Elsevier

Nutrition

Volume 25, Issue 3, March 2009, Pages 261-269
Nutrition

Review
Nutritional therapy for burns in children and adults

https://doi.org/10.1016/j.nut.2008.10.011Get rights and content

Abstract

Burns are a serious injury that requires optimal nutritional support. This review discusses the nutritional care for adults and children with major burns. A burned patient's metabolism is greatly accelerated with increased requirements for energy, carbohydrates, proteins, fats, vitamins, minerals, and antioxidants. Early nutrition by parenteral and enteral feedings is vital. Careful assessment of the nutritional state of the burn patient is also important to reduce infection, recovery time, and long-term sequelae.

Introduction

Burns are a serious and debilitating injury. Burns are the 10th most common cause of accidental death in children and adults and accounted in 2005 for 5678 adult and child deaths in the United States. Each year an average of 11,000 children and adults are hospitalized for burns [1]. Age is a prognostic factor with a mortality rate higher in children than in adults. In children, mortality from burns is increased until age 4 y. In adults, mortality increases after 60 y of age [2].

Nutritional support is recognized as one of the most significant aspects of care for the burned patient. Burns cause a hypermetabolic state where the patient is at risk for malnutrition. Without adequate nutrition, weight loss becomes progressive. Protein-energy malnutrition becomes evident with poor wound healing, muscle wasting, growth retardation, and diminished immunocompetence weeks and months after the burn has occurred. This review focuses on nutritional care of children and adults with major burns.

Section snippets

Metabolism in the burned patient

The burned body responds by an increase in endogenous catecholamines, cortisol, and other glucocorticoids to physiologically support the body's fight and escape the stress of the burn (i.e., “fight or flight”). Epinephrine and norepinephrine increase 10-fold shortly after 30–40% of the total body surface area is burned [3]. These catecholamines provoke the hypermetabolic response seen in burned patients [4]. This catecholamine release causes increases in heart rate and blood pressure, shifts

Energy requirements

Children have greater energy requirements than adults per unit weight because of their dynamic growth and physical activity. This basal higher-energy need for children increases from burns. In children and adults, the burned subject's metabolic rate is often doubled and caloric demands of more than 5000 cal/d are not uncommon. The size of the burn area determines the increased energy needs [20], [21], [22]. It was thought that the increase in metabolic rate was a response to the large

Carbohydrates

Carbohydrates are good sources for protein sparing especially for nitrogen retention in burned patients [48], [49]. However, although carbohydrates are recommended as the chief energy source for burned patients, there appears to be a maximum glucose load of 7 mg · kg−1 · min−1 above which glucose is not oxidized but rather is converted to fat [7], [50], [51], [52]. This lipogenesis causes increased oxygen consumption and carbon dioxide production. Besides excessive fat stores, high carbohydrate

Assessment of nutritional status

Assessment of burned patients' nutritional state is important. However, in burned patients, there are problems that may confuse the interpretation of the nutritional status: 1) impaired immunity from surgery and infection; 2) the effects of wound losses and plasma or albumin transfusions on serum proteins; 3) changes in the rates of muscle protein breakdown, which can affect the relation between creatinine excretion and lean body mass; and 4) rapid physical changes in extracellular volume that

Vitamins, antioxidants, and minerals

Vitamin needs are increased for burned patients to stimulate wound healing, but the requirements have not been established. Vitamin C is involved in collagen synthesis and immune function and may be required in increased amounts for wound healing. Vitamin A is also an important nutrient for immune function and epithelialization. Providing 5000 IU of vitamin A per 1000 cal of enteral nutrition is recommended [61].

Vitamin D is needed for burned patients. Burns cause an impairment of vitamin D

Methods of nutritional support

It is recommended that feedings should be started soon after fluid resuscitation is complete to avoid gastrointestinal dysfunction [90], [91]. Early enteral feeding within 24 h of hospitalization has been shown to decrease the hypercatabolic response, thus decreasing the release of catecholamines, glucagons, and weight loss, improve caloric intake, stimulate insulin secretion, improve protein retention, and shorten hospital length of stay [92], [93], [94].

There are many commercially prepared

Parenteral hyperalimentation

Sometimes burned patients cannot tolerate any enteral feeding. In general, patients who have severe diarrhea or serious tube feeding intolerance or previous gastrointestinal problems and cannot have sufficient enteral calories are candidates for parenteral nutrition. This parenteral nutrition should be by the central route because peripheral support will not provide adequate calories to prevent catabolism from the burns. Standard central total parenteral nutrition usually consists of 25%

Future research

There is controversy on the level of energy and protein to be provided in burned patients. There is a need for better methods to assess outcomes of nutritional intervention. Clinical outcome variables such as mortality rate, sepsis, and recovery time must be considered, but consideration of additional measurements of body composition, immune status, protein metabolism, pulmonary function, and skeletal muscle function might be employed as further indicators of nutritional status.

Research on

References (95)

  • T. Mayes et al.

    Evaluation of predicted and measured energy requirements in burned children

    J Am Diet Assoc

    (1996)
  • P.W. Curreri et al.

