The critical care nutrition landscape in sub-Saharan Africa: Field insights and clinical commentary from resource-limited clinical settings.

Critical care resources are very limited on the African continent. Within these limited resources, adequate and formalized critical care nutrition support is an even rarer clinical resource. While nutrition products for nasogastric feeding are specified in international consensus guidelines as essential requirements for critical care, these are desperately undersupplied in African Intensive Care Units (ICU). Malnutrition in ICUs in low and middle income countries is 65-78%, roughly double that of developed countries. Furthermore, malnutrition prevalence among severely ill oncology and infectious disease subgroups is 90-100% in the African setting. Dietetic resources in general are few and even fewer within critical care units. Integration of dietetic skills and services into ICU care is not routine, not governed by formalized protocols and is associated with low insight from non-nutrition health professionals. Overall level of perceived critical care nutrition skill and competency is lacking. These are barriers to ICU nutritional care along with poor compliance with clinical practice guidelines, delays in nutritional referrals, insufficient dietitian-to-patient ratios and severe shortage of medical nutrition products and feeding pumps. Both enteral and parenteral nutrition are subject to improvised formulation options because commercial product acquisition and procurement is not aligned to clinical need and is seldom reimbursed through government health systems. This results in both inadequate and inappropriate nutrition delivery as well as safety concerns. Combined clinical and political strategies for incremental quality enhancements and capacity building for critical care nutrition support are urgently needed in the region.