Introduction:

The concern for the patient’s health has revolutionized catering services at the hospital(s). It is in response to research conducted over the past decades to improve patient’s health at a faster pace by supplementing nutritious food along with the critical care. It has become imperative part of most of the hospitals to provide the patient with the required nutrition feed that support in rapid recovery of the patient (Concern at nutrition in hospitals).

The hospitals are following the diet charts based on ongoing research and studies that correlate diseases with nutrient supplement along with the therapeutics. It is evident that besides balanced food that is given to the patient some other nutrient supplements facilitate in recovery and reduce the health related troubles that become devastating if deficiency is related with the nutrients required for the well being.

Patients are getting variety and choice of nutrition feed because of the commercial availability of many products in the market. Many companies are coming up with a special protocol of feed and related illness. This enhances the awareness of patient about the kind of food essential to combat illness (Concern at nutrition in hospitals).

Nutrition supplements are licensed products and can be provided as the sole source of nutrition. They may be prescribed on medical grounds for diverse ailments. Depending on the severity and class of sickness, the nutrition supplements can be taken.

Hospitals play lead role in making the patient aware of the consequences if the nutrition is not provided in the desired quantity. Hospital staff must help the patient psychologically, the advantages and disadvantages of the feed type he has been introduced to. This not only prepares the patient mentally but patient also co-operates with the hospital staff.

Keeping this in mind the present study is conducted to build an understanding towards the nutritional support products, their advantages and problems and the available products that patient can utilize for better and sooner recovery.

Basically three types of feeds are given for diverse ailments these are:

Sip feeds,

Enteral (tube) feeds and

TPN feeds.

Sip Feeds

Various policies are defined to prescribe Sip feeds or Oral Nutrition Supplements for Patients with poor nutritional status especially those having:

? Disease related malnutrition

e.g.  Reduced appetite or experience difficulty in swallowing, in cancer of throat or gut.

? Short-bowel syndrome (SBS)

? Intractable malapsorption

? Pre-operative preparation of undernourished patients

? Proven inflammatory bowel disease

? Following total gastrectomy

? Dysphagia

? Bowel Fistulas

? CAP Dialysis (Nutrition support in adults)

Importance of Sip feed:Help the patient to gain weight or avoid loss of weight.

Help the patient to surmount weakness of tiredness

Help the patient to take in adequate liquid.

Help the patient to alleviate the pressure to eat

Help the patient to drink enough when dietary supplements cannot.

(Nutrition support in adults)

Before prescribing Sip feed it is essential to assess nutritional status, BMI calculation and weight loss by using simple nutritional risk scoring system

When prescribing sip feeds

* Do try equipped standard food

(by adding milk, butter, cheese or cream)

as first line therapy (4weeks before stipulating sip feeds).

* Ensure that all patients be given suitable dietary advice by a state-registered dietitian

or suitable trained member of the primary health care team.

* No long term use without regular monitoring and assessment

* It should not exceed 500-600kcals daily unless under the care of a dietitian.

* Ensure that supplements are not taken at meal times / after meals e.g. as a bedtime drink

to avoid reduction in food intake.

* It should not be given as the sole source of nutrition except in consultation with dietitian.

* It should not be prescribed for more than 4-6 weeks

* it should not be prescribed as repeat medication except in exceptional cases

* refer to dietician in case of no improvement

* The supplements must be chilled before use.

Monitoring

·         Regular weight and BMI monitoring is important to identify the improvement(s).

Some patients may face problems of constipation when taking sip feed (some products

Contain fiber)

·         Same taste and texture may become boring for the patient so commercially available mixed flavors /alternative products must be given.

·         Milk based liquid feeds are nutritionally complete, when taken in sufficient quantity

Examples of commercially available sip feed-

Build-Up,

Fortimel

Fortisip.

Build-Up was reported to be the best-tolerated product of the three (Boltonet al,Comparison of three oral sip-feed supplements in patients with cancer), as it was taken for longer time and was stopped by some patients due to flavour related problems. They are the sip feeds mostly given to cancer patients in various hospitals in UK.

Other kind of sip feed includes the soups and porridges Sip feed are not only rich in vitamins, minerals, proteins and energy but also help in maintaining proper salt balance in the body.

Enteral (tube) Feeds

This type of feed includes nutritional fluid and is given into the gut through a tube going into the stomach or small intestine. It is given to the patient if the digestive system is working well, but due to illness or some difficulty a patient is not able to eat enough e.g. in cancer of head or neck. (Nutrition support in adults)

Methods of EN are used in the surgery of head, neck, stomach or gullet.

