Dysphagia Nutrition Guidelines

Learning objectives

Link to RCP Stroke Guidelines 2016

Dysphagia

• People with acute stroke should have their swallowing screened, using a validated screening tool, by a trained healthcare professional within four hours of arrival at hospital and before being given any oral food, fluid or medication.
• Until a safe swallowing method is established, people with swallowing difficulty after acute stroke should: be immediately considered for alternative fluids; have a comprehensive specialist assessment of their swallowing; be considered for nasogastric tube feeding within 24 hours; be referred to a dietitian for specialist nutritional assessment, advice and monitoring; receive adequate hydration, nutrition and medication by alternative means.
• Patients with swallowing difficulty after acute stroke should only be given food, fluids and medications in a form that can be swallowed without aspiration.
• People with stroke with suspected aspiration or who require tube feeding or dietary modification should be considered for instrumental assessment (videofluoroscopy or fibre optic endoscopic evaluation of swallowing).
• People with stroke who require instrumental assessment of swallowing (videofluoroscopy or fibre-optic endoscopic evaluation of swallowing) should only receive this: in conjunction with a specialist in dysphagia management; to investigate the nature and causes of aspiration; to direct an active treatment/rehabilitation programme for swallowing difficulties.
• People with swallowing difficulty after stroke should be considered for swallowing rehabilitation by a specialist in dysphagia management. This should include one or more of: compensatory strategies such as postural changes (e.g. chin tuck) or swallowing manoeuvres (e.g. supraglottic swallow); restorative strategies to improve oropharyngeal motor function (e.g. Shaker headlifting exercises); sensory modification, such as altering the taste and temperature of foods or carbonation of fluids; texture modification of food and/or fluids.
• People with stroke who require modified food or fluid consistency should have these provided in line with nationally agreed descriptors.
• People with difficulties self-feeding after stroke should be assessed and provided with the appropriate equipment and assistance (including physical help and verbal encouragement) to promote independent and safe feeding.
• People with swallowing difficulty after stroke should be provided with written guidance for all staff/carers to use when feeding or providing fluids.
• People with stroke should be considered for gastrostomy feeding if they: need but are unable to tolerate nasogastric tube feeding; are unable to swallow adequate food and fluids orally by four weeks from the onset of stroke; are at high long-term risk of malnutrition.
• People with stroke who are discharged from specialist treatment with continuing problems with swallowing food or fluids safely should be trained, or have family/carers trained, in the management of their swallowing difficulty and be regularly reassessed.
• People with stroke receiving end-of-life (palliative) care should not have burdensome restrictions imposed on oral food and/or fluid intake if those restrictions would exacerbate suffering.

Nutrition

• Patients with acute stroke should be screened for the risk of malnutrition on admission and at least weekly thereafter. Screening should be conducted by trained staff using a structured tool.
• Patients with acute stroke who are adequately nourished on admission and are able to meet their nutritional needs orally should not routinely receive oral nutritional supplements. Patients with acute stroke who are at risk of malnutrition or who require tube feeding or dietary modification should be referred to a dietitian for specialist nutritional assessment, advice and monitoring.
• Patients with stroke who are at risk of malnutrition should be offered nutritional support. This may include oral nutritional supplements, specialist dietary advice and/or tube feeding in accordance with their expressed wishes or, if the patient lacks mental capacity, in their best interests.
• Patients with stroke who are unable to maintain adequate nutrition and fluids orally should be: referred to a dietitian for specialist nutritional assessment, advice and monitoring; be considered for nasogastric tube feeding within 24 hours of admission; assessed for a nasal bridle if the nasogastric tube needs frequent replacement, using locally agreed protocols; assessed for gastrostomy if they are unable to tolerate a nasogastric tube with nasal bridle.
• People with stroke who require food or fluid of a modified consistency should: be referred to a dietitian for specialist nutritional assessment, advice and monitoring; have the texture of modified food or fluids prescribed using nationally agreed descriptors.
• People with stroke should be considered for gastrostomy feeding if they: need but are unable to tolerate nasogastric tube feeding; are unable to swallow adequate food and fluids orally by four weeks from the onset of stroke; are at high long-term risk of malnutrition.
• People with difficulties self-feeding after stroke should be assessed and provided with the appropriate equipment and assistance (including physical help and verbal encouragement) to promote independent and safe feeding.
• People with stroke discharged from specialist care services with continuing problems meeting their nutritional needs should have their dietary intake and nutritional status monitored regularly.
• People with stroke receiving end-of-life (palliative) care should not have burdensome restrictions imposed on oral food and/or fluid intake if those restrictions would exacerbate suffering.