Nearly 1.4 million individuals suffer from traumatic brain injury (TBI) each year, leaving many survivors with significant deficits. Early and adequate nutrition support is challenging but may improve outcomes for TBI patients. The document discusses the metabolic and immune alterations caused by TBI and recommends enteral nutrition over parenteral nutrition when possible. It emphasizes starting nutrition within 48 hours and achieving full caloric needs by day 7 to prevent protein breakdown and support recovery. Barriers to providing nutrition like feeding intolerance are also reviewed.

1. A D E W I J A Y A , M D – A U G U S T 2 0 2 0
Nutrition
&
Traumatic Brain Injury

2. Introduction
 Nearly 1.4 million individuals per year suffer from
TBI, leaving many of the survivors with significant
deficits
 Moderate to severe traumatic brain injury (TBI)
results in a mortality rate of approximately 33%
 Early and adequate nutrition support is challenging
to provide in the TBI population, but it may improve
the overall clinical course in TBI patients as well
Brain Trauma Foundation. Management of severe traumatic brain injury. J Neurotrauma. 2007;24:S1-S95.
Langlois JA, Rutland-Brown W, Thomas KE. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths. Atlanta, GA: Centers for
Disease Control and Prevention, National Center for Injury Prevention and Control; 2004.
Taylor SJ, Fettes SB, Jewkes C, Nelson RJ. 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. 1999;27:2525-25

3. Metabolic and Immune Alterations
After Traumatic Brain Injury
Cook AM, Hatton J. Neurological impairment. In: Gottschlich MM, ed. The A.S.P.E.N. Nutrition Support Core Curriculum: A Case-Based Approach-The Adult Patient. Silver
Spring, MD: A.S.P.E.N; 2007:424-439

4. Nutrition Access
 Enteral > Parenteral
 Within 72 hours, in selected cases, parenteral until
enteral access can be obtained
 When TBI patients require long-term EN, a more
secured enteral access device, gastrostomy, is
optimal and preferred by most long-term care
facilities
Kattelmann KK, Hise M, Russell M, harney P, Stokes M, Compher C. Preliminary evidence for a medical nutrition therapy protocol: enteral feedings for critically ill patients. J Am
Diet Assoc. 2006;106:1226-1241.
Dobson K, Scott A. Review of ICU nutrition support practices: implementing the nurse-led enteral feeding algorithm. Nurs Crit Care. 2007;12:114-123.
Fertl E, Steinhoff N, Schofl R, et al. ransient and long-term feeding by means of percutaneous endoscopic gastrostomy in neurological rehabilitation. Eur Neurol. 1998;40:27-30.

5. Timing of Nutrition
 Early EN (within 48 hours) is clearly an important
goal for the initial nutrition support plan for a TBI
patient.
 Most TBI patients tolerate receiving at least 50% of
their caloric needs by injury day 2
 The Brain Trauma Foundation promotes a level II
recommendation that TBI patients attain full caloric
replacement by day 7 after injury
Cook, A. M., Peppard, A., & Magnuson, B. (2008). Nutrition considerations in traumatic brain injury. Nutrition in clinical practice, 23(6), 608-620

6. Enteral Nutrition in TBI
 Forestalls the breakdown of protein and fat stores
 Blunts the innate inflammatory response
 Promotes immune competence
 Decreases intensive care unit (ICU) infections
 Limits the risk of bacterial translocation
 Improve neurologic outcome at 3 months
Perel P, Yanagawa T, Bunn F, Roberts I, Wentz R, Pierro A. Nutritional support for head-injured patients. Cochrane Database Syst Rev. 2006:CD00153
Taylor SJ, Fettes SB, Jewkes C, Nelson RJ. 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. 1999;27:2525-25

7. Nutrition Assessment: Calories
Frankenfield D, Smith JS, Cooney RN. Validation of 2 approaches to predicting resting metabolic rate in critically ill patients. JPEN J Parenter Enteral Nutr. 2004;28:259-264.
Frankenfield D, Hise M, Malone A, Russell M, Gradwell E, Compher C. Prediction of resting metabolic rate in critically ill adult patients: results of a systematic review of the
evidence. J Am Diet Assoc. 2007;107:1552-1561

8. Nutrition Assessment: Protein
 The hypercatabolism evident in TBI patients stimulated
by inflammatory mediators and catecholamines often
results in excessive protein breakdown
 Protein catabolism appears to peak 8–14 days after
injury and appears to be related to the severity of injury
 Current recommendations suggest protein provision
ranging between 1.5 and 2 g/kg/day for acute TBI
patients to account for the excess catabolism
Young B, Ott L, Yingling B, McClain C. Nutrition and brain injury. J Neurotrauma. 1992;9(Suppl 1):S375-S383
Hatton J, Ziegler TR. Nutritional support of the neurosurgical patient. In: Tindall G, Cooper PR, Barrow DL, eds. The Practice of Neurosurgery. Baltimore, MD: Williams &
Wilkins; 1998: 381-396.

