Eating well after a major burn injury

Introduction

A major burn injury is usually classed as a burn of total body area of burn that is 20% or more (see glossary on page 1). If you have had a major burn injury, you may have been fed through a feeding tube for a while (see glossary on page 1). This enables us to meet your high nutritional needs during the early stages of your recovery. The reason for this is because having a major burn significantly increases your body’s metabolic rate for many months following your injury (see glossary on page 1). Your body’s need for protein and calories is much increased, even after your injury has first healed (see glossary below).

Even smaller burn injuries may require a higher protein and energy diet. In this case, eating and drinking can be done by mouth.

Changing from tube feeding to feeding by mouth

When changing from being tube fed to having food by mouth, sometimes you may have your tube removed to help with swallowing. You must be wide awake and be able to manage to cough up your saliva properly.

Start off with small amounts of pureed foods (see glossary below) and take sips of nutritional supplement drinks. These drinks can be prescribed by your dietitian (see ‘nutritional supplements’). A change in the sound of your voice or coughing when first drinking or eating indicates that you may not be ready to drink or eat yet.

However, if you find you have managed pureed textures well, trialling soft, mashable foods for your first meal would be recommended. It is important to chew more than you normally would. You may feel full very quickly when you first start to eat solid food again. You may start to feel more thirsty than usual. Drinking nutritional supplement drinks can provide a good source of nutrition at this time.

Poor appetite

A poor appetite is very common following a burn injury. This can be for many reasons some of which include: being in hospital, worrying, restrictive dressings, pain, pain on dressing changes, constipation, dislike of hospital food, feeling sick, feeling weak and taste changes. However, at this time in hospital after your injury, your body’s nutritional needs tend to be much higher. Therefore it is important to view food as an essential part of the healing process and make as much effort with your eating and drinking as you can. 

To help stimulate the appetite you can try:

• Eating more frequently; “little & often”, eg. 5-6 small meals or snacks, rather than 2-3 larger meals; try something every few hours. This is because not eating in itself can cause low appetite
• Eat what you want, whenever you want. Whilst in hospital, it can be useful to ask family and/or friends to bring in foods from outside the hospital
• If you’ve lost interest in food: Think of a food where the smell or sight of it usually makes you look forward to tasting it, then try a small portion
• Make eating easy; choose simple meals & snacks, and when at home, ensure cupboards/fridge are well stocked; choose favourite foods
• Choose nutritious fluids: do not fill up on water, tea, coffee; remember that drinking before a meal can fill you up
• If taking supplement drinks, only have these after a meal, otherwise they may fill you up

Nutritional supplements prescribed by dietitian

Sometimes high energy/high protein supplement drinks will be suggested by your dietitian. These are easy ways to take in a concentrated amount of energy and are available on prescription.

• Only use supplements when your appetite / weight is low
• Use to ‘supplement the diet’, not as meal replacements
• Try to take after or between meals, not before or with meals
• Juice based drinks(eg Ensure plus juice) can be made into jellies or sorbets/slushes.  If too thick, they can be diluted with fizzy drinks - lemonade, ginger ale, Fanta, tango (try not to dilute with water alone).
• Milk based drinks (eg Ensure Plus, Fortisip Extra) can be frozen to make ice cream or heated, (remove from packet if heating in a microwave).  They can be added to custards or yoghurts.  If too thick, they can be diluted with milk.
• Food Fortifiers (eg, Protifar powder) can be added to foods and drinks to increase protein.
• Supplements can be mixed with alcohol after you have been discharged from hospital (if alcohol allowed  and does not interfere with medication).

Drinks

Liquids are important but can be filling. Try to ensure drinks provide calories by possibly substituting water/coffee/tea with some of the following:

• Cocoa, drinking chocolate, coffee (made with all milk, i.e. latté or cappuccino, cream, evaporated milk)
•  Full fat milk (fortified) and milkshakes (fortified)
•  Lucozade or energy drinks
•  Fruit juices and full sugar squashes eg. Ribena / Robinsons
•  Drinking yoghurt
•  Fizzy drinks, include ginger ale (NB. can cause bloating)
•  Fruit smoothies (bought or homemade with fortified milk)

Food and fluid fortification

Choose high energy, high protein foods. Eating more of these will help you to gain/maintain weight. This means avoiding diet / slimline / low fat / no added sugar products.

