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## Complete Summary

#### GUIDELINE TITLE

Nutrition support in adults: oral nutrition support, enteral tube
feeding and parenteral nutrition.

#### BIBLIOGRAPHIC SOURCE(S)

National Collaborating Centre for Acute Care. Nutrition support in
adults: oral nutrition support, enteral tube feeding and parenteral
nutrition. London (UK): National Institute for Health and Clinical
Excellence; 2005 Nov. 451 p. \[384 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Malnutrition

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Screening\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Gastroenterology\
Geriatrics\
Internal Medicine\
Nutrition

#### INTENDED USERS

Advanced Practice Nurses\
Dietitians\
Nurses\
Occupational Therapists\
Patients\
Pharmacists\
Physician Assistants\
Physicians\
Psychologists/Non-physician Behavioral Health Clinicians

#### GUIDELINE OBJECTIVE(S)

To improve the practice of nutrition support by providing guidance to
assist all healthcare professionals to correctly identify patients in
hospital or the community who require nutritional intervention, and to
help them choose and deliver the most appropriate form of nutrition
support at the appropriate time

#### TARGET POPULATION

Adults (aged 18 years or older) who are either malnourished or are at
risk of malnutrition

Excluded patient groups include the following:

-   Patients requiring specific therapeutic or maintenance nutrition
    regimens in the context of diseases such as inborn errors of
    metabolism, diabetes and chronic renal or liver failure

-   Pregnant women, since the nutritional demands on the mother and baby
    need specialist considerations

-   Patients with eating disorders

-   People who are obese

-   Healthy individuals in the general population (i.e., for primary
    prevention of malnutrition)

-   Children and adolescents under 18 years of age

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Screening for malnutrition and risk of malnutrition in hospital and
    the community

2.  Consideration of nutritional support based on evaluation of body
    mass index, unintended weight loss, lack of nutritional intake, poor
    absorptive capacity and/or nutrient loss

3.  Determination of route of delivery of nutritional support and mode
    of access

4.  Oral nutrition support

5.  Enteral nutrition support (via tube through stomach, duodenum or
    jejunum)

6.  Parenteral nutrition support

7.  Monitoring of nutritional support

8.  Use of motility agents

9.  Consideration of ethical and legal issues

#### MAJOR OUTCOMES CONSIDERED

-   Effectiveness of nutritional support

-   Cost effectiveness of nutritional support

-   Adverse effects associated with nutritional support

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

A literature review was conducted to identify and synthesise relevant
evidence from the published literature. Three main search strategies
were developed for oral, enteral and parenteral nutrition interventions.
Four other search strategies were developed for nutritional screening,
monitoring, dysphagia and patient issues.

Search filters to identify systematic reviews (SRs) and randomised
controlled trials (RCTs) were applied to the search strategies. No
language restrictions were applied to the search; however, foreign
language papers were not requested or reviewed.

The following databases were included in the literature search:

-   The Cochrane Library up to 2005 (Issue 1)

-   Medline (Dialog Datastar) 1966-2005 (week)

-   Embase (Dialog Datastar) 1980-2005 (week)

-   Cinahl (Dialog Datastar) 1982-2005

-   Allied & Complementary Medicine (Dialog Datastar) 1985-2005

-   British Nursing Index (Dialog Datastar) 1994-2005

Although literature searching was started in 2003 update searches were
run for each search to ensure all reviews included literature up to the
same cut-off date. Therefore, each database was searched from its start
date up to 3rd March 2005. Papers identified after this date were not
considered, with the exception of the draft British Association of
Parenteral and Enteral Nutrition (BAPEN) report on \'The cost of
malnutrition in the UK and the economic case for the use of oral
supplements (ONS) in adults\', which the Guideline Development Group
(GDG) had been anticipating but which was received shortly after the
cut-off date. Search strategies can be found in Appendix Three of the
original guideline document.

There was no systematic attempt to search for all the \'grey
literature\' (conferences, abstracts, theses and unpublished
literature). The GDG searched for guidelines and reports from relevant
websites, including the following listed below. Bibliographies of
identified reports and guidelines were also checked to identify relevant
literature.

-   National Institute for Health and Clinical Excellence (NICE)
    ([www.nice.org.uk](http://www.nice.org.uk/))

-   National electronic Library for Health (NeLH)
    (<http://www.nelh.nhs.uk/>)

-   National Institutes of Health Consensus Development Program
    (<http://www.consensus.nih.gov/>)

-   New Zealand Guidelines Development Group (NZGG)
    (<http://www.nzgg.org.nz/>)

-   Scottish Intercollegiate Guideline Network (SIGN)
    ([www.sign.ac.uk](http://www.sign.ac.uk/))

-   US National Guideline Clearinghouse
    ([www.guideline.gov](http://www.guideline.gov/))

-   Web sites of relevant members of the Guidelines International
    Network ([www.g-i-n.net/)](http://www.g-i-n.net/)

-   [[Google
    (]{.underline}](http://www.g-i-n.net/)[www.google.com](http://www.google.com/))

**Study Selection**

One reviewer independently scanned the titles and abstracts of the
literature searches. Full publications were obtained for any studies
considered relevant or where there was insufficient information from the
title and abstract to make a decision.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**1++** High-quality meta-analyses, systematic reviews of randomised
controlled trials (RCTs), or RCTs with a very low risk of bias

**1+** Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs
with a low risk of bias

**1-** Meta-analyses, systematic reviews of RCTs, or RCTs with a high
risk of bias

**2++** High-quality systematic reviews of case-control or cohort
studies

High-quality case-control or cohort studies with a very low risk of
confounding, bias or chance and a high probability that the relationship
is causal

**2+** Well-conducted case-control or cohort studies with a low risk of
confounding, bias or chance and a moderate probability that the
relationship is causal

**2-** Case-control or cohort studies with a high risk of confounding,
bias, or chance and a significant risk that the relationship is not
causal

**3** Non-analytical studies (for example, case reports, case series)

**4** Expert opinion, formal consensus

#### METHODS USED TO ANALYZE THE EVIDENCE

Meta-Analysis\
Review of Published Meta-Analyses\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

**Data Extraction and Quality Assessment**

A team of reviewers individually applied the inclusion/exclusion
criteria to determine all potentially relevant studies. The reviewers
also assessed the quality of eligible studies by referring to the
Scottish Intercollegiate Guidelines Network (SIGN) quality checklists
for systematic reviews/meta-analyses and randomised control trials. Of
all the relevant studies data on the type of population, intervention,
comparator and outcomes was summarised onto evidence tables (see
Appendix Four of the original guideline document). In the instances
where there was missing data the Guideline Development Group (GDG) did
not attempt to contact the authors because of limited resources.

