13urus  Vul.  23,  No.  6,  pp.  517-514,     1997 
                                                                                                                                                    D  1997  Ekevier     Sciellce  Ltd  for  1331.  AI  rights    reserved 
                                                                                                                                                                                              Printed    in  Great   Britain 
                                                                                                                                                                                            0305-ami         517.00   T 0.00 
                     ELSEVIER 
                     PI!:  §0305-4~79(97)00030-2 
                     Hospital-made                                               diet  versus  commercial                                                                    supplement 
                     in  postburn                                    nutritional                                support 
                     Frema  Dhanraj,                    Ashok  Chacko,  Mary  Mammen                                          and  Ravindra                  Bharathi 
                     Department  of Plastic and Reconstructive  Surgery.  Christian  Medical  College and Hospital,  VeLlore 632 004, 
                     Tamil Nadu,  Tndia 
                                                                                                                              Therfore  nutritional                 support  is as important  as any 
                     Nutritional      sqort        is mz  imporfant        aspect of the  mamgenrent              o,f         other        aspect  of  burns  management.  Nutritional 
                     burl7  ptif37fs.  ,xLftritioil       quple~~zenfation          cm  be ackie-Jed  eithcv                  support  following  burns  can  be  achieved  by  either 
                     by  ‘kospital-Fmde           i;Y  ‘commercial         diets.  Carnmevcial  diets  are                    enteral  or  parenteral  routes.  Parenteral  nutrition                                      is 
                     $icacicIks  but  cx,vensioc arld  smetimes                 not  easily available.  This                  usually  avoided  because of  its expense  and  the  high 
                     study  was  undevtaken  to  compare  the  #ic~zcy  rind  tolerance  0,f a                                rate  of  complications.  Enteral  nutrition                            can  be  given 
                     hos@i-made           diet  with    a  commercial  diet.  Twenty  patients  ivith                         by      either        ‘hospital-made’                or     ‘commercial’              diets. 
                     harrzs    ranging       l’wn     20-50       per   cent  TBSA          were     s&died       to          Although           commercial  diets  are  efficacious  they  are 
                     conzynrr~   the  efficacy     and   tolerance     of  the  ‘hospital-made’        diet  with             expensive            and        sometimes  not                   easily        available. 
                     ‘cowmcrinl’        pmparatiorzs.       Patients  -were  divided  into  two  groups                       Hospital-made  diets                   are  cheap  and  the  ingredients 
                     o/  IO  each  and  randomised            WifhipZ each  group         to  yecceiz>e eifhcr  a             from  which  the  diet  is  made  are  easily  available. 
                     hosyital-made         diet    (j?vc  patiellts)      07  a  comnzevcial  diet            !fisIe          However,            the  tolerance  and  efficacv                        of  ‘hospital- 
                     patients).     E~ficncy 0J’ diet  was  assessed  by coaluntion                    of m&i-                made’  diets  compared  to  ‘commerciai’  diets  are  not 
                     iio~xd    stnflls,  gqft       hdaz,  number          0-f silrgicd      p~oceduws         Ned            known. 
                     dzwation      of iras@aZ stay.  Tolemnce                was  assessed  by  recovdillg                         Therefore,  the  aims of  the  present  study  were  to 
                     jidc   @is       suciz  LIS ~aawza,  mnitiq,             abdomi~ad        distclzfion     and            compare the tolerance  and  efficacy  of ‘hospital-made’ 
                     :iiaruhwa.     Bath  diets  mm  well  tolerated  by all  pntients.  There                                diets with  ‘commercial’  diets. 
                     was  no  signi,Ficunt  diffemce              in   imiuitional       sfatlks,  wn~ber         of 
                     suugicai  proccdum,             ~wcenfage        of graft      take  and  duration           qf          Method 
                     hospital  stay  017 eitkev diet,  suggesting                that  kos@al-made           diets            Subjects 
                     UYF similar      in  efficacy al7d  fo~eravrce but  cheaper  UFld more  easily                           Twenty         patients  with  flame  burns  ranging  between 
                     mailable.      They  are  a  good  alternative                to   ‘commercial’        diets,            211 and 50 per  cent  body  surface area, admitted  to  the 
                     especiai!y irz pow  patients.  0  1997  Eiseuiev Sciem                     Lfd  fur ISBI.                Burn  Unit  of  the  Christian  Medical  College                                 Hospital 
                    Kepords:          Burns,  enteral        nutrition,       hospital-made          diet.                    (CMC),  Vellore  were  studied.  There  were  11  males 
                                                                                                                              and  9 females and  their  ages ranged  from  17 to  50 yr. 
