Supplementation of Vitamin E, Vitamin C, and Zinc

Attenuates Oxidative Stress in Burned Children:

A Randomized, Double-Blind, Placebo-Controlled
Pilot Study
Eliana Barbosa, RD, MS,*† Joel Faintuch, MD, PhD,‡
Emilia Addison Machado Moreira, RD, PhD,* Viviane Rodrigues Gonçalves da Silva, RD,*
Maurício José Lopes Pereima, MD, PhD,†§ Regina Lúcia Martins Fagundes, RD, PhD,*
Danilo Wilhelm Filho, PhD¶

The aim of this study was to investigate the effect of supplementation of vitamin E, vitamin C,
and zinc on the oxidative stress in burned children. In a prospective double-blind placebo-
controlled pilot study, 32 patients were randomized as no supplementation (n ⴝ 15) or antioxi-
dant supplementation (n ⴝ 17) groups. Supplementation consisted of the antioxidant mixture
of vitamin C (1.5 times upper intake level), vitamin E (1.35 times upper intake level), and zinc
(2.0 times recommended dietary allowance) administered during 7 days starting on the second
day of admittance into the hospital. Energy requirement was calculated by the Curreri equation,
and protein input was 3.0 g/kg of ideal body mass index (percentile 50°). Total antioxidant
capacity of plasma and malondialdehyde were used to monitor oxidative stress. The time of
wound healing was evaluated as the main clinical feature. Patients (age 54.2 ⴞ 48.9 months,
65.6% males), who exhibited 15.5 ⴞ 6.7% of total burn area, showed no differences in age and
sex, when compared with controls. Intake of the administered antioxidants was obviously
higher in treated subjects (P ⴝ .005), and serum differences were confirmed for vitamin E and
C, but not for zinc (P ⴝ .180). There was a decrease in lipid peroxidation (malondialdehyde
level) (P ⴝ .006) and an increase in vitamin E concentrations in the antioxidant supplementa-
tion group (P ⴝ .016). The time of wound healing was lower in the supplemented group (P <
.001). The antioxidant supplementation through vitamin E and C and the mineral zinc appar-
ently enhanced antioxidant protection against oxidative stress and allowed less time for
wound healing. (J Burn Care Res 2009;30:859 – 866)

In burned patients, fluid administration to prevent and
treat hypovolemia and tissue necrosis may contribute to
the production and systemic spread of oxygen-derived
free radicals.1 The organism is ordinarily endowed with
From the *Postgraduate Program in Nutrition, Federal University of
Santa Catarina, Florianopolis, Brazil; †Burn Unit, Joana de
Gusmão Children’s Hospital, Florianopolis, Brazil; ‡Department of
Gastroenterology, São Paulo University Medical School, São Paulo,
Brazil; §Department of Pediatrics, Federal University of Santa
Catarina, Florianopolis, Brazil; and ¶Department of Ecology and
Zoology, Federal University of Santa Catarina, Florianopolis,
Brazil.
This study was supported by grants from the Secretary of Health
of the State of Santa Catarina, Dermus Pharmacy, Roche
Laboratories, Galena Quimica and Farmaceutica Ltda, and
Support Produtos Nutricionais Ltda, and fellowship from the
National Council for Research and Scientific Development
(CNPq).
abundant protective mechanisms, which encompass
both enzymatic and nonenzymatic antioxidant de-
fenses. However, an imbalance between oxidants and
antioxidants tends to occur in pathological circum-
stances, resulting in oxidative stress. Serious conse-
quences may follow, notably exacerbation of the inflam-
matory process and metabolic deterioration of the
organism.1,2 Therefore, prescription of the antioxidant
vitamins C and E have been recommended for many
Address correspondence to Emília Addison Machado Moreira, RD,
PhD, Departamento de Nutrição/Centro de Ciências da Saúde,
Universidade Federal de Santa Catarina, Campus Universitário,
S/N, Trindade, Florianópolis, Brazil.
Copyright © 2009 by the American Burn Association.
1559-047X/2009
DOI: 10.1097/BCR.0b013e3181b487a8

