What should be the nutritional support to adult patients with

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1
What should be the nutritional support to adult patients and children with Ebola Virus Disease
(EVD) in treatment centres in the current crisis areas?
Version 7, Geneva, 4 Sept 2014
Mija Ververs,
Manuel Duce and Valerie Captier (ICRC),
Nathalie Avril (MSF-CH)
This question refers to patients infected with EVD who are not malnourished.
QUESTION:
Please help me with more suggestions and ideas and experiences from the field, what worked,
what did not, etc?
One specific question: what experience do you have on preparing normal food/RUSF/RUTF for NG
tube feeding? What worked, what not taking into consideration the operational constraints in the
field?
ADULTS
Note: Most patients at this stage are adults.
Before suggestions could be listed we need to look at a few questions:
1.
2.
3.
4.
Are there specific symptoms that would hinder normal food?
What are the clinical treatment priorities?
Are there specific nutritional needs?
Are the specific circumstances in the treatment centre that impact nutritional care?
1. Are there specific symptoms that would hinder normal food?
Symptoms in patients with EVD that could interfere with nutrition (ref1,ref2):
Most patients suffer from:
- anorexia1 and sore throat
(most common complaint)
- Stomach pain
- Diarrhoea
- Vomiting
- Nausea
- General malaise
- Fever
Some patients suffer from:
- Difficulties in swallowing (it seems to
be present in half of the patients)
- Bleeding (external, internal)
- (note: bleeding in <50% of confirmed
cases; mostly in later stage of diseases)2
The lack of appetite and sore throat/difficulty swallowing is particularly hampering eating.
1
2
Worse in acute phase of EVD
Despite a common belief that haemorrhage is a defining feature, visible bleeding is not universal. When present, bleeding
is not an early presenting feature, but often only appears in the later stage (ref1).
2
Anti-emetic medications may provide some relief and facilitate oral rehydration if nausea and
vomiting are common (ref1).
If swallowing is difficult risk of aspiration is high. Then either food should be given via naso-gastric
tube or patient should be positioned semi-supine (‘half sitting’ position) or upright.
2. What are the clinical treatment priorities?
Standard treatment for Ebola HF is still limited to supportive therapy. This consists of:
• balancing the patient’s fluids and electrolytes (note: it seems that survival rate is strongly related
to rehydration – mostly done with ORS/fluids; IVs are not really an option!)
• maintaining their oxygen status and blood pressure
• treating them for any complicating infections
3. Are there specific nutritional and food needs?
Like most infectious diseases patients with EVD need sufficient energy (kcal), proteins and especially
lots of fluid (and electrolytes) to compensate for losses through diarrhea, vomiting, and fever.
Patients should be provided with food if they are conscious and can swallow. As most patients lose
their appetite, soft foods and fluids are easier to tolerate (ref1). Small frequent meals often are
tolerated better. Important is to offer food the patient likes to eat.
4. Are the specific circumstances in the treatment centre that impact nutritional care?
The following description refers to the crises areas at present in West-Africa. In most cases, once
diagnosed, the patients with EVD are in a hospital/special treatment centre. The current reality on
the ground is as follows:
-
There is limited access to staff (or visitors) being able to help to feed the patients
Health care has NO extra time for feeding patients
There is NO time for inserting and monitoring naso-gastric tubes by health staff (because of
lack of staff; this might change over time)
Eating utensils (as well as food) can be a source of transmission
Those that die, die within one week. Those that survive stay around 10-15 days. This is
subject to change as the situation is evolving with patients coming in earlier and in less
severe state.
For logistical reasons food that is offered should ideally be appropriate to ALL infected patients. This
might nevertheless clash with the strategy of providing food that the individual patient prefers to
eat.
Field feedback3: Over the last weeks it seems that EVD patients are now coming in the treatment
