Feeding and nutrition after brain injury

A person recovering from traumatic brain injury (TBI) will require close monitoring
of their nutritional status in the acute and rehabilitation phase of their injury. A
dietitian is able to assess the nutritional status, management of nutritional care and
education to patient and their family to ensure optimal nutrition and care is provided.

Acute Phase
Most people with brain injury are well nourished before the injury, however if
nutritional intervention is not put in place immediately, they are susceptible to
develop nutritional deficiencies. The stress of initial injuries also known as a
hypercatabolic state and may persist for 4 – 6 weeks or be sustained throughout the
injury. The importance of immediate nutrition care will decrease the change of rapid
loss of nutritional stores, in particular protein, resulting in lean muscle loss and
suppressed immune function.

Such patients are susceptible to a decrease in physical and cognitive abilities that may
lead to emotional and behavioural changes. These changes can affect their ability to
have food orally resulting in gradual nutrition deterioration that could lead to
starvation if not treated.

If a person with TBI is not be able to swallow food, then nutrition support should be
initiated by feeding liquid food through a feeding tube that is inserted through the
nose and into the stomach (Nasogastric feeding). If a person has facial trauma and the
nasal passage is not passable, then a tube through the mouth into the stomach
(Orogastric feeding) will be inserted.

If a feeding tube is required for more than 4 – 6 weeks, a tube may be inserted directly
into the stomach known as a Percutaneous Endoscopic Gastrotomy (PEG) tube. This
method allows for safer and more comfortable tube feeding.
There are two common methods for feeding:
 Continuous feeding: A liquid feeding formula that is delivered
continuously from a feeding pump given at a slow rate over a period of 12
– 24 hours depending on a person’s tolerance to the feeding.
  Bolus feeding: A liquid feeding formula that is given regularly via a
syringe at a 2 – 3 hour interval. Each feed is not more than 300ml volume
each time inclusive of water flushes.

The liquid foods selected for tube feeding are complete nutritional formulas that will
meet a person’s total nutritional requirements. They are convenient, hygienic and well
tolerated and are available in liquid or powder form. This can be obtained from
pharmacies and selected powder formulas are also available in supermarkets. Do
check with a dietitian on the formula that is tailored to the needs of a person.

(Source: “Learning About Tube Feeding At Home” Nutrition and Dietetics

Department, Tan Tock Seng Hospital)

The amount that a person will require will depend on a person’s calorie, protein, fluid,
healing and weight requirements. Additional considerations to feeding requirements
will be needed if a person has wounds, infections, other injuries, nutrient imbalance,
and medical or rehabilitation problems. This can be determined by a dietitian who will
manage the feeding and review accordingly. As their condition improves, nutritional
assessment needs to be planned for the future, most often includes weight monitoring.
If a person is underweight, gradual weight gain is preferred rather than rapid gain as
this can lead to excessive deposits of fat stores. The care plan is a continual effort and
reviewed with the person with TBI and their family before discharge from the acute or
rehabilitation program.

Rehabilitation phase
Some people with TBI will require tube feeding for a long period of time. However, if
a person with TBI is reviewed by a speech therapist and is safe to have oral feeding,
they will be monitored closely for the adequacy of intake base on the food and fluid
consistency suitable and safe for swallowing. If a person’s oral intake is poor, then
they will need to be supplemented with liquid formulas or to explore food habits and
preferences to encourage a person to eat through consistency of food, presentation of
food, and planning a balanced diet.

The consistency of food should be safe for a person with TBI. The speech therapist
will be able to determine the appropriate modified consistency of food (i.e. blended,
soft and moist or easy chew) and fluids (i.e. pudding, honey, nectar or thin) of a
person with TBI. Once the safe consistency of food is obtained, the food preparation
and ingredients need to be chosen with care to ensure safe swallowing.

A person with TBI will still have appreciation for well-presented and appetizing food
when served. It is essential especially if the food is in a modified consistency. This is
enhance through colour, variety of food and taste. It is also important that the meal
served is adequate in nutrition.

Planning a balanced diet is important to allow adequate nutrition for the recovery in a
person with TBI. The table below will be a guide to choosing and planning meals
from the four major food groups.
Breads,

cereals, rice, Vegetables Fruits Meat & Alternatives

pasta and

noodles

5 – 7 serves daily 2 serves daily 2 serves daily 2 –3 serves daily

1 serving =

2 slices bread ½ cup cooked 1 wedge papaya 1 palm size meat

1 bowl macaroni vegetables 1 medium banana 1 cup cooked lentils
1 bowl porridge 1 medium apple
1 glass of milk
1 bowl of oats
1 slice cheese
It should include complex carbohydrates such as breads, rice, cereals, pasta and
noodles. The diet should also incorporate a generous amount of vegetables and fruits
to provide vitamins and minerals. Proteins, iron, zinc, calcium and vitamin B12 are
essential for wound healing, prevention of abnormal red blood cells, and osteoporosis
or brittle bones. A person with TBI will benefit from a low fat diet to maintain ideal
body weight range. Lean meat, low fat dairy products and legumes should be chosen.
During food preparation, salt, oil, fat and sugar should be used in small amounts and
taken occasionally. Alcohol should be avoided after brain injury as it lowers the
seizure threshold.

When a person with TBI is not able eat adequately from a balanced diet due to a loss
in taste, smell or poor appetite, some suggestions include providing small, frequent
meals and snacks, serving food with stronger natural flavours to improve the appetite
and including all foods from the food groups as above. This can influence the
progress with rehabilitation. Oral formulas can also be supplemented with or between
meals to ensure adequate nutrition is obtained. Do check with a dietitian for the most
suitable oral formula if you are unsure.

Good nutrition is vital in the acute and rehabilitation phase in the management of
people with brain injury. Malnutrition is correlated with an increase in medical
complications, length of hospital stay and poorer functional outcome. A well-
nourished individual will be able to weather the initial stress of injuries and recover
better compared to a person who is malnourished.