enteral nutrition & role of milk
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Enteral Nutrition & Role of Milk
Delivery of all the necessary substrates (Amino acids + Carbohydrates + Lipids) via an access either through the natural anatomical GI route or surgically created one
The Total Enteral Nutrition (TN) Is-
Advantages of Enteral Nutrition Therapy
• Maintains GIT structure, integrity and
function• Easier, more Physiological• Enhances intestinal immune function• Reduces bacterial translocation• Decreases risk of sepsis• Fewer complications than with
parenteral nutrition• Lower costs, Less expensive
Advantages of Enteral Nutrition Therapy
• Improved Patient Outcomes• Improved wound healing• Decreased risk of complications
– Nosocomial infection
• Decreased length of ICU stay• Decreased healthcare costs
Advantages of Enteral Nutrition Therapy
Early Intervention as Part of Initial
Care Enteral Nutrition• Oral supplements• Tube feeding
Parenteral Nutrition• Total• Peripheral
Conditions That Often Require Nutritional Support
1. Critically ill : Prone for high energy expenditure and rapid protein breakdown. E N initiated within 24 hours of admission significantly reduces morbidity.
2. Parenteral support to be administered to all patients who cannot tolerate enteral regimen within 5 days of starvation.
3. Factors to be taken into consideration: preoperative fasting status/ level of
starvation before ICU admittance, number of days anticipated on ventilator and any associated systemic problems.
Basic Principles of Nutrition
4. Intra-operative Jejunal access for enteral nutrition: better option
5. Optimization of protein and energy requirement (avoid over/ under feeding)
Protein input - 1.5-2.5 g/kg/day with 50% of total administered enterally
Total caloric intake of 1500-2000 kcal/ day is to be achieved (25 kcal/kg/day ) as per BEE
Basic Principles of Nutrition
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6. Appropriate electrolyte supplementation : Na
P, K & Mg supplementation7. Substrate for provision of energy is
carbohydrates and lipids in the ratio of 70:30.• Peripheral insulin resistance and
hyperglycemic state, mainly due to impaired glucose utilization and gluconeogenesis.
• Overzealous administration of glucose ( eg: > 5 mg/kg/day) will increase the susceptibility to infection.
Basic Principles of Nutrition
8. Proper selection of volume, composition and route of administration, for patients with • Renal & hepatic insufficiency • Cardio-pulmonary diseased
9. Critical monitoring essential10. High degree of suspicion and constant
“looking out” for complications 11. Immunonutriton is still a contentious
issue, especially in terms of final outcome.
Basic Principles of Nutrition
Considerations in Enteral Nutrition
1. Applicable2. Site placement3. Formula selection4. Nutritional/medical
requirements5. Rate and method of
delivery6. Tolerance
Techniques of Access
Complications of GI access
• Dislodgements• Small bowel volvulus, infarction• Catheter/tube occlusion• Leakage/skin breakdown• Tube malposition
Gastric distention & aspiration
Complications of TEN
And diarrhea where milk could become the primary source of infection.
Complications of TEN
• Feed is not prepared in a hygienic way• Quality of milk is in-determinant• Commonly loose milk is used which is
supposed to be boiled first before consumption and for preparing the feed the milk should be at room temperature.
• Temperature changes happening during transportation of feed.
• Delays in administration of feeds.
Causes for Diarrhea among patients who are on EN
• Most of the time Enteral feed is stopped in such condition
OR• Feed is prepared milk free
Measures used to circumvent the problem
Less calories and less protein per ml of the feed
Consequences of Stopping Milk In Enteral Feed
Critical illness dramatically increases muscle proteolysis and more than doubles the dietary protein requirement.
Yet surprisingly, most critically ill patients receive less than half the recommended amount of protein during their stay in a modern intensive care unit.
Reference:
Why Critically Ill Patients Are Protein Deprived. Journal of Parenteral & Enteral Nutrition
However Protein is Critical
Muscle proteolysis dramatically increases in critical illness, making free amino acids available for new protein synthesis at sites of tissue injury and at other locations in the body to regulate inflammatory and immune responses.
Reference:
Why Critically Ill Patients Are Protein Deprived. Journal of Parenteral & Enteral Nutrition
Protein: Vital Nutrient
Amino acid uptake by the rapidly turning-over central proteins is constrained by the rate at which amino acids are released from muscle, suggesting that exogenous protein replacement could beneficially increase central protein synthesis, possibly moderate the intensity of systemic inflammation, and improve clinical outcomes in many situations.Reference:
• Nutrition and traumatic brain injury: a perspective from the Institute of Medicine report. JPEN J Parenter Enteral Nutr. 2011
• Metabolic vs nutrition support: a hypothesis.JPEN J Parenter Enteral Nutr. 2010
Protein: Vital Nutrient
There is strong support in the critical care literature for early and adequate protein provision
Reference:
Why Critically Ill Patients Are Protein Deprived. Journal of Parenteral & Enteral Nutrition
Protein: Vital Nutrient
Milk is universally considered a nearly perfect food.
In particular, dairy products are excellent protein sources. However, researchers have learned that dairy foods provide more than just essential nutrients (like protein). Indeed, they contain other “biologically active” components that may affect overall health.
