Enteral nutrition & Role of Milk

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Enteral nutrition & Role of Milk

  1. 1. Delivery of all the necessary substrates (Amino acids + Carbohydrates + Lipids) via an access either through the natural anatomical GI route or surgically created one
  2. 2. 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
  3. 3. 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
  4. 4. Advantages of Enteral Nutrition Therapy Early Intervention as Part of Initial Care Enteral Nutrition • Oral supplements • Tube feeding Parenteral Nutrition • Total • Peripheral
  5. 5. 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.
  6. 6. 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
  7. 7. 6. Appropriate electrolyte supplementation : Na P, K & Mg supplementation 7. 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. 9
  8. 8. 8. Proper selection of volume, composition and route of administration, for patients with • Renal & hepatic insufficiency • Cardio-pulmonary diseased 9. Critical monitoring essential 10. High degree of suspicion and constant “looking out” for complications 11. Immunonutriton is still a contentious issue, especially in terms of final outcome.
  9. 9. 1. Applicable 2. Site placement 3. Formula selection 4. Nutritional/medical requirements 5. Rate and method of delivery 6. Tolerance
  10. 10. Complications of GI access • Dislodgements • Small bowel volvulus, infarction • Catheter/tube occlusion • Leakage/skin breakdown • Tube malposition Gastric distention & aspiration
  11. 11. And diarrhea where milk could become the primary source of infection.
  12. 12. • 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.
  13. 13. • Most of the time Enteral feed is stopped in such condition OR • Feed is prepared milk free
  14. 14. Less calories and less protein per ml of the feed
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. Some milk components may modulate intestinal bacteria, whereas others may influence the nervous system. Reference: The American Journal of Clinical Nutrition. 2013
  21. 21. 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.
  22. 22. • 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
  23. 23. Aseptic Processing Aseptic Packaging
  24. 24. 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.
  25. 25. 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:
  26. 26. Milk Collection Quality Check* Aseptic Processing Aseptic PackagingConsumer * Milk undergoes quality check at customer’s dairy plant Milk not conforming to required quality checks cannot undergo Aseptic Processing
  27. 27. 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
  28. 28. 2,000 1,000 600 400 200 100 60 40 20 10 6 4 2 1 Time(inseconds) 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
  29. 29. Yeast Mould Virus Vegetative Cells Pathogens Spores
  30. 30. Vitamin Nutritional Loss Asorbic 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 Low Vitamin D Very Low Vitamin E Very Low SOURCE: Tetra Pak Dairy Handbook
  31. 31. Milk in a Tetra Pak package has less nutritive value
  32. 32. What Spoils Milk? What Protects Milk?
  33. 33. Milk is as fresh as when packed. Protected from all spoilage.
  34. 34. Milk in a Tetra Pak package needs preservatives
  35. 35. Tetra Pak cartons are 100% recyclable Packaging material made of 75% paper Pre-sterilised packaging material used
  36. 36. Tetra Pak cartons are 100% recyclable Packaging material made of 75% paper Pre-sterilised packaging material used Paper Board PE PE PEALPE OUTSIDE INSIDEPE: Polyethylene AL: Aluminium
  37. 37. Only best-quality milk is processed Minimal loss of nutrition No preservatives required Packaged in commercially sterile environment Tamper-evident 6-layer packaging Long shelf life Convenient to store; no need for refrigeration
  38. 38. So, with technology in place there is no point skipping milk, one of the most wonderful source of nutrient, from enteral feed.
  39. 39. Thank you

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