Table 4 Highlight of key metabolic processes requiring nutritional assessment and intervention during the rehabilitative phase of care

Protein synthesis and breakdown

Increased synthesis and breakdown. Skeletal muscle breakdown is normal. Exogenous protein can diminish protein breakdown rate.

Nitrogen balance

Provide 2.5 g/kg of protein to cover obligatory losses. Maintain nitrogen balance in the positive by 2 g protein/kg day.

Pre-albumin, CRP

Weekly

Energy expenditure

Resting energy expenditure declines for most patients. Increased total energy expenditure due to increased physical activity.

Indirect calorimetry

Hypermetabolic: REE × 1.2

Normal REE/intensive physical therapy: REE × 1.5 or 65 kcal/kg (to meet increased needs with physical activity)

Weekly

Bone mineral density

Altered vitamin D metabolism and bed rest results in large majority of burn patients to have mild to moderate bone loss following severe burn injury. Malnutrition increases the odds of having severe bone depletion.

DXA every 6 weeks

For bone mineral density z-scores

>−1.0: no intervention

Weekly

<−1.0: vitamin D3/calcium supplementation

4–8 years: 1,000 mg/600+ IU

9–18 years: 1,500 mg/600+ IU

<−2.0 as above with 0.1–0.2 mg/kg oxandrolone

Growth

Growth delay is apparent in children with massive burn injury, effecting height more than weight.

Height and weights

Energy and protein as above to promote age appropriate rate of weight gain.

Weekly