Estimating energy requirements
in burned children:
a new approach derived from measurements
of resting energy expenditure13
Michael
I Goran,
Lyle
Broemeling,
We examined
expenditure
(REE)
dren.
Predicted
area
(r2
basal
and
0.76).
Days
postburn
for 21%,
and
accounted
body
REE above PBEE.
was PBEE (REE
=
did
the
not
activity
used
X PBEE,
most
X PBEE)
to 2 X PBEE.
of other
the
measurements
of energy
valid
approach
to estimating
Nutr
199 1;54:35-40.
KEY
WORDS
our
variables
data
lower
than
for larger
The energy
energy
presented
expenditure,
balance
energy
success
and
represent
the
Energy
requirements
mination
of total
reported
that
tune,
indirect
calorimetry,
The
veston
most
and
energy
expendi-
Unit
March
excisional
port was
Introduction
that
aggressive
and
mortality
However,
it is also
evident
that
excessive
energy
intake
cannot
nutritional
after
in severely
completely
support
severe
burn
stressed
overcome
has
to achieve
energy
patients
with large
ular
used
patients,
the
equations
is reason
overestimate
balance
in burned
burns.
This beliefhas
used
are
not
based
to believe
energy
children,
arisen
on
by these
loss. In fact,
conventional
maintain
(4, 5). The
constant
by the
J C/in Nutr
fact
body
that
body
l991;54:35-40.
weight
weight
Printed
maintenance
in USA.
by deter(6)
recently
with
the
children
to formulate
requirements.
8). The
been
the
equations
are acpatients
receiving
recommendations
is not
is complia suitable
© 1991 American
majority
of the
Society
From
from
TX,
weight,
hospital
Basal
energy
basal
The
energy
via
enteral
Evansville,
mixtures.
The
University
followed.
(85
independent
expenditure,
of 127
observations
variables
body
surface
of BSA with 3#{176}
burn injury
(% BSA burned),
and days
expenditure
Unit,
supde-
analysis
children
percentage
admission
on admission
with
Nutritional
previously
Board,
were
1985
uniformly
was
retrospective
in females).
age,
on
the Metabolism
Review
in 56 burned
were
intake
at the GalMarch
Isocal (Mead-Johnson,
or, milk-Isocal
Galveston,
43 observations
treated
of energy
was generated
injury
between
described
(7).
to the equations
Institutional
Branch,
REE
for burn
Institute
patients.were
were either milk,
(Mead-Johnson),
to predict
by observation
of energy
situation
treated
equations
of Harris
and Benedict
from height
and weight
(10). The
particularly
in
because
the pop-
measurements
energy
requirements
recommended
tually
necessary
to avoid weight
markedly
less energy
intake than
We
be
catabo-
as determined
burned
Burns
as previously
according
of REE
postburn.
that currently
requirements
1
Am
All ofthe
Medical
area (BSA),
as estimated
protein
expenditure.
The basis for success
of these
equations
has generally
weight
maintenance
(3, 4). However,
it is unclear
whether
cated
1989.
measurements
in males,
injury.
catabolic
response
(1) and can have detrimental
physiological
effects (2). Consequently,
it is important
to accurately
estimate
energy
requirements.
There
used equations
significantly
be predicated
energy
were
Shriners
A database
agreed
studied
standards
of Texas
morbidity
in many
ofthe
therapy
standardized
(4,
ethical
It is generally
would
while
(TEE).
children,
to predicting
children
fluids, which
IN), Prosobee
burns
improved
because
intake
technique,
is strongly
correlated
with resting
(REE).
This observation
led us to examine
ofREE
approach
ideally
expenditure
in burned
labeled
water
expenditure
scribed
requirements,
TEE
mainly
energy
in fat synthesis
continues
(1).
should
energy
therapy,
excess
Methods
from
Am JClin
requirements.
