ReviewNutritional therapy for burns in children and adults
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
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The effect of a hydrolyzed collagen-based supplement on wound healing in patients with burn: A randomized double-blind pilot clinical trial
2020, BurnsCitation 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.