ETERNAL �AND PARENTERAL�NUTRITION�

Chapter No. 4

Pythons

Composed by: Shehzad Siyal

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OBJECTIVES:

By the end of this session, the students will be able to:

Define the key terms.

Identify the characteristics, nutritional composition and concentration of formula feeding.

Discuss complications associated with Enteral feeding.

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Key Points:

Enteral Nutrition: Supplying nutrients using GI tract, including tube feeding and oral diet.

Parenteral Nutrition: Intravenous provision of nutrients, bypassing the GI tract. (refers to the delivery of calories and nutrients into a vein)

Infant Formula: baby formula or just formula or baby milk, infant milk, false milk or first milk is a manufactured food designed and marketed for feeding to babies and infant under 12 month of age, usually prepared for bottle feeding or cup feeding from powder or liquid.

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Indications For Tube Feeding:

• Sever protein energy undernutrition.
• Coma or depressed sensorium.
• Prolonged anorexia.
• Liver failure.
• Inability to take oral feedings Critical illnesses e.g. Burns.

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Main Types of Enteral Tubes:

These are following main types:

Nasogastric tube NGT starts in the nose and ends in the stomach.

Orogastric tube OGT starts in the mouth and ends in the stomach. Nasoenteric tube starts in the nose and ends in the intestines subtypes include naso jejunal and nasoduodenal tubes.

Oro enteric tube starts in the mouth and ends in the intestines. Gastrostomy tube is placed through the skin of the abdomen straight to the stomach subtypes include PEG,PRG, and button tubes.

Jejunostomy tube is placed through the skin of the abdomen straight into the intestines subtype include PEG and PRG tubes.

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Standard

Blenderised

Disease Specific

Modular

Elemental

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Classification of Enteral Formula:

Standard

• Formula containing intact nutrition ( protein, fat, and CHO) which require normal or near normal digestive and absorptive capacity and are complete with respect to vitamin, minerals, and trace elements at specified volume .
• Contain 1-1.2 kcal/ ml and are used as over the counter oral supplement and tube feeding formula. protein content 30 – 40 gm/L

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Nestle Nuturen 2.0

• Tube feeding formula,500 calories.
• This formula provides complete, calorically dense liquid nutrition for those elevated caloric requirements or a fluid restriction.
• Nutren 2.0 contains taurine, carnitine, and ultra trace minerals for long term feeding.

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Elemental and Semielemental:

• Contain partially or completely hydrolyzed nutrient .
• Formula have been hydrolyzed to contain short chain .
• Carbohydrate or simple sugar and peptides or amino acid .
• Elemental formulas are easier for the digestive system to digest and absorb, making them better suited for adults and children with digestive problems.
• Including malabsorption, short bowel syndrome, inflammatory bowel disease, and other conditions that can cause problems with absorbing nutrition.

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Disease Specific:

• Designed for patients with specific disease states.
• Available for patients with respiratory disease, diabetes ,renal failure, hepatic failure and immune compromise.

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Blenderized Feeding:

• Used for patient that cannot tolerate semi- synthetic formulas or who wish to consume family food. Formulize with a mixture of blenderized food source .
• They are made from real food ingredients such as chicken, vegetables and fruit, along with added vitamins, minerals, fiber and other nutrients.
• Maintenance of aseptic technique is essential to prevent bacterial contamination. Example are Compleat®, Compleat® Pediatric, and Compleat® Pediatric Reduced Calorie

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Modular Formula:

• Modular provides protein, fat or carbohydrates as single nutrients or modular mixtures to allow adjustment of macronutrient mix.
• Created from individual macronutrient preparation called modules are prepared for patients who require specific nutrient combination to treat their illness.

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Compilications of Enteral Feeding:

• Food entering the lungs.
• Constipation.
• Diarrhea.
• Improper absorption of nutrients.
• Nausea and vomiting.
• Dehydration.
• Electrolyte Abnormalities
• High blood sugar.
• Vitamins and minerals deficiencies .

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Cont..

• Feeding tube inserted through the nose, such as nasogastric or naso enteric tubes can cause:
• Irritation of the nose and throat.
• Acute sinus infection.
• Ulceration of larynx and esophagus.
• Feeding tube inserted through the skin of the abdominal wall such as gastrostomy or jejunostomy tubes can become clogged or displaced and wound infection can occur.

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Complication With Tube Anterostomies:

• Skin irritation caused by leakage of digestive fluids onto the skin around the stoma;
• Irritation is the most common complication of ileostomies.
• Diarrhea. The development of abscesses.
• Inflammation of the ileum. Intestinal obstruction.

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Risk Factors Aspiration Includes:

• Decreased level of consciousness.
• Diminished gag reflex.
• Neurologic injury.
• Cardiac sphincter Incompetency.
• GI reflux.
• Supine position.
• Tube malposition.
• Delivery of nutrients intravenously, e.g. via the bloodstream.
• Central Parenteral Nutrition: often called Total Parenteral Nutrition (TPN); delivered into a central vein
• Peripheral Parenteral Nutrition (PPN): delivered into a smaller or peripheral vein.