Nutritional
of nutritional
because
expected
to result predominantly
lism of heavier
lean body mass
equal
are derived
they
of the
retention
a new
balance
X PBEE#{176}75), approximately
equations
indicator
of fluid
R Wolfe
commonly
burns.
achieve
and Robert
the determinants
predict
energy
J Peters,
doubly
energy
described
the
to maintain
in
of REE
recently
is used,
of patients
+ (2.39
Because
only
in the elevation
addition
is significantly
95%
REE
predictor
When
especially
that
with
powerful
patients
surface
(% BSA burned)
variation
requirement
which
to ensure
(1 .55
ofthe
prediction.
energy
size
enchil-
body
significantly
burn
X PBEE);
recommendations,
required
was
24%
1.29
(PBEE),
correlated
and
of 1.2 for burn
the average
is 1.55
weight
Edward
of resting
in 56 burned
expenditure
The single
improve
factor
the determinants
127 observations
energy
(BSA),
=
that
in
N Herndon,
was
predicted
(9) and BSA
% BSA burned
in the usual
Shriners
manner,
Burns
from
the
was calculated
was estimated
Institute,
and
we made
and the De-
partments
of Anesthesiology
and Surgery, University
of Texas Medical
Branch, Galveston,
TX.
2 Supported
by NIH grant GM-41089
and a grant from the Shriners
Hospitals.
3 Address
reprint requests to RR Wolfe, Shriners Burns Institute,
610
Texas Avenue, Galveston,
TX 77550.
Received
September
14, 1990.
Accepted
for publication
December
5, 1990.
for Clinical
Nutrition
35
Downloaded from www.ajcn.org at Norris Med Lib Serials Sect on July 11, 2008
ABSTRACI’
ergy
David
36
GORAN
TABLE
I
Description
of data group
ET
AL
TABLE 2
Individual
correlations
potential
predictors
analyzed1
between
Resting
energy
expenditure
and
Variable
Independent
Age(y)
9±5
Weight (kg)
Days Postburn
BSA (m2)
30
Burn size (% BSA)
32.6
25
1.06
57
Predicted BEE
(Mi/d)
4.76
17.6
20
0.39
24
±
±
±
±
PBEE (Mild)1
BSA (m2)
Weight (kg)
(5.6-77.6)
(0-99)
(0.28-1.94)
(4-98)
SD (range).
6.19
1480
n
2.58 (1.41-15.70)
616 (337-3755)
±
±
127. BSA, body surface
=
PBEE,
basal
this
factor
and
to account
carbon
calorimetry
indirect
metabolic
cart (Fullerton,
as previously
described
REE, resting
for
coverage
tempt
respect
was
to
made
fever,
usual
clinical
was
to control
infection,
around
the time
was to examine
dioxide-production
rates
by use of a Beckman
were
not
performed
interrupted
for standardizing
antibiotics,
pain
of measurement.
the determinants
conditions.
available
in the same
measurements.
patients,
repeated
they
were
in the early
and no at-
conditions
medication,
Our rationale
of measured
When
which
was
diverse
age
3 mo-21
and
burn
thropometric
basal
energy
burned,
compare
(with
etc)
for this approach
REE under
the
measurements
treated
were
as independent
REE
analysis
were
constructed
by
by using the measured
of REE as the dependent
variable.
The independent
were the potential
predictors
of REE and were the
measurements
expenditure
observed
(PBEE),
energy
multiplied
requirements,
by the
use of
value
variables
usual
an-
in burn patients
[predicted
BSA,
weight,
age, % BSA
with
respect
y; body
injury
to anthropometric
weight
(3#{176}
burns
5.6-77.6
covering
measurements
4-98%
made
variables
kg; BSA
between
(eg,
0.28-1.94
of BSA).
0 and
m2);
The
data
99 d after
burn
Prediction
ofresting
Table
and
energy
2 summarizes
the
between
REE
the correlation
independent
ranged
weight).
from
The
primarily
variables.
on body
by indirect
diture,
as predicted
in Figure
1.
The
postburn
the
ratio
% BSA
of REE
burned
are
is shown
to PBEE
during
shown
REE
expen-
equations,
in REE
(REE:
treatment
in Figures
counted
for only 2 1% and 24%, respectively,
ofthe
variation
the elevation
of REE above
predicted
normal.
The single
most powerful
predictor
of REE in this group
in
the
and % BSA burned
2
ac-
was
postburn
energy
thus
patients
Days
BSA, and
is therefore
between
basal
the Hams-Benedict
of the elevation
and
and 3, respectively.
and
(r2)
coefficients
The relationship
size.
between
a reflection
days
analysis
correlation
calorimetry,
from
relationships
PBEE),
The
0. 15 (% BSA burned)
to 0.76 (PBEE,
observed
rate ofREE
in burned
children
dependent
as measured
expenditure
of
PBEE:
REE
=
1.29
X
(1)
PBEE
Three
predicted
factor
study
in burn
1.2. This
in which
patients
components
of energy
expenditure
(by use of the Harris-Benedict
sured
by indirect
calorimetry;
and
factor
of 1.2. Energy
REE by an activity
expressed
as
MJ/d
and
are
TEE
Spreadsheet
MA)
software
or the
(Lotus
BMDP
activity
the
(6).