Fats and oil have the highest amount of energy per gram compared with all other foods in our diet & are therefore invaluable in food fortification.  Fortify foods & fluids using the methods below whenever possible to add extra energy:

• Fortified milk - Add 3-4 tablespoons skimmed milk powder, (e.g. Marvel) to 1 pint full fat milk. Use this in soups, sauces, puddings, drinks, and on cereal
• Add butter or margarine spreads liberally on bread, toast, crackers, vegetables & potatoes
• Fry or add oil to dishes like rice and pasta
• Add yoghurt / fromage frais / cream cheese / crème fraîche / cream to stews, soups, drinks (use full fat products)
• Add grated cheese, cream / sour cream, fortified milk to soups & sauces. Have sauces on meats, potatoes and pasta
• Add evaporated milk to soup, sauces, milk & other puddings (eg jelly)

If you have been told by your Doctor / Dietitian that you have high cholesterol or heart problems, try using poly or mono-unsaturated oils/spreads whenever possible. This are better for heart health. High calorie foods good for heart health include:

• Oils & Spreads: olive, vegetable (rapeseed), sunflower, safflower, soya, corn. Olive oil based spread
• Oily Fish: Mackerel, salmon, sardines, herring, trout, tuna 
• Nuts: Walnuts, chestnuts, almonds, hazelnuts, peanuts, pistachio, pecans
• Avocado: use in salads, sandwiches or as a snack

Long Term Diet

With larger burns, your energy needs for healing continue to be very high, sometimes up until 12 months from the date of injury. Some people with very large burns have shown to have had high energy needs for up to 2 years after they have healed, however, this is quite rare.

Generally, you will need to eat a diet high in protein and energy up until your burn is fully healed or as advised by your burns dietitian.

Once your burn is fully healed and your weight is stable, then you can switch to a healthier balanced diet that the general population are advised to follow. Please refer to pages 14 and 15 for guidance regarding this.

Vitamin and Mineral Supplementation

You may be prescribed vitamin and mineral supplements or a nutritional supplement whilst you are in hospital and after discharge from hospital.  Copper, selenium, zinc, vitamin C are regularly given to patients with a larger burn injury. This is because they help with wound healing. Please ask your Dietitian how long you need to take them after you are discharged from hospital.  Generally, supplements are no longer necessary when your burns have healed and you start to maintain your weight. 

Breakfast Ideas

• Cereals – Use fortified milk (see recipe). Porridge/Ready Brek, made with fortified milk, cream, evaporated milk, yoghurt. Try adding dried fruit, fresh fruit or nuts. Try adding honey, brown sugar, golden syrup or maple syrup to add taste to muesli or sugar coated cereals. Try cereal with fruit juice if milk is not tolerated. Remember cereals can be eaten any time of the day, hot or cold. NB: Scandishake, Build-up or Complan sachets & ‘Procal’ can be added to porridge
• Eggs (poached, boiled, scrambled with salmon, omelette); try bread ‘fingers’ dipped into beaten egg & fried. Ensure eggs are well cooked.
• Cooked breakfasts (bacon, sausage, ham & baked beans).
• Bread/toasts (sweet or savoury toppings).
• Croissants, muffins, scones, pitta bread (sweet or savoury toppings).
• Waffles or crumpets (with maple syrup, honey, savoury spreads).
• Yoghurts, fromage frais (full fat), flavoured or plain (try adding dried / fresh fruit, nuts, honey, spices etc).
• If you find that eating in the morning makes you feel sick, try dry toast or crackers.

Easy Small Meal Ideas

Eating several small meals and snacks can be much easier than facing a large meal.

