PEDIATRIC BURN MNT

A Clinical Case Study Presented by:

Katy Hillegass
Dietetic Intern
Pepperdine University, NCSP ISPP 2015-2016
February 4th, 2016

Presentation Overview
What is a Burn?
Metabolic Response and Pathophysiology
Medical Treatment
Nutrition Care Process and MNT for Burns
Special Considerations for the Pediatric Burn Patient
Case Study a Pediatric Burn Patient

Statistics Provided by the American Burn

Association
Burn injuries that receive medical treatment: 486,000
Hospitalizations r/t burn injuries: 40,000
Cause of burn: 43% flame, 34% scald, 9% contact, 4%

electrical, 3% chemical, 7% other

Where? 73% home, 8% occupational, 5% street/highway,
5% recreation/sport, 9% other
Survival rate: 96.7%
Fire-related burns are the 6th leading cause of death

among 5-14 year olds

What is a burn injury?

Thermal tissue injury caused by exposure to heat,

chemicals, radiation, or electricity

Classified based on:
% Total Body Surface Area (TBSA)
Depth
1st degree/superficial
2nd degree/superficial partial-thickness or deep partial-thickness
3rd degree/full-thickness burn
4th degree extends to fat, muscle, and/or bone

Rule of 9s vs. Lund and Browder

Metabolic Response Ebb Phase

Hypometabolism decreases in
Cardiac output
Oxygen consumption
Body temperature
Metabolic rate
Glucose tolerance
Also causes
Hypovolemia
Shock
Edema

Fluid Resuscitation - Parkland Formula

Metabolic Response Flow Phase

Hypermetabolism increases in
Temperature
Gluconeogenesis
Lipolysis
Proteolysis
Metabolism
Muscle and bone catabolism
Insulin resistance

Metabolic Response to Burn Injury

Skin Grafts
Autograft

Homograft

Hyperbaric Oxygen Therapy

Effects of Hyperbaric Oxygen Therapy

Oxandrolone as Adjunct Pharmacological Therapy

Anabolic synthetic derivative of testosterone
Benefits: Promotes weight gain and wound healing
Risks: hepatotoxicity, delayed bone growth, changes in

sexual development, hyperlipidemia, hyperglycemia,

electrolyte shifts, CNS disturbances, changes in
genitourinary system

Special Considerations in Pediatrics

Wound healing vs. normal growth
Higher TBSA : weight ratio
Different relative %body surface areas affected by growth
Higher BMR per kilogram
Feeding limitations
Food preferences

GOAL: Preserve LBM & promote wound

healing

Estimating Nutrition Needs for Pediatric Burn

Patients
Harris-Benedict
Boys: 66.47 + 13.75W + 5.0H 6.76A
Stress factors: 1.5-1.75
Curreri Junior
25 kcal/kg + (40 x %TBSA) ; age 4-15, <50% BSAB

Galveston, 1986
1800 kcal/m2 BSA + 2300 kcal/m2 BSAB ; age <15, >30% BSAB
Revised Galveston, 1990
1800 kcal/m2 BSA + 1300 kcal/m2 BSAB; age <12, >30%BSAB

Macronutrient Composition
Carbohydrates
Preferred fuel source
Do not exceed 7 g/kg/min
Lipids
Minimum 2-4% of total kcals; ideally 15% of total kcals
Increase Omega-3s, decrease Omega-6s
Protein
Adults: 1.5-2.5 g/kg/day
Children: 2.5-4.5 g/kg/day

Micronutrients of Concern
Vitamin A
Vitamin C
Vitamin E
Vitamin D
Copper
Selenium
Zinc

Medical Nutrition Therapy

Pediatric Enteral Nutrition Formulas

Adult Enteral Nutrition Formulas

Meet DS, a Pediatric Burn Patient

Patient DS

Initial Measurements

Age

7 years

Gender

Male

%TBSA Burns

15% TBSA 2nd & 3rd degree flame burns

Height

121.92 cm (4 ft)

Weight

31.5 kg (69 lb)

Length for Age %tile

25-50th %tile

Weight for Age %tile

95th %tile

Initial Labs

WBC 22.6, RBC 7.4, H/H 16.4/53.8, K 5.2, BUN 27,

GLU 148, ALB 2.9

Estimated Kcals Needs

1685-1909 kcal/d

Estimated Protein Needs

84-95 g/d

Diet Rx

Pediatric

Initial Assessment 12/9/15

Medical/Surgical: ~15% TBSA 2nd degree burn to neck,

ANT torso, BIL UE; fluid resuscitation; emesis x4; begin

twice daily HBO & hydrotherapy (ongoing); SE&G planned
for tomorrow
Education not appropriate at this time
Diet Rx: Pediatric Diet (Avg. 25% intake)
PES Statement: Increased nutrient needs r/t burns AEB
15% TBSA burns & est nutr needs
Intervention:
1. Place NGT & TF Pediasure Peptide 1.5 @60 ml/hr x20 hrs (1800
kcal, 81 g pro, 1386 ml H2O). 85 ml flushes q 6 hrs.
2. Provide pediatric diet as tolerated.
3. Provide burn nutrition education when appropriate