20
factor
doubly
labeled
r
are discussed:
PBEE
equations);
REE meaderived
>
0
0
by multiplying
expenditure
accompanied
by
the
by using
either
Development
statistical
software
0 76
15
10
and intake
caloric
LU
LU
equivalent
(kcal/d)
in parentheses.
All statistical
analyses
were performed
Cambridge,
was used to
developed.
for predicting
REE
equations
activity
was derived
in our recent
water
technique
was used
5
the Lotus
Corporation,
(BMDP
Inc,
Angeles).
0
0
2
4
FBEE
Results
Data
Harris-Benedict
and days postburnl.
A predictive
analysis
the forecasting
precision
of the equations
To predict
Los
from
injury.
and
Equations
for predicting
stepwise-linear-regression
1-2-3
and
CA) with a face mask for gas collections
(1). REE was derived
by using the equa-
tion of Weir ( 1 1 ). Measurements
morning.
Continuous
feeding
are
predicted
of wounds.
Oxygen-consumption
were measured
by
were
expenditure
set
Table
1 summarizes
in 56 burned
children.
the data
We treated
for 127 measurements
the data
as one
entire
of REE
group,
6
8
10
(MJ/day)
FIG 1. Relationship
between
resting energy
sured by indirect calorimetry
and basal energy
dicted by the equations
of Harris and Benedict
expenditure
expenditure
(9).
(REE) mea(PBEE) pre-
Downloaded from www.ajcn.org at Norris Med Lib Serials Sect on July 11, 2008
to adjust
energy
equations.
set included
attempt
-0.28
0.15
area; BEE, basal energy
expenditure
as predicted from the Harris-Benedict
equations;
energy expenditure
as measured
by indirect calorimetry.
no
0.73
Days posthurn
% BSA burned
1.22 (1.78-8.00)
(426-1914)
±
0.76
0.76
0.76
Age
I
Measured
REE
(Mild)
(kcal/d)
healing
r2
1 138 ± 292
(kcalld)
I
variable
(0.33-21)
ENERGY
EXPENDITURE
IN
BURNED
TABLE
Percent
3
relative
LU
37
CHILDREN
Percent
error
in predicting
resting
energy
expenditure1
Percent
of patients
relative
errort
LU
%
C-
0
10
25
50
LU
LU
DAYS
POST
r2
any
0.96
=
other
when
variables
predicted
value
(REE/PBEE)
as a
the
is fixed
equation
at zero.
did
not
Addition
improve
of equation
of the
predicted
value,
ofthe
energy
pre-
were
REE,
with
respect
REE
within
were
±45%
in the
127
Fifty
per-
to predicted
± 17%
within
(Table
basal
energy
residual
95th
random
vari-
expenditure.
oftotal
energy
Use of the activity
(6) allowed
derivation
requirements
percentile
was
to be
equation
factor
ofan
TEE
Because
value
this
equation
of PBEE,
have
a TEE
1.2 from our previous
publication
equation
to predict
the average
TEE:
=
is the
was
percentile,
patients,
our
the
less than
can
value
be derived
analysis,
the
the
for TEE
of the
value
given
the standard
expenditure
of TEE
by using
standard
value
one-half
the average
value ofTEE
and
a given value of basal energy
95th
average
approximately
that
(2)
1.55 X PBEE
that
would
in equation
deviation
ofTEE
are known,
then
is exceeded
weighted
deviation
for a given
patients
50% of
energy
(1.55
=
X PBEE)
+ (2.39
the energy
at least
enough
value
normal
multiplied
the
(3)
X PBEE#{176}75)
required
energy
was
distribution,
to ensure
to reach
that
a state
95%
of
of energy
The resulting
value for an average
patient
in this study
1 ) is 9.32 MJ/d
(2229
kcal/d),
which
is approximately
to twice
the PBEE
5 displays
by four
other
[9.5 1 MJ/d
the energy
(2276
kcal/d)].
requirements
equations
that would
currently
in use
be pre-
in addition
to
our new equations
2 and 3. The energy
requirements
dicted
for the average
patient
in the present
study
were prewith a burn
injury
in Figure
covering
either
30%
or 80%
BSA.
