Emergency Treatment of Severely Burned Pediatric Patients: Current Therapeutic Strategies

Gerd G. Gauglitz; David N. Herndon; Marc G. Jeschke

Disclosures

Pediatr Health. 2008;2(6):761-775. 

In This Article

Metabolic Response and Nutritional Support

The response to burn injury, known as hypermetabolism, occurs most dramatically following severe burn its modulation constitute an ongoing challenge for successful burn treatment.[73] Increases in oxygen consumption, metabolic rate, urinary nitrogen excretion, lipolysis and weight loss are directly proportional to the size of the burn.[74] Metabolic rates of burned children can dramatically exceed those of other critical care or trauma patients and cause marked wasting of lean body mass within days after injury.[17] Failure to circumvent the subsequent large energy and protein requirements may result in impaired wound healing, organ dysfunction, susceptibility to infection and death.[75] Thus, adequate nutrition is imperative for the treatment of severely burned patients. Owing to the significant increase in energy expenditure postburn, high-calorie nutritional support was thought to decrease muscle metabolism.[76] However, a randomized, double-blinded, prospective study performed by our group found that aggressive high-calorie feeding with a combination of enteral and parenteral nutrition was associated with increased mortality.[77] Therefore, most authors recommend adequate calorie intake via early enteral feeding and the avoidance of overfeeding to attenuate the catabolic response after injury.[14,17] Different formulations have been developed to address the specific energy requirements of burned adult and pediatric patients.[78,79,80] In children, formulas based on BSA are more appropriate because of the greater BSA per kilogram. The formulas change with age based on the BSA alterations that occur with growth ( Table 1 ).

Since essential fatty acid deficiency is a well-documented complication in hospital patients receiving long-term nutritional supplements, most ICUs provide a significant amount of caloric requirements as fat.[81] This has been shown to reduce the requirements for carbohydrates and can improve glucose tolerance significantly, which is often altered in the patient postburn.[75] However, several studies demonstrated that increased fat administration may lead to increased complications, including hyperlipidemia, hypoxemia, fatty liver infiltration, higher incidence of infection and higher postoperative mortality rates in the burned patient population.[82,83,84] We found in a large cohort of severely burned children that patients receiving a low fat/high carbohydrate diet (Vivonex® T.E.N.) displayed a significantly lower incidence of hepatic fatty metamorphosis upon autopsy when compared with milk-fed patients. These patients furthermore displayed a significantly lower incidence of sepsis when compared with children receiving a high-fat diet, demonstrated prolonged survival and had significantly shorter stays in the ICU as well as markedly decreased length of stay in the ICU per percentage in TBSA. Based on these findings, we would recommend that nutritional regimens for the treatment of postburn patients include diets with a significantly reduced proportion of fat as the source of total caloric intake.

In addition, various vitamins, minerals and other micronutrients are required for nutrition following burns. Diminished gastrointestinal absorption, increased urinary losses, altered distribution and altered carrier protein concentrations following severe burn may lead to a deficiency in many micronutrients if not supplemented. These deficiencies in trace elements and vitamins (copper, iron, selenium, zinc and vitamins C and E) have been repeatedly described in major burns since 1960,[85,86,87] leading to infectious complications, delayed wound healing and stunting in children.[88] However, evidence-based practice guidelines are currently unavailable for the assessment and provision of micronutrients in burn patients. Enhancing trace-element status and antioxidant defenses by selenium, zinc and copper supplementation has been shown to decrease the incidence of nosocomial pneumonia in critically ill, severely burned children in two consecutive, randomized, double-blinded, supplementation trials.[89] Caution should be used to avoid toxicities that can result in gastrointestinal tolerance as well as antagonistic reactions. A complete listing of micronutrients, their functions and supplementation protocols is beyond the scope of this article; excellent reviews are available.[90,91,92]

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