2. 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. 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

4. 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

5. Advantages of Enteral Nutrition
Therapy
Early Intervention as Part of Initial Care
Enteral Nutrition
• Oral supplements
• Tube feeding
Parenteral Nutrition
• Total
• Peripheral

7. 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.

8. 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

9. 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

10. 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.

11. 1. Applicable
2. Site placement
3. Formula selection
4. Nutritional/medical
requirements
5. Rate and method of delivery
6. Tolerance

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

14. And diarrhea where milk could become the
primary source of infection.

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

17. Less calories and less protein per ml of the
feed

18. 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. 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. 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. 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. 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. Some milk components may modulate
intestinal bacteria, whereas others may
influence the nervous system.
Reference:
The American Journal of Clinical Nutrition. 2013

24. 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.

26. • 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

28. Aseptic Processing Aseptic Packaging

30. 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.

31. 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:

32. 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

33. 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

34. 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

35. Yeast Mould Virus
Vegetative
Cells
Pathogens
Spores

36. 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

37. Milk in a Tetra Pak
package has less
nutritive value

38. What Spoils Milk? What Protects Milk?

39. Milk is as fresh as when packed.
Protected from all spoilage.

40. Milk in a Tetra Pak
package needs
preservatives

42. Tetra Pak cartons
are 100%
recyclable
Packaging
material made of
75% paper
Pre-sterilised
packaging material
used

43. 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

44. 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

45. So, with technology in place there is no
point skipping milk, one of the most
wonderful source of nutrient, from
enteral feed.

46. Thank you