As seen
5,
our predictions
are well below
the lowest
value.
The equation
designed
to include
95% of patients
(Eq 3) is approximately
equal to the value ofequation
2 X PBEE,
promulgated
by Wolfe
(12), which
predicts
energy
requirements
that are -20%
lower
2. If
than
for
the
LU
those
predicted
by the
Long
equation
(13).
by 5% of the
linear
of TEE
found
predicts
receive
balance.
(Table
dicted
this
of the standard
patients
equal
X PBEE#{176}75.When
5% point
Figure
Prediction
1.29 X PBEE.
relative error of 127 predictions.
Thus,
17% from the observed
rate of resting
upper
TEE
This
as a
4 as a function
show
as 1 .452
by the
and
expressed
in Figure
residuals
by using the equation
percent
deviated
by
of the
±30%,
3). The
predicted),
is displayed
4, these
within
were
minus
As seen in Figure
REE
was determined.
predictions
(measured
of measured
ation
for
ofthe
predictions
ofPBEE.
children
values
75%
expenditure
percent
1 in predicting
in 56 burned
measured
90%
determined
timated
reliability
measurements
cent
Values
of
the
diction.
The
44.84
189.0
t The median
predictions
expenditure.
the intercept
into
30.10
90
100
regression.
predictions
In
was
LU
200
-
150
-
100
-
es-
2.5
r=0.24
I
LU
2.0
..
.
‘-,
LU
I
..
:
I
1.0
S
I
(1’)
LU
:.
#{149} #{149}
2
4
PBEE
I
20
40
60
SIZE
80
#{149}.
6
8
10
(MJ/day)
100
(% TBSA)
3. Elevation
in REE above predicted
value (REE/PBEE)
of burn size [% total body surface burned (% TBSA)J.
#{149}#{149}#{149}
I
,:
#{149}#{149}S.
50
0
BURN
FIG
function
:
#{149}#{149}.#{149}
I
0.5
0
1t2
I
0
0
I
0.0
,S.
-J
I
C-
#{149}
.1
1.5
LU
LU
50
.
as a
FIG 4. Residual
of the predicted
REE vs PBEE. The residual
is the
difference between the observed REE and the REE predicted
by equation
1 (REE = 1.29 x predicted
basal) and expressed
as a percentage
of the
measured
REE.
Downloaded from www.ajcn.org at Norris Med Lib Serials Sect on July 11, 2008
where
above
75
BURN
I
FIG 2. Elevation
in REE
function
of days postburn.
0.41
4.42
9.34
17.08
38
ET AL
GORAN
I-
z
20
LU
::::i
LU
30%
burn
80%
burn
15
C
LU
LL
>-0
0
10
LU
LU’
LU
I-
0-
(I)
LU
1 .55.PBEE
1 .55.PBEE
2.PBEE
Long
Galveston
Curreri
+
2.39.PBEEP75
FIG 5. Total energy requirements
(I Mi/d = 239.2 kcal/d) for energy balance in burned children,
as predicted
by
various equations.
Energy requirements
were estimated
for the average patient in this study with either a 30% or an
80% burn. Requirements
were estimated
by using the following
equations:
1.55 X PBEE, equation
2; (1.55 X PBEE)
+ (2.39 X PBEE#{176}75),
equation
3; 2 X PBEE, reference
12; 2.52 X PBEE, Long equation
(13); Galveston
equation
(4);
Mi/d = (6.27 X BSA) + (6.27 X burn in m2), kcal/d = (1500 X BSA) + (1500 X burn in m2), Curreri equation
(3);
Mi/d = (0. 105 X weight) + (0. 167 X % of BSA burned),
kcal/d = (25 X weight) + (40 X % of BSA burned).
PBEE,
basal energy expenditure
predicted
from Harris-Benedict
equations
(9); BSA, body surface area (m2); weight, body
weight (kg).
The
most
important
presented
and
equations
is that
of the
from
burns,
trative
the
burn.
difference
popular
the
The
new
equations
are dependent
latter
discrepancy
in Figure
the
(4, 8) and
between
the various
equations
such as the 80% burn
purposes
between
Galveston
the
equations
Curreri
of basal
et al (3)
on the
estimations
size
derived
is particularly
evident
chosen
as representative
with large
for illus-
5.
energy
equations
recovery
recovery
study
burned
represents
children.
