30th July 2023

Management of malnutrition

The most crucial factor in managing malnutrition is identifying and addressing the underlying cause, which can involve medical, surgical or social interventions.

Patients may also require referral to dieticians, who can provide specialist support primarily focusing on optimising intake. They are an especially crucial part of the multidisciplinary team for chronic illnesses like cystic fibrosis.

Diet and nutritional support

NICE provides comprehensive guidelines on nutritional support. It should be considered in any malnourished patient (see definition above) and also people with little or no food intake for >5 days and who are unlikely to have adequate nutrition in the next 5 days.

Nutritional support can encompass oral, enteral or parenteral nutrition, including supplements and artificial feeding. Prescriptions are tailored to an individual’s requirement, but a general guideline is:

• 25–35 kcal/kg/day total energy (including that derived from protein)
• 0.8–1.5 g protein (0.13–0.24 g nitrogen)/kg/day
• 30–35 ml fluid/kg (with allowance for extra losses and inputs)
• Ensure adequate electrolytes, minerals, micronutrients and fibre

Oral supplements include high energy juices and milkshakes, with Fortisips and Fortijuices being commonly prescribed brands.

Enteral nutrition refers to supplementation that can be given when a patient has an adequately functioning GI tract. This includes the use of the oral route, and also ‘tube feeding’ with NG (nasogastric), PEG (percutaneous endoscopic gastronomy), and PEJ (percutaneous endoscopic jejunostomy) tubes, when the oral route is not accessible and is hence bypassed to provide direct nutrition to the GI tract

Parenteral nutrition is where the GI tract cannot be used to absorb nutrients, due to conditions relating to malabsorption, following bowel resections, or bowel obstruction. Nutrition is instead delivered through the IV route, with long-term venous access routes such as central lines used to administer this. Total parenteral nutrition (TPN) refers to patients who receive all of their nutritional requirements via this route. Parental nutrition can be given at regular intervals throughout the day, akin to meal times, or can be given continuously overnight, and is able to be delivered at home.

All of these forms of nutrition need to be prescribed by a qualified medical professional and require specialist input for long-term monitoring and management.