**Meta-analysis**

For some of their results the GDG were able to produce a meta-analysis
using Review Manager version 4.2, the software used by the Cochrane
Collaboration. For some studies the GDG approximated the mean length of
stay using the median and estimated the standard deviation as a weighted
mean of the standard deviations of the other studies.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus\
Expert Consensus (Delphi)\
Expert Consensus (Nominal Group Technique)\
Informal Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The Guideline Development Group (GDG) was presented with summaries (text
and evidence tables) of the best available research evidence to answer
the clinical questions. Recommendations were based on and explicitly
linked to the evidence that supported them. With the exception of the
nutrition screening recommendations the Group worked on an informal
consensus basis to formulate and grade recommendations according to the
level of evidence upon which they were based. In the final stages of the
guideline development process, the recommendations were further revised
at a number of meetings where the GDG members agreed by informal the
consensus the final wording and meaning of the recommendations as a
round table discussion.

**Recommendations in the Absence of Literature**

The recommendations in this guideline have been systematically developed
with as much scientific rigour as possible. However for a number of the
clinical questions there was an absence of randomised controlled trial
(RCT) evidence either because the clinical questions did not lend
themselves to controlled trials and systematic reviewing, or for which
there were too few trials identified to make substantive
recommendations. Invariably, the GDG needed to use additional approaches
such as surveys or informal/formal consensus development to assist with
some areas of the guidance. Below is a description of the areas of the
guideline that required additional approaches in addition to systematic
searching and reviewing of RCTs.

*Nutritional screening*: Because of weaknesses in the methodologies and
designs of the studies identified, no firm conclusions could be made. A
modified Delphi approach for consensus development was used, consisting
of two rounds of Delphi questionnaire surveys and then a nominal group
technique meeting. See Screening Chapter 4.7 Consensus development
methods in the original guidelines document.

*Indications for oral, enteral and parenteral interventions*: The
guidance could not be derived from controlled trials thus the
recommendations were drafted by the technical team at the National
Collaborating Centre for Acute Care (NCC-AC) and modified and agreed by
informal consensus with the GDG.

*Ethical and Legal issues*: The brief important comments on the ethical
and legal issues of nutrition support contained within these Guidelines
were derived from GDG expertise and previous expert treatises on these
topics.

*Dysphagia*: No RCT\'s were found to provide guidance on options of
nutrition support for patients with dysphagia. A specialist subgroup of
speech and language therapists with a special interest in dysphagia was
convened to develop and propose suitable recommendations. These were
agreed by informal consensus with the GDG.

*Prescription of nutrients*: Recommendations were proposed by GDG
members with relevant expertise and agreed by informal consensus among
all GDG members.

*Refeeding syndrome*: Recommendations were formulated by members of the
group based on previous published reviews and their own expertise, and
agreed by informal consensus among all GDG members.

*Monitoring*: The GDG were sent questionnaires electronically asking
them to determine how often certain nutritional and biochemical
parameters are and should be measured. Two GDG members with expertise in
this area considered the outcomes of the survey and proposed the
guidance/recommendations which the GDG agreed by informal consensus.

*Nutritional assessment*: Two GDG members with expertise in this area
proposed the guidance/recommendations to the whole GDG who agreed on
these by informal consensus.

*Nutrition support teams*: Both randomised and non-randomised trials
were considered for this section as some observational study designs
were also appropriate for this question.

*Patients\' and carers\' views*: The GDG sent letters requesting
evidence on patients\' and carers\' views of nutrition support to twenty
stakeholders. A literature search was conducted to identify relevant
evidence for any study design. Three sub-group meetings with patient
representatives on the GDG were held. Patient representatives were
involved in the sifting of the abstracts retrieved from the literature
search. A systematic reviewer summarised the evidence from the studies.
The text was included in discussion with patient representatives at
sub-group meetings and in consultation with GDG members at GDG meetings.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**A** - At least one meta-analysis, systematic review, or randomised
controlled trial (RCT) rated as 1++, and is directly applicable to the
target population, *or*

A systematic review of RCTs or a body of evidence that consists
principally of studies rated as 1+, directly applicable to the target
population, and demonstrating overall consistency of results

Evidence drawn from a NICE technology appraisal

**B** - A body of evidence that includes studies rated as 2++, is
directly applicable to the target population and demonstrates overall
consistency of results, *or*

Extrapolated evidence from studies rated as 1++ or 1+

**C** - A body of evidence that includes studies rated as 2+, is
directly applicable to the target population and demonstrates overall
consistency of results, *or*

Extrapolated evidence from studies rated as 2++

**D** - Evidence level 3 or 4, *or*

Extrapolated evidence from studies rated as 2+, *or*

Formal consensus

**D (GPP)** - A good practice point (GPP) is a recommendation for best
practice based on the experience of the Guideline Development Group

#### COST ANALYSIS

**Health Economics Methods**

To assess the cost-effectiveness of each recommendation, a comprehensive
systematic review of the economic literature was conducted. In addition
an original cost-effectiveness analysis was performed for malnutrition
screening.

The primary criteria applied for an intervention to be considered
cost-effective were either:

a.  The intervention dominated other relevant strategies (that is, it is
    both less costly in terms of resource use and more clinically
    effective compared with the other relevant alternative strategies);
    or

b.  The intervention cost less than 20,000 pounds sterling per
    quality-adjusted life-year (QALY) gained compared with the next best
    strategy (and compared with best supportive care). Between 20,000
    and 30,000 pounds sterling per QALY, judgments about the
    acceptability of the intervention as an effective use of National
    Health Service (NHS) resources have to make more explicit reference
    to such factors as the degree of uncertainty surrounding the
    calculation of cost-effectiveness, the innovative nature of the
    intervention and the particular features of the condition and the
    population receiving it.

**Cost-effectiveness Modelling**

Screening was selected for original economic analysis because it was
likely that the recommendations under consideration would substantially
change clinical practice in the NHS and have important consequences for
resource use. The details of the model are reported in chapter 4 and
Appendix Five: Cost-Effectiveness Analysis of Malnutrition Screening of
the original guideline document.

See the \"Availability of Companion Documents\" field for additional
costing information, including a \"Costing Template\" and a \"Costing
Report\" for nutrition support in adults.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The guideline was validated through two consultations.

1.  The first draft of the guideline (The full guideline, National
    Institute for Health and Clinical Excellence (NICE) guideline and
    Quick Reference Guide) were consulted with Stakeholders and comments
    were considered by the Guideline Development Group (GDG)

2.  The final consultation draft of the Full guideline, the NICE
    guideline and the Information for the Public were submitted to
    stakeholders for final comments.

3.  The final draft was submitted to the Guideline Review Panel for
    review prior to publication.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Levels of evidence **(1-4)** and grading of recommendations **(A- D
\[GPP\])** are defined at the end of the \"Major Recommendations\"
field.

**[Organisation of Nutrition Support in Hospital and the
Community]{.underline}**

**D (GPP)** - All healthcare professionals who are directly involved in
patient care should receive education and training, relevant to their
post, on the importance of providing adequate nutrition.