The
dren is primarily
of the elevation
liably predicted
the
most
analysis
extensive
revealed
analysis
that
REE
dependent
on body size, and
in REE above
predicted
normal
from the extent
of burn injury.
of REE
during
this period
in burned
chil-
REE
dicted
basal
mean
of 271
size
was
was
expenditure
injury
surprising
useful
state
to the recovered
ulation
such
not
other
set of equations
cifically
dren
designed
(14).
ments
equations
(WHO)
of energy
data
greater
than
that
for children.
with those
basal
WHO
3. 1 ± 7.5%
when
comparison.
The
energy
expenditure
expenditure
in children
predictions.
aged
thus
<
2 y of age
give similar
and
Health
et al (1 5). They
vation
reduced
to
from
the
predictions
during
performed
after
is an insufficiency
in a recent
times
report
children
full
of
from
our
Harris-Benedict
in four
that neither
a smooth
we did
in REE
the
of REE
and
pre-
studied
at a
the
time after injury
magnitude
state.
transition
elevation
in
in the ratio between
from
Uncovering
nor burn
of the
reflects
the
the fact
hypermetabolic
the relationship
between
an analysis.
Similarly
in chil-
y. For
familiar
REE and days postburn
would involve
longitudinal
measurements of REE in individuals
throughout
the course of treatment.
We did not have enough data on an individual
basis to perform
injury
6.2 ± 12.6%
was
is not
of burn
measure-
10-18
were
difference
children
available
World
on actual
predictions
This
we excluded
equations
in the
(14) are based
set, the Harris-Benedict
by the only
have been spe-
of that
recommended
report
We compared
generated
we are aware
for predicting
The
Organization
entire
be appropriate
predictions
Harris-Benedict
more
REE. The failure to detect an obvious decline
REE and PBEE by using cross-sectional
analysis
In examining
the elevation
in REE in response
to burn injury,
we expressed
the data as a function
of basal energy expenditure
as predicted
by the equations
of Hams and Benedict
(9). These
equations
were formulated
from observations
in an older popmay
the
are
(1).
in predicting
there
and
they
± 0.055
d after
that
the Harris-Benedict
we chose
although
1.12
energy
It may seem
in
the magnitude
cannot
be re-
because
should
be based on measurements
from burn injury.
However
there
laboratory,
This
and
analysis
used more frequently
in a clinical setting.
The ideal index for comparing
measurements
data
Discussion
expenditure,
in our
BSA.
(Fig
burn
in REE
The
without
observe
3). The
size
was
interpreted
was
patients
excisional
not
curvilinear,
an important
relationship
alluded
the
role
between
to in the
data
leveling
studied
by Wilmore
surgery
or use
the
studies
by suggesting
offat
for the degree
elevation
of Wilmore
that
a burn
size
et al (15) were
of occlusive
dressings,
the
dc-
of 50%
treated
which
shown to reduce metabolic
rate (16, 17). It is perhaps
more important
that Wilmore
et al (15) never claimed that there
was a relationship
between
burn size and REE at burn sizes
have
been
Downloaded from www.ajcn.org at Norris Med Lib Serials Sect on July 11, 2008
F
5
0
ENERGY
>
50% of BSA.
and protein
Similarly,
metabolism
in the many
conducted
EXPENDITURE
studies
in our
IN
of carbohydrate,
laboratory
(1, 2),
BURNED
27%
ofthe
coefficient
described
It is difficult
to assess
we never observed
a significant
effect of burn size in patients
with a burn size > 40% of BSA. Equations
estimating
energy
requirements
based on percent
burn size in patients
with large
al equation
because
burns
first
fat,
are thus
not
It is unclear
presence
based
on established
how much
of burn
injury
of the elevation
itself
and
explained
by energy expenditure
effect of feeding.
For example,
the
entire
effect
elevation
of feeding.
expenditure
in
We
REE
have
associated
ivation
of the
new
metabolic
how
in REE
much
in burn
patients
effect
by using
the
the
of feeding
relationship
that
it is appropriate
activity
for other
increases
with
patients.
