Enteral resuscitation and early enteral feeding in children with major burns--effect on McFarlane response to stress.
OBJECTIVE
Early enteral feeding has become standard practice for burned patients. The aim of this study was to determine whether early enteral feeding could be used as an avenue for resuscitation and feeding and the effect it would have on the induction/amelioration of the hormonal stress response.


METHODS
Eighteen children with <20% TBSA were randomly assigned to either early enteral feeding and resuscitation, or intravenous resuscitation with the induction of enteral feeding delayed. The enteral fluid volume was incrementally increased every 3h with a simultaneous equal reduction in the intravenous volume until all the calculated intravenous fluid requirements for resuscitation and maintenance could be administered enterally. In the second group, intravenous resuscitation continued for 48 h when enteral feeding was introduced. Parameters measured were the clinical responses and outcome as well as the concentrations of insulin, insulin-like growth factor 1, glucagon, cortisone and growth hormone. The estimated and calculated energy expenditure was measured calorimetrically and bowel permeability was assessed using a dual sugar absorption test.


RESULTS
Three children were excluded from the study because of early death from organ failure or carbon monoxide poisoning. Early enteral resuscitation and feeding (ER/EEF) was initiated within a median of 10.7h post-burn in nine children and late enteral feeding introduced on an average 54 h post-burn. The ER/EEF group showed an anabolic response with significantly higher insulin concentrations (p=0.008) and insulin: glucagon ratios (p=0.043). Although blood glucose concentrations were initially slightly elevated (EEF: 10.3g/l, LEF: 8.1g/l), they rapidly returned to within the normal range. The cortisol and IGF1 concentrations did not differ significantly between the two treatment groups. Growth hormone concentrations were significantly higher in the late enteral feeding (LEF) group (p=0.03). The estimated energy expenditure was not different amongst the groups. Small bowel permeability [lactulose:rhamnose (L:R) ratios] decreased significantly over time (p=0.02) in both study groups. No pulmonary aspiration was found. Diarrhoea in the ER/EEF settled quickly (2-4 days), whereas in the LEF group it persisted for longer than a week. The LEF group lost a median of 7.75% (acceptable range=<or=5%) of admission body weight, whereas the ER/EEF group lost a median of 3.01%. Patients in the LEF group required antibiotic treatment for a longer period (p=0.08) and their hospital stay was longer, though not significant.


CONCLUSIONS
Enteral resuscitation and early enteral feeding is a safe and effective method and particularly suited for children in developing countries. It resulted in the amelioration of the hormonal stress response and improved outcome. Enteral resuscitation should not be introduced in a patient in shock or with existing gastrointestinal disease. Complications were minimal.
Venter
M
M
Red Cross War Memorial Children's Hospital, Paediatric Surgery, Klipfontein Road, Rondebosch, Cape Town 7700, South Africa. marchaventer@yahoo.com
Rode
H
H
Sive
A
A
Visser
M
M
D000293:Adolescent; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D002056:Burns / Q000628:therapy*; D002648:Child; D002675:Child, Preschool; D002149:Energy Intake; D004734:Energy Metabolism; D004750:Enteral Nutrition / Q000379:methods*; D006801:Humans; D006854:Hydrocortisone / Q000378:metabolism; D007223:Infant; D007262:Infusions, Intravenous; D007334:Insulin-Like Growth Factor I / Q000378:metabolism; D036341:Intercellular Signaling Peptides and Proteins / Q000378:metabolism; D010952:Plasma Substitutes / Q000008:administration & dosage; D011446:Prospective Studies; D012151:Resuscitation / Q000379:methods*; D013312:Stress, Physiological / Q000378:metabolism / Q000517:prevention & control*
D000900:Anti-Bacterial Agents; D036341:Intercellular Signaling Peptides and Proteins; D010952:Plasma Substitutes; D007334:Insulin-Like Growth Factor I; D006854:Hydrocortisone