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Nutritional demands and enteral formulas for moderate-to-severe burn patients
Author: Amalia Cochran, MD

Section Editor: Marc G Jeschke, MD, PhD
Deputy Editor: Kathryn A Collins, MD, PhD, FACS
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Apr 2018. | This topic last updated: Jul 17, 2017.
INTRODUCTION — Nutritional support represents one of the most important cornerstones in the management of
patients with a moderate-to-severe burn injury. This topic covers determination of caloric requirements and
selection of enteral formulas. The target goal of avoiding the extremes of starvation and overfeeding is defined
by estimating energy requirements and is subject to continued monitoring and revision based upon the metabolic
characteristics of patients and their tolerance of enteral nutrition [1,2].
Information on patient selection and timing of nutritional support and evaluating nutritional support is discussed
elsewhere. (See "Overview of nutritional support for moderate-to-severe burn patients" and "Evaluating
nutritional support for moderate-to-severe burn patients".)
DETERMINING CALORIC REQUIREMENTS — The fundamental goal in nutritional support is to meet but not
exceed the nutritional requirements of patients with moderate-to-severe burns. Assessment of nutritional support
falls into two distinct categories: the initial requirements and the ongoing requirements. The assessment of
caloric demands within the first 24 hours generates an initial goal so that nutritional support can be initiated.
However, the most critical component is to make adjustments for the ongoing needs during what is often a
prolonged recovery associated with a prolonged course of hypermetabolism [1,2]. The hypermetabolic response
is likely more prolonged than previously thought, possibly extending for up to three years postinjury [3]. (See
"Hypermetabolic response to severe burn injury".)
Initial nutritional support goal — The target goal of avoiding the extremes of starvation and overfeeding is
determined by estimating energy requirements and is subject to revision based upon the metabolic
characteristics of patients and their tolerance of enteral nutrition [1,2]. Initial estimates of energy expenditure in
burn patients provide a particular challenge because of the variability of the hypermetabolic response and the
factors that result in heterogeneity of energy expenditure in burn patients [4]. (See "Hypermetabolic response to
severe burn injury".)
Calculating energy requirements — The assessment of the energy requirements represents a composite of
the following factors [5]:
● Basal metabolic rate
● Hypermetabolism
● Percent of total body surface area (TBSA) burned
● Ventilatory support
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● Infections
● Sepsis
● Multiple organ failure
● Level of physical activity
● Thermic effect of food
Assessment of the energy requirements is an ongoing process and modified according to the progress of the
patient [6]. No single formula accurately assesses the true caloric needs, and continued vigilance is required to
avoid complications associated with either overfeeding or underfeeding [7-9].
Many mathematical equations have been devised to estimate the caloric requirements of the burn patient [10-
13]. Avoidance of overfeeding minimizes the risks of hyperglycemia, fat accretion, and infections [1,2,8].
However, most of the formulas overestimate the amount of calories required in burn patients [14,15]. Indirect
calorimetry is the most accurate tool to assess caloric requirements but requires specialized equipment [16,17].
One of the first formulas, the Curreri formula, is used worldwide to estimate the caloric requirement in adult and
pediatric burn patients. The Galveston Shriners Burns Institute has also developed formulas to be used in
children.
Indirect calorimetry estimation — Indirect calorimetry (IDC) has been more beneficial for estimating caloric
requirements of the burn patient than the predictive Curreri formula; however, the equipment necessary to
perform the tests is not widely available [10,16,17]. Considered the "gold standard" for assessing energy
expenditure, the IDC method uses respiratory gas exchange to estimate fuel consumption. Results of IDC are
affected by oxygen therapy, hemodynamic instability, fever, and any ongoing procedures [18].
Harris-Benedict equation — The Harris-Benedict equation and the Curreri formula are the most widely used
algebraic formulas for the estimation of caloric requirements in adult burn patients. The Harris-Benedict equation
is an accepted standard for estimating basal energy expenditure (BEE). For burn patients, the BEE is multiplied
by an arbitrary activity or stress factor of 1.2 to 2.0. For all but the most extensive burn injuries, the acceptable
stress factor is between 1.2 and 1.5 [6,14]. While useful for initial estimate of energy demands, the equation
overestimates the caloric requirements of burn patients [14].
● The equation used for men is:
BEE (kcal per day) = 66.5 + (13.8) Weight in Kg + (5) Height in cm - (6.76) Age in years.
● The equation used for women is:
BEE (kcal per day) = 655 + (9.6) Weight in Kg + (1.85) Height in cm - (4.68) Age in years.
Curreri formula — The Curreri formula provides for maintenance needs plus the additional caloric
requirements for the burn injury [6,19-21]. The two factors used in this formula, percent TBSA and body weight
