29). These different conclusions suggest that additional large studies may be needed.

Consequences of malnutrition

A large number of studies have shown that malnutrition is associated with poor prognosis in patients with stroke (14,38). The mortality rate increases significantly (P<0.001) after adjusting for age, stroke severity, and other stroke risk factors, and this correlation remains significant (P<0.001) (38). A multicenter cohort study in China found that after adjusting for confounding factors, the new cases of malnutrition within 2 weeks of admission (rather than malnutrition at admission) independently predicted the outcome after 3 months [odds ratio (OR) 1.37, 95% confidence interval (CI), 1.03–1.83] (14), suggesting that new cases of malnutrition should be given more attention by medical and nursing staff. An experiment on C57BL/6 mice demonstrated that inadequate food and water intake may influence mortality following experimental stroke. After filament middle cerebral artery occlusion, appropriate nutritional support reduced the 14-day mortality by up to 75% (39).

Serum albumin and prealbumin levels can not only reflect nutritional status but also predict adverse outcomes in patients with stroke. The recurrence of stroke within 1 year is significantly increased in patients with relatively low serum albumin levels after first-ever IS (40). The serum albumin level is decreased after acute IS due to a large ischemic focus and strong catabolic reaction, and a low serum albumin level is a risk factor for worsened neurological state (41). Low serum albumin levels have been shown to be significantly associated with adverse outcomes after 3 months, with an adjusted OR (aOR) value of 1.972 (95% CI: 1.103–4.001; P<0.001) (42). The recurrence and mortality rates of stroke in patients with low serum albumin are also significantly higher than those in patients with high serum albumin levels. A similar conclusion was obtained in a study on recurrence in 753 Chinese patients 1 year after stroke. In this study, patients with hypoproteinemia had a more than 3 times increase in the likelihood of suffering from recurrence (aOR =3.261, 95% CI: 1.914–5.555, P<0.001) after adjustment for other indicators (43), suggesting that low serum albumin levels may increase the risk of stroke recurrence in patients with acute IS. These studies not only confirmed the protective effect of serum albumin on the nervous system but also revealed that the nutritional status of patients was significantly related to clinical prognosis and stroke recurrence from the initial stage of IS to 1 year later. It is suggested that medical staff should pay attention not only to the nutritional level of patients at admission but also to the nutritional status of patients after discharge, as well as necessary nutrition.

Vitamin deficiency, especially the level of vitamin D (VD), which is associated with anxiety (44) and depression (45), also affects the prognoses of stroke patients. Approximately 68.8% of IS patients have VD deficiency, and only 13.6% of patients have ideal VD levels (46). The level of serum VD in patients with good clinical outcomes at 3 months was significantly higher than that in patients with poor outcomes. The increased level of VD in patients with acute stroke has been shown to be significantly correlated with a relatively small cerebral infarction size. Every 10% decrease in serum 25(OH)D doubles the risk of a poor outcome within 90 days (47). Previous research has shown that after adjusting for confounding factors, the functional outcomes of the four groups with the highest levels of 25(OH)D were improved at 3 months (46).

Insufficient fluid intake and fluid loss may be caused by drowsiness, dysphagia, infection-induced fever, vomiting, or diarrhea, resulting in dehydration in stroke patients (48). Approximately 62% of patients experience varying degrees of dehydration (49). Studies have suggested that dehydration adversely affects stroke patients in several ways (50,51). Acute IS patients with dehydration have a higher infection rate (P=0.006), a worse Barthel index at discharge (62.8±37.4 vs. 73.4±32.4, P<0.001, adjusted P<0.001), a lower modified Rankin scale score (2.7±1.6 vs. 2.3±1.5, P<0.001, corrected P=0.009), and higher hospitalization costs (2,470.8±3,160.8 vs. 1,901.2±2,046.8 USD) compared to those without dehydration (P<0.001, corrected P=0.013) (52). The clinical symptoms of patients with mild to moderate dehydration (dry and wrinkled skin, decreased skin elasticity, hypotension, mucosal flushing, or dryness) are not obvious; it is also difficult to diagnose clinical symptoms in elderly patients with dehydration (53). Since there is no current common diagnostic standard, it is difficult to diagnose dehydration accurately (54).

