Undernutrition and COVID-19

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection or coronavirus disease 2019 (COVID-19) is a condition associated with a high risk of malnutrition. The prevalence of malnutrition in people hospitalised with COVID-19 is 40%, and up to 70% in intensive care units. The mechanisms explaining malnutrition are multiple, associating a drop in ingesta, an increase in energy losses and in energy requirements. Undernutrition is associated with the severity of COVID-19. Screening and management of undernutrition is therefore a priority. Screening for undernutrition is based on the French National Authority for Health (HAS) criteria, combining a phenotypic criterion (weight loss, low body mass index, loss of muscle mass and/or strength), and an etiological criterion (always present in COVID-19). Management follows the May 2020 recommendations of the French-speaking Society of Clinical Nutrition and Metabolism (SFNCM), based on a diet adapted to the nutritional status (enrichment, oral nutritional supplements, artificial nutrition), prevention of the syndrome of inappropriate renutrition, and physiotherapy for muscle strengthening. Nutritional management should also be continued after the acute phase of COVID-19 to prevent and treat sarcopenia.

Applying learning from 1st to the 3rd wave of the COVID19 pandemic: nutritional provision in critical care

The aim of this analysis was to compare route and adequacy of nutrition support in patients with COVID19 admitted to an intensive care unit (ICU) between March-June 2020 (T1) compared to January-April 2021 (T2). Parameters related to nutrition support were collected from the records of all patients admitted to ICU with COVID19 with length of stay of ≥7days on mechanical ventilation requiring artificial nutrition support. Data was collected during the late acute phase which was defined as day 4-7 post intubation. Energy and protein intake was compared to calculated estimated nutritional requirements. 35 patients met the inclusion criteria in T1, 94% were on enteral nutrition (EN), 3% parenteral nutrition (PN) and 3% EN+PN. In T2, there were 54 patients (92% EN, 2% PN and 6% EN+PN). [Formula presented] Of patients who achieved <70% of energy and protein requirements in T1 (n=17) 35% had constipation or ileus and 47% had GI intolerance (high gastric residual volumes or vomiting). In T2 (n=19), 84% experienced constipation or ileus and 63% had GI intolerance. 35% of patients in T1 had hypernatraemia vs. 47% in T2 and 41% in T1 had hyperglycaemia vs. 100% in T2 despite only 12% and 32% of patients respectively having a history of diabetes. Despite a higher incidence of GI intolerance in T2, a statistically significant improvement in achieving energy targets was noted. Learning from T1 showed that where strategies to improve GI tolerance are unsuccessful supplementary PN should be considered without delay to optimise nutritional intake. There was a clinically significant trend in protein intake which may be attributed to prompt initiation of modular protein supplements or perhaps an earlier transition from fat-based sedation. Meeting protein requirements while preventing overfeeding remains a challenge in the ICU. Disclosure of Interest: None Declared

Characteristics and nutritional outcomes of patients recovering from COVID-19 infection post intensive care admission

Patients transferred out of intensive care recovering from COVID-19 infection are at high risk of malnutrition1.Untreated malnutrition has the potential to increase length of stay and increase morbidity and mortality. To inform service planning we aimed to describe nutritional status and dietetic outcomes of patients recovering from COVID-19 infection post ICU admission. Baseline data was collected retrospectively from patient electronic records and included age, gender, comorbidities, weight, height, Body Mass Index (BMI), Vitamin D status, type of nutrition support, length of stay and discharge destination. Of 51 COVID-19 patients transferred out of ICU, 71% remained as inpatients and had further dietetic follow up. [Formula presented] Of those with data sets available, 82% had a decrease in weight during their ICU stay with an average loss of 7.6kg (9% body weight). Thirty percent moved into a lower BMI category over the course of their ICU stay. On discharge from hospital and dietetic service, 50% were weight stable and 29% had gained weight following dietetic input. Seventy two percent of patients required ongoing artificial nutrition support on transfer out of ICU. Prior to discharge home, 82% required advice on a high protein, high calorie diet with 25% of these requiring additional advice for therapeutic diets such as diabetic diets, no added salt diet, dietary advice for stoma management, renal dietary advice and modified consistency dietary advice. In terms of follow up, 11% were referred to community dietetics, 8% returned to dietetic outpatient clinics and 18% were stable on nutrition care plan and discharged from dietetic caseload at ward level. The data obtained highlights the deterioration in nutritional status and risk of malnutrition in this cohort of patients post COVID-19 infection. Ongoing nutrition support and dietetic input should be considered as integral on transfer from ICU to ward level in preventing, treating and diagnosing malnutrition. References 1. Bedock.D, Bel Lassen.P, Mathian.A, Moreau.P, Couffignal.J, Ciangura.C, Poitour-Bernert.C, Jeannin, AC, Mosbah.h, Fadlallahj, Amoura.Z, Oppert.JM, Faucher.P. Prevalence and severity of malnutrition in hospitalized COVID-19 patients. Clinical Nutrition ESPEN. 2020;Vol. 40 214-219 2. Haraj.NE, EL Aziz.S, Chadli. A, Dafir.A, Mjabber. A, Aissaoulo, Barrou.L, EL Kettanie EL Hamidi.C, Nsiri.A, AL Harrar.R, Ezzouine.H, Charra.B, Abdallaoui. Ms, EL Kebbaj.N, Kamal.N, Mohamed Bennouna.M, EL Filali.KM, Ramdani.B, EL Mdaghri.N, Benghanem Gharbim, Hicham Afif. Nutritional status assessment in patients with COVID-19 after discharge from intensive care unit. Clinical Nutrition ESPEN. 2020;2405-4577

Nutrition management for critically and acutely unwell hospitalised patients with coronavirus disease 2019 (COVID-19) in Australia and New Zealand.

