GENERAL SYMPTOMS

• Declining Growth Curve / Failure to Thrive
• Pressure ulcers
• Weight Loss / Malnutrition
• Hyperemesis Gravidarum
• Nutritional Problems in the Nursing Care Population
• Dysphagia
• Nutritional Problems Related to Pregnancy

 

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Declining Growth Curve / Failure to Thrive

Children

 

Best time to refer to the dietician:

• When at least one of the following is present:

• weight loss of > 1 SD in 3 months for weight-for-age/height
• decline in height of > 0.5 SD before age 4 and of > 0.25 SD after age 4 within 1 year, for height-for-age
• weight- and/or height-for-age < -2 SDS (standard deviation score).

 

Relevant information for the dietician:

• Diagnosis: underlying disorder, any comorbid conditions
• Symptoms: anorexia, vomiting, diarrhea, fever, frequent infections, food refusal
• Medication/Treatment: if relevant
• Other: height and (changes in) weight, growth curve, number of weeks premature, the extent of fluid restriction, any relevant oxygen requirements.

 

Aims of the diet:

• Achieve a satisfactory growth curve.

 

Characteristics of the diet:

• Energy-enriched: resting metabolism (Schofield) + extra allowances
• Protein-enriched: depending on age, illness and type of malnutrition (for acute malnutrition: 9‑11.5% of total caloric intake in the form of protein; for chronic malnutrition: 11-15% of total caloric intake in the form of protein)
• Fluids: restrict fluids if necessary, e.g. for congestive heart failure or bronchopulmonary dysplasia.

 

Treatment time:

• Care level 2*, see “Dietician’s working methods.”

 

Specific remarks:

• Age correction in the case of children (under age 2) who were born prematurely: subtract the number of weeks of prematurity from the child’s age.
• Special growth curves exist for premature babies (weight below 1500 g and gestational age < 38 weeks), Turkish and Moroccan children (1-20 years old) and for children with certain syndromes (such as Down syndrome, Turner syndrome, Prader-Willi syndrome); see www.kindengroei.nl.

 

References:

Hulst JM, Zwart H et al. Dutch national survey to test the STRONGkids nutritional risk screening tool in hospitalized children. Clinical Nutrition 2010 Feb;29(1):106-11.Epub 2009 Aug 13

 

McDonald CM. Nutrition Management of Failure to Thrive. In: Pediatric Manual of Clinical Dietetics, Nevin-Folino NL. Second edition; 2003; 243-57

 

Meer K de, Taminiau JAJM. Definitie van ondervoeding. In: Taminiau JAJM, Meer K de et al, editors. Werkboek enterale voeding bij kinderen. Amsterdam: VU Boekhandel/Uitgeverij BV.; 1997; 9-18. See also: www.stuurgroepondervoeding.nl > ziekenhuis > toolkit kinderen

 

Rudolf MCJ, Logan S. What is the long term outcome for children who fail to thrive? A systematic review. Arch Dis Child 2005:90:925-931

 

World Health Organization. Protein and amino acid requirements in human nutrition. Report of a Joint WHO/FAO/UNU Expert Consultation. Geneva: 2007, no. 935: 185-193

 

Declining Growth Curve / Failure to Thrive was updated by Mieke Tummers-Boonen, dietician at Maastricht Universitair Medisch Centrum (MUMC+) and Annemiek de Hullu, dietician at Leids Universitair Medisch Centrum (LUMC), writing also on behalf of Kinderdiëtetiek Overleg Diëtisten Academische Ziekenhuizen (KODAZ).

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Pressure ulcers

Adults

 

Best time to refer to the dietician:

Preventively, for patients with an increased risk of developing pressure ulcers:

• when there is a (risk of) malnutrition, as measured using a validated screening tool
• when unintended weight loss exceeds 5% in a 1 month period or 10% in a 6-month period
• when the BMI is less than 20 kg/m2 or more than 30 kg/m2.

Treatment:

• pressure ulcers at stage III/IV
• pressure ulcers at stage I/II: if the nutritional score is unsatisfactory.

 

Relevant information for the dietician:

• Diagnosis: pressure sore, stage, dimensions, underlying condition, any comorbid conditions
• Laboratory tests: albumin, hemoglobin, transferrin, lymphocytes, total cholesterol
• Medication: corticosteroids, cytostatics, sleeping pills, pain medication, sedatives, antispasmodics, anticoagulants, antimicrobial agents, antimycotic agents, medications for congestive heart failure and cardiostimulants, diuretics
• Other: height, (changes in) weight.