Reference:
The American Journal of Clinical Nutrition. 2013
And Why Milk Is Important?
Some milk components may modulate intestinal bacteria, whereas others may influence the nervous system.
Reference:
The American Journal of Clinical Nutrition. 2013
Milk- The Wonder Protein Source
In a recent article published in the June 2013 issue of The American Journal of Clinical Nutrition, states that many of these proteins might very well be active in regions of the small intestine. This article is accompanied by an editorial by Paul Ross and colleagues, who argue that the “black box” of human protein digestion has clearly now been opened.
Milk- The Wonder Protein Source
So Why to stop milk when we have safer options available – UHT MILK
• Doesn’t require boiling• Preservatives, adulterants free• Convenience i.e. easy to prepare
the Enteral feed using UHT milk• Administration of the feed will be
easier (feed can even be prepared at patient’s bedside)
• Reduce chances of infection as it is bacteria free
UHT Milk – Safer option for Enteral feeds
Case study
The technology breakthrough
Aseptic Processing
Aseptic Packaging
How Aseptic Processing and Packaging is integral to Food Safety
The technology breakthrough
Aseptic Processing
Aseptic Packaging
Ultra High Temperature (UHT) treatment of milk destroys all bacteria, and keeps its nutrition intact for more than three months without any need for preservatives at ambient storage temperature.The most important food science advancement of the
20th Century - Institute of Food
Technologists, 1989
“ “Aseptic packaging of UHT milk ensures good quality milk from farm to table. And the packaging
is tamper evident.
The UHT processIt all starts with quality milk
pH 6.6 - 6.8
Alcohol Stability >68%
Bacterial Count <600,000 cfu/ml
Spores <10 per ml
All milk that undergoes the Ultra-High Temperature (UHT) process first needs to pass through strict quality checks:
The UHT processThe journey of UHT milk in Tetra Pak cartons
Milk Collection
Quality Check*
Aseptic Processing
Aseptic Packaging
Consumer
* Milk undergoes quality check at customer’s dairy plant
Milk not
conforming to
required
quality checks
cannot
undergo
Aseptic
Processing
The UHT processWhat happens at the UHT plant?
After undergoing the UHT treatment, the milk is then packed aseptically in Tetra Pak
cartons
The UHT process removes all micro-organisms from the milk, including bacterial
spores. Flash heating the milk for a few seconds ensures minimal damage to
nutrients
The milk is then heated to very high temperatures (135-150ºC), also known as
the Ultra-High Temperature (UHT) process, in a closed system for a few seconds. The milk
is then force cooled to room temperature
The entire loop of UHT plant is sterilised using steam at 130º C for 20-30 minutes. Quality tested milk is then brought in for processing
and then homogenisedThe milk is first pasteurised
The UHT processPerfect time-temperature combination
2,000
1,000
600
400
200
100
60
40
20
10
6421
Tim
e (
in s
eco
nds)
Temperature (in ºC)110 130 140 150120
UHT Region
3% destruction of Vitamin B1 (thiamine)
1% destruction of lysine
Thermophilic spores(55ºC)
Mesophilic spores(30ºC)
Region of in-container
sterilisation
The UHT processEnsuring absolute safety
Yeast Mould Virus
Vegetative Cells
PathogensSpores
Vitamin Nutritional LossAsorbic Acid 0-80%Folic Acid 10-20%Vitamin B12 (Cobalamines) 0-30%
Vitamin B6 (Pyridoxine) 0-20%
Vitamin B2 (Riboflavine) <10%
Thiamin <10%Vitamin A Very LowVitamin D Very LowVitamin E Very Low
The UHT processEnsures minimal loss of vitamins
SOURCE: Tetra Pak Dairy Handbook
Busting the myth
Milk in a Tetra Pak package has less nutritive value
Tetra Pak packagingFreshness without the need for preservatives
What Spoils Milk?
MILK
What Protects Milk?
UHT Treatment137ºC for 4 seconds
MILKZero Bacteria
Tetra Pak packagingFreshness without the need for preservatives
MILKZero Bacteria
MILK UHT Treatment137ºC for 4 seconds
LIGHT
BACTERIA
OXYGEN
CONTAMINATION
Milk is as fresh as when packed.Protected from all spoilage.
Busting the myth
Milk in a Tetra Pak package needs preservatives
Milk for life
Aseptic packagingProtecting what’s good
Tetra Pak cartons are 100% recyclablePackaging material made of 75% paper
Pre-sterilised packaging material used
Aseptic packagingProtecting what’s good
Tetra Pak cartons are 100% recyclable
Packaging material made of 75% paper
Pre-sterilised packaging material used
Paper Board PE PE PEALPE
OUTSIDE INSIDE
Microorganisms
Light
Moisture
Oxygen
Odours/ Smell
Liquid
Flavours
PE: PolyethyleneAL: Aluminium
The technology breakthroughAseptic technology best protects milk
Only best-quality milk is processedMinimal loss of nutrition
No preservatives required
Packaged in commercially sterile environment
Tamper-evident 6-layer packaging
Long shelf lifeConvenient to store; no need for refrigeration
So, with technology in place there is no point skipping milk,
one of the most wonderful source of nutrient, from enteral
feed.
Thank you