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Infant Formula Feeding:

• Formula Feeding: Feeding an infant or toddler prepared formula instead of or in addition to breastfeeding.
• Some parents choose formula-feeding either because of personal preference or because medical conditions of either the mother or the infant make breastfeeding ill-advised.

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Reasons for Choosing Formula Feeding:

• There is an inadequate supply of maternal breast milk.
• The baby is sucking inefficiently.
• Parents are unable to quantify the amount of breast milk received by the baby.
• Some parents want to know exactly how much their baby is receiving at each feeding, and formula/bottle feeding allows exact measurement.
• A significant reason for not breastfeeding is concern about transferring certain drugs the mother is taking through the breast milk to the infant.

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Cont..

• A benefit of bottle-feeding is that the entire .
• Family can immediately become intimately involved in all aspects of the baby’s care, including feeding.
• An increasing number of mothers must return to work shortly after their baby's delivery.

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Best Formula For the Baby:

There is no evidence that one brand of formula is better than another. However, you should consider:

• Choosing a formula based on cow’s milk, unless there is a cultural, religious or health reason to use a different formula.
• If possible, choosing a formula with a lower protein level, which may reduce your baby’s risk of being overweight or obese in later life.
• Only using special formulas (HA, AR, lactose-free or soy formula) if they are recommended by a doctor.
• Taking into account price and affordability.

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Available Infant Formula Prepration:

Infant formulas come in three forms. The best choice depends on your budget and desire for convenience:

Powdered Formula: Powdered formula is the least expensive. Each scoop of powdered formula must be mixed with water.

Concentrated Liquid Formula: This type of formula also must be mixed with water.

Ready-to-use formula: Ready-to-use formula is the most convenient type of infant formula. It doesn't need to be mixed with water. It's also the most expensive option.

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Types of Formula Milk:

Commercial infant formulas are regulated by the Food and Drug Administration (FDA). Three major types are available:

• Cow Milk Protein-based formulas.
• Soy-based formulas.
• Protein hydrolyzed formulas.

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Cow Milk Based Formula:

• Most infant formula is made with cow's milk that's been altered to resemble breast milk.
• This gives the formula the right balance of nutrients and makes the formula easier to digest.
• Most babies do well on cow's milk formula. Some babies, however such as those allergic to the proteins in cow's milk need other types of infant formula.

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Lactose Free Formula:

• This formula is suitable for babies who are lactose intolerant. This means they can't absorb lactose, a sugar found in milk and dairy products.
• Lactose intolerance Symptoms include diarrhea, abdominal pain, wind and bloating.

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Soya Based Formula:

• Soy-based formulas can be useful if you want to exclude animal proteins from your child's diet.
• Soy-based infant formulas might also be an option for babies who are intolerant or allergic to cow's milk formula or to lactose, a carbohydrate naturally found in cow's milk.
• However, babies who are allergic to cow's milk might also be allergic to soy milk.

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Good Night Milk:

• Some follow-on formula has cereal added to it and is sold as a special formula for babies to have at bedtime.
• This type of formula isn't needed, and there's no evidence that babies settle better or sleep longer after having it.
• Good night formula should never be given to babies under six months old.

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Hydrolyzed Protein Formula:

If the baby is diagnosed as being allergic to cows' milk, the appropriate infant formula is fully hydrolyzed (broken down) proteins. There are two versions available .

Partially hydrolyzed formula (Comfort formula) This type of formula milk is made completely from whey protein. It is marketed as being easier to digest, and as suitable for babies suffering from colic, wind, and stomach pain. They are also sometimes promoted as being good for babies with allergies.

Fully hydrolyzed formula is specially designed for babies with an allergy or intolerance to cow's milk.

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Grwoing Up Milk Toddler Milk:

• Growing-up and toddler milks are marketed as an alternative to whole cows' milk for toddlers and children aged over one.
• Whole cows' milk is a suitable choice as a main drink for your child from age one.
• Semi-skimmed cows' milk is a suitable main drink for children over two who are eating a balanced diet.

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Refernces:

• Enteral nutrition supplies and equipment. https://www.medicare.gov/coverage/enteral-nutrition-supplies- equipment Accessed April 21, 2020.
• Bankhead R, et al. Enteral Nutrition Practice Recommendations. In: Journal of Parenteral and Enteral Nutrition. United States. The American Society for Parenteral and Enteral Nutrition; 2009: 122- 167.
• Mesejo A, Acosta JA, Ortega C, et al. Comparison of a high-protein disease-specific enteral formula with a high-protein enteral formula in hyperglycemic critically ill patients. Clin Nutr,2003;22:295-305.
• Tehila M, Gibstein L, Gordgi D, Cohen JD, Shapira M, Singer P. Enteral fish oil, borage oil and antioxidants in patients with acute lung injury (ALI). Clin Nutr, 2003;22(S1):S20

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THANKS!

For Your Patience!

Group Members: Faryad Mehmmod, Roy Ibtisim, Kareena Riyaz,

Hamna Ijaz, Nabila Griffen, Nirmal

Zion Zahid, Muhammad Shehzad, Kainat, Rubbab, Raheel