Diet

Any burn survivor is in need of a high quality diet as soon as possible after the burn, continuing for a long time after the incident. The child or adult needs far more protein and fluid than they might normally have. Many children who are burned, come from extremely poor homes and have not been well fed in the months or years before the accident.

For children like Dorah who have had facial burns, it can be very difficult to ensure that they get enough to eat at all. Loss of lips make it difficult to keep food in, and to chew and swallow properly.

In Southern African hospitals it cannot be assumed that nursing staff are aware of the child's dietary needs at this crucial time. The charity will assist with high protein food supplements if asked.

The information below is provided by Luise Marino, a British dietician who works extensively with paediatric burn victims at hospitals in the Durban area of South Africa.

Puréed Diet

A puréed diet is essentially a "normal" diet, which is made into a smooth consistency, which is easier to swallow or administer via a gastrostomy.

Some foods such as yoghurt/ custard may be at the correct consistency, other foods need to be pureed using a liquidiser, food processor, or hand blender.

Some foods are easier to puree than others and the following guidelines will give you some ideas.

Meat and Poultry:
Minced meat and poultry is often easier to puree in slices. It may be necessary to add extra gravy or stock to reach the correct consistency.

Fish:
Fish without bones and skin may be pureed, with a white, cheese or tomato sauce.

Eggs:
Eggs are a good source of protein, as are meat and fish. Savoury egg custards, cheese puddings and scrambled eggs are a few suggestions. Eggs should always be thoroughly cooked before they are eaten.

Milk:
It is best to use whole milk, unless you are otherwise advised. You should aim to use a least 500ml of milk per day, which can be used in soups, mashed potatoes, sauces, milky drinks and custards.

Cheese:
Cheese is a nutritious and versatile food, which can be the main part of a meal, e.g. pureed cauliflower cheese, or cheese sauce with pureed vegetables or fish.

Beans, Pulses and Lentils:
These are alternative source of protein to meat and poultry. Cooked lentils puree well. However, beans such as kidney beans, and chickpeas, have tough skin which may not puree well; therefore you will need to puree the beans and sieve them.

Vegetables:
Most well-cooked vegetables can be pureed easily and should be included to form part of the well balanced diet. Care must be taken to ensure that vegetables are evenly pureed and that no lumps, skins etc. remain. Tomatoes are not suitable because of the seeds.

Nuts:
These DO NOT puree well and should be excluded from the diet.

Potatoes:
These should be included with the diet, as they are filling and nutritious. Boil and them cream the potatoes, adding margarine and/ or grated cheese and/or milk to increase the nutritional content. Instant mashed potato is an excellent quick alternative, made more nourishing by making up with hot milk instead of water.

Pasta:
This is also filling and nutritious and purees well. Pasta with a sauce e.g. pureed macaroni cheese, is a suggestion.

Cereals:
Some cereals can be included within a puree diet e.g. porridge, weetabix. Other cereals such as Bran, Bran Flakes and Weetabix require pre-soaking with milk or cream to form the correct consistency. Occasionally the fluid and solid part of a pureed meal may separate e.g. with vegetables. Foods can be thickened to prevent this from happening by using cornflour, ground rice, mashed potato, instant potato powder, instant sauce granules and custard powder.

Advice for People with Swallowing Problems

Swallowing difficulties can be a side effect of many problems. Dysphagia is the medical name for a swallowing problem, which may be short or long term.Many people with dysphagia find thin liquids are difficult to swallow and cause coughing, spluttering and even choking. This could give rise to chest infections. Thickened drinks are often needed for safer swallowing.

Why must I drink?
We all need to drink some liquid to prevent dehydration. If you have dysphagia, then your drinks may need to be thickened, but it is still important that you have an adequate intake - ideally at least 8-10 cups per day (approx 1.5 litres).

A Speech and Language Therapist can help you if you have swallowing difficulties as they are trained to assess your ability to swallow and will determine the thickness of drinks and consistency of foods that you are able to manage.

