1. Enteral Nutrition & Role of
Milk

2. 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

3. 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

4. Benefits of Enteral Nutrition Therapy
Improved Patient Outcomes
Improved wound healing
Decreased risk of complications
Decreased length of stay
Decreased healthcare costs

5. 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!”

6. Conditions That Often Require
Nutritional Support

7. 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.

8. Techniques of Access

9. 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.

10. 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!

11. 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

12. Considerations in Enteral
Nutrition
1. Applicable
2. Site placement
3. Formula selection
4. Nutritional/medical requirements
5. Rate and method of delivery
6. Tolerance

13. Complications of TEN
Complications of GI access
• Dislodgements
• Small bowel volvulus, infarction
• Catheter/tube occlusion
• Leakage/skin breakdown
• Tube malposition
Gastric distention & aspiration

14. 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

15. 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.

16. Route taken
• Most of the time Enteral feed is stopped in
such condition
OR
• Feed is prepared milk free

17. Consequences of Stopping
Milk In Enteral Feed
Less calories and less protein per ml of
the feed

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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.

25. Then arises the issues
concerning milk quality

26. Issues concerning milk
quality
 Contamination
 Adulteration
 Addition of Preservatives
 Wrong boiling practices

27. The technology breakthrough
What are the attributes a consumer looks for in milk
 Quality
 Hygiene
 Nutrition
 Non – adulterated
 Free from preservatives
 Convenient

28. So Why to stop milk when we have
safer options available – UHT MILK

29. 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

30. 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

31. ►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.

32. 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.

33. ► 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 …

34. Thank you