prior to the burn, estimate the energy requirements by linear regression analysis based on the number of calories
required to prevent weight loss during the first few weeks postburn [10]. This formula was based on nine adult
patients. It does not take into account gender, age, activity, or ventilatory status.
While the Curreri formula has been accepted worldwide, it overestimates the caloric needs of burn patients when
compared to metabolic expenditure requirements [6,10,22]. The overestimation may be related to the changes in
burn care since the formula was developed. Early wound closure, higher ambient temperature, improvements in
infection control, and pain management all reduce the hypermetabolic response to the burn injury. (See
"Hypermetabolic response to severe burn injury".)
● The Curreri formula for adults age 16 to 59 years is:
Caloric requirement (kcal per day) = 25 kcal/kg/day + 40 kcal/percent TBSA burned/day
● The Curreri formula for adults over age 60 years is:
Caloric requirement (kcal per day) = 25 kcal/kg/day + 65 kcal/percent TBSA burned/day
Cunningham prediction equation — The Cunningham prediction equation uses fat-free body mass (FFM) in
calculating resting energy expenditure (REE) [23,24] (see 'Permissive underfeeding for obese patients' below).
FFM is calculated by defining the ideal body mass index as 25, back-calculating ideal weight using the patient's
height, and defining excess weight as the difference between actual weight and ideal weight. An injury factor of
20 percent is used to calculate the increase in energy expenditure in burned patients. FFM is defined as the sum
of the ideal weight plus 25 percent of the excess weight.
● REE (kcal/day) = 370 + 21.6(FFM).
Toronto formula — Another complicated formula, the Toronto formula is used to predict the energy
requirements of the ventilated burn patient [6,12,25]. The formula requires an ongoing collection of patient data.
The formula was developed by using multiple regression analyses to determine the factors that best
approximated the measured energy expenditure (MEE). The factors included in the equation are a factor of
activity, total body surface area (TBSA), caloric intake (CI), estimated basal energy expenditure (EBEE)
calculated by the Harris-Benedict formula, and number of postburn days (PBD).
● MEE (kcal/day) = -4343 + (10.5 x percent TBSA) + (0.23 x CI) + (0.84 x EBEE) + (114 x Temp (degree C)) -
(4.5 x PBD).
Pediatric formulas — The most frequently used calculation schemes for caloric requirements in pediatric burn
patients include Recommended Dietary Allowances/Recommended Daily Intake (RDA/ RDI), Curreri Junior, and
the Galveston formulas.
RDA/RDI — The Recommended Dietary Allowance or RDA (sometimes referred to as Recommended Daily
Allowance) is defined as the average daily dietary intake level that is sufficient to meet the nutrient requirements
of nearly all (approximately 98 percent) healthy individuals [26]. Reference Daily Intake (or Recommended Daily
Intake; RDI) is the daily dietary intake level of a nutrient that was considered at the time they were defined to be
sufficient to meet the requirements of nearly all (97 to 98 percent) healthy individuals. RDIs are based on the
older RDA recommendations. Use of this scheme prevents overfeeding found with the older formulas (eg, Curreri
and Galveston).
The caloric requirement for adults based upon the RDI recommendations is RDI (kcal per day) = 37 (weight in
kilograms). The caloric requirements for children with a 40 percent TBSA are calculated using a formula that
contains a modifier based on age multiplied by weight in kilograms [6]. The United States Department of
Agriculture has an online interactive dietary reference intake calculator for healthcare professionals (link provided
in following reference) [27].
Curreri Junior — The Curreri Junior formula is based upon adult Curreri calculations with modification for
age and RDA (table 1). It also overestimates the caloric requirements of burn patients. The formulas to calculate
caloric requirements for children are based upon age [6].
Galveston Shriners Burns Institute — The Galveston Shriners Burns Institute formulas are frequently used
to estimate energy demands for pediatric burn patients (table 2) [28]. These formulas are a reasonable
alternative to the RDA/RDI formulas. The formula for children under one year of age was derived from a
multivariate regression analysis of 30 children with at least a 25 percent TBSA burn [29]. The formulas for
children over one year of age were derived by direct observations of the actual caloric intake required to maintain
weight in 121 pediatric patients with burns greater than 30 percent TBSA [30]. The formulas are based on age
and TBSA burned.
Permissive underfeeding for obese patients — Lean body mass (LBM) is the site of metabolism, and LBM is
just slightly greater in obese compared to normal-weight individuals [23]. Permissive underfeeding, which uses
ideal body weight to estimate caloric need, counters hyperglycemia and weight gain that result from overfeeding
critically ill patients [31]. Permissive underfeeding is a reasonable strategy in obese critically ill patients who have
less metabolic derangement and less need for short-term support than burn patients. Permissive underfeeding
relies on fat oxidation to mobilize peripheral stores as an energy source, a process that is impaired in patients
with a significant burn injury [32-34].