centres earlier, the length of stay has increased and people arrive in better conditions. From
30% of people that were able to eat a normal food (beginning of the ebola crisis) now this % is
around 50-60 %. This means more patients will be able to tolerate normal meals.
3
From one treatment centre
3
WHAT FOOD COULD BE OFFERED?
The features of food and how to should be offered can be summarised:
1. Food could be offered in
a) disposable materials (for single use only) that should be burned after use (plastic,
polystyrene, straws, wooden/paper/plastic spoons, foil)
or
b) cutlery that is kept on the patient’s ward (at bedside) with chlorination
procedures in place to clean utensils.
2. Food should be easy to ingest whilst lying down or in half-sitting position (semi-solid or
liquid: mashed, porridge or completely liquid)
3. Food should be sufficient in energy (calories)4 and protein (electrolytes are corrected
through other means, e.g. ORS5)
4. Food should be attractive to the patient as he/she suffers from anorexia, sore throat and
general malaise.
Note: for all those that have difficulties to swallow or are too sick naso-gastric feeding should be
offered. However, due to workload and reality at bedside this seems not yet an option, but in the
future this needs to be reconsidered.
IMPORTANT: Whenever possible an assessment should be done on what patients themselves
indicate what they can and prefer to eat in order to bridge that what is nutritionally needed is similar
to what patients with EVD want.
Food to be considered for in-patient treatment of Ebola:
Food commodity
SPREADS
- Ready-to-Use Therapeutic
Food (PlumpyNut,
EezeePaste)
- Ready-to-Use
Supplementary Food
(Plumpy’Soy/Sup,
EezeeRUSF)
in individual packaging
Advantages
Hygienic, individual portions,
easy to eat
Does not need preparation and
can be positioned at bedside
(Plumpy’Soy for adults)
Comments
Rather dry and plenty of
liquid should be offered
separately
Problematic in patients
with minor swallowing
difficulties
Ready-to-Use
Supplementary Food =
cheaper
BISCUITS
Ready-to-Use Therapeutic Food
in biscuit form (BP100)
Can be made into a porridge
with adding water.
Does not need preparation if
used as dry biscuit and can be
positioned at bedside
If offered as biscuit, plenty
of water should be offered
separately
4
5
≥2500 kcal/day and 10-15 en% protein (suggestion authors)
Note: ORS cannot be replaced by fruit juices.
4
Super cereal (i.e. Corn-SoyBlend = CSB+)
(without milk powder for adults)
F100
Offered as porridge
Enteral feeding products,
supplement, e.g. Fortimel,
Fresubin
Normal food (mashed or solid)
Based on preference of the
individual patients
Individual package, easy to
ingest with straw and
contributes to fluid intake
E.g. rice-gruel or rice porridge,
fou-fou, mashed carrots, etc
Question: does anyone know
more on cereal based-ORS
food (see annex)?
This was used in Bangladesh
in case of diarrheal epidemic
like shigella (to treat
dehydration and
bring nutrients
simultaneously)
Note: a new option has been
suggested – dilute PlumpyNut
with water in blenders
This will make PlumpyNut easier
to ingest, ensures fluid intake
and avoid it to be stuck in the
mouth (possibly useful for the
very sick)
Others?
IDEAS????
Offered as liquid drink (through
straw), easy to ingest and
contributes to fluid intake
Requires preparation in a
kitchen and regular
distribution
Risk for those with lactose
intolerance present
Risk of contamination if
kept at ward >2 hrs
Expensive; possibly not an
option for current area of
crisis
Not suitable for those that
have eating difficulties. This
might be nutritionally
insufficient if this is the only
food offered.
This is relatively low in
calories. Option needs to
be tested for results.
This option only possible
when blenders are
available, operational and
in small centres.
This option needs to be
tested for results and
feasibility.
ADULTS - SUGGESTED PROTOCOL FOR THE TIME BEING:
The following nutritional protocol is developed for ADULTS and is divided for two categories of
patients.
Category of patients ADULTS
Category 1:
Patients who are alert (confirmed cases and
recovering patients6), can eat and swallow
semi-solid/solid food AND have appetite
Category 2:
Patients who hardly eat
Nutritional protocol
 1-2 porridges per day (CSB+/Supercereal)
 normal meal
 Ready-to-Use Supplementary Food as
snacks or BP100 (as biscuit or porridge)