**D (GPP)** - Education and training should cover:

-   nutritional needs and indications for nutrition support

-   options for nutrition support (oral, enteral and parenteral)

-   ethical and legal concepts

-   potential risks and benefits

-   when and where to seek expert advice

**D (GPP)** - Healthcare professionals should ensure that care provides:

-   food and fluid of adequate quantity and quality in an environment
    conducive to eating

-   appropriate support, for example, modified eating aids, for people
    who can potentially chew and swallow but are unable to feed
    themselves

**D (GPP)** - Healthcare professionals should ensure that all people who
need nutrition support receive coordinated care from a multidisciplinary
team (the composition of this team may differ according to setting and
local arrangements).

**D (GPP)** - All acute hospital trusts should have a multidisciplinary
nutrition support team which may include: doctors (for example
gastroenterologists, gastrointestinal surgeons, intensivists or others
with a specific interest in nutrition support), dietitians, a specialist
nutrition nurse, other nurses, pharmacists, biochemistry and
microbiology laboratory support staff, and other allied healthcare
professionals (for example, speech and language therapists).

**D (GPP)** - All hospital trusts should have a nutrition steering
committee working within the clinical governance framework.

**D (GPP)** - Members of the nutrition steering committee should be
drawn from trust management, and include senior representation from
medical staff, catering, nursing, dietetics, pharmacy and other
healthcare professionals as appropriate, for example, speech and
language therapists.

**D (GPP)** - All acute hospital trusts should employ at least one
specialist nutrition support nurse.

**D (GPP)** - The specialist nutrition support nurse should work
alongside nursing staff, as well as dietitians and other experts in
nutrition support, to:

-   minimise complications related to enteral tube feeding and
    parenteral nutrition

-   ensure optimal ward-based training of nurses

-   ensure adherence to nutrition support protocols

-   support coordination of care between the hospital and the community

**[Screening for Malnutrition and the Risk of Malnutrition in Hospital
and the Community]{.underline}**

**D (GPP)** - Screening for malnutrition and the risk of malnutrition
should be carried out by healthcare professionals with appropriate
skills and training.

**D (GPP)** - All hospital inpatients on admission and all outpatients
at their first clinic appointment should be screened. Screening should
be repeated weekly for inpatients and when there is clinical concern for
outpatients.

**D (GPP)** - Hospital departments who identify groups of patients with
low risk of malnutrition may opt out of screening these groups. Opt-out
decisions should follow an explicit process via the local clinical
governance structure involving experts in nutrition support.

**D (GPP)** - People in care homes should be screened on admission and
when there is clinical concern.

**D (GPP)** - Screening should take place on initial registration at
general practice surgeries and when there is clinical concern, (Clinical
concern includes, for example, unintentional weight loss, fragile skin,
poor wound healing, apathy, wasted muscles, poor appetite, altered taste
sensation, impaired swallowing, altered bowel habit, loose fitting
clothes or prolonged intercurrent illness.) Screening should also be
considered at other opportunities (for example, health checks, flu
injections).

**D (GPP)** - Screening should assess body mass index (BMI) \[BMI is
weight (kg)/height(m^2^) (weight in kilograms divided by height in
metres squared)\] and percentage unintentional weight loss and should
also consider the time over which nutrient intake has been
unintentionally reduced and/or the likelihood of future impaired
nutrient intake. The Malnutrition Universal Screening Tool (MUST), for
example, may be used to do this.

**[Indications for Nutrition Support in Hospital and the
Community]{.underline}**

**D (GPP)** - Nutrition support should be considered in people who are
malnourished, as defined by any of the following:

-   a BMI of less than 18.5 kg/m^2^

-   unintentional weight loss greater than 10% within the last 3 to 6
    months

-   a BMI of less than 20 kg/m^2^ and unintentional weight loss greater
    than 5% within the last 3 to 6 months

**D (GPP)** - Nutrition support should be considered in people at risk
of malnutrition who, as defined by any of the following:

-   have eaten little or nothing for more than 5 days and/or are likely
    to eat little or nothing for the next 5 days or longer

-   have a poor absorptive capacity, and/or have high nutrient losses
    and/or have increased nutritional needs from causes such as
    catabolism

**D (GPP)** - Healthcare professionals should consider using oral,
enteral or parenteral nutrition support, alone or in combination, for
people who are either malnourished or at risk of malnutrition. Potential
swallowing problems should be taken into account.

Healthcare professionals involved in starting or stopping nutrition
support should:

-   obtain consent from the patient if he or she is competent

-   act in the patient\'s best interest if he or she is not competent to
    give consent

-   be aware that the provision of nutrition support is not always
    appropriate. Decisions on withholding or withdrawing of nutrition
    support require a consideration of both ethical and legal principles
    (both at common law and statute including the Human Rights Act 1998)

**D (GPP)** - When such decisions are being made guidance issued by the
General Medical Council (\"Withholding and withdrawing life prolonging
treatments: good practice in decision making,\" 2005) and the Department
of Health (Good Practice in Consent Advisory Group, 2001) should be
followed.

**D (GPP)** - Healthcare professionals should ensure that people having
nutrition support, and their carers, are kept fully informed about their
treatment. They should also have access to appropriate information and
be given the opportunity to discuss diagnosis and treatment options.

**[What to Give in Hospital and the Community]{.underline}**

**D (GPP)** - Healthcare professionals who are skilled and trained in
nutritional requirements and methods of nutrition support should ensure
that the total nutrient intake (total intake includes intake from any
food, oral fluid, oral nutritional supplements, enteral and/or
parenteral nutrition support and intravenous fluid) of people prescribed
nutrition support accounts for:

-   energy, protein, fluid, electrolyte, mineral, micronutrients (the
    term micronutrient is used throughout to include all essential
    vitamins and trace elements) and fibre needs

-   activity levels and the underlying clinical condition -- for
    example, catabolism, pyrexia

-   gastrointestinal tolerance, potential metabolic instability and risk
    of refeeding problems

-   the likely duration of nutrition support

**D (GPP)** - For people who are not severely ill or injured, nor at
risk of refeeding syndrome, the suggested nutritional prescription for
total intake should provide all of the following:

-   25 to 35 kcal/kg/day total energy (including that derived from
    protein \[This level may need to be lower in people who are
    overweight, BMI\>25. When using parenteral nutrition it is often
    necessary to adjust total energy values listed on the
    manufacturer\'s information which may not include protein energy
    values.\])

-   0.8 to 1.5 g protein (0.13 to 0.24 g nitrogen)/kg/day

-   30 to 35 ml fluid/kg (with allowance for extra losses from drains
    and fistulae, for example, and extra input from other sources -- for
    example, intravenous drugs)

-   adequate electrolytes, minerals, micronutrients (allowing for any
    pre-existing deficits, excessive losses or increased demands) and
    fibre if appropriate

**D (GPP)** - The prescription should be reviewed according to the
person\'s progress, and care should be taken when:

-   using food fortification which tends to supplement energy and/or
    protein without adequate micronutrients and minerals

-   using feeds and supplements that meet full energy and nitrogen
    needs, as they may not provide adequate micronutrients and minerals
    when only used in a supplementary role

-   using pre-mixed parenteral nutrition bags that have not had tailored
    additions from pharmacy

**D (GPP)** - Nutrition support should be cautiously introduced in
seriously ill or injured people requiring enteral tube feeding or
parenteral nutrition. It should be started at no more than 50% of the
estimated target energy and protein needs. It should be built up to meet
full needs over the first 24 to 48 hours according to metabolic and
gastrointestinal tolerance. Full requirements of fluid, electrolytes,
vitamins and minerals should be provided from the outset of feeding.

