Since essential fatty acid deficiency is a welldocumented complication in hospital patients receiving long-term nutritional supplements, most intensive care units (ICUs) provide a significant amount of caloric requirements as fat [76]. This has been shown to reduce the requirements for carbohydrates and can improve glucose tolerance significantly, which is often altered in the patient postburn [70]. However, several studies showed that increased fat administration may lead to increased complications, including hyperlipidemia, hypoxemia, fatty liver infiltration, higher incidence of infection and higher postoperative mortality rates in the burned patient population [77–79]. We found in a large cohort of severely burned children that patients receiving a low fat/high carbohydrate diet (Vivonex T. E. N.) displayed a significantly lower incidence of hepatic fatty metamorphosis upon autopsy when compared to milk fed patients. These patients furthermore displayed a significantly lower incidence of sepsis when compared to children receiving a high fat diet, demonstrated prolonged survival and had significantly shorter stays in the ICU as well as markedly decreased length of stay in the ICU per % TBSA. Based on these findings, we would recommend that nutritional regimes for treatment of post-burn patients include diets with a significantly reduced proportion of fat as the source of total caloric intake.

In addition, various vitamins, minerals and other micronutrients are required for nutrition following burns. Diminished gastrointestinal absorption, increased urinary losses, altered distribution and altered carrier protein concentrations following severe burn may lead to a deficiency in many micronutrients if not supplemented. These deficiencies in trace elements and vitamins (Cu, Fe, Se, Zn, vitamins C and E) have been repeatedly described in major burns since 1960 [80–82], leading to infectious complications, delayed wound healing and stunting in children [83]. However, evidence-based practice guidelines are currently unavailable for the assessment and provision of micronutrients in burn patients. Enhancing trace element status and antioxidant defences by selenium, zinc, and copper supplementation has been shown to decrease the incidence of nosocomial pneumonia in critically ill, severely burned children in two consecutive, ran-

domised, double-blinded, supplementation trials [84]. Caution should be used to avoid toxicities that can result in gastrointestinal tolerance as well as antagonistic reactions. A complete listing of micronutrients, their functions and supplementation protocols is beyond the scope of this chapter; excellent reviews are available [85–87].

Modulation of the hormonal and endocrine response

Severe burn injury leads to significant metabolic alterations, characterized by a hyperdynamic circulatory response associated with increased body temperature, glycolysis, proteolysis, lipolysis and futile substrate cycling [88–90]. These responses are present in all trauma, surgical, or critically ill patients, but the severity, length and magnitude is unique for burn patients [10]. Modification of adverse components of the hypermetabolic response, particularly protein catabolism, seems desirable. Recombinant growth hormone, insulin-like growth factor, anabolic steroids, beta-adrenergic blockade and beta-adrenergic supplementation are under active investigation.

Recombinant human growth hormone

Daily intramuscular administration of recombinant human growth hormone (rhGH) at doses of 0.2 mg/ kg as a daily injection during acute burn care has favorably influenced the hepatic acute phase response [91, 92], increased serum concentrations of its secondary mediator IGF-I [93], improved muscle protein kinetics, maintained muscular growth [94, 95], decreased donor site healing time by 1.5 days [96], improved resting energy expenditure and decreased cardiac output [97]. These beneficial effects of rhGH are mediated by insulin-like growth factor (IGF) -I and patients receiving treatment, demonstrated 100 % increases in serum IGF-I and IGF-binding protein (IGFBP) -3 relative to healthy individuals [98, 99]. However, in a prospective, multicenter, double-blind, randomized, placebocontrolled trial involving 247 patients and 285 critically ill non-burned patients Takala et al. found that high doses of rhGH (0.10 +/– 0.02 mg/kg BW)