A Speech and Language Therapist will also advise you on:

• The best sitting position and posture to make swallowing easier.
• Certain techniques to aid swallowing.

He or she should assess you regularly, as the thickness of the drinks may have to be adjusted according to the changes in your condition.

Thickened Drinks
What is a thickened drink?
Drinks can be divided into 3 categories according to consistency.

'Thin Drinks' which may be thickened include: Water, tea, coffee, fruit juice, hot chocolate.

'A slow moving drink' is any liquid which is smooth and poured easily e.g drinking yoghurt, double cream (before whipping), canned tomato soup and cartons of pouring custard.

'Thick Drinks' are smooth liquids that appear semi-solid e.g. milk-shakes bought from burger take-aways, where the straw stands up on its own. There are a few thick drinks readily available in the shops, e.g. French set yoghurt (stir well before drinking) and home made thick custards suitable for trifles. Slow moving and thick drinks probably need no added thickener.

A thickened drink can be made by mixing a thin drink with a food thickener e.g. Thick n' Easy, Nestargel. You can thicken any thin drink, but some of them will give better result than others . The quantity of thickener to add depends on the drinks used and the type of thickener. Guidelines are given on each tin of thickener.

How can I check whether a drink is 'thick' or not?
A simple check of the correct consistency is the 'straw' test; if a straw will stand up on its own in a cup of fluid, it is a thick drink. If the straw slowly 'falls' to one side, you have a slow moving drink.

NB: Milk shakes can be of different consistencies, depending of their ingredients. Milk shakes made from milk and syrup are thin drinks. Milk shakes with ice-cream and puréed fruit can be 'slow moving' or 'thick' depending on the quantity of thickening ingredients added. The straw test will help you to determine whether the thickness of the drink is suitable for you.

Soft and Puréed Foods:
In addition to thickened drinks, soft, pureed or liquidised foods are often necessary in order to provide you with a balanced varied diet.

Try to include the following:

• 3 small meals a day, as well as 2-3 nutritious drinks between meals.
• Use at least one pint of full cream milk or high fat Mass per day.
• Meat, fish, chicken, well cooked eggs, cheese, yoghurt, beans or lentils at least twice daily.
• One serving of bread, potatoes, pasta, rice, cereal or maize meal with each meal.
• Fruit and vegetables daily. Drink a glass of juice if little fruit has been taken.
• Use plenty of sugar in drinks and puddings.
• Use plenty of butter, margarine, cream, skimmed milk powder or evaporated milk in dishes.

Tips:

• Most foods can be adapted to make them suitable. A liquidiser is useful but not essential, a potato masher or hand Mouli works just as well.
• Puréed foods separately to keep the flavours and colours. Serve different coloured foods to add interest e.g savoury mince, puréed carrots, mashed potatoes. Puréed tinned peaches and custard.
• Some foods may need thickening. Useful thickening agents are flour, cornflour, arrowroot, ground rice, semolina, custard powder, blancmange, instant potato, breadcrumbs, weetabix or use a food thickener.
• If foods need thinning, do not add water, as this does not add any nutritional value. Milk, cream, evaporate milk, butter, ice-cream, custard, sauces and meat gravy are better alternatives.
• Convenience foods are often very useful, e.g. tinned/packet custard & milk pudding.

Foods that may be difficult to swallow:

Here is a guide for foods that may cause problems for some people.

Hard boiled eggs, pith of orange and grapefruit segments, chunky raw or lightly cooked vegetables, celery, lettuce, cabbage stalks, peas, beans, sweetcorn, chunky soup, outer part of roast meat, tough meat, new white soft bread, crusty white bread, nuts, raisins, skin of fruit, dried fruit, breakfast cereals, dry biscuits, thick porridge, dry mashed potato.

Ideas for suitable soft foods.