**D (GPP)** - People who have eaten little or nothing for more than 5
days should have nutrition support introduced at no more than 50% of
requirements for the first 2 days, before increasing feed rates to meet
full needs if clinical and biochemical monitoring reveals no refeeding
problems.

**D (GPP)** - People who meet the criteria in the table below entitled
\"Criteria for determining people at high risk of developing refeeding
problems\" should be considered to be at high risk of developing
refeeding problems.

**Criteria for Determining People at High Risk of Developing Refeeding
Problems**

+-----------------------------------------------------------------------+
| Patient has one or more of the following:                             |
|                                                                       |
| -   BMI less than 16 kg/m^2^                                          |
|                                                                       |
| -   unintentional weight loss greater than 15% within the last 3 to 6 |
|     months                                                            |
|                                                                       |
| -   little or no nutritional intake for more than 10 days             |
|                                                                       |
| -   low levels of potassium, phosphate or magnesium prior to feeding  |
|                                                                       |
| Or patient has two or more of the following:                          |
|                                                                       |
| -   BMI less than 18.5 kg/m^2^                                        |
|                                                                       |
| -   unintentional weight loss greater than 10% within the last 3 to 6 |
|     months                                                            |
|                                                                       |
| -   little or no nutritional intake for more than 5 days              |
|                                                                       |
| -   a history of alcohol abuse or drugs including insulin,            |
|     chemotherapy, antacids or diuretics                               |
+-----------------------------------------------------------------------+

**D (GPP)** - People at high risk of developing refeeding problems (see
table above) should be cared for by healthcare professionals who are
appropriately skilled and trained and have expert knowledge of
nutritional requirements and nutrition support.

**D (GPP)** - The prescription for people at high risk of developing
refeeding problems should consider:

-   starting nutrition support at a maximum of 10 kcal/kg/day,
    increasing levels slowly to meet or exceed full needs by 4 to 7 days

-   using only 5 kcal/kg/day in extreme cases (for example, BMI less
    than 14 kg/m^2^ or negligible intake for more than 15 days) and
    monitoring cardiac rhythm continually in these people and any others
    who already have or develop any cardiac arrhythmias

-   restoring circulatory volume and monitoring fluid balance and
    overall clinical status closely

-   providing immediately before and during the first 10 days of
    feeding: oral thiamin 200 to 300 mg daily, vitamin B compound (co)
    strong 1 or 2 tablets, three times a day (or full dose daily
    intravenous vitamin B preparation, if necessary) and a balanced
    multivitamin/trace element supplement once daily.

-   providing oral, enteral or intravenous supplements of potassium
    (likely requirement 2 to 4 mmol/kg/day), phosphate (likely
    requirement 0.3 to 0.6 mmol/kg/day) and magnesium (likely
    requirement 0.2 mmol/kg/day intravenous, 0.4 mmol/kg/day oral)
    unless pre-feeding plasma levels are high. Pre-feeding correction of
    low plasma levels is unnecessary

**[Monitoring of Nutrition Support in Hospital and the
Community]{.underline}**

**D (GPP)** - Healthcare professionals should review the indications,
route, risks, benefits and goals of nutrition support at regular
intervals. The time between reviews depends on the patient, care setting
and duration of nutrition support. Intervals may increase as the patient
is stabilised on nutrition support.

**D (GPP)** - People having nutrition support in hospital should be
monitored by healthcare professionals with the relevant skills and
training in nutritional monitoring.

**D (GPP)** - Healthcare professionals should refer to the protocols for
nutritional, anthropometric and clinical monitoring, shown in Table 3 of
the original guideline document, when monitoring people having nutrition
support in hospital.

**D (GPP)** - Healthcare professionals should refer to the protocols for
laboratory monitoring, shown in Table 4 of the original guideline
document, when monitoring people having nutrition support in hospital.
Table 4 of the original guideline document is particularly relevant to
parenteral nutrition. It could also be selectively applied when enteral
or oral nutrition support is used, particularly for people who are
metabolically unstable or at risk of refeeding syndrome. The frequency
and extent of the observations given may need to be adapted in acutely
ill or metabolically unstable people.

**D (GPP)** - People having parenteral nutrition in the community need
regular assessment and monitoring. This should be carried out by home
care specialists and by experienced hospital teams (initially at least
weekly), using observations marked \* in Table 3 of the original
guideline document. In addition, they should be reviewed at a specialist
hospital clinic every 3 to 6 months. Monitoring should be more frequent
during the early months of home parenteral nutrition, or if there is a
change in clinical condition, when the full range of tests in Tables 3
and 4 of the original guideline document should be performed. Some of
the clinical observations may be checked by patients or carers.

**D (GPP)** - People having oral nutrition support and/or enteral tube
feeding in the community should be monitored by healthcare professionals
with the relevant skills and training in nutritional monitoring. This
group of people should be monitored every 3 to 6 months or more
frequently if there is any change in their clinical condition. A limited
number of observations and tests from Table 3 of the original guideline
document should be performed. Some of the clinical observations may be
checked by patients or carers. If clinical progress is satisfactory,
laboratory tests are rarely needed.

**D (GPP)** - If long-term nutrition support is needed patients and
carers should be trained to recognise and respond to adverse changes in
both their well-being and in the management of their nutritional
delivery system.

**[Oral Nutrition Support in Hospital and the Community]{.underline}**

**People with Dysphagia**

**D (GPP)** - People who present with any obvious or less obvious
indicators of dysphagia listed in the table below, titled \" Indicators
of dysphagia\" should be referred to healthcare professionals with
relevant skills and training in the diagnosis, assessment and management
of swallowing disorders.