                                                                                                                              Patients  with               diabetes  mellitus,                 psychosis,  renal 
                     Burns,  VOL. 23, .Vo.  6, 512-514,               1997                                                    failure  and  those admitted  3 days after  the burn  were 
                                                                                                                              excluded. 
                                                                                                                                   Patients were  divided  into  two  groups  depending 
                     Introduction                                                                                             on  extent  of  burn  injury.  Group  I  (10 patients)  had 
                                                                                                                              2&35  per  cent  burns  while  Group  II  (10  patients) 
                     After      burn  injury,           patients  enter  a  severe  catabolic                                 had  36-50  per  cent  burns.  Patients  in  each  group 
                     state       characterised              by       elevated          metabohc  rate,                        were  randomised  to  receive  either  ‘hospital-made’ 
                     ancreased protein  mobilisation  and  gluconeogenesis.                                                   (five  patients)  or ‘commercial’  diets (five  patients). 
                     In  burned  patients  these  catabolic  changes  lead  to 
                     significant  increases in  energy  and  protein  require-                                                Diets 
                     ments’.  Weig.ht  loss  during  this  phase  is virtually                                                The  composition  of  the  ‘hospital-made’  and ‘commer- 
                     inevitable         unless  aggressive  nutritional                          therapy          is          cial’  diets  were  similar  (T&le  I).  Both  diets  were 
                     instituted        soon after  the  burn.  Weight  loss of  more                                          prmepared in  the  dietary  department,  appeared  similar 
                     than       10  per  cent  has  been  shown  to  increase                                                 and  were  packed  in  similar  bottles.  The  diets  were 
                     mortality        and  a weight  loss of  more  than  30 per  cent                                        prepared  twice  a day  and  were  stored  in  the  ward’s 
                     is  associated  with                almost  100  per  cent  mortality’.                                  refrigerator  prior  to use. 
                                Dhanraj  et al.: Postburn  nutritional                                                      support                                                                                                                                                                                                                513 
                                Table           I.  Compiticm                           of ‘hospital-made’                             iliFt  per 15011 ml 
                                                                                                       Amount               (g)                                  CHO  k/l                                          Protein           (g)                                  Fat      (gl                                  Calories            (Kcals) 
                                Hospital            made 
                                     Cottage             cheese                                                   375                                                     2.1                                             32.0                                               36.4                                                     464 
                                     Eggs         (Nos)                                                               3                                                                                                    19.8                                              19.8                                                     255 
                                     Malted            ragi  *                                                     20                                                   15.9                                                 1.2                                               0.2                                                     70 
                                     Ragi        flour                                                              80                                                 63.6                                                  5.0                                                1.0                                                   280 
                                     Sugar                                                                          55                                                 55.0                                                                                                                                                           220 
                                     Refined             Oil                                                        25                                                                                                      -                                                25.0                                                     225 
                                     Total                                                                                                                           136.6                                                58.0                                               82.4                                                    1514 
                                Commercial                                                                                                                           132.1                                                57.3                                               83.6                                                    1515 
                                 *Ragi         is  a  millet          (Eleusine             coracana). 
                                 Feeding regimen                                                                                                                                                     once  a  week.  Total  protein,  albumin,  serum  trans- 
                                Tlw              cahric                  requirement                              for          each               patient                   was                      ferrin  and  total  lymphocyte                                                   count  were  measured at 
                                 estimated  using  the  Curreri  formula’.  Diets were  fed                                                                                                          admission  and  repeated  after                                                                      2 weeks  and  at 
                                 as continuous  infusions  over  24  h.  All  patients  were                                                                                                          discharge. 