9. Nutrition Assessment:
Fluids and Electrolytes
 Crystalloids > Colloids
 Intravenous solutions containing dextrose should be
avoided in the acute phases of TBI
Cook, A. M., Peppard, A., & Magnuson, B. (2008). Nutrition considerations in traumatic brain injury. Nutrition in clinical practice, 23(6), 608-620

10. Drug-Nutrition Interactions
Cook AM, Hatton J. Neurological impairment. In: Gottschlich MM, ed. The A.S.P.E.N. Nutrition Support Core Curriculum: A Case-Based Approach-The Adult Patient. Silver
Spring, MD: A.S.P.E.N; 2007:424-439
Hatton J. Pharmacotherapy and nutrition. In: Carter BL, ed. Pharmacotherapy Self-assessment Program.Vol 8. 3rd ed. Kansas
City, MO: American College of Clinical Pharmacy; 1999:157-178.

11. Feeding Intolerance
Diarrhea
Aspiration
Pneumonitis
Abdominal
Distention
Rapp RP, Hatton J, Ott L, Luer MS, Young B. Specific problems associated with enteral nutrition in patients with head injury. Clin Nutr. 1993;12:S70-S74

12. Facilitating Enteral Nutrition Tolerance
 30-45 degress head elevation
 Nasojejunal/duodenal feeding tube
 Increase rate gradually
 Continuous infusion
 Concentrated formula
 Promotility agents such as metoclopramide or
erythromycin may also be considered
Cook, A. M., Peppard, A., & Magnuson, B. (2008). Nutrition considerations in traumatic brain injury. Nutrition in clinical practice, 23(6), 608-620

13. Challenges
 Continued increase in metabolism and protein loss
due to persistent inflammatory response and
prolonged immobility due to injury.
 Spasticity, decorticate or decerebrate posturing, and
periodic sympathetic discharges (“storming”) are all
associated with increased caloric needs
 Inadequate nutrition support for TBI patients, even
well past the initial injury, may result in malnutrition
and muscle wasting and cachexia
Cook, A. M., Peppard, A., & Magnuson, B. (2008). Nutrition considerations in traumatic brain injury. Nutrition in clinical practice, 23(6), 608-620

14. Challenges
 Many TBI patients are not able to take in an
adequate volume of fluids orally to meet their daily
fluid needs due to impaired swallowing or altered
consciousness
 As the TBI patient transitions to a less intensive care
setting, the calorically dense formula used in the ICU
should be gradually converted to a more high-
volume, isotonic enteral formula to provide a higher
percentage of free water per volume
Cook, A. M., Peppard, A., & Magnuson, B. (2008). Nutrition considerations in traumatic brain injury. Nutrition in clinical practice, 23(6), 608-620

15. Oral Diets
 The incidence of dysphagia after a TBI is reported to be
as high as 61%
 Most TBI patients regain their independence in oral
feeding within the first 6 months after injury
 Oral feedings increase the quality of a patient’s life
 Initial swallowing assessment begin within 2-4 weeks of
injury
 The patient’s swallowing ability should continue to be
assessed and treated until the patient is able to tolerate
the least restricted diet or functional recovery plateau
 Speech pathologist
Cook, A. M., Peppard, A., & Magnuson, B. (2008). Nutrition considerations in traumatic brain injury. Nutrition in clinical practice, 23(6), 608-620

16. Pediatric Consideration
 More quality evidence is needed in many areas of
pediatric TBI to guide decision-making.
 At this point, it appears prudent to initiate nutrition
(preferably EN) as soon as is feasible and to target up
to 160% of the calculated BEE until indirect
calorimetry can be performed.
Cook, A. M., Peppard, A., & Magnuson, B. (2008). Nutrition considerations in traumatic brain injury. Nutrition in clinical practice, 23(6), 608-620

17. Summary
 TBI care: multiaspects  including nutrition
 Enteral nutrition: optimal route
 Provision of adequate calories and protein is critical
for recovery
 ASPEN: Early EN initiated within 24–72 hours after
injury
 The Brain Trauma Foundation recommends the TBI
patient receive their goal nutrition support by at
least day 7 of injury

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