For a patient admitted with acute stroke, should fortified (nutrient‑enhanced) milk feeding be preferred over a plain‑milk diet?

Fortified Milk Feeding vs Plain Milk Diet in Acute Stroke

For acute stroke patients, fortified (nutrient-enhanced) milk feeding should be used instead of plain milk only if the patient is identified as malnourished or at nutritional risk through validated screening tools like MUST within 48 hours of admission. 1

Key Decision Framework

The decision hinges entirely on nutritional status at admission, not on the stroke itself:

For Well-Nourished Patients Without Dysphagia

• Routine fortified milk or oral nutritional supplements (ONS) are NOT recommended for adequately nourished acute stroke patients who can swallow safely 1
• The landmark FOOD trial (4,023 patients) demonstrated that routine supplementation in predominantly well-nourished stroke patients showed no benefit on mortality (0.7% absolute risk reduction, 95% CI -1.4 to 2.7, p=0.5) or functional outcomes 2, 3
• Only 8% of stroke patients in the FOOD trial were undernourished at baseline, yet routine supplementation provided no measurable advantage 2

For Malnourished or At-Risk Patients

• Fortified milk/ONS ARE strongly recommended when malnutrition or nutritional risk is identified through screening 1
• High-energy, high-protein formulations (2 kcal/ml, 9g protein/100ml) demonstrated superior functional outcomes compared to standard formulations in rehabilitation stroke patients, including better motor scores and 6-minute walking test results 1
• Nutritional support in at-risk patients has a likelihood ratio of 2.9 for positive clinical outcomes 1

Mandatory Screening Protocol

All stroke patients must undergo nutritional screening within 24-48 hours of admission using the Malnutrition Universal Screening Tool (MUST) 1, 4:

• Screen again weekly throughout hospitalization 1
• MUST correlates with critical outcomes including length of stay (RR 1.30,95% CI 1.07-1.58, p≤0.01) and mortality (p<0.001) 1
• Screening must be performed by trained staff using standardized, validated tools 1

Critical Dysphagia Assessment

Before ANY oral intake (including milk), perform swallow screening using validated tools 1, 4:

• Use Gugging Swallowing Screen or Massey Bedside Swallowing Screen within 24 hours 4
• Keep patient strictly NPO until screening completed 4
• 30-50% of acute stroke patients have dysphagia, which dramatically increases aspiration pneumonia risk and mortality 1
• If screening abnormal, obtain immediate speech-language pathology consultation for videofluoroscopic modified barium swallow 4

Practical Algorithm

1. Admission (0-24 hours):

   • Perform swallow screening immediately 4
   • Perform MUST nutritional screening within 24-48 hours 1, 4

2. If swallow screen PASSES:

   • MUST indicates well-nourished: Provide normal hospital diet with plain milk; do NOT add fortified supplements 1
   • MUST indicates malnutrition/risk: Provide fortified milk or high-energy/high-protein ONS (aim for 1.5-2 kcal/ml, 5-9g protein/100ml) 1

3. If swallow screen FAILS:

   • Initiate nasogastric tube feeding within 3-4 days regardless of nutritional status 4, 3
   • Early enteral nutrition reduces mortality risk by 5.8% (95% CI -0.8 to 12.5) 3

Common Pitfalls to Avoid

• Do not routinely supplement all stroke patients - this wastes resources and provides no benefit to the 92% who are adequately nourished 2, 3
• Do not delay swallow screening - aspiration pneumonia is the leading cause of mortality in stroke patients 1, 5
• Do not use clinical judgment alone - validated screening tools (MUST, NRS-2002) are essential for identifying true nutritional risk 1
• Do not continue supplementation indefinitely - reassess nutritional status weekly and discontinue if no longer indicated 1

Multidisciplinary Coordination

A nutrition specialist (dietitian) should develop and monitor the individualized nutrition care plan for all patients identified at nutritional risk 1:

• Coordinate with speech-language pathology for texture modifications 4
• Monitor daily weight, caloric intake, and laboratory markers (serum protein, albumin) 4
• Adjust fortification based on ongoing assessment 1