A retrospective review of 28 obese burn and trauma patients found that the Harris-Benedict equation and the
Cunningham prediction equation underpredicted the resting energy expenditure (REE) [23] (see 'Calculating
energy requirements' above). When an injury factor of 20 percent is included in the calculations, the Cunningham
equation was the most accurate for predicting REE. The Cunningham equation potentially alleviates overfeeding
in obese burn patients by using lean body weight, rather than current weight [23,24].
NUTRIENT COMPOSITION FOR ENTERAL FORMULAS — The following sections describe the recommended
macronutrients and micronutrients in the enteral formulas used for moderate-to-severe burn injury patients. We
recommend delivery of:
● 1.5 to 2.0 grams protein/kg/day
● 5 to 7 mg/kg/minute of glucose per day representing approximately 50 percent of total calories
● Fewer than 15 percent of nonprotein calories from fat sources
● Vitamins A, C, and D in standard multivitamin formulations
● Trace minerals (eg, selenium, zinc and copper) in standard formulations
Macronutrients — In addition to establishing initial caloric energy requirements, determination of the appropriate
composition of protein, carbohydrates, and fats for a nutrition support regimen is an early priority. Carbohydrates
stimulate protein synthesis and limit loss of lean body mass, thereby making a high-carbohydrate diet preferable
in patients who have sustained a moderate-to-severe burn injury.
This was illustrated in a muscle protein kinetic trial performed on 14 severely burned children [35]. Subjects
randomly received either a high-carbohydrate enteral diet (3 percent fat, 82 percent carbohydrate, 15 percent
protein) or a high-fat enteral diet (44 percent fat, 42 percent carbohydrates, 14 percent protein) for one week and
then crossed over to the other diet for a second week. Patients treated with a high-carbohydrate diet had
significantly decreased muscle protein degradation and significantly increased endogenous insulin
concentrations.
Protein — Administration of nutrition support with protein of 1.5 to 2.0 grams/kg/day, approximately 20 to 25
percent of calories per day, will provide a balance between synthesis and breakdown. (See "Nutrition support in
critically ill patients: An overview".)
Urea production, and therefore protein oxidation, in burned patients occurs at a rate approximately twice that of
healthy individuals [36]. Studies of protein intake in burns have examined intake levels of 1.5 grams/kg/day and
greater to determine optimal quantities. Delivery of greater than 1.5 grams/kg/day in adult burns does not
improve protein synthesis but does enhance maintenance of an isonitrogenous state [37].
Sufficient protein is a priority in the nutrition support of burn patients to minimize the impact of the catabolic
response to burn injury and to assist in the protein synthesis required for wound healing and immune function. It
has been estimated that healthy individuals synthesize protein at a rate of approximately 4 grams/kg/day, in
contrast to the 7.6 grams/kg/day rate of protein synthesis that has been estimated in burn patients [36].
Glucose — Glucose is the preferred substrate for wound healing and should be the major source of calories
in burn patients [38,39]. Ideally, carbohydrates administered for burn nutrition support should consist of 5 to 7
mg/kg/minute of glucose and represent approximately 50 percent of total calories provided [40].
Data from an observational study suggested that there is a maximal rate of glucose infusion beyond which
physiologically significant increases in protein synthesis and direct oxidation of glucose cannot be expected [41].
There also appeared to be a physiological cost of exceeding the optimal glucose infusion rate, as indicated by
increased rates of CO2 production during infusion as well as large fat deposits in the liver at autopsy in patients
infused with large amounts of glucose.
Lipids — Lipids are an important dietary component as they contain the essential fatty acids, but they should
comprise no more than 15 percent of total calories. Lipids serve as carriers of lipid-soluble vitamins. Following a
moderate-to-severe burn injury, oxidation of free fatty acids occurs at a rate more than double that of healthy
people [36]. This enhanced process of lipolysis allows for excess exogenous fat to heighten recycling of free fatty
acids and may result in increased fat storage.
Nutritional support with more than 15 percent of calories from lipids has been demonstrated to impair
immunologic function [40,42-45]. In a randomized clinical trial, 43 moderate-to-severe burn patients were
assigned to one of the following groups: high-fat solution (35 percent of total calories as fat), low-fat solution (15
percent fat), or low-fat solution with fish oil (15 percent fat), which was administered for 30 days [42]. Compared
with the high-fat control group, groups on low-fat support had significantly fewer cases of pneumonia (3 out of 24
versus 7 out of 13) and a significantly shorter time to healing (1.2 versus 1.8 days/percent total body surface
area burned). There was no difference in nitrogen balance between the high-fat and low-fat groups, and 3-
methylhistidine excretion was higher and serum free cortisol lower in the low-fat groups. Fish oil did not seem to
add clinical benefit to low-fat solutions.
Micronutrients — Maintaining appropriate levels of trace elements in moderate-to-severe burn patients is