**Indicators of Dysphagia**

  -----------------------------------------------------------------------
  **Obvious Indicators of          **Less Obvious Indicators of
  Dysphagia**                      Dysphagia**
  -------------------------------- --------------------------------------
  Difficult, painful chewing or    Change in respiration pattern
  swallowing                       

  Regurgitation of undigested food Unexplained temperature spikes

  Difficulty controlling food or   Wet voice quality
  liquid in the mouth              

  Drooling                         Tongue fasciculation (may be
                                   indicative of motor neurone disease)

  Hoarse voice                     Xerostomia

  Coughing or choking before,      Heartburn
  during or after swallowing       

  Globus sensation                 Change in eating habits -- for
                                   example, eating slowly or avoiding
                                   social occasions

  Nasal regurgitation              Frequent throat clearing

  Feeling of obstruction           Recurrent chest infections

  Unintentional weight loss -- for Atypical chest pain
  example, in people with dementia 
  -----------------------------------------------------------------------

**D (GPP)** - 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 the table below, titled \"Factors to be
    considered before modification of nutrition support and hydration in
    people with dysphagia\"

**Factors to Be Considered Before Modification of Nutrition Support and
Hydration in People with Dysphagia**

  -----------------------------------------------------------------------
  Recurrent chest infections\
  \
  Mobility\
  \
  Dependency on others for assistance to eat\
  \
  Perceived palatability and appearance of food or drink\
  \
  Level of alertness\
  \
  Compromised physiology\
  \
  Poor oral hygiene\
  \
  Compromised medical status\
  \
  Metabolic and nutritional requirements\
  \
  Vulnerability (for example, immunocompromised)\
  \
  Comorbidities

  -----------------------------------------------------------------------

**D (GPP)** - 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.

**Indications for Oral Nutrition Support**

**A** - Healthcare professionals should consider oral nutrition support
(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) to improve
nutritional intake for people who can swallow safely and are
malnourished (see definition above in \"Indications for Nutrition
Support in Hospital and the Community\") or at risk of malnutrition (see
definition above in \"Indications for Nutrition Support in Hospital and
the Community\").

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

**Oral Nutrition Support for Surgical Patients**

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

**A** - 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.

**[Enteral Tube Feeding in Hospital and the Community]{.underline}**

In this guideline, enteral tube feeding refers to the delivery of a
nutritionally complete feed (as specified in Chapter 9 of the original
guideline document) via a tube into the stomach, duodenum or jejunum.

**Indications for Enteral Tube Feeding**

**D (GPP)** - Healthcare professionals should consider enteral tube
feeding in people who are malnourished or at risk of malnutrition
respectively, and have:

-   inadequate or unsafe oral intake, and

-   a functional, accessible gastrointestinal tract

**A** - Enteral tube feeding should not be given to people unless they
are malnourished or at risk of malnutrition and have; inadequate or
unsafe oral intake and a functional, accessible gastrointestinal tract,
or they are taking part in a clinical trial.

**D (GPP)** - Enteral tube feeding should be stopped when the patient is
established on adequate oral intake.

**Enteral Tube Feeding for Surgical Patients**

**B** - Surgical patients who are: malnourished and have; inadequate or
unsafe oral intake and a functional, accessible gastrointestinal tract
and are due to undergo major abdominal procedures, should be considered
for pre-operative enteral tube feeding.

**A** - General surgical patients should not have enteral tube feeding
within 48 hours post-surgery unless they are malnourished or at risk of
malnutrition and have; inadequate or unsafe oral intake and a
functional, accessible gastrointestinal tract.

**Route of Access**

**A** - People in general medical, surgical and intensive care wards who
are malnourished or at risk of malnutrition and have; inadequate or
unsafe oral intake and a functional, accessible gastrointestinal tract
should be fed via a tube into the stomach unless there is upper
gastrointestinal dysfunction.

**D (GPP)** - People who are malnourished or at risk of malnutrition and
have inadequate or unsafe oral intake and a functional, accessible
gastrointestinal tract, with upper gastrointestinal dysfunction (or an
inaccessible upper gastrointestinal tract) should be considered for
post-pyloric (duodenal or jejunal) feeding.

**D (GPP)** - Gastrostomy feeding should be considered in people likely
to need long-term (4 weeks or more) enteral tube feeding.

**A** - Percutaneous endoscopic gastrostomy (PEG) tubes which have been
placed without apparent complications can be used for enteral tube
feeding 4 hours after insertion.

**People with Dysphagia**

**A** - In the acute setting, for example following stroke, people
unable to swallow safely or take sufficient energy and nutrients orally
should have an initial 2 to 4 week trial of nasogastric enteral tube
feeding. Healthcare professionals with relevant skills and training in
the diagnosis, assessment and management of swallowing disorders should
assess the prognosis and options for future nutrition support.

**Mode of Delivery**

**B** - For people being fed into the stomach, bolus or continuous
methods should be considered, taking into account patient preference,
convenience and drug administration.

**D (GPP)** - For people in intensive care, nasogastric tube feeding
should usually be delivered continuously over 16 to 24 hours daily. If
insulin administration is needed it is safe and more practical to
administer feeding continuously over 24 hours.

**Motility Agents**

**A** - For people in intensive care with delayed gastric emptying who
are not tolerating enteral tube feeding, a motility agent should be
considered, unless there is a pharmacological cause that can be
rectified or suspicion of gastrointestinal obstruction.

**D (GPP)** - People in other acute care settings who have delayed
gastric emptying and are not tolerating enteral tube feeding should also
be offered a motility agent unless there is a pharmacological cause that
can be rectified or suspicion of gastrointestinal obstruction.

**D (GPP)** - If delayed gastric emptying is severely limiting feeding
into the stomach, despite the use of motility agents, post-pyloric
enteral tube feeding and/or parenteral nutrition should be considered.

**Management of Tubes**

**D (GPP)** - People requiring enteral tube feeding should have their
tube inserted by healthcare professionals with the relevant skills and
training.

**D (GPP)** - The position of all nasogastric tubes should be confirmed
after placement and before each use by aspiration and pH graded paper
(with X-ray if necessary) as per the advice from the National Patient
Safety Agency (NPSA) 2005. Local protocols should address the clinical
criteria that permit enteral tube feeding. These criteria include how to
proceed when the ability to make repeat checks of the tube position is
limited by the inability to aspirate the tube, or the checking of pH is
invalid because of gastric acid suppression.

**D (GPP)** - The initial placement of post-pyloric tubes should be
confirmed with an abdominal X-ray (unless placed radiologically). Agreed
protocols setting out the necessary clinical checks need to be in place
before this procedure is carried out.

**[Parenteral Nutrition in Hospital and the Community]{.underline}**

**Indications for Parenteral Nutrition**

**D (GPP)** - Healthcare professionals should consider parenteral
nutrition in people who are malnourished or at risk of malnutrition,
respectively, and meet either of the following criteria:

-   inadequate or unsafe oral and/or enteral nutritional intake

-   a non-functional, inaccessible or perforated (leaking)
    gastrointestinal tract

**Prescription**

**D (GPP)** - Parenteral nutrition should be introduced progressively
and closely monitored, usually starting at no more than 50% of estimated
needs for the first 24 to 48 hours. Parenteral nutrition can be
withdrawn once adequate oral or enteral nutrition is tolerated and
nutritional status is stable. Withdrawal should be planned and stepwise
with a daily review of the patient\'s progress.

**D (GPP)** - Patients who need parenteral nutrition should have their
nutritional requirements determined by healthcare professionals with the
relevant skills and training in the prescription of nutrition support.
Before using most parenteral nutrition products, micronutrients and
trace elements should be added and additional electrolytes and other
nutrients may also be needed. Additions should be made under appropriate
pharmaceutically controlled environmental conditions before
administration.