Remember to try and include as much variety of foods as possible to help to provide you with a balanced diet. It is important to remember that plenty of 'moisture' is needed. e.g. gravy, sauce or custard.

Ideas for suitable puréed foods:

• Poached, tinned or flaked fish in a sauce, e.g. parsley, cheese, tomato sauce. Ensure there are no bones.
• Meat, chicken - minced, stewed or roast liquidised with gravy or sauce.
• Eggs and cheese can be added to sauces (ensure egg yolks are well cooked).
• Beans, lentils, pulses.

NB: A thickener can be added to these to aid swallowing.

Ideas for puddings:

• All milk puddings are suitable e.g. semolina, ground rice. Liquidise puddings with grains e.g. rice, sago.
• Fruit, tinned or stewed then liquidise and add to custard or mix with double cream or evaporated milk. Avoid using fibrous fruits e.g. pineapple, mango.
• Instant whips and cream desserts.
• Ice-cream and jelly (may be liquidised together if necessary).
• Smooth yoghurt and fromage frais.
• Egg custard
• Crème caramel.
• Mousse.

Getting a lot out of a little:
Many people with swallowing problems find it difficult to keep their weight stable. If this is one of your problems then the following are a few ideas to help you.

The most obvious way to increase your nutritional intake is to eat more. This is often difficult when you are ill so you need to look at other ways of adding extra nourishment to your food. These are adding nourishment to everyday foods and taking snacks in between meals either as food or as nourishing drinks.

Adding nourishment to everyday foods

Fortified Milk
Mix 2-4 tablespoons of milk powder into ½ litre of full cream milk. Use in place of ordinary milk or water to make up coffee, packet soups, sauces, jelly, milk puddings and breakfast cereals.

Breakfast Cereals
Use fortified milk. Sprinkle extra sugar on top. Add syrup and fortified milk to porridge.

Soups
Add cream, grated cheese, mince, lentils, beans, or pasta to soup. Use fortified milk to make up packet or condensed soups. Use savoury Build-Up or Complan.

Sauces
When making home made sauces use fortified milk, cream or evaporated milk. Flavour with cheese or for a sweet sauce, syrup or milk shake sugars. Full fat yoghurt can be used as sweet sauces.

Meat or fish dishes
Add sauce made with cream or fortified milk to meat or fish dishes.

Casseroles
Add lentils and beans to stews and casseroles. Make a sauce for the casserole with either fortified milk or cream.

Beans
Add grated cheese to baked beans on toast.

Puddings
Add cream, ice-cream, evaporated milk to hot or cold puddings such as fruit pies, sponge pudding, trifles. Use fortified milk to make up jellies, milk, puddings, custard, instant deserts. Put fruit in a liquidiser with cream, custard or evaporated milk - freeze individual portions. Add sugar, jam, honey, or syrups to ice-cream or other puddings. It can help to eat puddings ½ - 1 hour after main courses; this will give time for the first course to settle. Have a pudding at least once a day.

Yoghurts
Use full fat yoghurt. Puréed fruit, jam marmalade, syrup or honey can be whisked into yoghurt - eat as a pudding or use as a sweet sauce over sponge or ice-cream. Add herbs to plain yoghurt and use as a savoury sauce.

Drinks
Use fortified milk instead of water when making coffee or bedtime drink. Add sugar or glucose to drinks. Add cold milk to blackcurrant juice or milk shake flavourings. If you have a blender make milk shakes with milk, fruit and ice-cream.

Nourishing Drinks
When you do not feel like eating, it is better to have a nourishing drink. Ready made products such as Build Up, Complan, Ensure, Pediasure (for children) are available from most chemists and some supermarkets. Sweet and savoury flavours are available. They may be taken as a drink between meals or be used to replace a meal occasionally. The natural and unflavoured varieties may be added to puddings and soups.

Suggested meal plan for puréed diet:
Small amounts eaten regularly is better than fewer large meals.