difficult due to exudative losses consequent to loss of the skin barrier. A comprehensive review of the impact of
burns on micronutrients and the relevance of those micronutrients to recovery from burn injury is beyond the
scope of this topic, but vitamins A, C, and D and the three trace minerals copper, zinc, and selenium will be
discussed.
Vitamins A, C, and D — Vitamin A plays an important role in immune function, wound epithelialization, and
prevention of free radical damage [46]. Vitamin A toxicity can occur with high doses; vitamin C does not appear
to have any known toxicities in high doses. (See "Overview of vitamin A".)
Vitamin C, an antioxidant, is an essential component of collagen cross-linking and therefore also influences
wound healing. Levels of vitamins A and C are decreased in patients following burn injury but can be replenished
with supplementation [47]. (See "Overview of water-soluble vitamins".)
Vitamin D deficiency is most likely due to a combination of acquired defects in vitamin D metabolism and
immobility associated with significant burn injury [48,49]. While vitamin D supplementation has been
recommended in burn patients, an optimal dosing or method for delivery has not been identified [48,50,51]. (See
"Overview of vitamin D".)
Trace minerals — Copper, zinc, and selenium serve as antioxidants. Zinc also plays a role in collagen cross-
linking, wound healing, and immune function. The depletion of copper and zinc in burn patients is attributed to a
combination of urinary losses and exudative losses from wounds [52,53]. The mechanism for the selenium
deficiency is unclear and appears to be multifactorial [54,55].
ESPEN (European Society for Clinical Nutrition and Metabolism) recommends that the trace elements copper,
zinc, and selenium be supplemented in "higher than standard dose" [1]. Doses of 40.4 mmol copper, 2.9 mmol
selenium, and 406 mmol zinc are recommended for at least 30 days postburn [56]. These ESPEN guidelines
were developed by an interdisciplinary expert group in accordance with officially accepted standards and are
based on published studies since 1985.
A randomized trial evaluated the benefit of intravenous copper, selenium, and zinc (trace element group) in
comparison to a placebo vehicle (control group) in 21 severe burn adult patients [56]. There was a significant
decrease in the median number of pulmonary infections in the trace element group compared with the control
group (two versus four per patient), and wound healing was also significantly improved, with fewer requiring
regrafting. Other studies have shown that supplementation with trace elements is associated with a shortened
hospital stay and improved wound healing [57,58].
Due to the limited data supporting supernormal repletion of any micronutrients, routine practice at our center is to
supplement all adult burn patients simply with an adult multivitamin, and all pediatric burn patients with a
pediatric multivitamin. This practice is uniform in United States burn centers, although some centers provide
vitamin C and zinc in addition to a multivitamin [28].
Electrolytes — Burn injury involves loss of water, electrolytes, and protein. Resuscitation with a hypertonic
lactated saline solution (eg, lactated Ringer's solution) reduces the risk of electrolyte imbalances and tissue
edema [59]. Electrolyte balance, however, must be monitored and corrected throughout all phases of burn care
[60]. Hyponatremia and hyperkalemia occur during the initial resuscitation period. Hypernatremia, hypokalemia,
hypomagnesemia, and hypophosphatemia commonly occur during the early postresuscitation period and the
hypermetabolic phase. We use a pharmacist-driven electrolyte protocol at our institution to reduce the risk of
electrolyte imbalances.
FORMULA SELECTION FOR ENTERAL NUTRITION — The preferred method of nutritional support is by the
enteral route (see "Overview of nutritional support for moderate-to-severe burn patients", section on 'Delivery of
nutritional support'). Many commercial preparations exist for this purpose. These formulas come in a variety of
compositions, and the "standard" adult nutritional formulas can provide appropriate support for wound healing
and maintenance of lean body mass when they are used to provide adequate calorie and protein intake.
Involvement of a dietician in the initial nutrition support of the burn patient, as well as when changes in
physiologic and clinical status occur, is desirable.
Immunonutrition — The use of immune-modulating supplements or formulas holds particular appeal for
patients with the profound hypermetabolic response and immune suppression that are associated with severe
burns. However, there is insufficient evidence to support the use of commercially available immune-enhancing
formulas, and the only agent with any supporting evidence to date is glutamine [1,61].