This
convalescence
of TEE to REE will generally
be higher later
during the initial stages. Therefore
the factor
overestimate
the
prediction
of TEE
from
energy
requirements
contain
a factor
actual
measurements
in burned
for burn
children.
size,
Whereas
neither
ofenergy
equation
expenditure.
the
ratio
(MJ/d)
Using
from
our database,
x burn
TEE
(kcal/d)
=
(1 180 X BSA
Both coefficients
than
x
derived
X burn
in this equation
are substantially
used
be explained
by Hildreth
burned
volume
water
by the fact that
et al (4) was
children
of fluid
vaporization
based
size in m2)
the original
(4)
lower
[kcal/d
=
(1800
large discrepancy
approach
on observations
described
of fluid
in
during the initial 48-h resuscitation
phase. The
loss was then multiplied
by the energy cost of
to derive
the coefficient.
This
factor
is there-
fore
inappropriate
on two accounts.
First, it is based only on
observations
made in patients treated during acute resuscitation,
and second,
it is not based on actual measurements
of energy
expenditure.
and
Similarly,
% BSA
when TEE was expressed
in terms
of body weight
burned,
an equation
comparable
to the Curreri
et
al (3) equation
TEE
(MJ/d)
was generated:
(0. 147
=
X weight
in kg)
+ (0.045
TEE
(kcal/d)
=
(35.2
X weight
determined
X % BSA burned)
in kg)
+ (10.8
Our experimentally
body-weight
coefficient
during
the
X % BSA burned)
for % BSA burned
requirements.
the
predictive
3 are limited.
were
dependent
The
power
of the
observation
within
and,
±17%
that
as already
ofthe
discussed,
the
interpre-
weight in burn patients
is complex
and may not
reflection
of metabolically
active tissue. Second,
of body
likely
that
therapy
involved,
patient,
and
to control
the
a combination
(5)
is
use
presence
for these
determinants
treated
offactors
our
of excisional
offever
in addition
early
treated
conditions
Institute
because
under
to PBEE
could
our
natural
they
are
excision
not
hormonal
status
We made
aim
of
no attempt
was to examine
clinical
circumstances
laboratory
conditions.
Although
our
in a population
of burn children
excision,
without
surgery,
or infection.
of REE
to controlled
were developed
with
detect
likely
because
any
to be appropriate
a previous
difference
report
in REE
in
from
in adults
with and without
excisional
surgery (19).
In a recent publication,
Allard et al (20) assessed
the performance of a complex
equation
for predicting
REE in burn patients, which includes
factors to account
for % BSA burned,
treated
energy
loss
estimated
used,
2 and
50% ofpredictions
patients
in the actual Galveston
equation
BSA in m2) + (2200 x burn size in m2)]. This
can
those
size in m2)
in m2)
+ (845
weight
measured value
can be explained
by a number
of factors. First, the predictions
of basal energy expenditure
that we used were determined
by
the equations
of Harris and Benedict
(9), and as already stated,
these may be inappropriate
for children.
Moreover,
whichever
equation
is used, the predictions
ofbasal
energy expenditure
are
only
as opposed
equations
+ (3.53
of the
database
equations
it is also
equations
both
was a retrospective
in body
also affect REE. These might include
nutritional
status of the
patient at the time of REE measurement,
activity ofthe subject
(eg, dressing
change)
preceding
measurement,
time between
measurement
and most recent surgery, type of medication
and
of predicting
was derived
20%
large
be an accurate
et al equation
x BSA in m2)
(4.93
=
only
the
proposed
tation
we rederived
equations
with similar
general
structures
to the
Galveston
and Current equations.
When TEE is expressed
in terms of BSA and m2 burn (cf, the
original Galveston
approach),
the following
was obtained:
TEE
received
Despite
measurements
in the early stages of recovery.
The Galveston
equations
(4, 8) and the Curreri
(3) are probably
the most commonly
used means
are
weight
in recovery
than
1.2 may tend to
REE
study
changes
et
rationale
in der-
is because
so that
(3). Their
and
or even
intake,
PBEE,
complex
equation
not
that
clear
temperature,
is cumbersome
significant
power
energy
requirements
PBEE.
If we had included
et al (20) in our analysis,
by the
the
and
days
to use and
is added
consideration
postburn.
furthermore
to the
This
it is
predictions
of factors
other
of
than
the additional
factors used by Allard
r2 ofour predictive
equation
would
have decreased.
In addition
to the problems
of formulating
a good equation,
it must be realized
that there is a certain
amount
of variation
in REE that is not explained
by body size or body composition
even in normal
volunteers
(2 1, 22). It is of further
concern
that
the error assessment
presented
in Table 3 does not include
the
error in predicting
TEE from REE. From our previous
experiment in a limited
number
of patients
in whom both REE and
TEE were measured
(6), equation
2 functioned
poorly in predicting TEE even though there was a significant
correlation
between TEE and REE.