• Scrambled eggs, omelette, with added cheese, avocado, bacon, herbs etc
• Baked beans on toast (well buttered/spread), topped with melted cheese
• Cheese on toast (try spreading cream cheese & top with Cheddar/hard cheese)
• Bacon buttie—bacon with onions, mushrooms on bread or toast
• Mini pizzas—bought or homemade (can use bagel, muffin or crumpet as a base)
• Sausage rolls, pork pies, scotch eggs, Falafel
• Soups (canned/packet/homemade)—add full fat milk, cream or cheese, croutons
• Flans, quiches, pies, pasties
• Sausages (or hotdogs), bacon, egg with baked beans
• Pancakes/kievs stuffed with vegetables/meats in cheese sauce
• Spaghetti, macaroni cheese (sold in small or large tins)
• Oily fish—eg tinned mackerel, sardines or salmon on toast
• Takeaways—burgers, fish and chips, Chinese, Indian, Kentucky Fried Chicken
• Instant, frozen and microwave meals—can be very nutritious

High Energy Snack Ideas

• Cereals (see breakfast section)—can be eaten any time of the day
• Small sandwiches (see sandwich section) or toast with topping
• Muffins and scones (cheese or sweet), crumpets, croissants (filled), waffles, flapjacks
• Nuts (peanuts, pecan, cashew, pistachio, brazil, walnuts, almonds,), dried fruit, olives, Bombay mix
• Avocado (with oil or seafood dressing)
• Milkshakes, ‘Fruit Smoothies’
• Tortilla crisps, breadsticks, pitta bread with dips such as taramasalata, humus, cream cheese, satay, peanut butter, avocado/guacamole, soured cream
• Desserts (see next section) such as yoghurts, rice pudding can be taken at any time

If high cholesterol isn’t a problem for you, the following snacks may also be useful, as long as they are used as part of a balanced diet:

• Doughnuts (large or mini), pastries, fruit strudels
• Crisps
• Mini pork pies, scotch eggs, sausage rolls, mini sausages
• Cheese and biscuits (remember to also use butter or spread)
• Samosas, bhajis

Puddings and desserts

Fruit is an easy dessert, but quite low in energy, so try to combine it with other higher calorie ingredients.

Other dessert ideas can be used as snacks between meals.

• Fruit, served with full-fat yoghurt, cream, ice cream, custard, condensed/evaporated milk, tinned fruit in syrup, dried fruit and nuts (soaked in juices or alcohol, if allowed)
• Fruit yoghurts (full fat), Greek yoghurt and honey, fromage frais, crème fraîche (add extra dried/fresh fruit, nuts (flaked/chopped), honey, syrups, crunchy cereals, spices)
• Custards, mousse, fools, whips, crème caramel, blancmange
• Mini trifles, cheesecakes, banoffee pie
• Rice pudding, milk puddings (semolina, tapioca)—can add sugar, syrups, jam
• Ice-cream (including ready bought on stick)
• Jelly (make with evaporated milk or fruit-juice supplement drinks)
• Fruit crumbles, fruit pancakes or fritters, fruit pasties, pies
• Flour based—sticky toffee pudding, spotted dick, bread and butter pudding served with cream, ice cream or custard
• Cakes—chocolate, lemon drizzle, fruit sponge, Victoria sponge, carrot

Sandwich ideas

For variety and greater flavour, try using different breads (fresh, hot, toasted)—rolls (eg with seeds), baps, French bread/baguettes, focaccia, naan, ciabatta, bagels, pitta bread, muffins, crumpets, scones, croissants. Always have at least two fillings such as ham and cheese.

Remember:

• White breads can be less filling/bulky than wholemeal types
• Try an ‘open sandwich’, ie only one slice of bread, with plenty of filling
• Ensure bread/roll is well spread with butter or margarine (not low fat varieties!)
• Use plenty of mayonnaise or salad cream (if enjoyed)—a dash of mustard or tomato puree adds flavour
• Try adding chopped herbs (fresh or dried) to add extra flavour.