 

Aims of the diet:

Prevention

• Reduce the risk of developing pressure sores by resolving the nutrient deficiencies.

Treatment

• Contribute to healing of the pressure sore.

 

Characteristics of the diet:

Prevention + treatment for stages I and II:

• Energy-enriched: basal metabolism (Harris-Benedict) plus extra allowances
• Protein-enriched: 1.25-1.5 g/kg of actual body weight
• Fluids (increased intake): 1.5-2 L (or 1 ml fluids/kcal/day)
• Ensure adequate amounts of vitamins A, D and E, iron and zinc.
• Frequent, small meals (6-8 per day).

Treatment for stages III and IV

• Energy-enriched: basal metabolic rate (Harris & Benedict) plus extra allowances
• Protein-enriched: 1.5-1.7 g/kg actual body weight
• High fluid intake: 2-2.5 L (or 1 ml fluids/kcal/day)
• Ensure adequate amounts of vitamins A, C and E, iron and zinc. If necessary, extra vitamin C supplementation up to a maximum total of 1000 mg/day, depending on the severity of the wound.
• Frequent, small meals (6-8 per day)

 

Treatment time:

• Care level 2, see “Dietician’s working methods.”

 

Specific remarks:

• Multidisciplinary approach to treatment is preferable.

 

References:

Cereda E, Gini A et al. Disease-Specific, Versus Standard, Nutritional Support for the Treatment of Pressure Ulcers in Institutionalized Older Adults: A Randomized Controlled Trial. JAGS 2009 (57):1395–1402

 

Schols JMGA, Heyman H, Meijer EP. Nutritional support in the treatment and prevention of pressure ulcers: An overview of studies with an arginine enriched Oral Nutritional Supplement. Journal of Tissue Viability. 2009 (18):72-79

 

Schols JMGA, Meijer EP et al. Een Europese richtlijn over voeding en decubitus. Tijdschrift voor VerpleeghuisGeneeskunde. 2007 (32):100-03

 

 Pressure ulcers was updated by Lotte van Heteren, dietician at Medisch Centrum Alkmaar (AMC) and Dea Schröder-Van de Nieuwendijk, dietician at “Het Roessingh” rehabilitation center in Enschede.

 

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Weight Loss / Malnutrition

 

Adults

 

Best time to refer to the dietician:

• If unintended weight loss of over 5% occurs within a 1-month period or over 10% within a 6-month period, and/or if the patient’s body weight is too low (ages 18-65: BMI < 18.5 kg/m2 and over age 65: BMI < 20 kg/m2)
• When the patient’s screening result is “malnourished,” with the use of a validated screening tool.

 

Relevant information for the dietician:

• Diagnosis: underlying causes, any comorbid conditions, fistulae
• Symptoms: anorexia, nausea, vomiting, diarrhea, dysphagia or disorders of taste,

mastication, or passage of foods

• Laboratory tests: where relevant, renal function, liver function, glucose HbA1c
• Medication/Therapy: where relevant, nutritional therapy (liquid meals) and medication that affects food intake (pain medication, cytostatic agents, antibiotics)
• Other: height, (changes in) weight

 

Aims of the diet:

• Maintain/improve nutritional status and/or prevent worsening of nutritional status.

 

Characteristics of the diet:

• Energy-enriched: basal metabolism (Harris-Benedict) plus extra allowances
• Protein-enriched: 1.2 to 1.5 g/kg actual body weight
• Fluids: at least 1.5 L + losses
• Prevention of refeeding syndrome.

 

Treatment time:

• Care level 2, see “Dietician’s working methods.”

 

Specific remarks:

• Weight of 1 month and/or 6 months earlier should serve as the point of reference for establishing the extent of weight loss.
• Edema and ascites may mask weight loss.
• If optimal nutrition cannot be achieved with oral food, supplemented with liquid meals if necessary, enteral nutrition should be considered. If enteral nutrition is not possible, parenteral nutrition should be considered.
• When evaluating malnutrition, it is recommended that the evaluation be based on a fat-free mass index (measured via bioelectrical impedance analysis) rather than BMI.

