By Blake Avery, RD and Brandi Jed, RD
Rainbow Rehabilitation Centers
For many people, nutrition is no more complicated than choosing what to eat. However, for individuals with a traumatic brain injury (TBI), getting adequate nutrition can be extremely difficult. Due to the complex nature of brain injuries, pinpointing one specific cause of altered nutritional status is nearly impossible. Contributing factors can include a decreased appetite, lack of motor skills, increased metabolism, dysphagia (trouble with swallowing), and more. As a result of these complications, many people will require enteral nutrition support, also referred to as tube feeding, at some point in their recovery process.
Enteral nutrition therapy involves placing a tube along the patient’s digestive tract and infusing a specialized liquid formula that provides the individual with fat, protein, carbohydrates, water, vitamins and minerals.
Registered Dietitians (RDs) are professionally trained to assess each person’s unique nutritional needs in order to provide the correct tube feeding formula, amount, and rate. Specially trained RDs at Rainbow assist and monitor clients requiring tube feeding to ensure they are receiving the best nutrition therapy for their individual needs.
Information to consider when choosing the right enteral nutrition formula include time since injury, client age, preexisting health conditions, and post-injury complications. Immediately following a severe brain injury, metabolic rate can increase up to as high as 240 percent1 greater than those without TBI. An increase in metabolic rate and catabolism can increase protein breakdown which can lead to malnutrition. More often than not, persons in the hospital following a TBI cannot consume an adequate amount of oral nutrition required to meet the body’s increased demands. Thus, calorie and fluid intake is often supplemented or entirely provided via enteral nutrition.
Early initiation of tube feeding is often the preferred protocol to prevent malnutrition, speed recovery, and reduce overall length of stay. Almost every patient will require a high protein and/or high calorie formula to meet these increased needs.
As individuals transition out of the acute care setting, they may no longer need tube feeding support. However, those who cannot meet their daily nutritional requirements through oral intake may still require total or partial enteral support as they continue their recovery.
Clients requiring long-term tube feeding support may need even more individualized nutritional plans which take into account pre-existing medical conditions and post-injury complications. Chronic health conditions to consider include diabetes, heart disease, obesity, and renal disease, all of which have corresponding therapeutic formulas. For example, a formula with a special balance of protein and electrolytes can be provided for individuals with chronic kidney diseases, and a formula with low-glycemic carbohydrates will help support clients with altered blood sugar control.
Some formulas contain immune enhancing vitamins, minerals and other additions to help combat metabolic and gastrointestinal stress. Prebiotics and probiotics may be added to a formula for “good” bacteria growth in the colon. Increased amounts of antioxidants, vitamin C and E may be added to reduce free radical damage. The addition of EPA and DHA omega-3 fatty acids can help fight inflammation and support immune function. Arginine and glutamine support immune function and can assist with wound healing, while hydrolyzed proteins are often included for optimal absorption.
Once a formula has been carefully selected and initiated, close observation for any potential intolerances is required. Common long-term complications that can arise are constipation, diarrhea, and malabsorption. RDs will continually assess and closely monitor tube feeding tolerance to provide evidence-based interventions in order to reduce these symptoms as much as possible. One example may be a high fiber tube feeding formula or a fiber supplement to help alleviate constipation.
Clients with traumatic brain injury will have an evolving nutritional status on their road to recovery. In the acute care setting, nutritional status is at its most critical point with malnutrition prevention being the number one priority. As they transition to post-acute settings, their needs shift to preventing exacerbation of pre-existing conditions and preventing long-term complications. No matter where a client is in their tube feeding journey, a Registered Dietitian will be there to help them along the way.
- Horn, Susan et. Al. Enteral Nutrition for Patients with Traumatic Brain Injury in the Rehabilitation Setting: Associations with Patient Pre-Injury and Injury characteristics and outcomes. ___Archives of Physical Medicine and Rehabilitation. 2015: 96(8suppl3):S245-55. https://www.archives-pmr.org/article/S0003-9993(15)00321-4/pdf