Nutritional management

We have identified 15 guidelines and expert consensus statements, which are discussed and summarized as follows (55-69). Since the Veterans Affairs (VA)/Departments of Defense (DOD) guidelines (65) only have one recommendation about TF, guideline for primary care of IS [2021] (69) just mention the assessment of swallowing, patients with dysphagia receive nutrition support within 7 days, nasogastric tube (NGT) for patients with short-term dysphagia, and gastrostomy tube for long-term, these two are not listed in Table 1.

When, by whom, and how to judge whether a patient needs nutritional support

Identifying patients with nutritional risk or malnourishment is a prerequisite for nutritional management. Ten out of the 15 guidelines recommend that stroke patients should be screened for nutritional risk, and 5 of them suggested as soon as possible after admission (55,56,59,62,63), 2 of them proposed within 24 h (66,67), 3 of them indicated within 48 h (57,58,64). In addition, 3 of them required rescreen at least weekly thereafter (55,56,62), and regularly during rehabilitation (64). A structured tool has been recommended for screening malnutrition (55,56,59,64,66). Body mass index (BMI) and percentage of unintentional weight loss should be assessed during screening (62). The malnutrition universal screening tool (MUST) (70) is a recommended and established nutritional screening tool (58,62) that can be used on stroke patients to identify those at risk of malnutrition (38). Nutrition Risk Screening 2002 (NRS2002) (71) is recommended by three Chinese guidelines (60,63,68). Mini nutritional assessment-short form (MNA-SF) was recommended as the preferred tool for geriatrics by nursing practice guideline for EN in patients with stroke (68) due to its relatively high prediction accuracy (reliability, validity, sensitivity, and specificity). However, Chinese dysphagia and nutrition management manual for acute stroke patients (66) does not recommend it as the preferred screening tool as it has no good correlation and poor specificity with the mortality, complications and other outcome indicators of the elderly. A study from China showed that both NRS2002 and MUST can be used to screen for malnutrition risk in patients with stroke (30). Screening for malnutrition and the risk of malnutrition should be carried out by trained staff (56,62) or by first visited nurse (66). In addition to nutritional risk, screening for swallowing (55,57,58,60,63,67-69) and hydration (56,60) status on admission is also necessary (59,62,66). The guidelines suggest that routine nutritional supplementation for patients without oral intake restriction, malnutrition, or risk of malnutrition is unnecessary (55,56,58,62,67). Abnormal results of swallowing and nutrition screening should be further assessed, and conditions should be managed (55,56,59,62,64,66-69). An individualized nutrition care plan that is developed and monitored by professionals is recommended (56,58,62,64,67).

When, by whom, and how to deliver EN

EN is the most natural way in which nutrients are absorbed (72); the theory of “if the gut works, use it” is widely recognized. EN can be administered via a nasogastric (NG), nasoduodenal or nasojejunal (NJ) TF; percutaneous endoscopic gastrostomy (PEG); or percutaneous endoscopic jejunostomy (PEJ) (72), which is the first choice for patients who can tolerate EN (63). EN can be accomplished by a continuous, set-rate, or intermittent method (72). Figure 1 displays a flow chart showing how to choose the delivery methods of EN for stroke patients after admission.

Figure 1 Tube feeding selection flowchart. NRS2002, Nutritional Risk Screening 2002; MUST, Malnutrition Universal Screening Tool; MNT, medical nutrition therapy; ONS, oral nutritional supplements; TF, tube feeding; NGT, nasogastric tube; EN, enteral nutrition; NJT, nasoduodenal or nasojejunal tube; PEG, percutaneous endoscopic gastrostomy.