ESPEN (European Society for Clinical Nutrition and Metabolism) has made no recommendation regarding
supplementation with alpha-3 fatty acids, arginine, or nucleotides for burned patients due to insufficient data but
recommends that glutamine be added to standard formulas [1]. The Society of Critical Care Medicine (SCCM)
and the American Society for Parental and Enteral Nutrition (ASPEN) guidelines include consideration of the
addition of enteral glutamine to an enteral feeding regimen in burn patients while managed in the intensive care
unit [2,62].
Glutamine supplementation is beneficial in the nutritional support of burn patients [1,2,63-70]. A meta-analysis of
four randomized trials that included 155 patients with moderate-to-severe burns found that patients receiving
glutamine supplementation were significantly less likely to develop a gram-negative bacteremia compared with
patients not receiving the supplementation (odds ratio [OR] 0.27, 95% CI 0.08-0.92, p = 0.04) [70]. In addition,
patients receiving glutamine supplementation also had significantly lower in-hospital mortality rates (OR 0.13,
95% CI 0.03-0.51, p = 0.004).
Other trials have shown that enteral glutamine supplementation decreases infectious complications, shortens
length of hospital stay, and reduces mortality rates following burn injury [1,2,63-69,71]. For example, a clinical
trial randomly assigned 40 patients sustaining 50 to 80 percent total body surface area (TBSA) burns to a
glutamine-enriched enteral nutrition (0.35 grams Gln/kg body weight/day) or the standard enteral formulation,
within 24 hours of burn injury [67]. In the group receiving glutamine-enriched enteral nutrition, plasma glutamine
levels were normalized compared to the persistently low levels in the standard formulation diet group. Compared
to the standard formula group, the glutamine-enriched group had a significantly shorter length of hospital stay (67
versus 73 days) and greater percent wound healing at day 30 postburn (86 versus 72 percent). Endotoxin levels,
which were initially elevated in both groups, decreased significantly in the glutamine-enriched group.
Branched-chain amino acids — The branched-chain amino acids (BCAAs) have anabolic or, at a minimum,
anticatabolic properties. Leucine, in particular, has received much attention because plasma leucine levels are
typically depleted following a severe burn injury [72]. However, clinical studies have failed to show any benefit to
the administration of supplemental leucine as a component of nutritional support for burn patients [73]. At this
time, supplementation of BCAAs in burn patients is not recommended.
Specialty formulas — Several specialty formulas are commonly used in critical illness in an attempt to reduce
renal failure, glucose intolerance, and pulmonary failure. Commercially available formulas for renal failure
patients are lower in protein and restrict electrolytes, particularly potassium and phosphate. Many of these
formulas use additional carbohydrate calories to compensate for the protein calories that are restricted in renal
patients, and some contain additional fat as the source of calories.
Formulas that are higher in carbohydrates and lower in fat may be used appropriately in burn patients with renal
failure and electrolyte abnormalities, recognizing the likely need to supplement protein in the moderate-to-severe
burn patient population. Formulas available for patients with diabetes or those with stress glucose intolerance are
lower in carbohydrates and higher in fat; therefore, this makes them an ineffective choice in burns, since higher-
carbohydrate, low-fat diets have been clearly associated with better immune function and lesser loss of lean
body mass [35,42,44]. The use of pulmonary care formulas, designed for use in acute respiratory distress
syndrome (ARDS) to minimize excessive carbon dioxide production via increased fat and decreased
carbohydrates, is not recommended for the same reasons.
NUTRITIONAL SUPPORT ADJUSTMENTS — The energy and nutrient needs of burn patients are
heterogeneous through the course of recovery. Nutritional needs fluctuate based upon wound closure and
physical activity and may be impacted by complications such as pneumonia, renal insufficiency, or wound sepsis.
The prolonged nature of the hypermetabolic response, which may persist for more than one year following injury,
must be considered even after wound healing is complete. (See "Hypermetabolic response to severe burn
injury".)
Adjustments in nutritional support are best conducted under the guidance of an experienced dietician as a
member of the care team and using a constellation of techniques that aid in monitoring the adequacy of
nutritional support. (See "Evaluating nutritional support for moderate-to-severe burn patients".)
SCCM/ASPEN RECOMMENDATIONS — The 2009 Society of Critical Care Medicine (SCCM)/American Society
