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

9

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