Coronavirus disease 2019 (COVID-19) results from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The clinical features and subsequent medical treatment, combined with the impact of a global pandemic, require specific nutritional therapy in hospitalised adults. This document aims to provide Australian and New Zealand clinicians with guidance on managing critically and acutely unwell adult patients hospitalised with COVID-19. These recommendations were developed using expert consensus, incorporating the documented clinical signs and metabolic processes associated with COVID-19, the literature from other respiratory illnesses, in particular acute respiratory distress syndrome, and published guidelines for medical management of COVID-19 and general nutrition and intensive care. Patients hospitalised with COVID-19 are likely to have preexisting comorbidities, and the ensuing inflammatory response may result in increased metabolic demands, protein catabolism, and poor glycaemic control. Common medical interventions, including deep sedation, early mechanical ventilation, fluid restriction, and management in the prone position, may exacerbate gastrointestinal dysfunction and affect nutritional intake. Nutrition care should be tailored to pandemic capacity, with early gastric feeding commenced using an algorithm to provide nutrition for the first 5-7 days in lower-nutritional-risk patients and individualised care for high-nutritional-risk patients where capacity allows. Indirect calorimetry should be avoided owing to potential aerosol exposure and therefore infection risk to healthcare providers. Use of a volume-controlled, higher-protein enteral formula and gastric residual volume monitoring should be initiated. Careful monitoring, particularly after intensive care unit stay, is required to ensure appropriate nutrition delivery to prevent muscle deconditioning and aid recovery. The infectious nature of SARS-CoV-2 and the expected high volume of patient admissions will require contingency planning to optimise staffing resources including upskilling, ensure adequate nutrition supplies, facilitate remote consultations, and optimise food service management. These guidelines provide recommendations on how to manage the aforementioned aspects when providing nutrition support to patients during the SARS-CoV-2 pandemic.

Nutrition management for critically and acutely unwell hospitalised patients with coronavirus disease 2019 (COVID-19) in Australia and New Zealand.

Coronavirus disease 2019 (COVID-19) results from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The clinical features and subsequent medical treatment, combined with the impact of a global pandemic, require specific nutritional therapy in hospitalised adults. This document aims to provide Australian and New Zealand clinicians with guidance on managing critically and acutely unwell adult patients hospitalised with COVID-19. These recommendations were developed using expert consensus, incorporating the documented clinical signs and metabolic processes associated with COVID-19, the literature from other respiratory illnesses, in particular acute respiratory distress syndrome, and published guidelines for medical management of COVID-19 and general nutrition and intensive care. Patients hospitalised with COVID-19 are likely to have preexisting comorbidities, and the ensuing inflammatory response may result in increased metabolic demands, protein catabolism, and poor glycaemic control. Common medical interventions, including deep sedation, early mechanical ventilation, fluid restriction, and management in the prone position, may exacerbate gastrointestinal dysfunction and affect nutritional intake. Nutrition care should be tailored to pandemic capacity, with early gastric feeding commenced using an algorithm to provide nutrition for the first 5-7 days in lower-nutritional-risk patients and individualised care for high-nutritional-risk patients where capacity allows. Indirect calorimetry should be avoided owing to potential aerosole exposure and therefore infection risk to healthcare providers. Use of a volume-controlled, higher-protein enteral formula and gastric residual volume monitoring should be initiated. Careful monitoring, particularly after intensive care unit stay, is required to ensure appropriate nutrition delivery to prevent muscle deconditioning and aid recovery. The infectious nature of SARS-CoV-2 and the expected high volume of patient admissions will require contingency planning to optimise staffing resources including upskilling, ensure adequate nutrition supplies, facilitate remote consultations, and optimise food service management. These guidelines provide recommendations on how to manage the aforementioned aspects when providing nutrition support to patients during the SARS-CoV-2 pandemic.

Maternal transmission of SARS-COV-2 to the neonate, and possible routes for such transmission: a systematic review and critical analysis.

BACKGROUND: Early reports of COVID-19 in pregnancy described management by caesarean, strict isolation of the neonate and formula feeding. Is this practice justified? OBJECTIVE: To estimate the risk of the neonate becoming infected with SARS-CoV-2 by mode of delivery, type of infant feeding and mother-infant interaction. SEARCH STRATEGY: Two biomedical databases were searched between September 2019 and June 2020. SELECTION CRITERIA: Case reports or case series of pregnant women with confirmed COVID-19, where neonatal outcomes were reported. DATA COLLECTION AND ANALYSIS: Data were extracted on mode of delivery, infant infection status, infant feeding and mother-infant interaction. For reported infant infection, a critical analysis was performed to evaluate the likelihood of vertical transmission. MAIN RESULTS: Forty nine studies included information on mode of delivery and infant infection status for 655 women and 666 neonates. In all, 28/666 (4%) tested positive postnatally. Of babies born vaginally, 8/292 (2.7%) tested positivecompared with 20/374 (5.3%) born by Caesarean. Information on feeding and baby separation were often missing, but of reported breastfed babies 7/148 (4.7%) tested positive compared with 3/56 (5.3%) for reported formula fed ones. Of babies reported as nursed with their mother 4/107 (3.7%) tested positive, compared with 6/46 (13%) for those who were reported as isolated. CONCLUSIONS: Neonatal COVID-19 infection is uncommon, rarely symptomatic, and the rate of infection is no greater when the baby is born vaginally, breastfed or remains with the mother. TWEETABLE ABSTRACT: Risk of neonatal infection with COVID-19 by delivery route, infant feeding and mother-baby interaction.