for Parental and Enteral Nutrition (ASPEN) recommendations for initiation of enteral nutrition in critically ill
patients include [2,62]:
● Perform an assessment of the patient’s nutritional status pre-burn (pre-illness) prior to initiating feedings and
include:
• Nutrition intake.
• Weight loss (or weight gain).
• Comorbid illness.
• Severity of preexisting comorbidities.
• Function of the gastrointestinal tract.
● When the patient is unable to maintain volitional intake, nutritional support therapy in the form of enteral
nutrition (EN) should be initiated:
• EN is the preferred over parental nutrition (PN).
• Enteral feeding should be started within the first 24 to 48 hours following admission.
• The feedings should be advanced toward the goal requirements over the following 48 to 72 hours. (See
'Determining caloric requirements' above.)
• Presence of bowel sounds or evidence of passage of flatus or stool is not required for the initiation of
enteral feedings.
• EN administered through either a gastric or small bowel feeding tube is acceptable.
● In the setting of hemodynamic compromise, EN should be withheld until the patient is fully resuscitated
and/or stable.
ESPEN RECOMMENDATIONS — The European Society for Clinical Nutrition and Metabolism (ESPEN)
generated a series of eight recommendations in 2013 regarding nutritional therapy in major burns [74]. These
include the following strong recommendations:
● Initiate feeding early, within 12 hours of injury.
● Use of the enteral route preferentially.
● Deliver protein requirements of 1.5 to 2.0 g/kg in adult patients and 1.5 to 3 g/kg in children.
● Limit carbohydrate delivery to 60 percent of total energy intake, not to exceed 5 mg/kg/minute in adults and
children.
● Keep glucose requirements under 8 mmol/L using continuous infusion of intravenous insulin.
● Supplement zinc, copper, and selenium as well as vitamins B1, C, D, and E in adults and children.
Use non-nutritional strategies (warm ambient temperature, early excision, nonselective beta blockers, and
oxandrolone) to attenuate hypermetabolism.
SUMMARY AND RECOMMENDATIONS
● The assessment of the energy requirements in burn patients is a composite of the basal metabolic rate,
hypermetabolism, percent of total body surface area (TBSA) burned, ventilatory support, infections, sepsis,
multiple organ failure, thermic effect of food, and level of physical activity. (See 'Determining caloric
requirements' above.)
● The preferred method to estimate caloric requirements in burn patients is by indirect calorimetry (IDC). (See
'Determining caloric requirements' above.)
● IDC requires specialized equipment that may not be readily available. Alternatives for estimating caloric
requirements for adult burn patients include the modified Harris-Benedict equation and the Curreri formula
(see 'Determining caloric requirements' above). Caution must be used with both formulas to avoid
overfeeding.
● In our practice, we use the Recommended Dietary Allowance (RDA)/Reference Daily Intake (RDI) for
pediatric burn patients. (See 'Determining caloric requirements' above.)
● We use a formula that provides at least 50 percent of calories as carbohydrates, 35 percent as protein, and
no more than 15 percent as fat, supplemented with micronutrients and macronutrients. (See 'Nutrient
composition for enteral formulas' above.)
● In our practice, we supplement the enteral formula with a standard multivitamin with trace minerals. These
include vitamins A, C, and D and trace minerals copper, zinc, and selenium. We also use a standard
protocol for electrolyte replacement. (See 'Micronutrients' above.)
● For patients with moderate-to-severe burn injuries, we suggest that glutamine be added to standard enteral
formulas (Grade 2B). (See 'Formula selection for enteral nutrition' above.)
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Topic 820 Version 18.0
GRAPHICS
Caloric needs for children with burns Curreri Junior formula
Age (years) Calories (kcal/day)
<1 RDA + 15 kcal/TBSA
1 to 3 RDA + 25 kcal/TBSA
4 to 15 RDA + 40 kcal/TBSA
RDA: recommended daily allowance; TBSA: total body surface area burned.
Data from: Saffle JR, Graves C, Cochran A. Nutritional Support of the Burned Patient. In: Total Burn Care, 4th ed, Herndon DN
(Ed), Saunders Elsevier, Philadelphia 2012. p.335.
Graphic 78277 Version 8.0
Caloric needs for children with burns Shriners Burn Institute
Age (years) Calories (Kcal/day)
0 to 1 2100 Kcal/m 2 plus 1000 Kcal/m 2 burn
Data from: Saffle JR, Graves C, Cochran A. Nutritional support of the burned patient. In: Total Burn Care, 4th ed, Herndon DN
(Ed), Saunders Elsevier, Philadelphia 2012. p.335.
Graphic 69059 Version 5.0
Contributor Disclosures
Amalia Cochran, MD Nothing to disclose Marc G Jeschke, MD, PhD Nothing to disclose Kathryn A Collins,
MD, PhD, FACS Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform to
UpToDate standards of evidence.
Conflict of interest policy