EN is recommended to be administered within 24 h (56,62,66) or within 24–48 h (63,67) or not more than 72 h (58), or within 7 days (61-63,66,69) for stroke patients who are unable to maintain adequate nutrition, are already malnourished, or have eating difficulties. A NGT should be considered within 72 h (58) or within the first 7 days (61) for patients who cannot consume adequate nutrition or water orally, or have prolonged severe dysphagia lasting for more than 7 days (58). NGT is the first choice for patients who receive EN within 2 weeks (63). A nasal bridle tube can be applied if the NGT is intolerable or rejected, EN is expected to last for more than 14 days, or the NGT needs frequent replacement (56). Gastrostomy feeding (PEG or PEJ) can be considered if the NGT cannot be tolerated (56,62), if the patient is unable to consume adequate food or fluids orally over 2–3 weeks (67) or 4 weeks (56,57,67) after the onset of stroke or if the patient has a high risk of long-term malnutrition (56). PEG should be considered within 1 week if mechanical ventilation lasts for longer than 48 h (58) or after 14–28 days if EN is needed for a long period of time (>4 weeks) (55,57,58,61,64,68). If conditions permit, PEG is recommended for patients requiring long-term EN (63). A gastrostomy tube is a more sustainable choice than NGT for patients with dysphagia in the post-acute phase of stroke (65). For patients with gastroesophageal reflux and aspiration, the NJ tube (NJT) may be the best choice (57) and continuous drip feeding was recommended (67,68).

Both the amount and rate of EN administered should begin low and be gradually increased, from 20–50 mL/h on the first day to 80–100 mL/h on the next day, and the infusion should be completed in 12–24 h and reach the full amount within 3 days (63,67). The amount of nasal feeding should not exceed 200 mL each time, and the interval should be established according to the total amount of the whole day and the digestion and absorption of the patient (66). Also, a dietitian or nutritional specialist should perform a nutritional assessment, provide advice, and conduct monitoring if a patient is at risk of malnutrition (56,58,59,62,63,67,68), TF placement, dietary modification (56,57,59,64,66), or requires thickened liquids (56,58,66).

According to previous reports, looped NGT feeding is associated with a 17% higher volume of feed and fluids, as well as fewer NGT reinsertions and electrolyte abnormalities compared to conventional adhesive dressings (73). However, there were no differences in case fatality, composite death, or dependency rates between NGT and PEG, but there were fewer treatment failures, less gastrointestinal bleeding, higher feed delivery, and higher albumin concentrations in the PEG group than in the NGT group (8). Another study demonstrated that there was no difference in the outcome of nutritional status, including weight change from baseline and mid-arm circumference at the endpoint, between the PEG and NGT groups; additionally, there were no differences in mortality, overall adverse events at any follow-up time point, and pneumonia (aspiration) rates (74).

For stroke patients who are able to eat but are malnourished (55) or those at risk of malnutrition (58,61), oral nutrition supplements are recommended (68). Fluid balance and nutritional intake for patients who receive texture-modified diets or thickened fluids should be monitored, as they may lead to reduced energy and fluid intake (58).

How much and what to deliver

Indirect calorimetry to estimate energy consumption is recommended (55,67). If indirect calorimetry is not available, the Schofield equation can be used to calculate the basal metabolic rate, or empirical formulas can be used to calculate the energy demand of patients and adjust the basic substrate supply according to the severity of the disease (55).

Energy requirements should be estimated as 25–35 kcal/kg body weight for moderately ambulatory patients [Glasgow coma scale (GCS) score >12 or Acute Physiology and Chronic Health Evaluation (APACHE II) score ≤16]; 20–25 kcal/kg body weight for bedridden patients, with a sugar-lipid mass ratio of 7:3–6:4 and calorie nitrogen ratio of 100–150:1; and 20–25 kcal/kg body weight for severe acute stress patients, with a sugar-lipid mass ratio of 5:5 and a calorie nitrogen ratio of 100:1 (63,67). Dietary fiber intake should be reach 25–30 g/day (55). It is recommended to estimate the daily protein demand of patients through the determination of 24-h urinary urea nitrogen (UUN) (67).

Complications and management

Diarrhea refers to thin stools >3 times/day or >200 g/day. The incidence of diarrhea ranges from 29.4% to 38% (75,76) and often results in electrolyte imbalance, dehydration, perianal skin breakdown, and wound contamination (77). If unable to control diarrhea, clinicians often stop EN, resulting in inadequate nutrition intake (78). Factors associated with the occurrence of diarrhea include the following: EN formulation, supply mode, and speed; EN initiation time and duration (79,80); EN contamination; medication use (antibiotics, proton-pump inhibitors, prokinetics, laxatives); infectious etiologies (77); as well as the NIHSS score (81,82), GCS score (81,83), length of stay (80,81), antibiotic use (80,81) and hypoalbuminemia. A 24-h delivery set hang time is associated with a lower risk of diarrhea and longer diarrhea-free survival in patients with acute stroke under TF than a 72/96-h delivery set hang time (84). Furthermore, 7 days or more of enteral TF is independently associated with diarrhea (82). Altering the composition of polymeric enteral diets to include a rapidly fermentable fiber source can prevent the onset of enteral feeding-related diarrhea (85).

