Meta Analysis Early versus delayed enteral nutrition support for burn injuries (review)
This review may be edited
Summary
Posted By:	Pip Heighes
E-Mail:	pheighes@nsccahs.health.nsw.gov.au
Posted Date:	10/11/08
Title:	Early versus delayed enteral nutrition support for burn injuries (review)
Authors:	Wasiak, J., Cleland, H., & Jeffery, R.
Reference:	Cochrane Database Syst Rev. 2006 July 19;(3):CD005489.
Link:	Click here for a direct link to the paper. A password may be required for access to fulltext.
Abstract:	BACKGROUND: A burn injury increases the body's metabolic demands, and therefore nutritional requirements. Provision of an adequate supply of nutrients is believed to lower the incidence of metabolic abnormalities, thus reducing septic morbidity, improving survival rates, and decreasing hospital length of stay. Enteral nutrition support is the best feeding method for patients who are unable to achieve an adequate oral intake to maintain gastrointestinal functioning, however, its timing (i.e. early versus late) needs to be established. OBJECTIVES: To assess the effectiveness and safety of early versus late enteral nutrition support in adults with burn injury. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, issue 1, 2006), the Cochrane Injuries Group's Specialised Register, MEDLINE (1966 to May week 1, 2006), EMBASE (1980 to week 17, 2005) and CINAHL (1982 to May week 1, 2006). SELECTION CRITERIA: We included all randomised controlled trials comparing early enteral nutrition support (within 24 hours of injury) versus delayed enteral support (greater than 24 hours). DATA COLLECTION AND ANALYSIS: Two authors used standardised forms to independently extract the data. Each trial was assessed for internal validity with differences resolved by discussion. MAIN RESULTS: A total of three randomised controlled trials were eligible for inclusion in this review. Results of the studies indicate that evidence about the benefit of early enteral nutritional support on standardised clinical outcomes such as length of hospital stay and mortality, remains inconclusive. Similarly, the question of whether early enteral feeding influenced or decreased metabolic rate as documented in part by our included studies, remains uncertain. AUTHORS' CONCLUSIONS: This systematic review has not found sufficient evidence to support or refute the effectiveness of early versus late enteral nutrition support in adults with burn injury. The trials showed some promising results that would suggest early enteral nutrition support may blunt the hypermetabolic response to thermal injury, but this is insufficient to provide clear guidelines for practice. Further research incorporating larger sample sizes and rigorous methodology that utilises valid and reliable outcome measures, is essential.
Are the Results Valid?
1. Did the overview address a focused clinical question?
	Yes. Authors focused on adults (>16 years) with any type of burn injury to the epidermis, subcut tissue, vessels, nerve, tendons or bone. Intervention clearly defined as enteral nutrition support (liquid nutritional formula) within 24 hours of injury versus comparison of delayed (>24hours). Clinically important outcomes (mortality, length of stay, frequency of infection, adverse events) examined as well as secondary outcomes (weight, biochemistry).
2. Were the criteria used to select articles for inclusion appropriate?
	Included all RCT's evaluating clinical question (as stated above). Methods of randomisation not reported. No restrictions placed for language or publication status
3. Is it unlikely that important, relevant studies were missed?
	A thorough search was performed in a wide variety of bibliographic databases (Medline, EMBASE, CINAHL, Cochrane CENTRAL). Appropriate search terms used for burns and nutrition. Experts and authors contacted to identify any unpublished or ongoing studies. They did not report hand searching of bibliographies.
4. Was the validity of the included studies appraised?
	Authors reported results of review of methodological quality including randomisation techniques, allocation concealment, patient baseline characteristics, blinding, intention to treat analysis and loss to follow up. This appraisal process found overall quality was 'poor' for all 3 included RCT's.
5. Were assessments of studies reproducible?
	It is reported that 3 authors reviewed intitial records, then 2 authors identified trials that met inclusion criteria. Full text articles were retrieved by 2 authors to apply inclusion criteria independently, differences resolved by discussion. Data was extracted independently by 2 authors.
6. Were the results similar from study to study?
	The authors only report finding 3 RCT's meeting inclusion criteria. For the majority of outcomes studied only 1 RCT contributed results, therefore tests for heterogeneity were not applied.
What are the Results?
1. What are the overall results of the overview?
	There are no significant results from this overview.
2. How precise were the results?
	Not applicable
Will the Results Help Me In Caring For My Patients?
1. Can the results be applied to my patient care
	Due to the small number of trials and also the small numbers of patients within these trials it is difficult to apply to clinical practice.
2. Were all clinically important outcomes considered?
	Yes
3. Are the benefits worth the harms and costs?
	N/A
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