A pilot study to assess Total Energy Expenditure in Children with Severe Burns during acute hospitalization: Application of the Doubly Labelled Water Method
Authors: Polychronopoulou Efstathia , Singh Gurjit , Malagaris Ioannis , Craig Porter , Sidossis Labros , Herndon David 
Published: November 2023

Introduction

Severe burn injury causes a prolonged hypermetabolic response leading to losses in weight and lean mass, whereas excessive feeding has been associated with increased morbidity and mortality. Several equations have been developed to assist nutritional management in pediatric burn patients, but there are no universally accepted guidelines. The doubly labelled water (DLW) technique is a validated method to calculate total energy expenditure (TEE), which has only been used in burn children during rehabilitation. The aim of this study is two‐fold; to assess the feasibility of employing the DLW method in critically injured children and to estimate total energy needs of these patients compared to healthy children.

Methods

For this prospective exploratory study we are recruiting children aged 4–18 years with at least 30% of Total Body Surface Area (TBSA) burned admitted to Shriners Hospital for Children, Galveston. TEE is measured during the acute phase of their injury, while being non‐ambulatory, using the DLW method over a 4–7 days period. Time of study initiation and termination are determined from their surgery schedule and overall health status. The average study starting time is 23 ± 5 days post burn. A second DLW dose is administered on the last study day on children who have more than 3% weight loss to determine changes in total body water. A group of healthy children are also being recruited and administered DLW over a 14‐day period. For both groups REE is measured by indirect calorimetry during the study period.

Results

To date we have studied 6 burned and 2 healthy children. Because burn injury and subsequent skin grafting procedures result in high water turnover that can affect the precision of the method, we had to exclude from further analysis two patients that exhibited estimated water turnover rates of > 40% daily. One more patient was excluded due to undergoing an unscheduled surgery during the study. Our preliminary results are based on the remaining 3 patients; mean burn size was 59% ± 20% (range, 34%–83%) of TBSA, mean age was 12.6 ± 0.4 years (range, 12–13) and mean weight was 50 ± 6.5 kg (range, 41–55.3). Daily TEE averaged 66 ± 16 kcal/kg (range, 48–87) and was 1.45 ± 0.25 times measured REE (range, 1.2–1.7). For healthy children mean age and weight were 8 ± 1 years (range, 7–9) and 28.5 ± 4 kg (range, 24.5–32.6) respectively. Average daily TEE was calculated to be 62 ± 7 kcal/kg (range, 55–69) and 1.6 ± 0.03 times measured REE (range, 1.58–1.64).

Conclusions

Burn injury presents several challenges to the application of the DLW method. A significant percentage of recruited patients may have to be excluded from final analysis due to very high water turnover or unanticipated surgeries with associated fluid transfusion. However such an approach is feasible and can provide precise estimates of TEE. Energy requirements of bedridden children during acute burn injury are elevated to levels comparable or higher than healthy active individuals.

Support or Funding Information

This work was funded by NIH (P50 GM060338 and R01 GM056687) and SHC (84080 and 80490)