A recent hypothesis suggests that diarrhea may be induced by the presence of poorly absorbed short-chain carbohydrates, including fermentable oligosaccharides (FOs), disaccharides (Ds), monosaccharides (Ms), and polyols (FODMAP) (86). Individuals with digestive impairment and problems with the absorption of these carbohydrates frequently exhibit intolerance to foods rich in FODMAPs, presenting abdominal distension, colic, and diarrhea, among other intestinal symptoms (87). A previous study pointed out that FODMAPs at levels in current enteral formulas are not involved in the pathophysiology of enteral feeding-related diarrhea, and they are likely to be beneficial rather than detrimental (88).

The incidence of diarrhea can be reduced by slowing the infusion speed, reducing the total infusion amount, administering an isotonic nutritional formula, strictly abiding by aseptic techniques, paying attention to the diagnosis of antimicrobial-associated diarrhea (63), correcting hypoproteinemia according to the clinical situation, avoiding the long-term use of broad-spectrum antibiotics, maintaining proper temperatures, administering lactose-free formulas to lactose-intolerant patients (55), administering continuous infusion, and including fiber in enteral diets (89).

Stroke associated pneumonia (SAP) is one of the most fatal complications of stroke (90), and a high NIHSS score (91), dysphagia (91), and proton-pump inhibitor use (92) were found to be correlated with an increased risk of aspiration pneumonia. Disturbance of consciousness after stroke, aspiration caused by swallowing dysfunction and immunosuppression caused by stroke are considered to be the main pathogenesis of SAP (93). Whether NGT placement increases the risk of pneumonia is not clear (94,95). Prophylactic antibiotics were reported to have no effect on pneumonia in stroke patients (96) and is not recommended (97) Previous studies have shown that a three-step multidisciplinary dysphagia screening intervention (95), a formal screening protocol and early dysphagia screening (98) and training for swallowing (97), a structured protocol incorporating cough reflex testing (99), an integrated team approach and dysphagia clinical pathway, and implementing oral hygiene protocols (61,97) had positive impacts on incidence of SAP (100,101). Raising the patient’s bedside 30°–45° is an effective measure to prevent SAP (68,97). Compared with intermittent feeding, continuous feeding helps reduce lung infection and aspiration (68). For patients with pyloric obstruction, gastroparesis, esophageal reflux, or aspiration, the use of post-pyloric TF can reduce the incidence of SAP (97).

Vomiting and abdominal distension can be managed by slowing the speed of infusion, reducing the total infusion amount, identifying causes, treating symptoms, and changing to parenteral nutrition when symptoms are not relieved (63).

Conclusions

The consistency and effectiveness of different nutritional screening tools in stroke patients requires further investigation in large-scale studies in Chinese populations. A simple, fast, easy to understand, and accurate nutritional risk screening tool is helpful in identifying patients who will benefit from nutrition management. Due to the low acceptance of PEG by Chinese patients, there is a lack of research on nutrition satisfaction, prognoses, and complications associated with different feeding methods (NGT, NJT, and PEG) in patients who require long-term (>4 weeks) EN, especially those with a long-term indwelling NGT that should be replaced by PEG but is not.

Nutritional management is an important part of the treatment of stroke patients. Standard nutritional management contributes to the treatment and rehabilitation of stroke. In China, most hospitals do not have nutrition departments or dietitians, and the nutritional management of stroke patients is supervised and implemented by clinicians. Therefore, continuous improvements in nutritional management recommended by the stroke guidelines will be helpful for clinicians and dietitians to standardize the nutritional management of stroke patients.

Acknowledgments

Prof. Yulin Gao merits our gratitude for his advice in revising the review.

Funding: None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://dx.doi.org/10.21037/apm-21-2922

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://dx.doi.org/10.21037/apm-21-2922). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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(English Language Editor: A. Kassem)