859

860 Barbosa et al
years,2,3 and consideration to enzymatically relevant
zinc and additional trace elements can also be found.1,4
Major burns are serious aggressions followed by
nutritional, metabolic, homodynamic, endocrine,
and immune-inflammatory changes.3–7 The skin is
considered as the largest organ of the human body and
represents about 15% of body weight. Upregulation of
the transcription factor nuclear factor k␤, along with
other afferent routes in thermally injured subjects, has
been shown to activate the proinflammatory-cytokine
cascade represented by tumor necrosis factor ␣, inter-
leukin 1␤, and interleukin 6, together with hormones,
prostaglandins, and multiple other mediators.1,3–7
Oxidative stress is not simply a by-product of tissue
ischemia triggered by direct damage and fluid seques-
tration, followed by reperfusion in the form of resus-
citation fluids. This imbalance between prooxidants
and antioxidants is able to produce generalized cellu-
lar damage that affects much more than burned skin,
which extends to the heart, lungs, liver, and other
sites.1,2,8 Within such a context, attenuation of lipid
peroxidation and other consequences of overgenera-
tion of free radicals have been demonstrated to ben-
efit not only oxidative stress but also clinical course
and mortality of burned patients.2,4,5,9
Despite potential prognostic implications, pharma-
cologic replenishment of antioxidant components is
not a standard care in burn units. Only physiologic or
slightly modified amounts of vitamins and trace ele-
ments to cover losses are endorsed by scientific soci-
eties.4,10 Management of children is an even bigger
dilemma, and much is questioned about drugs, dos-
age, duration of treatment, risks, and benefits.3–5,10
Nevertheless, one recent review5 emphasizes that few
antioxidants have reached level of evidence in seriously
ill patients and none in pediatric burns. Despite highly
encouraging experience, most of these micronutrients
are still on the clinical benchmark level.4,5
To our knowledge, no previous investigation has
addressed the association of relatively large doses of
vitamin C, E, and zinc in burned children. Given the
interest of the subject, a randomized, double-blind,
placebo-controlled study was designed, aiming to in-
vestigate the antioxidant effects of such supplemen-
tation in burned children.
SUBJECTS AND METHODS
Experimental Design
This was a prospective, randomized, double-blind
trial conducted at the Burn Unit of Joana de Gusmão
Children’s hospital, Florianopolis, Santa Catarina,
Brazil. The study complied with good clinical prac-
Journal of Burn Care & Research
September/October 2009
tices and was conducted in accordance to the Decla-
ration of Helsinki and its subsequent amendments.
The protocol was approved by the Comitê de Ética
do Centro de Pesquisas Oncológicas, and a written
informed consent was obtained from the parents,
in accordance with Brazilian regulations (process
016/04).
Subjects
Children patients (n ⫽ 32) admitted at the Burn Unit
of the Joana de Gusmão Children’s hospital were ran-
domized as a no supplementation group (n ⫽ 15) or
an antioxidant supplementation group (n ⫽ 17) and
were selected to this project according to the ensuing
criteria.
Criteria for Inclusion. Age 2 to 15 years, males or
females, consent obtained within 48 hours of the
thermal trauma, burned area bigger than 10% of
TBSA, and including one or more segments of sec-
ond-degree injury (partial-thickness skin burn).
Criteria for Exclusion. To reach sample homog-
enization regarding clinical aspects and energy de-
mand afforded for severe burn injury,11 patients with
a burned area bigger than 50% TBSA, as well as those
with polytrauma or brain trauma, tracheal intubation
or mechanical ventilation, refractory shock, intoler-
ance to oral/enteral nutrition, diabetes mellitus, can-
cer or chemo/radiotherapy, organ failure, chronic in-
fection, and a supplementation period smaller than 7
days were excluded.
Randomization. As already mentioned, among
the 32 patients included in the study, 17 were ran-
domized as antioxidant supplementation group and
15 as no supplementation group. These cases repre-
sent 30.5% of the 105 children admitted in the
9-month period of the study because of the strict
exclusion criteria.
Antioxidant Supplementation
Antioxidant supplements were administered after
meals via syringes with a photo protection device
from the second day of admittance into the hospital,
which were maintained onward during 7 days and
divided in three doses per day at 8:00 AM, 1:00 PM,
and 6:00 PM. Supplementation intake was checked
daily throughout the experimental period.
Reference values for antioxidants followed the di-
etary reference intake and recommended dietary al-
lowance (RDA) and also the upper intake level (UL)
recommendation.15,16 For vitamin C (Redoxon;
Roche Laboratories威, São Paulo, SP, Brazil) supple-
mentation, a 1.5 times UL was used,17 equivalent to
600 mg for children 1 to 3 years old; 975 mg for