 

References:

CBO. Richtlijn peri-operatief voedingsbeleid. Utrecht: 2007

 

Elia M. The ‘MUST’ Report. Nutritional screening of adults: a multidisciplinary responsibility. Development and use of the ‘Malnutrition Universal Screening Tool’ (‘MUST’) for adults. BAPEN: 2003

 

Kruizenga HM, Tulder MW Van et al. Effectiveness and cost effectiveness of early screening and treatment of malnourished patients. The American Journal of Clinical Nutrition. 2005 28(5):1082-9

 

Sauerwein HP, Strack van Schijndel RJM. Perspective: How to evaluate studies on perioperative nutrition? Considerations about the definition of optimal nutrition and its key role in the comparison of the results of studies on nutritional intervention. Clinical Nutrition 2007(1):154-158

 

Stanga Z, Brunner A et al. Nutrition in clinical practice - the refeeding syndrome: illustrative cases and guidelines for prevention and treatment. European Journal of Clinical Nutrition. BAPEN: 2008(62):687-94

 

Weijs PJ, Kruizenga HM et al. Validation of predictive equations for resting energy expenditure in adult outpatients and inpatients. Clinical Nutrition. 2008(1):150-7

 

Weight Loss / Malnutrition was written by Hinke Kruizenga, dietician at VU medisch centrum (VUmc) and project leader of malnutrition in the Stuurgroep Ondervoeding, writing also on behalf of Diëtisten Ondervoeding Nederland (DON) and Cora Jonkers, dietician at Academisch Medisch Centrum (AMC), writing also on behalf of the NEtherlands Society for Parenteral and Enteral Nutrition (NESPEN).

 

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Hyperemesis Gravidarum

Adults

 

Best time to refer to the dietician:

• following diagnosis

 

Relevant information for the dietician:

• Diagnosis: hyperemesis gravidarum, any comorbid conditions
• Symptoms: nausea, excessive vomiting, weight loss, dehydration, ketonuria, electrolyte imbalances
• Laboratory tests: sodium, potassium, phosphate, magnesium, glucose
• Medication: antiemetics
• Other: height, weight (changes), duration of pregnancy, duration of vomiting, previous medical history of (hyper)emesis.

 

Aims of the diet:

• Improve the nutritional status following intravenous rehydration, and gain recovery from fluid and electrolyte imbalances and ketosis.
• Achieve a normal weight gain for pregnancy.

 

Characteristics of the diet:

• Complete nutrition, consistent with dietary needs during pregnancy
• Energy: basal metabolism (Harris & Benedict) plus extra allowances
• (High) protein: 1.0-1.5 g/kg actual body weight
• Frequent, small meals, as tolerated
• Tube feeding via a nasogastric tube, nasoduodenal tube or, if necessary, a nasojejunal tube, if oral food intake is still insufficient 1-2 days after diagnosis.

 

Treatment time:

• Care level 2, see “Dietician’s working methods.”

 

Specific remarks:

• Refeeding may lead to refeeding syndrome. It is important to use a progressive feeding regimen with enteral nutrition, and to supplement with phosphate, magnesium and potassium, based on laboratory results, as well as supplementing thiamine.
• Recommend a vitamin and mineral supplement formulated specially for pregnant women until total oral feeding is achieved.
• Advise taking 10 μg of vitamin D throughout the pregnancy.
• If total parenteral nutrition is not indicated, due to risk of complications, enteral nutrition promotes tolerance of restarting normal feeding.

 

References:

Baars A, Timmer R, Slee PHThJ. Metabole ontregeling na opnieuw beginnen met voeding: refeeding-syndroom; de centrale rol van fosfaat. Ned Tijdschr Geneeskd 2002;146: 906-9

 

Ismail SK, Kenny L. Review on hyperemesis gravidarum. Best Practice & Research Clinical Gastroenterology 2007, Vol. 21 no 5: 755-769

 

Jager-Wittenaar H, Holm JP. Thuisbehandeling van patiënten met hyperemesis gravidarum. Beschrijving van een multidisciplinair behandelprotocol. Ned Tijdschr Diëtisten 2002;57:125-9.