·         Nasogastric (NG) feeding- where a thin tube is passed from the patients nasopharynx to the stomach. It is preferred when the feed is to be given for short time. E.g. patients undergone radiotherapy of mouth, throat or gullet as in this case swallowing becomes difficult due to swelling followed by radiotherapy. (Nutrition support in adults)

Problems associated with NG: Uncomfortable and distressing insertion, patient may feel embarrassing. The tube can e pulled out of the stomach if not fixed properly, occasional dislodging may occur, blocking of the tube. The process is follow slow flow of food else it may flow in the gullet so it is very unpleasant for the patient. (Nutrition support in adults)

·         Percutaneous Endoscopic Gastrostomy (PEG) feeding- it is recommended if the digestive system is not in problem. Here a fistula is created through abdominal wall and feeding tube can be passed in the stomach and tube is held at its place with a stitch. (Nutrition support in adults)

·         Radiologically-inserted Gastrostomy (RIG) where tube is passed in the stomach, through the skin of muscles of abdomen. The process is performed under x-ray conditions. (Nutrition support in adults)

Advantages of RIG/PEG: enables patient to get proper nutrition.

Problems are related with blockage. This may increase the chances of infection at the site of incision. A patient may develop temperature. This may give the feeling of some fluid oozing out of stomach. In PEG/RIG, tubes can remain in place for approximately two years and must be replaced if required. (Nutrition support in adults)

·         Percutaneous endoscopic Jejunostomy (PEJ). It is very rarely used. In this method a feeding tube is passed into the top part of the small bowel i.e. jejunum which is present just below the stomach. (Nutrition support in adults)

Commercially available products:

Toptainer® Enteral Nutrition Container With Preattached Flexiflo® Quantum™ Pump Setby Ross, Division of Abbott Labs,Stackable design permits easy prefilling, storage, and transportation. 58-mm opening with screw cap makes filling easy (Enteral Nutrition Feeds).

MIC® Gastrostomy Tubeby KIMBERLY CLARK-BALLARD,Features medical grade silicone construction, silicone internal retention balloon, SECUR-LOK® external retention ring, universal feeding poor (Enteral Nutrition Feeds).

Patrol™ Enteral Pumpby Ross, Division of Abbott Labs,Unique Safe-T-Valve™ feature on feeding set prevents accidental product free-flow if set is improperly loaded or becomes dislodged from pump (Enteral Nutrition Feeds).

MIC-KEY® Low-Profile Gastrostomy Tube Kitby KIMBERLY CLARK-BALLARD,Features medical grade silicone construction, low-profile design, tapered distal tip, silicone internal retention balloon, distal tip recess (Enteral Nutrition Feeds).

They are all rich in protein, fat, electrolytes and vitamins in fixed proportions.

TPN/ PN Feeds

Parenteral nutrition (PN) is given through vein and is also called as Total Parenteral Nutrition (TPN) since it focuses on providing the patient with total nutritional support. PN provides nutrition directly to the blood stream whereas TPN indicates providing complete nutrition in the blood stream (Nutrition support in adults).

Advantages: It is given under rare condition when people are unable to have EN e.g. if the patient has undergone major surgery on the small bowel or have any kind of bowel obstruction, when the digestive system is not working and the process provides relaxation to it. PN is given through thin tube called as central line, inserted in the vein. This is also called a PICC (peripherally inserted central catheter) (Nutrition support in adults).

TPN is normally done when the other two feed processes cannot be performed e.g. when insertion of the EN tubes is difficult especially when a patient has undergone some kind of surgery of head, neck or stomach (Nutrition support in adults).

Problems with the TPN:

Infection may occur near the incision either inside the line or around the exit site. Swelling may occur; discharge may come out of the site. This may be followed by the course of antibiotics. In some patients thrombosis may occur and medicines are to be given to the patient (Nutrition support in adults).

Commercially Available TPN:

Intralipid contain soybean

LiposynII contains soybean and Safflower

LiposynIII contains soybean

Several lipid emulsions are commercially available what contain soybean, safflower, olive and fish oils. They are long chain lipids.

Some medium chain triglycerides (MCT) are also available (David, F).

Some are available as single oil entities, that encompass soybean and fish oils, while others are available in various oil mixtures like

Soybean-safflower

Soybean-MCT

Soybean-olive

Soybean-MCT-fish

Soybean-MCT-fish-olive oil emulsions (David, F)

These are rich source of energy, oils and their pharmacological actions are of great benefit to the patient. They are best when diseases are associated with the liver.

The initial formula is based on fluid volume, calories, protein and fat requirements and they are also supplemented with electrolytes, calories, proteins and fat requirements that give the correct assessment. They contain various amino acids in different combinations.