Audit of successful weight maintenance in adult and paediatric survivors of thermal injury at a UK regional burn centre

Children's growth and motor development following a severe burn: a systematic review

Background

The epidemiological data on post-burn growth, body composition and motor development is ambiguous and scattered. The aim of this systematic review was therefore to summarize the current body of evidence on post-burn growth, body composition and motor development in children.

Methods

A literature search was conducted in PubMed, EMBASE and Web of Science up to March 2021. We considered observational studies that reported (1) metrics on weight, height, body composition, bone mineral content, bone mineral density or motor development, in (2) paediatric burn patients and (3) published in a peer-reviewed journal.

Results

A total of 16 studies were included. Each of the included studies used quantitative methods, but with differing methodology: prospective cohort studies (n = 8), retrospective chart reviews (n = 3), case-control studies (n = 2), cross sectional studies (n = 2) and a retrospective cohort study (n = 1). When combined, the included studies represented 2022 paediatric burn patients, with a mean age of 7.7 (±3.2) years. The average burn size was 52.8% (±12.7) of the total body surface area. Identified outcome measures included weight (n = 12), height (n = 7), muscular strength (n = 4), bone mineral content (n = 5), bone mineral density (n = 5), body mass index (n = 3), fat mass (n = 5), lean body mass (n = 7) and fine and gross motor development (n = 1).

Conclusions

Following an initial decline, patients' growth and motor development started to recover during the first or second year post-burn. Nonetheless, burns may have a profound and prolonged effect on the paediatric burn patients' muscular strength, bone mineral content and lean body mass. It should be noted that the vast majority of studies included only patients with burns covering ≥30% total body surface area. The evidence presented in this review may thus not be representative of the whole paediatric burn population.

Dietetic service provision for burn care in the United Kingdom: are nutrition support standards being met?

BACKGROUND

Catabolism and lean body mass losses in severe burn injury present an extreme challenge to the dietitian. A high level of nutritional intervention is often required, but service levels have not been described in the UK. This study aimed to identify levels of current dietetic services with respect to burns and to assess adequacy against existing nutrition support standards.

METHODS

A postal survey of 34 UK dietetic departments known to provide care to burned adult and paediatric admissions was undertaken. Data were collected on burns settings, hospital service characteristics, staffing and caseload issues, and absence cover. Comparison was made between funding and activity to National Health Service standards for the nutritional care of inpatients.

RESULTS

The response rate was 71% and data were analysed for 20 departments Clinical settings were either burn units or plastic surgery wards. Dietetic care was provided to critically ill burned patients in 16 hospitals. Most hospitals had no dietetic funding assigned for burn care. The funding deficit for critical care compared to recommendations was 5.9 full-time equivalents and no individual hospital met funding standards. Thirty-seven percent of dietitians were unable to provide daily follow up for critically ill patients. Absence cover was limited in 60% of cases. Approximately one-third of dietitians were members of a nutrition support team.

CONCLUSIONS

Compared to national guidelines for nutrition support, deficiencies of dietetic service provision exist within UK burns settings. This is further reinforced when practice is compared with existing multi-professional burns management standards.

Glutamine Supplementation in Critical Illness: Evidence, Recommendations, and Implications for Clinical Practice in Burn Care

Glutamine is considered a conditionally essential amino acid in metabolic stress. Depletion of plasma and muscle glutamine is observed in acute burn injury and contributes to muscle wasting, weight loss, and infection. In critical illness, supplementation has been shown in patients to minimize these effects and reduce the rate of mortality and length of stay. The evidence for glutamine use and its implications for burn care practice are considered here. Work published to February 2006, which investigated enteral and parenteral glutamine supplementation in burns and critical care, is reviewed. Randomized controlled trials in burns, systematic reviews, and nutrition support practice guidelines are considered. Randomized controlled trials in burns suggest significant clinical benefit in terms of morbidity, mortality, and length of stay but are limited by sample size. Parenteral glutamine studies are under-represented. Systematic reviews and practice guidelines generally support glutamine supplementation in critical illness but vary in the level of recommendations for its use in burns. There also are features unique to burn injury that require consideration. Patients with severe burns or inhalation injury may have a prolonged critical illness phase. In large burns, inflammation and hypermetabolism may persist well beyond 4 weeks of injury. The justification and safety of long-term glutamine supplementation is yet to be established. The outlook for glutamine therapy in burns is promising. However, to strengthen recommendations for routine therapy in burns, further research focusing on larger-scale enteral glutamine studies, parenteral glutamine supplementation, and long-term use of the substrate is necessary.

Immune modulating nutrition support for a patient with severe toxic epidermal necrolysis

Toxic epidermal necrolysis (TEN) is a rare but serious condition with a high mortality rate, whose clinical features resemble major thermal injury. Nutritional substrates which can affect the immune response have been shown to benefit burned and critically ill patients but there is a lack of data in the TEN literature. A case study is presented of a 63-year-old female admitted to our burn unit with extensive skin and mucosal involvement. Immune modulating artificial nutrition support was given initially via the parenteral route and then the nasogastric route. Maintenance of the patient's nutritional status and clinical outcome suggest that there may be a role for this type of intervention in TEN.