Enteral Nutrition & Role of Milk

The Total Enteral Nutrition (TN)

DEFINED :

Delivery of all the necessary substrates (Amino acids + Carbohydrates + Lipids) via an access either through the natural anatomical GI route or surgically created one

Benefits 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

Benefits of Enteral Nutrition Therapy

Improved Patient OutcomesImproved wound healingDecreased risk of complicationsDecreased length of stayDecreased healthcare costs

Benefits of Enteral Nutrition Therapy

Early Intervention as Part of Initial

Care

Enteral Nutrition• Oral supplements• Tube feeding

Parenteral Nutrition• Central• Peripheral

If the gut works, use it!”

Conditions That Often Require Nutritional Support

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.

Techniques of Access

Nutrition : Basic Principles

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 to 7 days of starvation.

Nutrition : Basic Principles

4. Appropriate electrolyte supplementation like vitamins and minerals.

5. Critical monitoring essential.

6. Immunonutriton is still a contentious issue, especially in terms of final outcome!

Nutritional Requirement►Energy requirements►Can be calculated from Harris Benedicts equation► In clinical settings: 25 – 30 Kcals / kg / day►Average of 1500 – 2000Kcal or it can vary as per the

patients requirement / condition

►Protein requirements►Critical patients: 0.8 to 2 gm / kg of IBW, this range can

vary depending upon patient’s conditions

Considerations in Enteral Nutrition

1. Applicable

2. Site placement

3. Formula selection

4. Nutritional/medical requirements

5. Rate and method of delivery

6. Tolerance

Complications of TEN

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 become the primary source for the cause of Diarrhea.

Main Causes : • Drugs like certain antibiotics, • Enema, • Therapy line (Chemo therapy or Radiation), • High speed feeding, • Mishandling of milk & Milk related causes

Milk specific causes for Diarrhea among patients who are on EN

• 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.

Route taken

• Most of the time Enteral feed is stopped in such condition

OR• Feed is prepared milk free

Consequences of Stopping Milk In Enteral Feed

Less calories and less protein per ml of the feed

However Protein is Critical

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

Why Protein is Important?

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

Why Protein is Important?

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

Why Protein is Important?

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

Why Milk?

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

Milk- The Wonder Protein Source

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.

Then arises the issues concerning milk quality

Issues concerning milk quality

Contamination Adulteration Addition of Preservatives Wrong boiling practices

The technology breakthrough

What are the attributes a consumer looks for in milk Quality Hygiene Nutrition Non – adulterated Free from preservatives Convenient

So Why to stop milk when we have safer options available –

UHT MILK

UHT Milk – Safer option for Enteral feeds

• 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

Case study

►26yrs male admitted in causality with pneumonia and high grade fever.

Nutritional Assessment

Height – 180cm

Weight – 65kg

BMI (kg/m2) – 20.06

IBW – 80kg

Clinical Parameters

Serum Albumin – 2.7g/dl

Nutritional Requirement – 30 * 65 = 1980 ~ 2000Kcal

Protein requirement – 1.2 * 65 = 78gm

Fat – 30% of total calories

►Ryle’s Tube Feeding started @ 50 ml / hr, then increased to 100ml / hr.

►Target was to provide atleast 1 Kcal / ml of the feed and to meet the current protein requirement as calculated.

►But then suddenly the patient started with few of the Gastrointestinal problems due to which the feed was stopped for a day as per the doctor’s instructions.

►Checked the patient record for all possible causes but nothing can be ruled out, then tracked the possibilities of mishandling of the feed during preparation till the time it is given to the patient.

Gaps in feeding

►Then found the following gaps:• Milk was not boiled by the kitchen staff, and cold milk

from the refrigerator was used for the feed preparation• There was 15 mins. delay in feeding the patient by the

ICU staff as per their chart• To overcome the above challenges, we have started

preparing the enteral feeds in UHT milk and all the problems related to feed preparation resorted automatically.

• The patient was able to handle the feed well.• The feed frequency was then increased further to 120ml

per hour.

► Aseptic processing ensures that everything in the production chain is commercially sterile including the food, packaging materials, machinery and the environment in which the packaging takes place.

► It removes all micro-organisms from milk including bacterial spores.

► Ultra Heat Treatment (UHT) is given to milk and the heating period is so brief, it causes less damage to nutrients and flavour compounds.

► Aseptic packaging involves transferring the UHT-treated milk into pre-sterilized packages in a sterile environment.

► Because of the sterile packaging, there is no risk of contamination.

► Aseptic packaged milk has unparalleled hygienic quality offering intact nutrients necessary for child’s growth and development.

If Technology Has a Solution Then Why Not Adopt It …

Thank you