 

Lord LM, Pelletier K. Management of Hyperemesis Gravidarum with Enteral Nutrition. Practical Gastroenterology, June 2008, Volume 32, Issue 6: 15-31

 

The description of Hyperemesis Gravidarum was co-written with Mieke Tummers-Boonen, dietician at Maastricht Universitair Medisch Centrum+ (MUMC+), Willy Visser, dietician at Leids Universitair Medisch Centrum (LUMC), Janny Klingenberg, dietician at Martini Ziekenhuis Groningen and Jannie IJbema, dietician at Universitair Medisch Centrum Groningen (UMCG).

 

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Nutritional Problems in the Nursing Care Population

Adults

 

General information:

Individuals requiring nursing care may be living in a nursing home, a long-term care facility or assisted living facility (in a special care unit), a hospital or at home. Individuals should be screened for malnutrition at the start of the nursing care. The factors that most affect nutritional status are food and drink preferences, the composition and consistency of the food, how the food is served, ambiance and presentation of the meals, adequate assistance with eating and drinking, dental conditions, problems chewing and swallowing, changes in taste, posture while eating and/or drinking, and disorders causing a loss of nutrients or increased nutritional requirements (as in the case of pressure sores, COPD, Parkinson disease, wandering, restlessness). In addition, medical problems such as nausea, constipation, medication usage, depression and/or psychological/social problems may also have an effect.

 

Best time to refer to the dietician:

• should be based on the institution’s protocol: to contribute to the integrated diagnostics
• when the screening outcome is “malnourished” using a validated screening tool

 

Relevant information for the dietician:

• Diagnosis: underlying disorder, any comorbid conditions
• Symptoms: anorexia, problems chewing and swallowing, drooling, dry mouth, nausea, constipation
• Laboratory tests: depending on the disorder
• Medication/Therapy: if relevant, and depending on treatment policy (passive, active, palliative)
• Other: height, (changes in) weight, disabilities.

 

Aims of the diet:

• Maintain/improve the nutritional status.
• Aims depend on the care/treatment policy and the personal choices of the resident.

 

Characteristics of the treatment/diet:

• Contribute to the integrated care or treatment policy (also if the nature of the problem changes and/or if new problems arise)
• Diet depends on the disorder or condition, such as chronic constipation, pressure sores, COPD and weight loss / malnutrition (see descriptions for the various disorders in this Doctors' reference guide on dietetics).

 

Treatment time:

• Care level 2, see “Dietician’s working methods.”

 

Specific remarks:

• The determination of a treatment plan is a multidisciplinary responsibility. The resident and/or family/representative, caregiver, doctor, dietician, physiotherapist, speech therapist and occupational therapist should all be involved in the determination of the care/treatment plan. Other disciplines may be involved, depending on the indication.
• It is important that the resident’s eating habits be observed by the caregiving staff.

 

References:

Arcares. Multidisciplinaire richtlijn verantwoorde vocht- en voedselvoorziening voor Verpleeghuisgeïndiceerden. Utrecht: 2001

 

Nijs KA, Graaf C de, et al. Effect of family style mealtimes on quality of life, physical performance, and body weight of nursing home residents: cluster randomised controlled trial. BMJ. 2006;332:1180-4

 

Stuurgroep Ondervoeding. SNAQrc. Amsterdam: 2008

 

 Nutritional Problems in the Nursing Care Population was updated by Karin Kouwenoord-Van Rixel, dietician at ZorgbalansVelserduin, writing also on behalf of Diëtisten Verpleeg- en Verzorgingshuizen (DV&V).

 

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Dysphagia

Adults

 

Best time to refer to the dietician:

• following development of dysphagia, if this condition is expected to last longer than 1 week - if unwanted weight loss occurs exceeding 5% within a 1-month period or 10% in a 6-month period, and/or if underweight (ages 18-65: BMI < 18.5 kg/m2 and over age 65 BMI < 20 kg/m2)
• when the screening outcome is “malnourished” when using a validated screening tool
• radiation therapy in the head and neck region (referral in advance or in the first week of radiation treatment)

 

Relevant information for the dietician:

• Diagnosis: underlying disorder, any comorbid conditions
• Symptoms: problems swallowing, weight loss
• Medication/Therapy:

• psychopharmaceuticals, anticholinergics or a combination
• surgery, radiotherapy, chemotherapy or a combination
• nature of treatment (designed to be curative or palliative).