**D (GPP)** - Parenteral nutrition should be stopped when the patient is
established on adequate oral and/or enteral support. There is no minimum
length of time for the duration of parenteral nutrition.

**Parenteral Nutrition for Surgical Patients**

**B** - Healthcare professionals should consider supplementary
peri-operative parenteral nutrition in malnourished surgical patients
who have an inadequate or unsafe oral and/or enteral nutritional intake
or a non-functional, inaccessible or perforated (leaking)
gastrointestinal tract

**B** - Peri-operative supplementary parenteral nutrition should not be
given to surgical patients unless they are malnourished or at risk of
malnutrition and have an inadequate or unsafe oral and/or enteral
nutritional intake or a non-functional, inaccessible or perforated
(leaking) gastrointestinal tract.

**B** - If intestinal tolerance persistently limits enteral tube feeding
in surgical or critical care patients, parenteral nutrition should be
used to supplement or replace enteral tube feeding.

**Route of Access**

**B** - In hospital, parenteral nutrition can be given via a dedicated
peripherally inserted central catheter as an alternative to a dedicated
centrally placed central venous catheter. A free dedicated lumen in a
multi-lumen centrally placed catheter may also be used.

**B** - Administration of parenteral nutrition via a peripheral venous
catheter should be considered for patients who are likely to need
short-term parenteral nutrition (less than 14 days) who have no need for
central access for other reasons. Care should be taken in catheter
choice and in attention to pH, tonicity and long-term compatibility of
the parenteral nutrition formulations in order to avoid administration
or stability problems.

**D (GPP)** - Tunnelling subclavian lines is recommended for long-term
use (more than 30 days).

**B** - Catheters do not have to be tunnelled for short-term use (less
than 30 days).

**Mode of Delivery**

**B** - Continuous administration of parenteral nutrition should be
offered as the preferred method of infusion in severely ill people who
require parenteral nutrition.

**B** - Cyclical delivery of parenteral nutrition should be considered
when using peripheral venous cannulae with planned routine catheter
change.

**D (GPP)** - A gradual change from continuous to cyclical delivery
should be considered in patients requiring parenteral nutrition for more
than 2 weeks.

**Management of Catheters**

**D (GPP)** - Only healthcare professionals competent in catheter
placement should be responsible for the placement of catheters and they
should be aware of the importance of monitoring and managing these
safely (National Collaborating Centre for Nursing and Supportive Care,
2003).

**[Supporting Patients in the Community]{.underline}**

**D (GPP)** - Healthcare professionals should ensure that patients
having enteral or parenteral nutrition in the community and their
carers:

-   are kept fully informed and have access to appropriate sources of
    information in formats, languages and ways that are suited to an
    individual\'s requirements. Consideration should be given to
    cognition, gender, physical needs, culture and stage of life of the
    individual

-   have the opportunity to discuss diagnosis, treatment options and
    relevant physical, psychological and social issues

-   are given contact details for relevant support groups, charities and
    voluntary organisations

**Enteral Tube Feeding**

**D (GPP)** - All people in the community having enteral tube feeding
should be supported by a coordinated multidisciplinary team, which
includes dietitians, district, care home or homecare company nurses,
General Practitioners (GPs), community pharmacists and other allied
healthcare professionals (for example, speech and language therapists)
as appropriate. Close liaison between the multidisciplinary team and
patients and carers regarding diagnoses, prescription, arrangements and
potential problems is essential.

**D (GPP)** - Patients in the community having enteral tube feeding and
their carers should receive an individualised care plan which includes
overall aims and a monitoring plan.

**D (GPP)** - Patients in the community having enteral tube feeding and
their carers, should receive training and information from members of
the multidisciplinary team on:

-   the management of the tubes, delivery systems and the regimen,
    outlining all procedures related to setting up feeds, using feed
    pumps, the likely risks and methods for troubleshooting common
    problems and be provided with an instruction manual (and visual aids
    if appropriate)

-   both routine and emergency telephone numbers to contact a healthcare
    professional who understands the needs and potential problems of
    people on home enteral tube feeding

-   the delivery of equipment, ancillaries and feed with appropriate
    contact details for any homecare company involved

**Parenteral Nutrition**

**D (GPP)** - All people in the community having parenteral nutrition
should be supported by a co-ordinated multidisciplinary team, which
includes input from specialist nutrition nurses, dietitians, GPs,
pharmacists and district and/or homecare company nurses. Close liaison
between the multidisciplinary team and patients and carers regarding
diagnoses, prescription, arrangements and potential problems is
essential.

**D (GPP)** - People in the community having parenteral nutrition and
their carers should receive an individualised care plan which includes
overall aims and a monitoring plan.

**D (GPP)** - People in the community having parenteral nutrition and
their carers should receive training and information from members of the
multidisciplinary team on:

-   the management of the delivery systems and the regimen, outlining
    all procedures related to setting up feeds, using feed pumps, the
    likely risks and methods for troubleshooting common problems and be
    provided with an instruction manual (and visual aids if appropriate)

-   routine and emergency telephone numbers to contact a healthcare
    professional with the relevant competencies (specialist nutrition
    nurse, pharmacist)

-   the arrangements for the delivery of equipment, ancillaries and feed
    with appropriate contact details for any homecare company involved

**[Definitions]{.underline}**:

**Evidence Categories**

**1++** High-quality meta-analyses, systematic reviews of randomised
controlled trials (RCTs), or RCTs with a very low risk of bias

**1+** Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs
with a low risk of bias

**1-** Meta-analyses, systematic reviews of RCTs, or RCTs with a high
risk of bias

**2++** High-quality systematic reviews of case-control or cohort
studies

High-quality case-control or cohort studies with a very low risk of
confounding, bias or chance and a high probability that the relationship
is causal

**2+** Well-conducted case-control or cohort studies with a low risk of
confounding, bias or chance and a moderate probability that the
relationship is causal

**2-** Case-control or cohort studies with a high risk of confounding,
bias, or chance and a significant risk that the relationship is not
causal

**3** Non-analytical studies (for example, case reports, case series)

**4** Expert opinion, formal consensus

**Recommendation Grades**

**A** - At least one meta-analysis, systematic review, or randomised
controlled trial (RCT) rated as 1++, and is directly applicable to the
target population, *or*

A systematic review of RCTs or a body of evidence that consists
principally of studies rated as 1+, directly applicable to the target
population, and demonstrating overall consistency of results

Evidence drawn from a NICE technology appraisal

**B** - A body of evidence that includes studies rated as 2++, is
directly applicable to the target population and demonstrates overall
consistency of results, *or*

Extrapolated evidence from studies rated as 1++ or 1+

**C** - A body of evidence that includes studies rated as 2+, is
directly applicable to the target population and demonstrates overall
consistency of results, *or*

Extrapolated evidence from studies rated as 2++

**D** - Evidence level 3 or 4, *or*

Extrapolated evidence from studies rated as 2+, *or*

Formal consensus

**D (GPP)** - A good practice point (GPP) is a recommendation for best
practice based on the experience of the Guideline Development Group

#### CLINICAL ALGORITHM(S)

Algorithms are provided in the original guideline document for:

-   Patient Pathway

-   Oral Support

-   Enteral and Parenteral Support

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=8739)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is provided for each recommendation (see
\"Major Recommendations\" field).