Porridges (made from CSB+/Supercereal,
BP100)
And/or Ready-to-Use Supplementary Food
anything the patient likes (cookies, local
juices, BP5)
Naso-gastric feeding recommended, but as not
possible for the time being the listed suggestion
Note: soups and cereal-based ORS are not encouraged for the time being as they are low in calories
See Annex 2 for a menu for ADULTS.
6
Suspected cases are in isolation centres and could receive normal food
5
Ideally, a ‘menu’ of 4-5 choices could be presented (e.g. CSB+/Supercereal porridge, rice-gruel or rice
porridge, fou-fou, F100, mashed carrots, BP100 porridge) every day. This increases the likelihood
that the patients will eat and is logistically probably still manageable.
Glucose/fructose and tasty fluids should be available at bedside.
CHILDREN
CHILDREN > 6 months - SUGGESTED PROTOCOL FOR THE TIME BEING:
The following nutritional protocol is developed for CHILDREN > 6 months and is divided for two
categories of patients.
Category of patients CHILDREN > 6 months
Category 1:
Patients who are alert (confirmed cases and
recovering patients7), can eat and swallow semisolid/solid food AND have appetite
Category 2:
Nutritional protocol
 1-2 porridges per day
(CSB+/Supercereal)
 normal meal
 Ready-to-Use Supplementary Food
as snacks or BP100 (as biscuit or
porridge)
 F100
Patients who hardly eat
And if desired/possible:
 Porridges (made from
Naso-gastric feeding recommended, but as not
CSB+/Supercereal, BP100)
possible for the time being the listed suggestion
 And/or Ready-to-Use
Supplementary Food
 anything the patient likes (cookies,
local juices, BP5, mashed fruit)
Note: soups and cereal-based ORS are not encouraged for the time being as they are low in calories
See Annex 3 for a menu for children > 6 months.
CHILDREN < 6 months - SUGGESTED PROTOCOL/GUIDANCE FOR THE TIME BEING:
See infant feeding and EVD
http://www.en-net.org/question/1445.aspx
and
http://www.ennonline.net/infantfeedinginthecontextofebola2014
IMPORTANT
Care Support: In the near future the option needs to be considered to recruit ex-patients with EVD
as carers; they could be a support in the feeding process as they have access to the patients and
they are at low risk to fall ill (for the particular EVD strain they recovered from).
7
Suspected cases are in isolation centres and could receive normal food
6
If visitors in protective gear are allowed to regularly stay with patients with EVD other
(normal/mashed) food can be offered. Visitors can then be requested to support the feeding process
with offering regularly small portions of food and drinks.
At discharge of the patient: Provision of food ration.
Thank you experts in the field and at home who contacted us directly. Your inputs are essential
and have been very helpful. Keep on writing!
*********
Ref 1. Clinical Management of Patients with Viral Haemorrhagic Fever: A Pocket Guide for the Frontline Health Worker 13 April 2014 Interim emergency guidance-generic draft for West African
adaptation. World Health Organization.
Ref 2. Ebola hemorrhagic Fever. Fact Sheet, Centers of Disease Control CDC, (2014). National Center
for Emerging and Zoonotic Infectious Diseases Division of High-Consequence Pathogens and
Pathology (DHCPP)
7
Annex 1.
DIFFERENT CEREAL BASED ORS STUDIED IN ICDDR, BANGLADESH
Type of Cereal ORS
Quantity/ Water
Rice flour
50g/litre8
Maize flour
60g/litre
Millet flour
60g/litre
Sorghum Flour
60g/litre
Wheat flour
60g/litre
Mashed Potatoes
200g/litre
Mashed GN Plantain
250g/litre
Recipe
1 one litre water to be taken in a clean saucepan
2 Then to add 50ml more water for cooking loss
3 Now to add two pinch of salt and the cereals
4 Then to mix thoroughly and cook to make it even solution, it needs one minute boiling when bubbles come out
5 It needs continuous stirring when cooking
6 Now the solution is ready to serve
7 Solution can be kept 6 hours in room temperature during summer season and 8 hours in the winter in Bangladesh
8
Low in energy (in kcal)
8
Annex 2. Menu for ADULTS with EVD
Category 1:

1-2 porridges per day (CSB+/Supercereal):
150 g CSB+/Supercereal
10 g oil
10 g sugar

normal meal (mashed or solid):
130 g cereal (e.g. rice)
60 g pulses (or meat9/chicken/fish)
50 g vegetables
10 g oil

Ready-to-Use Supplementary Food:
2 sachets of Plumpy’Soy/Sup, EezeeRUSF10
OR
Ready-to-Use Therapeutic Food (if porridge is preferred):
3 bars/6 tablets of BP100 + water
Provides ± 2500 kcal and 13 en% protein
Category 2:

1-2 porridges per day (CSB+/Supercereal):
150 g CSB+/Supercereal
10 g oil
10 g sugar
OR
Porridge from BP10011:
3 bars/6 tablets of BP100 + water

Ready-to-Use Supplementary Food: (2 sachets)12

Other food: anything the patient likes (cookies, BP5, mashed meals, etc) and plenty of tasty
drinks13 (an assessment is needed). This category is particularly important for those that have
limited chance of survival.
Provides ± 1800 kcal and 11 en% protein (‘other food’ not included in calculation)
9
No bush meat
If RUSF not available, this can be replaced by PlumpyNut or EezeePaste
11
If BP100 is not available, BP5 can be used temporarily.
10
12
If Ready-to-Use Supplementary Food is not available Ready-to-Use Therapeutic Food can be used
(e.g. PlumpyNut, EezeePaste)
13
Juices in tetra/carton package
9
Annex 3. Menu for CHILDREN > 6 MONTHS with EVD
Category 1:

1-2 porridges per day (CSB+/Supercereal):
100 g CSB+/Supercereal
10 g oil
10 g sugar

normal meal (mashed or solid) (in 2-3 portions):
see adults but smaller portions, and/or mashed fruits

Ready-to-Use Supplementary Food:
2 sachets of Plumpy’Soy/Sup, EezeeRUSF14
OR
Ready-to-Use Therapeutic Food (if porridge is preferred):
3 bars/6 tablets of BP100 + water
Category 2:

F100 (as much as the child wants)(see Annex 4 for guidance)
And if desired/possible:
 1-2 porridges per day (CSB+/Supercereal):
100 g CSB+/Supercereal
10 g oil
10 g sugar
OR
Porridge from BP10015:
3 bars/6 tablets of BP100 + water

Ready-to-Use Supplementary Food: (2 sachets)16

Other food: anything the patient likes (cookies, BP5, mashed meals, etc) and plenty of tasty
drinks17 (an assessment is needed). This category is particularly important for those that have
limited chance of survival.
14
15
If RUSF not available, this can be replaced by PlumpyNut or EezeePaste
If BP100 is not available, BP5 can be used temporarily.
16
If Ready-to-Use Supplementary Food is not available Ready-to-Use Therapeutic Food can be used
(e.g. PlumpyNut, EezeePaste)
17
Juices in tetra/carton package
10
Annex 4. Guidance on F100
Children
weight in kg
3
4
5
6
7
8
9
10
11
12
13
14
15
F-100 X 4 meals + RUSF X 2 meals = 6 meals / day
ml of milk per
feeding
quantity of RUSF per feeding
4 feedings / day
2 feedings / day
100
1/4
150
1/4
150
1/2
200
1/2
250
1/2
300
1/2
300
1
300
1
350
1
350
1
400
1
450
1
500
1
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