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11/5/2018 Nutritional demands and enteral formulas for moderate-to-severe burn patients - UpToDate

Official reprint from UpToDate®

Nutritional demands and enteral formulas for moderate-to-severe burn patients

Author: Amalia Cochran, MD

● Basal metabolic rate

● Percent of total body surface area (TBSA) burned

● Multiple organ failure

● Level of physical activity

● Thermic effect of food

● The equation used for men is:

● The equation used for women is:

● The Curreri formula for adults age 16 to 59 years is:

Caloric requirement (kcal per day) = 25 kcal/kg/day + 40 kcal/percent TBSA burned/day

● The Curreri formula for adults over age 60 years is:

Caloric requirement (kcal per day) = 25 kcal/kg/day + 65 kcal/percent TBSA burned/day

● REE (kcal/day) = 370 + 21.6(FFM).

● 1.5 to 2.0 grams protein/kg/day

● 5 to 7 mg/kg/minute of glucose per day representing approximately 50 percent of total calories

● Fewer than 15 percent of nonprotein calories from fat sources

● Vitamins A, C, and D in standard multivitamin formulations

● Trace minerals (eg, selenium, zinc and copper) in standard formulations

Micronutrients — Maintaining appropriate levels of trace elements in moderate-to-severe burn patients is

• Weight loss (or weight gain).

• Severity of preexisting comorbidities.

• Function of the gastrointestinal tract.

• EN is the preferred over parental nutrition (PN).

• EN administered through either a gastric or small bowel feeding tube is acceptable.

● Initiate feeding early, within 12 hours of injury.

● Use of the enteral route preferentially.

SUMMARY AND RECOMMENDATIONS

Use of UpToDate is subject to the Subscription and License Agreement.

Topic 820 Version 18.0

Caloric needs for children with burns Curreri Junior formula

Age (years) Calories (kcal/day)

<1 RDA + 15 kcal/TBSA

Graphic 78277 Version 8.0

Caloric needs for children with burns Shriners Burn Institute

Age (years) Calories (Kcal/day)

0 to 1 2100 Kcal/m 2 plus 1000 Kcal/m 2 burn

1 to 11 1800 Kcal/m 2 plus 1300 Kcal/m 2 burn

12 to 18 1500 Kcal/m 2 plus 1500 Kcal/m 2 burn

Graphic 69059 Version 5.0

Conflict of interest policy

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