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate use of nutritional support in patients who are malnourished
to improve nutritional intake

#### POTENTIAL HARMS

-   Potential risk of refeeding syndrome in patients receiving
    nutritional support

-   Oral supplementation can cause pneumonia in dysphagic patients,
    while enteral tube feeding and parenteral nutrition can cause
    gastrointestinal problems, infections, metabolic upset and trauma.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

This guidance represents the view of the Institute, which was arrived at
after careful consideration of the evidence available. Healthcare
professionals are expected to take it fully into account when exercising
their clinical judgement. The guidance does not, however, override the
individual responsibility of healthcare professionals to make decisions
appropriate to the circumstances of the individual patient, in
consultation with the patient and/or guardian or carer.

**Specific Problems with Evidence Relating to the Development of
Nutrition Support Guidelines**

Literature searching, appraising the evidence and developing
recommendations for this guideline proved to be particularly
challenging. In part, this was due to a shortage of randomised
controlled trials relating to some of the clinical questions, but the
Guideline Development Group (GDG) also observed problems with the types
of patients entered into many of the selected controlled trials.
Providing adequate nutrition is usually seen as a part of basic care,
and this creates obstacles to good quality research in nutrition
support. For example, although it is obvious that inadequate provision
of nutrition for prolonged periods eventually leads to death, no
randomised trials support this statement and any recommendation that
patients should not be allowed to die of starvation is therefore grade
D.

Other fundamental problems with available evidence include:

a.  In trials of nutritional intervention it is often neither feasible
    nor ethical to have \'no nutrition\' as the control.

b.  Patients who are malnourished and therefore eligible to be recruited
    for trials of nutrition support have very variable diagnoses and
    come from a wide variety of settings. Trial populations are
    therefore very heterogeneous with wide potential variation in
    outcomes of interest. Large scale studies are therefore needed to
    demonstrate any potential benefits on outcome but most nutritional
    trials have been small.

c.  When performing trials on invasive means of nutrition support such
    as enteral and parenteral nutrition, it is usually considered
    unethical to randomise patients who have an \'undoubted\' need for
    such support. Trials therefore recruit patients who are at lower
    nutritional risk than those conventionally fed by these methods and
    so their results may be inapplicable to normal clinical practice.

d.  Developments in the formulations and delivery of enteral and
    parenteral nutrition support and consequent reductions in risk have
    made many older studies less relevant. For instance, in recent years
    it has been recognised that too much additional nutrient provision
    can sometimes be more harmful than no nutrition support, yet much of
    the literature pre-dates this change in thinking.

The GDG also encountered methodological problems with the available
nutritional research, including:

a.  Significant heterogeneity in the outcomes reported (e.g. for one
    type of intervention, 5 separate studies may use 5 different
    indicators to report change in nutritional status).

b.  Lack of information on the period prior to starting nutrition
    support despite the fact that the duration and intensity of
    starvation before intervention is clearly pertinent to any outcome.

c.  Study periods which were often too short to determine the true
    effect of any intervention (e.g. reporting change in body weight two
    weeks after prescribing a oral nutritional supplement may not be
    long enough to establish whether the patient benefits in the long
    term).

d.  Weak characterisation of patient populations in terms of underlying
    diagnosis, illness severity or degree of malnutrition.

e.  Lack of information on the amount of feed actually received by
    patients and/ or the wide variation in the amount received (a
    particular weakness of older enteral feeding studies).

f.  The presence of many potentially confounding issues when reporting
    outcomes attributed by authors to nutritional intervention in small
    trials (e.g. infection rates and mortality).

g.  The predominance of evidence from limited acute or chronic care
    settings with complete absence of evidence from other settings makes
    generalisation of conclusions difficult.

In view of the above, many questions related to nutrition support may be
better addressed by study designs other than RCTs but the broad scope of
these Guidelines and the difficulties with handling the biases
associated with observational studies prevented the GDG from formally
searching for sources of non-RCT evidence. In the absence of evidence
from RCT\'s many of the clinical questions have therefore been addressed
using expert opinion and consensus techniques.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

**[Key Priorities for Implementation]{.underline}**

The following recommendations have been selected from the full list as
priorities for implementation.

**Key Clinical Priorities**

-   Screening for malnutrition and the risk of malnutrition should be
    carried out by healthcare professionals with appropriate skills and
    training.

-   All hospital inpatients on admission and all outpatients at their
    first clinic appointment should be screened. Screening should be
    repeated weekly for inpatients and when there is clinical concern
    for outpatients. People in care homes should be screened on
    admission and when there is clinical concern.

-   Hospital departments who identify groups of patients with low risk
    of malnutrition may opt out of screening these groups. Opt-out
    decisions should follow an explicit process via the local clinical
    governance structure involving experts in nutrition support.

-   Nutrition support should be considered in people who are
    malnourished, as defined by any of the following:

    -   A body mass index (BMI) of less than 18.5 kg/m^2^

    -   Unintentional weight loss greater than 10% within the last 3 to
        6 months

    -   A BMI of less than 20 kg/m^2^ and unintentional weight loss
        greater than 5% within the last 3 to 6 months.

-   Nutrition support should be considered in people at risk of
    malnutrition, defined as those who have:

    -   Eaten little or nothing for more than 5 days and/or are likely
        to eat little or nothing for 5 days or longer

    -   A poor absorptive capacity and/or high nutrient losses and/or
        increased nutritional needs from causes such as catabolism.

-   Healthcare professionals should consider using oral, enteral or
    parenteral nutrition support, alone or in combination, for people
    who are either malnourished or at risk of malnutrition, as defined
    above. Potential swallowing problems should be taken into account.

**Key Organisational Priorities**

-   All healthcare professionals who are directly involved in patient
    care should receive education and training, relevant to their post,
    on the importance of providing adequate nutrition.

-   Healthcare professionals should ensure that all people who need
    nutrition support receive coordinated care from a multidisciplinary
    team.

-   All acute hospital trusts should employ at least one specialist
    nutrition support nurse.

-   All hospital trusts should have a nutrition steering committee
    working within the clinical governance framework.

**[Implementation in the National Health Service]{.underline}**

The Healthcare Commission will assess the performance of National Health
Service (NHS) organisations in meeting core and developmental standards
set by the Department of Health in Standards for better health issued in
July 2004.

Suggested audit criteria based on the key priorities for implementation
are listed in Appendix D of the original guideline document (short
version), and can be used to audit practice locally.

