Malnutrition and supplementary feeding

Question 1

When should cystic fibrosis patients receive a nutritional assessment from a specialist dietitian?

Answer 1

The cystic fibrosis specialist dietitian should offer advice on the benefits of optimal nutrition, and at the annual assessment review the person’s:

• total nutritional intake, including energy intake (calories)
• estimated nutritional needs
• pancreatic enzyme replacement therapy, if appropriate

Question 2

CF patients are at risk of being underweight and at risk of fat-soluble vitamin deficiencies. Which vitamins are particularly affected and why?

Answer 2

fat-soluble vitamin deficiencies (including vitamins A, D, E and K)

Question 3

What is the primary serological test used in the diagnosis of coeliac disease in adult patients?

Answer 3

When healthcare professionals request serological tests to investigate suspected coeliac disease in young people and adults, laboratories should:

• test for total immunoglobulin A (IgA) and IgA tissue transglutaminase (tTG) as the first choice
• use IgA endomysial antibodies (EMA) if IgA tTG is weakly positive
• consider using IgG EMA, IgG deamidated gliadin peptide (DGP) or IgG tTG if IgA is deficient

Question 4

Patients with coeliac disease are at an increased risk of malabsorption of which key nutrients?

Answer 4

calcium or vitamin D

Question 5

In January 2018, a decision was taken by the government (following a full consultation) to restrict the prescription of gluten-free foods (in England only) to which types?

Answer 5

bread and mixes

Question 6

Methods of increasing nutrient intake

Answer 6

Oral supplementation

Enteral feeding

Parenteral feeding

Question 7

Enteral feeds

Answer 7

Feeds contain either 1 kcal/mL or 1.5 kcal/mL and there are two types available.

Whole Protein (Polymeric)
-The patient needs to have a fully functioning gut for digestion and absorption of polymeric feeds.  The protein component is provided as either milk protein, hydrolysed casein or soya protein.  The carbohydrate is provided as maltodextrins, corn syrup solids, glucose and sucrose.  The fat component is usually a vegetable oil derivative.

Elemental/Peptide
-These feeds are recommended for patients who do not have a fully functioning GI tract. The protein component is provided as peptides and amino acids which do not need to be digested.

Question 8

Enteral feeding and diabetes

Answer 8

Enteral feeding is OK in diabetics but a lower calorific intake needs to be given (1 kcal/mL feeds only). They should also be given at a slower rate (80-100 mL per hour). Blood glucose should be monitored every 2-4 hours. If the blood glucose levels increase, small amounts of soluble insulin can be given.

Question 9

Problems with Enteral Feeding

Answer 9

Diarrhoea - Reduce the flow rate of the feed
Caused by:
-Too fast a flow rate of the feed
-Poor hygiene (change the giving set every 24 hours)
-Malabsorption of feed (swap to peptide or amino acid formula)
-Eliminate all possible causes before stopping feed
Could try:
-Feed with added fibre
-Milk-free formula
-Peptide feed

Constipation Caused by:

• Dehydration
• Immobility
• Rehydrate patient if necessary
• Consider fibre containing feed if patient sufficiently hydrated

Nausea and vomiting Caused by:

• Poor gastric emptying. Ensure patient’s head and shoulders are at a 30o angle
• Consider drugs that would speed up gastric emptying
• Rapid infusion of feed.
• Decrease the rate of feed but increase the duration to ensure adequate nutritional intake.

Question 10

Parenteral feeding

Answer 10

Parenteral feeds are only effective if used for more than 3-5 days. A peripheral or central line must be inserted for feeding and the line should be reserved only for TPN administration (no drug or fluid administration through the same lumen for multiple lumen lines).

The sub-clavian vein is most commonly used for the insertion of a central Hickman line. The catheter must be tunnelled so that there is sufficient distance between the exit from the vein and the exit from the skin. The patient’s non-dominant side is usually used.

Peripheral lines must run through a 20G needle and the site must be rotated every 4 days or at the first signs of thrombophlebitis. A 5mg GTN patch over the vein distal to the line site will help to keep the vein patent (unlicensed use). This patch must be changed every 72 hours.

Question 11

There are two general types of infant formula milks available in the UK

Answer 11

whey-dominant and casein-dominant

Whey-dominant milks are modified cow’s milk where the ratio of casein:whey is 40:60; this mimics human milk composition. These milks are generally considered to be the most suitable for babies aged below 3 months.

Casein-dominant milks have a casein:whey ratio of 80:20; this is much more similar to cow’s milk. Because of this similarity, casein-dominant milks are generally considered suitable only for babies over the age of 3 months who have more mature liver enzyme systems and kidney function.

Soy-based milks are available, but should only be prescribed in exceptional circumstances. Hydrolysed protein milks (derived from cow’s milk) are suitable for babies who are intolerant of cow’s milk protein.

Question 12

Offer serological testing for coeliac disease to people with any of the following:

Answer 12

• persistent unexplained abdominal or GI symptoms
• faltering growth
• prolonged fatigue
• unexpected weight loss
• severe or persistent mouth ulcers
• unexplained iron, vitamin B12 or folate deficiency
• type 1 diabetes, at diagnosis
• autoimmune thyroid disease, at diagnosis
• IBS (in adults)
• first‑degree relatives of people with coeliac disease.