COMPARATIVE STUDY OF TOLERANCE AND COMPLICATIONS OF EARLY ENTERAL NUTRITION IN CHILD AND ADULT BURN PATIENTS

loannovich J., Koulermou G., Achilleos 0., Panayotou P., Vaos G., Tsirigotou S., Skondras K.

Clinic for Plastic Surgery and Microsurgery Second Department of Paediatric Surgery P. and K Kyriakou', Athens, Greece

SUMMARY. The results are reported of a clinical study in which the clinical and biochemical side-effects of early total enteral nutrition (TEN) in adult and child burn victims are compared. It was found that TEN was satisfactorily tolerated as there were no major gastric or intestinal side-effects or irreversible hepatic side-effects. Children had no GI side-effects and their hepatic enzymes responded well. There was no GI-tract bleeding in adults or children, and septicaemia either decreased or, in the case of children, did not occur.

Introduction
Total enteral nutrition (TEN) tends to become the treatment of choice in burns, since there is experimental and clinical evidence that it diminishes the incidence of complications and ameliorates the outcome of burn victims (Wilson, 1975; Moss, 1975; Kirksey, 1968).
We have already presented studies from our clinic, where we evaluated the tolerance of early TEN and investigated its clinical and biochemical side-effects. In this study we compare tolerance and complications of TEN in children and adult patients.

Material and Methods
Thirty-two adult and 26 child patients were studied.
The adults' age ranged from 20 to 60 years, and the extent of their burns from 20 to 75% TI1SA. The children's age ranged from 4 months to 13 years, and their burns from 15 to 60% TI1SA.
Three groups were formed according to the initiation of TEN. In group A nutrition commenced in the first post-burn hours, in group B on the first post-burn day, and in group C between the 2nd and the 5th post-burn day, since patients of this group were transferred to our Unit after some delay. There were 18 adults and 18 children in group A, 10 adults and 6 children in group B, and 4 adults and 2 children in group C.
On admission a fine radiopaque nasoduodenal tube was inserted in all patients. An enteral nutrition pump for continuous and controlled administration of a semielemental enteral solution was used. The solution contained 17.5% of energy as hydrolysed proteins.
The calculation of nutritional needs was performed according to the Davies/Li1jendalil formulae, up to 45% TBSA. Nutritional needs were recalculated at the end of the first post-burn week and from then on every ten days, according to the reduction of TBSA.
In an attempt to.investigate the tolerance of early TEN, the GI tract and hepatic behaviour, together with the mean and maximum compliance, were used as indices.
We also examined mortality and morbidity in each group of patients and compared the results between children and adults.

Results
There were no GI-tract related episodes of diarrhoea either in adults or in children in group A. TEN was very well tolerated from the very first hours of administration since there was no evidence of paralytic ileus in any patient. All side-effects from the upper GI tract were observed in one group B patient; for this patient the quantity and rate of administration Was initially modified and then temporarily discontinued, because of persistent vomiting. Bowel distension was observed in one group A patient and this was relieved by modifying the quantity.
In children no GI-tract side-effects were observed in any group. In adults hepatic enzymes showed an increase between the 7th and 17th post-burn day, and they all returned to normal levels after the 20th post-burn day.
In children there was an increase between day 5 and day 10, after which a decrease was observed in all groups of patients.
Alkaline phosphate and 'Y-GT ranged at the same levels for all three groups in adults.
In children both enzymes ranged at higher levels in groups B and C than in group A. In groups B and C these levels reduced to normal later than in group A.
Transaminase and especially SGOT remained almost at normal levels in group A adults. In children, they ranged at higher levels in groups B and C, and decreased to normal levels in groups A and B.
The calculation of caloric and protein compliance showed that the maximum compliance in all groups of patients ranged from 85 to 94.5% (kcal) in adults, and from 91 to 113% in children.
The maximum compliance for proteins ranged from 78 to 92% in adults and from 79 to 97% in children. Compliance ratios of more than 65% are considered to be sufficient (Bell et al., 1986).
No adult patient died in groups A or B. Two of the patients from group C died on the 7th and 10th post-burn day, one because of invasive wound sepsis and the other because of co-existing renal and hepatic insufficiency.
The overall morbidity was 15.4%, including one patient with pulmonary infection in group A and one with wound sepsis in group C.
No child patient showed any side-effects in the GI tract, the respiratory or any other system. There were no deaths among the children.

Discussion
Examining tolerance of TEN with clinical and biochemical criteria we observed that it is satisfactorily tolerated, since:

1. No major gastric side-effects were observed in adults.
2. No major intestinal side-effects such as diarrhoea were observed.
3. No irreversible side-effects on the hepatic tissue were observed.

In children, no GI-tract side-effects were observed, and they had a very good response of the hepatic enzymes. High compliance rates were achieved for kcal and proteins administered to adults and children.
Low morbidity was registered. Overall, we observed:

1. improvement of the patient's general clinical condition;
2. absence of upper GI-tract bleeding in adults and children; and
3. decrease in adults in the incidence of septicaemia and its complications, and no septicaemia in children.

In conclusion, this study shows clearly that TEN is well tolerated by adult and child patients, irrespective of the time of its initiation.

RESUME. Les auteurs préentent les réultats d'une etude clinique qui a examine les effets secondaires de la nutrition enterale totale (TEN) prèoce chez des patients brfilés adultes et enfants. lls ont observe que la TEN a éte tolerée en maniere satisfaisante, sans effets secondaires intestinaux ou hepatiques irreversibles. Les enfants n'ont pas montre Weilets G1 collatéraux et leurs enzymes hepatiques ont bien réagi. 11 nly a pas eu un seul eas d'hemorragie de Pappareil G1 m chez les adultes ni chez les enfants, et la septicemie ou se réduisait on (chez les enfants) èait absente.