#### IMPLEMENTATION TOOLS

Audit Criteria/Indicators\
Clinical Algorithm\
Patient Resources\
Quick Reference Guides/Physician Guides\
Slide Presentation

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

National Collaborating Centre for Acute Care. Nutrition support in
adults: oral nutrition support, enteral tube feeding and parenteral
nutrition. London (UK): National Institute for Health and Clinical
Excellence; 2005 Nov. 451 p. \[384 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2005 Nov

#### GUIDELINE DEVELOPER(S)

National Collaborating Centre for Acute Care - National Government
Agency \[Non-U.S.\]

#### SOURCE(S) OF FUNDING

National Institute for Health and Clinical Excellence (NICE)

#### GUIDELINE COMMITTEE

Guideline Development Group

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Group Members*: Dr Mike Stroud (*Chair*) Institute of Human Nutrition,
Southampton General Hospital; British Association of Parenteral and
Enteral Nutrition (BAPEN); Ms Christine Baldwin, Dietitian, Department
of Medicine and Therapeutics, Imperial College, London; British Dietetic
Association (BDA); Mrs Vicky Bradnam, Chief Pharmacist, Bromley
Hospitals NHS Trust, Bromley, Royal Pharmaceutical Society of Great
Britain; Mrs Andrea Cartwright, Senior Nutrition Nurse Specialist,
Basildon University Hospital; National Nurses Nutrition Group (NNNG);
Miss Gwen Coleman, Manager, Food for Thought, Patient representative for
Alzheimer\'s Society; Mrs Linda Ditchburn, Community Nutrition Nurse
Specialist, Fernbank Medical Centre, Birmingham; National Nurses
Nutrition Group (NNNG); Professor Marinos Elia, Professor of Clinical
Nutrition & Metabolism, Institute of Human Nutrition, Southampton
General Hospital; Royal College of Physicians/Malnutrition Action Group
(BAPEN); Professor Richard Griffiths, Professor of Medicine (Intensive
Care), Division of Metabolic and Cellular Medicine, School of Clinical
Science, University of Liverpool, and the Intensive Care Society (UK);
Ms Judith Jackson, Principal Speech and Language Therapist, Islington
PCT based at Whittington Hospital; Royal College of Speech and Language
Therapists Advisor in dysphagia; Professor Paul Little, Professor of
Primary Care Research, University of Southampton; Royal College of
General Practitioners; Mr Bruce McElroy, Associate Director of Pharmacy,
University Hospital Birmingham Foundation Trust, Birmingham, Royal
Pharmaceutical Society of Great Britain; Dr Jeremy Nightingale,
Consultant Gastroenterologist, Digestive Disease Centre, Leicester Royal
Infirmary; British Society of Gastroenterology; Miss Joanna Prickett,
Chief Dietitian, Department Nutrition and Dietetics, North Bristol NHS
Trust, British Dietetic Association; Professor Alan Shenkin, Professor
of Clinical Chemistry and Hon Consultant Chemical Pathologist,
Department of Clinical Chemistry, University of Liverpool;
Intercollegiate Group for Nutrition; Mrs Carolyn Wheatley, Chairman,
Patients on Intravenous and Nasogastric Nutrition Therapy (PINNT);
Patient Representative for PINNT

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

The Guideline Development Group was asked to declare any possible
conflict of interest and none that could interfere with their work on
the guideline were declared. All documentation is held by the National
Collaborating Centre for Acute Care.

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) format
from the [National Institute for Health and Clinical Excellence (NICE)
Web site](http://www.nice.org.uk/guidance/CG32/?c=91500).

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   National Collaborating Centre for Acute Care. Nutrition support in
    adults. Nutrition support in adults: oral nutrition support, enteral
    tube feeding and parenteral nutrition. London (UK): National
    Institute for Health and Clinical Excellence (NICE); 2006 Feb. 54 p.
    (Clinical guideline; no. 32). Electronic copies: Available in
    Portable Document Format (PDF) format from the [National Institute
    for Health and Clinical Excellence (NICE) Web
    site](http://www.nice.org.uk/page.aspx?o=cg032niceguideline).

-   Nutrition support in adults. Oral nutrition support, enteral tube
    feeding and parenteral nutrition. Quick reference guide. National
    Collaborating Centre for Acute Care; 2006 Feb. 25 p. Electronic
    copies: Available from the [National Institute for Health and
    Clinical Excellence (NICE) Web
    site](http://www.nice.org.uk/page.aspx?o=cg032quickrefguide).

Print copies: Available from the National Health Service (NHS) Response
Line 0870 1555 455. ref: N0977. 11 Strand, London, WC2N 5HR.

The following are also available:

-   National Institute for Health and Clinical Excellence. Nutrition
    support in adults: oral supplements, enteral and parenteral feeding.
    Costing template (England). London (UK): National Institute for
    Health and Clinical Excellence (NICE); 2006 Feb. Various p.
    Electronic copies: Available from the [National Institute for Health
    and Clinical Excellence (NICE) Web
    site](http://www.nice.org.uk/page.aspx?o=293229).

-   National Institute for Health and Clinical Excellence. Nutrition
    support in adults: oral nutrition support, enteral tube feeding and
    parenteral nutrition. Costing report. London (UK): National
    Institute for Health and Clinical Excellence (NICE); 2006 Feb. 45 p.
    Electronic copies: Available from the [National Institute for Health
    and Clinical Excellence (NICE) Web
    site](http://www.nice.org.uk/page.aspx?o=293232).

-   National Institute for Health and Clinical Excellence. Nutrition
    support in adults. Presenter slides. London (UK): National Institute
    for Health and Clinical Excellence (NICE); 2006 Feb. 28 p.
    Electronic copies: Available from the [National Institute for Health
    and Clinical Excellence (NICE) Web
    site](http://www.nice.org.uk/page.aspx?o=293581).

-   National Institute for Health and Clinical Excellence.
    Implementation advice. Suggested actions for implementing the NICE
    clinical guideline on nutrition support in adults. London (UK):
    National Institute for Health and Clinical Excellence (NICE); 2006
    Feb. 17 p. Electronic copies: Available from the [National Institute
    for Health and Clinical Excellence (NICE) Web
    site](http://www.nice.org.uk/page.aspx?o=293585).

#### PATIENT RESOURCES

The following is available:

-   Nutrition support in adults. Understanding NICE guidance --
    information for people who need nutrition support, their families
    and carers, and the public. National Institute for Health and
    Clinical Excellence (NICE), 2006 Feb. 17 p.

Electronic copies: Available in Portable Document Format (PDF) from the
[National Institute for Health and Clinical Excellence (NICE) Web
site](http://www.nice.org.uk/page.aspx?o=cg032publicinfo).

Print copies: Available from the National Health Service (NHS), 11
Strand, London, WC2N 5HR. Response Line 0870 1555 455, ref N0978.

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
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we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This summary was completed by ECRI on April 20, 2006. The information
was verified by the guideline developer on September 4, 2006.

The National Institute for Health and Clinical Excellence (NICE) has
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found at [www.nice.org.uk](http://www.nice.org.uk/).

#### COPYRIGHT STATEMENT

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Date Modified: 11/10/2008