Re. “Early nutritional supplementation in non-critically ill patients hospitalized for the 2019 novel coronavirus disease (COVID-19): rationale and feasibility of a shared pragmatic protocol.” Author response

Dear Editor,

We read with interest the letter of Piquet and Dupont [1], who presented their nutritional management protocol in hospitalized, non–intensive care unit patients with coronavirus disease 2019 (COVID-19).

While certainly sharing the same ideas on the fundamental importance of early nutritional management of hospitalized patients with COVID-19, we would like to point out the following clarifications. We did not mention any restrictive or low-sugar/low-salt diet in our protocol, but we indicated that high-calorie dense diets in a variety of different textures and consistencies with highly digestible foods and snacks (yogurt, custard, fruit mousse, sliced fruit, soft cheese, etc) were available for all hospitalized patients to favor the maintenance or increase of protein-calorie intake [2]. With regard to nutritional screening and assessment, we are well aware that most patients reduce their food intake during the early phases of the disease and that a nutritional supplementation is likely to be promptly necessary. For this purpose, we proposed a systematic supplementation of whey proteins orally (20 g/day) and multivitamin, multimineral, trace-element solutions intravenously on admission. However, we believe that a basic nutritional assessment should be performed for trying to tailor nutritional interventions according to actual calorie-protein needs. This was certainly hard to implement during the beginning of the COVID-19 outbreak, but the current situation would allow the safe recording of most nutritional parameters and the customization of nutritional support. Similarly, the initial emergency scenario pushed us to choose peripheral parenteral nutrition for patients requiring artificial nutrition support. Nowadays, the whole clinical management is luckily more feasible, at least in Western countries, and enteral nutrition (EN) could be the first choice in the majority of non–critically ill patients with COVID-19 requiring artificial nutrition, and peripheral parenteral nutrition could be certainly considered when EN is not practical.

With regard to vitamin D supplementation, several epidemiologic and observational studies seem to support the hypothesis of its protective role [3], but most of these are based on retrospective data or small case series, and whether vitamin D25OH adequacy may prevent the infection or improve clinical outcomes still needs to be assessed by adequately sized and designed population-based studies and intervention trials. Nevertheless, in accordance with our protocol, we recommend the prompt supply of vitamin D25OH in the presence of documented deficiency, and we agree with Piquet and Dupont that daily dosing could be a preferable administration option when feasible.

Other nutrients (vitamins A, B6, B12, C, E, and folate; trace elements, including zinc, iron, selenium, magnesium, and copper; and omega-3 fatty acids) are known to play important and complementary roles in supporting the immune system and could be useful in improving clinical outcomes of patients with COVID-19 in the presence of nutritional derangements [4]. We appreciated the protocol proposed by Piquet and Dupont, but, whenever possible, we would advise basing the supplementation dosing on documented deficiencies to avoid overdosing risks or futile administrations.

In conclusion, we are happy that our article stimulated the development and adoption of several protocols aimed at promptly implementing nutritional care in patients with COVID-19, and it is our hope that early appropriate nutritional management will be systematically considered in this fragile patient population, as it is potentially beneficial to clinical outcomes and effective in preventing the consequences of malnutrition.