Individuals having sustained a traumatic brain injury (TBI) often present swallowing difficulties, known as dysphagia. As dysphagia increases the risk of pneumonia, it is essential to assess the swallowing functions as soon as the person’s condition allows it. Interventions to reduce swallowing difficulties and related complications include adapted feeding strategies, safe feeding training, proper oral care and education.

Individuals with TBI are also at a greater risk of inadequate nutrition in the acute and post-acute phases. A comprehensive assessment of the nutritional and hydration status should be conducted and appropriate nutritional support should be installed as soon as possible after TBI. Parenteral and enteral nutrition are both effective feeding strategies to increase caloric intake in individuals unable to self-feed. Consider monitoring protein and mineral intake closely as they have been shown to improve neurological functions when supplementation is provided.

The adequate management of dysphagia and nutrition requires the availability of professionals with proper training and expertise in these areas, usually through the combination of nutritionists, speech language pathologists and occupational therapists. Videofluoroscopic equipment should be available to support dysphasia assessment.

Nutrition management should be an integral part of the interdisciplinary plan, with close monitoring of the person’s global nutrition and hydration status, regular reviews of the target objectives and adaptation of the feeding strategies as required. Family members need to be educated and trained as they often participate intensively to the feeding sessions. 

 Indicators exemples

• Proportion of individuals presenting a risk factor for aspiration post-injury for whom there is evidence of complete assessment of swallowing function.

•  Proportion of individuals with TBI whose nutritional status was assessed.

The following are suggestions of tools and resources that can be used to support the implementation of the recommendations in this section. Healthcare professionals must respect the legal and normative regulations of the regulatory bodies, in particular with regards to scopes of practice and restricted/protected activities, as these may differ provincially

Clinical Tools:

• INPAC: Integrated nutrition pathway for acute care
• Canadian nutrition screening tool (CNST) – Canadian Malnutrition Task Force
• Passy Muir Valve placement protocol
• Dépistage précoce de la dysphagie oropharyngée (Standardized screening for dysphagia) (in French only)
• Dysphagia – APNED
• Dysphagia tools – APNED
• Avis : Intervention spécifique du diététiste en dysphagie (Notice: Dietitian-specific intervention in dysphagia) – OPDQ (in French only)
• Adult dysphagia – American Speech-Language-Hearing Association
• Guidelines – American Society for Parenteral and Enteral Nutrition
• Practice standards and guidelines for dysphagia intervention by speech-language pathologists – College of Audiologists and Speech-Language Pathologists of Ontario (CASLPO) (2014) –
  Note: According to existing legal and normative regulations, some of the standards proposed in this tool are not applicable to the clinical practice of speech language pathologists in the province of Quebec.

Patient and Family Resources:

• L’installation d’une gastrostomie : Guide pour le patient (Gastrostomy installation : Patient guide – CHUS (in French only)
• Parenteral and Enteral feeding information
• Tube feeding and parenteral nutrition – Canadian Cancer Society

Other Resources:

• Rapport d’évaluation : Pratiques optimales d’évaluation de la dysphagie pour la clientèle hospitalisée (Evaluation report: Best practices for the assessment of dysphagia in hospital settings) – UETMIS of CHU de Québec
• Développement et implantation d'outils et de procédures interdisciplinaires pour évaluer et intervenir au niveau de la santé bucco-dentaire pendant la réadaptation : Projet SAGE, rapport synthèse (Development and implementation of tools and procedures to assess and provide interventions related to oral and dental health during rehabilitation : Projet SAGE; Summary report) – CIUSSS du Centre-Sud-de-l'Île-de-Montréal, Installation Gingras-Lindsay-de-Montréal (in French only)
• Oral Health FactSheet for Dental Professionals

The evidence for dysphagia and nutritional assessments are limited for brain injury. Therefore, many recommendations are modelled after practices studied in the stroke literature and utilized in stroke rehabilitation.

Since dysphagia is a significant concern post acquired brain injury (ABI) which can lead to aspiration pneumonia, feeding strategies should be monitored. One RCT found an increased risk of developing pneumonia for ventilated patients fed by a naso-gastric versus a gastrostomy tube (Kostadima, Kaditis, Alexopoulos, Zakynthinos, & Sfyras, 2005). A retrospective audit found that pneumonia was more common among individuals with low levels of consciousness and for those with a feeding or tracheotomy tube (Hansen, Engberg, & Larsen, 2008). None the less, self-feeding is encouraged for individuals with dysphagia. An observational study of elderly outpatients found that dependence in self-feeding could accurately predict the risk of pneumonia; individuals with dysphagia who were fed by another person had a 20-times greater risk of developing aspiration pneumonia than those patients who are able to feed themselves (Langmore et al., 1998).