Fillings:

• Fish—tuna, salmon, pilchards, sardines (tinned in oil), smoked/peppered mackerel
• Cheese, hard or soft, try different varieties; try a layer of cream cheese & topping with grated hard cheese
• Avocado and/or bacon
• Pastes eg olive, pesto, smoked mackerel, pate
• Meats—corned beef, cold meats, hams, chicken, spam
• Egg mayonnaise (ensure egg is well cooked)
• Peanut butter, tahini
• Taramasalata, houmous, falafel
• Sweet spreads: jam, marmalade, banana and honey, chocolate/nut spreads

Pastas & Rice

Pasta provides a good base to meals; try to use sauces that provide additional energy & protein:

• Try creamy sauces eg use cream, full fat milk, yoghurt/fromage frais
• Macaroni or cauliflower cheese; add croutons or cubes of ham/bacon/pancetta/salami/pepperoni
• Use grated cheese or sour cream to top tomato or vegetable based sauces
• Pesto or oil-based sauces
• Add avocado, nuts, bacon, olives, mackerel, hard boiled egg, prawns
• If appetite is poor, use less pasta and more sauce

Salads and vegetables

Although full of vitamins and minerals, salads and vegetables can be filling, while providing little energy. The following ideas help increase calories.

• Serve with coleslaw, pasta, rice & potato salads
• Use mayonnaise & salad cream or oil-based dressings (not low-fat versions)
• Try adding chopped nuts, seeds, pinenuts, olives, dried fruit
• Add avocado, hard-boiled egg, bacon, ham, cubes of cheese
• Add pieces of sausage / hotdogs, chicken, fish (tinned or fresh)
• Try croutons (bought or homemade - cubes of bread fried in oil, herbs, garlic)
• Stirfrys: add nuts, tofu / quorn, chicken, fish; use oil in dressings 

Potatoes

Potatoes can provide easy and economical meals—try these:

• Filled jacket potatoes (see below) & potato skins (deep-fried)
• Chips, bought, oven cooked or deep-fried (can use unsaturated oils)
• Mashed potato (packet or homemade) - add butter / marg, milk, cream or cheese
• Potato fritters - mash & fry with onion, cheese, bacon, ham etc.
• Potato layers - bake sliced potato with onion, cheese sauce, egg & milk
• Croquettes, bread crumbed potatoes, wedges, hash browns.
• Add potato to soups to thicken
• Use crisps (crushed) & grated cheese for toppings.

Jacket/Baked potatoes (See sandwich fillings for other ideas):        

• Tuna mayonnaise, sweetcorn and cheese
• Baked beans and cheese
• Bolognaise or chilli sauce, topped with grated cheese or sour cream
• Ratatouille, topped with grated cheese or sour cream
• Coleslaw
• Egg mayonnaise
• Sausage and baked beans
• Pizza sauce and grated mozzarella
• Scrambled egg, tomato and green pepper
• Prawn mayonnaise / prawn cocktail
• Brie and cranberry sauce
• Sauteed mushrooms, garlic and grated cheese

Glossary

Total Body Surface Area of Burn or TBSA) – Refers to the area or percentage of the body that has been affected by a burn injury.

Metabolic Rate – The amount of energy used by the body when at rest.

Tube fed – A way of giving artificial food through a tube into the stomach, sometimes it is placed after the stomach at the top of the small intestine.

NG tube – Shortened way of writing or saying a Nasogastric feeding tube. This is a type of feeding tube that is inserted via the nose, through the food pipe into the stomach.

Calories – Unit of energy that comes from breaking down food from the digestive tract.

Protein – A type of essential nutrient that act as building block in the human body. Protein is an important source of fuel / energy for the body. Proteins are also involved in healing burn injuries.

Pureed foods – Foods with a similar consistency to baby food or apple sauce containing no lumps or stringy pieces.

Soft foods – Foods that can be mashed easily with a fork.