1st Follow-up 12/11/15

Medical/Surgical: ~15% TBSA 2nd & 3rd degree burn to neck, ANT

torso, BIL UE; SE&HG yesterday; transferred to BICU; placed NGT

during sx; IV LR @50 ml/hr; anemia d/t blood loss during surgery;
infused 1 unit prbcs
Education not appropriate at this time
Diet Rx: Pediatric Diet + Pediasure Peptide 1.5 @60 ml/hr
(tolerating TF at goal w/20-40 ml residuals)
PES Statement: Increased nutrient needs r/t burns AEB 12/11. Dx
ongoing. 15% TBSA burns & est nutr needs
Intervention:
1. Continue TF Pediasure Peptide 1.5 @60 ml/hr x20 hrs (1800 kcal, 81 g pro,
1386 ml H2O). 85 ml flushes q 6 hrs.
2. Provide 1 oz ProMod daily (100 kcal, 10 g pro) x3 days
3. Provide pediatric diet as tolerated
4. Provide burn nutrition education when appropriate

2nd Follow-up 12/14/15

Medical/Surgical: NGT removed 12/13; PO intake

improving; grafts look good overall, some areas need further

tangential excision; anemia stable; plan for next SE&G
tomorrow; calorie count in progress from 12/13-12/15
Education not appropriate at this time
Diet Rx: Pediatric + Food from outside (Avg. 45% intake)
PES Statement: Increased nutrient needs r/t burns AEB
12/14: Dx ongoing. 15% TBSA burns & est nutr needs
Intervention:
1. Continue current pediatric diet & supplements
2. Provide burn nutrition education when appropriate
3. Assess diet appropriateness once calorie count has finished

3rd Follow-up 12/16/15

Medical/Surgical: SE&G yesterday (AG to BIL UE & neck; HG to

torso & back; donor site L thigh); sx planned for 12/18

Education: Provided mother verbal/written education on burn MNT;
will F/U at D/C
Diet Rx: Pediatric + food from outside (Avg. 42% intake)
*Meeting 74% kcal & 48% pro needs per calorie count

PES Statement:
1. Increased nutrient needs r/t burns AEB 12/16: Dx ongoing. 15% TBSA burns
& est nutr needs
2. Inadequate Protein/Energy Intake r/t increased needs for wound healing AEB
intake less than estimated needs
Intervention:
1. Provide 2 oz ProMod daily (200 kcal, 20 g pro)
2. Provide Pediasure once daily (200 kcal, 7 g pro)
3. F/U w/education prior to D/C

4th Follow-up 12/18/15

Medical/Surgical: SE&G this morning; appetite improving but does

not like ProMod

Education: Discussed importance of high-protein diet; Will F/U at
discharge
Diet Rx: Pediatric + 2 oz ProMod + Pediasure + food from outside
(Avg. 74% intake)
PES Statement:
1. Increased nutrient needs r/t burns AEB 12/18: Dx ongoing. 15% TBSA burns
& est nutr needs
2. Inadequate Protein/Energy Intake r/t increased needs for wound healing AEB
12/18: Dx ongoing. Intake less than estimated needs

Intervention:
1. Provide Pediasure Peptide TID and D/C ProMod
2. Recommend providing milk of magnesium on PRN list (LBM 12/12)
3. F/U w/education prior to D/C

5th Follow-up 12/23/15

Medical/Surgical: s/p SE&AG to BLUE, neck, torso (12/22); Foley

and central line out; slowly beginning to ambulate; good appetite

Education: Mom would like more education prior to d/c
Diet Rx: Pediatric + Pediasure Peptide TID + food from outside
(Avg. 57% intake)

PES Statement:
1. Increased nutrient needs r/t burns AEB 12/23: Dx ongoing. 15% TBSA burns
& est nutr needs
2. Inadequate Protein/Energy Intake r/t increased needs for wound healing
AEB 12/23: Dx improving. Appetite and intake improving.
Intervention:
1. Continue Pediasure Peptide TID
2. Continue Pediatric diet
3. F/U w/education prior to D/C

Final Follow-up 12/28/15

Medical/Surgical: Grafts look good overall, small open

areas; ambulating with walker

Education: Provided written & verbal education to father
Diet Rx: Pediatric + Pediasure Peptide TID + food from
outside
PO intake 80-100%

PES Statement:
1. Increased nutrient needs r/t burns AEB 12/28: Dx ongoing. 15%
TBSA burns & est nutr needs
2. Inadequate Protein/Energy Intake r/t increased needs for wound
healing AEB 12/28: Dx improving. Appetite and intake improving.
Intervention: Continue w/current diet and Pediasure

Peptide TID

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