Oral hygiene is important for all individuals post ABI but it can be complicated by a diagnosis of dysphagia. One RCT found that patients with TBI who were provided verbal oral hygiene instructions and taught to remove plaque had significantly less plaque on their teeth post intervention compared to the control group. The reduction of plaque and greater oral hygiene lead to greater integration back into society as well (Zasler, Devany, Jarman, Friedman, & Dinius, 1993). Good oral care also can reduce the risk of pneumonia. A study examining an enhanced oral care protocol found a significant decrease in acquired pneumonia when compared to the standard oral care group (Robertson & Carter, 2013).

Ensuring patients with TBI have adequate nutrition is an important part of their medical management. Denes (2004) found that malnutrition increased the risk of complications such as pressure sores, pneumonia and increased lengths of stay. Both enteral and parenteral nutrition are effective in increasing caloric intake to patients with TBI. RCTs have found that parenteral nutrition results in greater caloric intake when compared to enteral nutrition (Hadley et al., 1986; Meirelles & Aguilar-Nascimento, 2011; Young et al., 1987). Parenteral nutrition can be safely administered without causing serum hyperosmorality or influencing intracranial pressure levels in patients post TBI (Young et al., 1987).

Early enhanced enteral feeding solutions enriched with immune-enhancing nutrients may decrease the occurrence of sepsis and reduce the inflammatory response. Chourdakis et al. (2012) compared delayed enteral feeding with early enteral feeding in 59 individuals post severe TBI. Although rates of complications were comparable between groups, the length of feeding was significantly shorter in the early enteral feeding group, and there was greater improvement in hormone production. Similarly, Minard, Kudsk, Melton, Patton, and Tolley (2000) found timing had no significant impact on mortality, length of stay or complications. Further, enhanced enteral nutrition was shown to accelerate neurologic recovery while reducing complications and also inflammatory post injury responses (Taylor, & Fettes, S. , 1998; Taylor, Fettes, Jewkes, & Nelson, 1999). A Cochrane review by Yanagawa, Bunn, Roberts, Wentz, and Pierro (2000) identified six RCTs that addressed the timing to initiation of feeding and mortality as an outcome. The relative risk for death associated with early nutritional support was 0.71 (95% CI 0.43-1.16). The pooled relative risk from three trials, which also assessed death and disability, for early feeding was 0.75 (0.50-1.11). Although the results were not statistically significant, it was concluded that early feeding may be associated with a trend towards better outcomes in terms of survival and disability (Yanagawa et al., 2000). A study found that among individuals with closed head injuries, early parenteral nutrition was beneficial in modifying immunologic function by increasing production of lymphocytes (Sacks et al., 1995).

After a brain injury, some individuals have difficulty with managing gastric emptying. A single RCT by Nursal et al. (2007) found that administration of 10 mg of metoclopramide did not influence absorption parameters compared to the control group.

Other supplements have been suggested to be beneficial in improving post ABI recovery. An RCT examined the effect of parenteral zinc supplementation following ABI (Young et al., 1996) and reported an improvement in protein synthesis and neurological recovery in patients who received supplementation. Amino acids are not just nutritionally beneficial, but they may also impact cognitive function. It is thought that the BCAAs improve cognitive functioning by providing substrates and increasing brain insulin availability (Aquilani et al., 2005).

Finally, following an ABI, metabolic changes can influence cell turnover use of substrate and body composition. Twyman (1997) noted that urinary urea nitrogen levels increase by a factor of three compared with normal levels within 10 days after severe head injury. On average, about 5 to 10 g of urea nitrogen are excreted daily from an individual; however, patients with ABI lose a mean of 21g urinary urea in a single day (Twyman, 1997).

REFERENCES
Aquilani, R., Iadarola, P., Contardi, A., Boselli, M., Verri, M., Pastoris, O., . . . Viglio, S. (2005). Branched-chain amino acids enhance the cognitive recovery of patients with severe traumatic brain injury. Arch Phys Med Rehabil, 86(9), 1729-1735.

Chourdakis, M., Kraus, M. M., Tzellos, T., Sardeli, C., Peftoulidou, M., Vassilakos, D., & Kouvelas, D. (2012). Effect of early compared with delayed enteral nutrition on endocrine function in patients with traumatic brain injury: an open-labeled randomized trial. JPEN J Parenter Enteral Nutr, 36(1), 108-116.