    Nutritional support of the burned patient

    Surg Clin North Am

    (1978)
  • P.W. Curreri et al.

    Dietary requirements of patients with major burns

    J Am Diet Assoc

    (1974)
  • R. Rimdeika et al.

    The effectiveness of caloric value of enteral nutrition in patients with major burns

    Burns

    (2006)
  • M.M. Gottschlich et al.

    Significance of obesity on nutritional, immunologic, hormonal, and clinical outcome parameters in burns

    J Am Diet Assoc

    (1993)
  • M.J. Dibley et al.

    Development of normalized curves for the international growth reference: historical and technical considerations

    Am J Clin Nutr

    (1987)
  • R.R. Wolfe et al.

    Glucose metabolism in man: responses to intravenous glucose infusion

    Metabolism

    (1979)
  • R.R. Wolfe et al.

    Glucose metabolism in severely burned patients

    Metabolism

    (1979)
  • X. Wu et al.

    Insulin decreases hepatic acute phase protein levels in severely burned children

    Surgery

    (2004)
  • J.J. Cunningham et al.

    Calorie and protein provision for recovery from severe burns in infants and young children

    Am J Clin Nutr

    (1990)
  • J.P. De Bandt et al.

    Therapeutic use of branched-chain amino acids in burn, trauma, and sepsis

    J Nutr

    (2006)
  • X. Peng et al.

    Clinical and protein metabolic efficacy of glutamine granules-supplemented enteral nutrition in severely burned patients

    Burns

    (2005)
  • M.R. Uhing

    The albumin controversy

    Clin Perinatol

    (2004)
  • G.L. Klein et al.

    Histomorphometric and biochemical characterization of bone following acute severe burns in children

    Bone

    (1995)
  • L.S. Edelman et al.

    Sustained bone mineral density changes after burn injury

    J Surg Res

    (2003)
  • V.S. Voruganti et al.

    Impaired zinc and copper status in children with burn injuries: need to reassess nutritional requirements

    Burns

    (2005)
  • N.N. Lam et al.

    Early enteral feeding for burned patients—an effective method which should be encouraged in developing countries

    Burns

    (2008)
  • 2005 Report, dataset version 2.0

    (2006)
  • M. Goodall et al.

    Urinary output of adrenaline and noradrenaline in severe thermal burns

    Ann Surg

    (1957)
  • D.W. Wilmore et al.

    Catecholamines: mediator of the hypermetabolic response to thermal injury

    Ann Surg

    (1974)
  • R.P. Mlcak et al.

    The influence of age and gender on resting energy expenditure in severely burned children

    Ann Surg

    (2006)
  • E.E. Tredget et al.

    The metabolic effects of thermal injury

    World J Surg

    (1992)
  • N.A. Meyer et al.

    Nutrient support of the healing wound

    New Horiz

    (1994)
  • R.L. Rutan et al.

    Growth delay in postburn pediatric patients

    Arch Surg

    (1990)
  • R. Przkora et al.

    Metabolic and hormonal changes of severely burned children receiving long-term oxandrolone treatment

    Ann Surg

    (2005)
  • G. Mulder et al.

    Factors complicating wound repair

  • E.A. Milner et al.

    A longitudinal study of resting energy expenditure in thermally injured patients

    J Trauma

    (1994)
  • J.P. Allard et al.

    Factors influencing energy expenditure in patients with burns

    J Trauma

    (1988)
  • T. Matsuda et al.

    The effect of burn wound size on resting energy expenditure

    J Trauma

    (1987)
  • F.T. Caldwell et al.

    The effect of occlusive dressings on the energy metabolism of severely burned children

    Ann Surg

    (1981)
  • B. Zawacki et al.

    Does increased evaporative water loss cause hypermetabolism in burn patients?

    Ann Surg

    (1970)
  • N.A. Stotts et al.

    Co-factors in impaired wound healing

    Ostomy Wound Manage

    (1996)
  • C. Ireton-Jones et al.

    Improved equations for predicting energy expenditure in patients: the Ireton-Jones equations

    Nutr Clin Pract

    (2002)
  • C.S. Ireton-Jones et al.

    Equations for the estimation of energy expenditures in patients with burns with special reference to ventilatory status

    J Burn Care Rehabil

    (1992)
  • M. Gottschlich et al.

    The Curreri formula: a landmark process for estimating caloric needs of burn patients

    Nutr Clin Pract

    (2001)
  • J.R. Solomon

    Nutrition in the severely burned child

    Prog Pediatr Surg

    (1981)
  • M.A. Hildreth et al.

    Reassessing caloric requirements in pediatric burn patients

    J Burn Care Rehabil

    (1988)
  • Cited by (65)

    • The effect of a hydrolyzed collagen-based supplement on wound healing in patients with burn: A randomized double-blind pilot clinical trial

      2020, Burns
      Citation Excerpt :

      The total daily energy need of each patient was calculated by Curreri formula. Based on available recommendations, the diet should consist of 20–25% protein [7]. It has been decided to provide 1000 kcal of total energy requirement from the supplements and the rest from usual meals.

    View all citing articles on Scopus
    View full text