• Other: height, (changes in) weight, receiving speech therapy (e.g. swallowing tests).

 

Aims of the diet:

• reduce the symptoms
• maintain/improve nutritional status.

 

Characteristics of the diet:

• Texture: customized based on the type of dysphagia and in consultation with the speech therapist.
• Energy-enriched: basal metabolism (Harris & Benedict) + extra allowances
• Ensure a sufficient intake of fluids, dietary fiber, and vitamins and minerals.

 

Treatment time:

• Care level 2*, see “Dietician’s working methods.”

 

References:

Franchimont H, Boogaardt HCA, Ravensberg CD van. Slikproblemen bij verpleeghuisbewoners. Multidisciplinaire richtlijn chronisch neurologische dysfagie bij verpleeghuisbewoners. Vakinhoudelijk diëtistisch deel. Amersfoort: Nederlands Paramedisch Instituut/NPi; 2001

 

Kalf H, Rood B et al. Slikstoornissen bij volwassenen: een interdisciplinaire benadering. 2008. Houten: Bohn Stafleu en van Loghum

 

Dysphagia was updated by Nel Fredrikze-De Jong, dietician with Zorgpartners Midden-Nederland, writing also on behalf of Diëtisten Verpleeg- en Verzorgingshuizen (DV&V).

 

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Nutritional Problems Related to Pregnancy

Adults

 

Best time to refer to the dietician:

• When there is a desire to become pregnant, or upon becoming pregnant, in combination with:

Underlying disease, such as:

• diabetes
• elevated risk of gestational diabetes, based on family history
• cardiovascular disease
• thyroid disease
• muscle diseases
• bowel diseases
• chronic constipation
• epilepsy
• eating disorders
• food sensitivities
• (imminent) kidney failure

High risk factor, such as:

• overweight / obesity (before the pregnancy, a BMI of ≥ 25 and waist circumference of ≥ 88 cm)
• unwanted substantial weight gain in a previous pregnancy
• hypertension / gestational hypertension
• underweight condition
• experience with underweight condition in a previous pregnancy
• elevated risk of gestational diabetes, based on family history

Persistent nausea and morning sickness

Specific problems and/or questions related to food, such as:

• How do I eat a healthy diet before, during and after the pregnancy?
• specific questions regarding vitamin and/or iron deficiencies
• specific questions regarding breastfeeding
• vegetarian or vegan diet

 

Relevant information for the dietician:

• Diagnosis: pregnancy, any comorbid conditions
• Symptoms: nausea, vomiting, fatigue, gastrointestinal symptoms, extreme thirst, polyuria, proteinuria, dizziness, tingling in extremities, cramps, edema
• Laboratory tests: (depending on comorbidity) include HbA1c1, glucose, Hb, vitamin B12, MMA, tHcy, TSH, free T4
• Medication/treatment: iron medication, antiemetics, antihypertensives, insulin, thyroid hormone, hormonal fertility treatment
• Other: height, weight prior to conception, (changes in) weight, desire to have children, duration of pregnancy, blood pressure, fetal growth, psychological factors, obstetric history, allergic symptoms (also in her partner and/or older children in the family)

 

Aims of the diet:

• maintain/improve nutritional status of mother and child
• normal weight gain (see Special details)
• reduce complications
• blood pressure ≤ 130/80 mmHg
• for diabetes, restore blood glucose to normal levels:

• diabetes mellitus types 1 and 2: target value for fasting blood glucose (BG) 4.0-7.0 mmol/L, postprandial < 8 mmol/L, HbA1c1 < 53 mmol/mol
• gestational diabetes: target value for fasting BG ≤ 5.3 mmol/L, postprandial ≤ 7.8 mmol/L

 

Characteristics of the diet:

• Nutrients based on recommended daily allowances during pregnancy, with special attention to:

• Energy: extra requirements during the 1^st, 2^nd and 3^rd trimesters, as follows: +0.2 MJ/day (1^st trimester), + 0.9 MJ/day (2^nd trimester), + 2.6 MJ/day (3^rd trimester)
• Protein: 0.9 g/kg preconception weight
• Fats: 10% or less of total calorie load from saturated fat, 2.5% from LA, 1% from ALA, 450 mg/day omega-3 LCP fatty acids, of which 200 mg/day should be DHA.
• If fish oil capsules are to be taken, check the fatty acid composition (omega-3, ‑6, ‑9)
• Carbohydrates: regular distribution for high blood sugar levels. Aim for a balance between carbohydrate intake, physical exercise, stress and, if applicable, insulin use. If possible, self-regulate through self-monitoring.
• Alcohol is not recommended
• Dietary fiber 3.4 g/MJ
• Fluids 2-2.5 L per day
• Vitamin A: up to 3000 μg/d
• Vitamin D: supplement with 10 μg/d
• Folic acid: supplement with 400 μg through week 10 of pregnancy. Throughout the pregnancy, the RDA for folic acid is 400 μg/d.
• Vitamin B12: Supplement adequately in the case of (partial) vegetarianism / veganism. If deficient, an oral dose of at least 500 μg/day is required. Depending on serum levels, the duration of pregnancy and the symptoms, and in consultation with the primary care physician or specialist, vitamin B12 injections may be an option.
• Iron recommendations are related to duration of pregnancy: 11, 15 and 19 mg in the 1st, 2^nd and 3rd trimester, respectively.
• Iodine: Supplementation may be necessary, depending on the consumption levels of foods such as bread, fish and iodized salt.
• Sodium: Avoid processed (instant, ready-to-eat) products and excessive use of salt, as much as possible. In the case of high blood pressure, no (strict) salt restriction unless sensitivity to salt was in evidence already before the pregnancy.
• Magnesium: Deficiency can be the cause of cramping (in the calves).

• Be alert to (preventing) Listeria and toxoplasmosis infections.
• Note the use of products containing glycyrrhizin, especially with high blood pressure or edema.
• Ensure consumption of frequent meals with a high nutrient density, particularly when there are GI problems, vomiting, underweight condition
• For hyperemesis gravidarum (severe morning sickness), see “Hyperemesis gravidarum”
• For food sensitivities, see “Food allergies”

 

Treatment time:

• Care level 2, see “Dietician’s working methods.”

 

Specific remarks:

• Recommended weight gain based on pre-pregnancy BMI:

• 12.5-18 kg for BMI < 18.5 kg/m2 (underweight)
• 11.5-16 kg for BMI 18.5-25 kg/m2 (normal weight)
• 7-11.5 kg for BMI 25-30 kg/m2 (overweight)
• 5-9 kg for BMI > 30 kg/m2 (obesity)

• It is a good idea to calculate the intake of micronutrients. In general, multivitamins are required in order to meet recommended allowances for pregnancy.
• Green food supplements, such as algae and seaweed (e.g. Spirulina), contain a form of vitamin B12 that is not usable by humans, and therefore they cannot serve as supplements for B12 deficiencies.
• Nutritional standards apply to a single pregnancy. No (Dutch) guidelines have been set for multiple gestation.
• Exercise caution in the use of teas or herbs with a laxative effect (senna, aloe); they can induce abortion.
• “White clay” or pimba (from Surinam), which is sometimes taken orally by non-Caucasian women for morning sickness, can be harmful to the unborn child, due to its high lead content.
• The use of probiotics during the last month of pregnancy and during lactation seems to reduce the risk of allergies.

 

¹ As of April 6, 2010, HbA1c is expressed in mmol/mol units.

 

References:

Gezondheidsraad. Preconceptiezorg; voor een goed begin. Nr. 2007/19 Den Haag: 2007

 

Koletzko B, Lien E et al. (World Association of Perinatal Medicine Dietary Guidelines Working Group.) The roles of long-chain polyunsaturated fatty acids in pregnancy, lactation and infancy: review of current knowledge and consensus recommendations. J Perinat Med. 2008 36(1): 5-14

 

Obeid R, Herrmann W. Homocysteine, folic acid and vitamin B12 in relation to pre- and postnatal health aspects. Clin Chem Lab Med 2005;43(10):1052–1057

 

Rasmussen KM, Yaktine AL, editors. (Committee to Reexamine IOM Pregnancy Weight Guidelines, Institute of Medicine, National Research Council) Weight Gain During Pregnancy: Reexamining the Guidelines Washington DC: National Academies Press, 2009

 

Nutritional Problems Related to Pregnancy was updated by Anita Badart-Smook, Dietician / Lactation Specialist with “IBCLC Voedingspraktijk Rond & Gezond”