College of Audiologists and Speech-Language Pathologists of Ontario (CASLPO). (2015). Practice Standards and Guidelines for Acquired Cognitive Communication Disoders.

Denes, Z. (2004). The influence of severe malnutrition on rehabilitation in patients with severe head injury. Disabil Rehabil, 26(19), 1163-1165.

Evidence-Based Review of Moderate To Severe Acquired Brain Injury (ERABI). (2016). http://www.abiebr.com/.  

Hadley, M. N., Grahm, T. W., Harrington, T., Schiller, W. R., McDermott, M. K., & Posillico, D. B. (1986). Nutritional support and neurotrauma: a critical review of early nutrition in forty-five acute head injury patients. Neurosurgery, 19(3), 367-373.

Hansen, T. S., Engberg, A. W., & Larsen, K. (2008). Functional oral intake and time to reach unrestricted dieting for patients with traumatic brain injury. Arch Phys Med Rehabil, 89(8), 1556-1562.

Justo Meirelles, C. M., & de Aguilar-Nascimento, J. E. (2011). Enteral or parenteral nutrition in traumatic brain injury: a prospective randomised trial. Nutr Hosp, 26(5), 1120-1124.

Kostadima, E., Kaditis, A. G., Alexopoulos, E. I., Zakynthinos, E., & Sfyras, D. (2005). Early gastrostomy reduces the rate of ventilator-associated pneumonia in stroke or head injury patients. Eur Respir J, 26(1), 106-111.

Langmore, S. E., Terpenning, M. S., Schork, A., Chen, Y., Murray, J. T., Lopatin, D., & Loesche, W. J. (1998). Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia, 13(2), 69-81.

Minard, G., Kudsk, K. A., Melton, S., Patton, J. H., & Tolley, E. A. (2000). Early versus delayed feeding with an immune-enhancing diet in patients with severe head injuries. JPEN J Parenter Enteral Nutr, 24(3), 145-149.

Nursal, T. Z., Erdogan, B., Noyan, T., Cekinmez, M., Atalay, B., & Bilgin, N. (2007). The effect of metoclopramide on gastric emptying in traumatic brain injury. J Clin Neurosci, 14(4), 344-348.

Robertson, T., & Carter, D. (2013). Oral intensity: reducing non-ventilator-associated hospital-acquired pneumonia in care-dependent, neurologically impaired patients. Can J Neurosci Nurs, 35(2), 10-17.

Sacks, G. S., Brown, R. O., Teague, D., Dickerson, R. N., Tolley, E. A., & Kudsk, K. A. (1995). Early nutrition support modifies immune function in patients sustaining severe head injury. JPEN J Parenter Enteral Nutr, 19(5), 387-392.

Taylor, S., & Fettes, S. . (1998). Enhanced enteral nutrition in head injury: effect on the efficacy of nutritional delivery, nitrogen balance, gastric residuals and risk of pneumonia. J Hum Nutr Diet,, 11(5), 391-401.

Taylor, S. J., Fettes, S. B., Jewkes, C., & Nelson, R. J. (1999). Prospective, randomized, controlled trial to determine the effect of early enhanced enteral nutrition on clinical outcome in mechanically ventilated patients suffering head injury. Crit Care Med, 27(11), 2525-2531.

Twyman, D. (1997). Nutritional management of the critically ill neurologic patient. Crit Care Clin, 13(1), 39-49.

Yanagawa, T., Bunn, F., Roberts, I., Wentz, R., & Pierro, A. (2000). Nutritional support for head-injured patients. Cochrane Database Syst Rev(2), Cd001530.

Young, B., Ott, L., Haack, D., Twyman, D., Combs, D., Oexmann, J. B., . . . Dempsey, R. (1987). Effect of total parenteral nutrition upon intracranial pressure in severe head injury. J Neurosurg, 67(1), 76-80.

Young, B., Ott, L., Kasarskis, E., Rapp, R., Moles, K., Dempsey, R. J., . . . McClain, C. (1996). Zinc supplementation is associated with improved neurologic recovery rate and visceral protein levels of patients with severe closed head injury. J Neurotrauma, 13(1), 25-34.

Zasler, N. D., Devany, C. W., Jarman, A. L., Friedman, R., & Dinius, A. (1993). Oral hygiene following traumatic brain injury: a programme to promote dental health. Brain Inj, 7(4), 339-345.