                                 fed  buttermilk                            on  the  first  postburn  day  at  50 ml/h                                                                                       Standard  burn  management  was carried  out  on  all 
                                 through  a  I4  Fr  size nasogastric  tube.  The  tip  of  the                                                                                                      patients.  Fluid  resuscitation  was performed  according 
                                 tube  was positioned  in  the  antrum  of  the  stomach.                                                                                                             to  a  modified  Brooke  formula’.  Cultures  of  urine, 
                                 Aspiration  was performed  every  4  h  to  exclude  reten-                                                                                                         blood  and intravenous  catheter  tips were  taken  when 
                                 tion.  Half  strength  burn  formula  diet  (BFD),  at  the                                                                                                          necessary  and  appropriate                                                      antibiotics  administered 
                                 rate         of  50 ml/h,  was started  on  second  postburn  day                                                                                                    depending  on                                the  culture  and  sensitivity                                                     reports. 
                                 and increased to 100 ml/h  on third  postburn  day.  Full                                                                                                           Wounds  were  dressed with  silver  sulfadiazine  and 
                                 strength  burn  formula  diet  at  the  rate  of  100 ml/h                                                                                                          eschar debrided  in  the  ward.  Patients were  taken  for 
                                 was  given  from  the  fourth  day  and  increased  by                                                                                                              skin  grafting  when  granulation  was  healthy.  Early 
                                 SO ml/h  per day  until  the  full  caloric  requirement  was                                                                                                       excision  was not  performed. 
                                 reached.  Patients  wt’re  allowed  to eat solid  food  from                                                                                                                The  efficacy                            of        the  burn  formula                                         feeds  were 
                                 day  111. The  daily  intake  of  energy  and  protein  from                                                                                                         assessed by  improvement  in  nutritional  status,  graft 
                                 solid  food                   were  calculated  by  a dietitian  and  appro-                                                                                         take,  number  of  surgical  procedures  required  and 
                                 priate  reduct.ion  of  BFD  was made  according  to  the                                                                                                            duration  of  stay.  The  study  protocol  was  approved 
                                 amount  ot  solid  food  consumed’.  Both  groups  of                                                                                                               by  the  Research Committee  of  the  Christian  Medical 
                                 patients  were  on bed  rest with  minimal  activity,  such                                                                                                          College,  Vellore. 
                                 as walking  in  the  room                                          and  mild  exercises to  prevent 
                                 contractures.                                                                                                                                                        Statistical method 
                                        Tolerance  of  diet  was assessed by  recording  side-                                                                                                        Comparison  of  study  parameters  between  two  diets 
                                 effects  for                       12xample nausea,  vomiting,                                                          abdominal                                   was  performed  using  the  Mann-Whitney                                                                                          U  test. 
                                 distension  and  diarrhoeas.  If  patients  complained  of                                                                                                          Data  were  analysed  using  SPSS PC+  software. 
                                 any            of  the  above,  the  volume                                                        of  the  feed  was 
                                 reduced  anJ  increased  gradually                                                                  to  the  calculated                                              Results 
                                 requirement. 
                                                                                                                                                                                                      Ihhlc  II  shows that  age, sex, per  cent  surface  area of 
                                 Nutritional                             status  evaluation                                          and  burn                                                        burn,  weight  at  admission  and  energy  and  protein 
                                 management                                                                                                                                                           intake  were  similar  in  patients  fed  with  ‘hospital- 
                                                                                                                                                                                                      made’  and  ‘commercial’  diets  in  the  two  groups 
                                 Cljnical  and  biochemical  parameters  were  used  to                                                                                                               studied.  Hospital-made  and  commercial  feeds were 
                                 evaluate                   nutritional                      status.  Patients  were  weighed                                                                         well  tolerated  by  all  patients  in  the                                                                 study  with  no 
                                 Table II.  Patient                         char