In summary,
the most reliable
estimates
of energy requirements are obtained
by actual measurements
of REE on an in-
Downloaded from www.ajcn.org at Norris Med Lib Serials Sect on July 11, 2008
feel
physical
paper
data
(3).
in the Curreri
20 d of recovery
in nine burn
patients.
Change
in body
weight was plotted against actual dietary intake, expressed
as a
between
REE and TEE. This factor (1.2) was determined
experimentally
in a limited
number
of patients
by using the doubly
labeled
water technique
to measure
TEE (6). Although
this factor was
derived in a patient group studied in the latter stages of recovery,
we
supportive
intake
et al equation
for the factors
energy
thermic
for the
no
in the original
ofdietary
in the Curreri
the basis
percentage
of ideal caloric intake calculated
by the Curreni formula. Even the original data presented
by Curreri et a! (3) argue
against the validity of the equation
because
patients
receiving
significantly
less energy
intake
than prescribed
by the equation
nonetheless
maintained
body weight. The only patient
who lost
be potentially
by
accounted
the thermic
equations
is due to the
can
associated
with the thermic
Allard et al (18) accounted
for
indirectly
with
processes.
provided
analysis
39
CHILDREN
40
GORAN
dividual
basis in conjunction
which is 1.2 in the convalescent
of REE
that
is not
if energy
patients
will
to their
feasible,
receive
desirable
to
x PBEE
to energy
paper
twice
an amount
In severely
stressed
of energy
energy
according
this will be sufficient
the
support
the
PBEE,
patients
intake
who
it may
to
equation
to maintain
balance.
We are grateful to Manu Dessai who allowed us
ments ofresting energy expenditure
in patients under
we thank Tom Rutan, James Richardson,
and the
staffofthe
Shriners
Burns Institute
for performing
calorimetry
measurements.
all
equal
are unable
excess,
the
notion
virtually
of energy
side effects
provide
because
in this
at about
at least
expenditure.
potential
close
the data
is provided
to tolerate
with an appropriate
activity
factor,
burned
child (6). If measurement
be more
1.55
most patients
U
to perform measurehis cane. In addition,
Respiratory
Therapy
some ofthe indirect
1. iahoor F, Desai M, Herndon
DN, Wolfe RR. Dynamics
ofthe protein metabolic
response to burn injury. Metabolism
1988;37:330-7.
2. Wolfe RR. Nutrition
and metabolism
in burns. Crit Care Med
l986;7: 19-63.
3. Curreri
PW, Richmond
D, Marvin i, Baxter CR. Dietary requirements of patients
with major burns. i Am Diet Assoc 1974;65:
415-7.
4. Hildreth
MA, Herndon
DN, Desai MH, Duke MA. Caloric needs
of adolescent
patients
with burns. i Burn Cane Rehabil
1989;l00:
523-6.
5. Cunningham
ii, Lydon MK, Russell WE. Calorie and protein provision from severe burns in infancy and young children.
Am i Clin
Nutr l990;51:553-7.
6. Goran MI, Peters El, Herndon
DN, Wolfe RR. Total energy cxpenditure
in burned children
using the doubly labeled water technique. Am J Physiol l990;259:E576-85.
7. Herndon
DN, Curreri PW, Abston 5, Rutan TC, Barrow RE. Treatment ofburns.
Curr Probl Surg 1987;2:347-97.
AL
8. Hildreth
MA, Carvajhal
HF. Caloric requirements
in burned children: a simple formula
to estimate
daily caloric requirements.
i
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l982;3:78-80.
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FG. A biometric
study of basal metabolism
in
man. Washington,
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(Publication
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10. Du Bois D, Du Bois EF. A formula
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Arch Intern
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WHO
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15. Wilmore
DW, Long JM, Mason AD, Streen AW, Pruitt BA Jr. Catecholamines:
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response
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16. Caldwell
FT ir, Bowser BH, Crabtree
JH. The effect of occlusive
dressings
on the energy metabolism
of severely burned
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Ann Surg 198 l;193:579-9l.
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GB. Direct measurement
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ofa burned
child. Arch Surg l972;105:4l0-3.
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KN, Whitwell
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Factors
influencing
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the energy requirements
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22.
Fontain ER, Savard A, Trembly iP, Despres E, Poehlman
ET, Bouchard C. Resting metabolic
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References
ET