children 4 to 8 years old; 1800 mg for children 9 to
Journal of Burn Care & Research
Volume 30, Number 5
13 years old; and 2700 mg for children 14 to 18 years
old. For vitamin E (Galena Química and Farmaceu-
tica Ltda威, Campesinas, SP, Brazil) 1.35 times UL,1
equivalent to 270 mg for children 1 to 3 years old;
405 mg for children 4 to 8 years old; 810 mg for
children 9 to 13 years old; and 1080 mg for children
14 to 18 years old. For zinc (Galena Química and
Farmaceutica Ltda威, Campesinas, SP, Brazil), the
prescription was 2.0 times RDA,1 equivalent to 6 mg
for children 1 to 3 years old; 10 mg for children 4 to
8 years old; 16 mg for children 9 to 13 years old; and
18 or 22 mg for children 14 to 18 years old, irrespec-
tive of gender.
Dietary Contribution of Antioxidants
Conventional oral diet according to dietary reference
intake-RDA15,16 or commercial polymeric tube feed-
ing (Support Produtos Nutricionais威, São Paulo,
Brazil) was provided according to clinical course.
Weight of ingested diet was registered on days 2, 4,
and 6, and the content of the three relevant micro-
nutrients was calculated by Nutwin威 software (São
Paulo, Brazil), which has been validated for Brazilian
foods.19
Clinical Evaluation
Total white blood cells (WBC) counts, lymphocytes
and neutrophils, and C-reactive protein (CRP) were
used as serum biomarkers of inflammation.20 Urea,
creatinine, and bilirubin were used to monitor renal
and hepatic functions. All these assays are important
to ensure the supplementation efficiency.21
Albumin, urea, creatinine, and total bilirubin were
determined using Kit Labtest Diagnóstica威 (Lagoa
Santa, Minas Gerais, Brazil). Prealbumin determination
was held by Kit Dade Bhering Ltda威 (Sao Paulo, Sao
Paulo, Brazil). CRP was evaluated by Kit Biotécnica威
(Sao Paulo, Sao Paulo, Brazil). The assays of total WBC
counts, lymphocytes, and neutrophils were made by us-
ing Micros equipment Cobas, Coulter (Coulter &
Beckman). Vitamins C and E were assayed by high-
performance liquid chromatography22 and zinc by
atomic absorption spectrometry.23
Total Antioxidant Capacity and
Malondialdehyde Determinations
Plasma total antioxidant capacity (TAC) was assayed
by means of a commercial kit (Randox Laboratories,
United Kingdom).24,25 TAC is an important tool to
evaluate total redox status in animal tissues.26 Malon-
dialdehyde (MDA) was assayed by the standard col-
orimetric method.26 Despite same methodological
limitations, this assay is still largely used in clinical
assays.27,28
Barbosa et al 861
Evaluation of Wound Healing
The wound healing was determined clinically by the
presence of a new stable layer of epithelium completely
covering the burn, without bleeding, or ulceration and
was calculated in days from the time of the injury.29 The
evaluation was made by the surgeon-service team, with-
out the knowledge of the treatment of both groups, to
avoid any interference in this regard.
Statistical Analysis
Values are presented as mean ⫾ SD. The Kolmogorov-
Smirnov normality test was applied to evaluate the dis-
tribution of each data set. Parametrical (Student’s t-test)
and nonparametrical tests (Mann-Whitney U test) were
applied as appropriate. Two-way analysis of variance
(ANOVA) with interaction between groups (no supple-
mentation group and antioxidant supplementation
group) vs time (before vs after supplementation) was
also applied. Fisher’s exact test or ␹2 was applied as ap-
propriate. A significance value of 5% (P ⬍ .05) was
adopted. Statistical analyses were performed using the
SPSS 14.0 Statistical Software (SPSS Inc, 2006, Chi-
cago, IL).
RESULTS
Subjects Characteristics
Groups were comparable regarding age, sex, and nu-
tritional status, and no significant differences were
detected. The mean age between groups was 54.2 ⫾
48.9 months. There was a predominance of male chil-
dren (66.6% in no supplementation group and 64.7%
in antioxidant supplementation group) and a nutri-
tional status of normal range (66.7% in no supple-
mentation group and 70.6% in antioxidant supple-
mentation group). The mean %TBSA in the no
supplementation group and in the antioxidant sup-
plementation group was 16.2 ⫾ 5.3% and 15.0 ⫾
7.4%, respectively (Table 1).
Dietary and Supplementary Antioxidants
Baseline intake of energy, protein, and the three stud-
ied nutrients were equivalent in the two groups. Dif-
ferences regarding vitamin C, vitamin E, and zinc
(average of 900 mg/d, 400 mg/d, and 7 mg/d, re-
spectively) should be ascribed to supplementation in
Table 2.
Clinical Characteristics
There was a significant decrease in the levels of albu-
min (P ⫽ .027), hematocrit (P ⫽ .003), and hemo-
globin (P ⫽ .025) in both groups when compared the
baseline periods and after 7 days. There was an in-
 Journal of Burn Care & Research
862 Barbosa et al September/October 2009

Table 1. Age, gender, nutritional status, and burned tation group, there was a reduction. No changes
area (%TBSA) could be observed in the WBC, neutrophils, and lym-
No Antioxidant
phocytes numbers, although a nonsignificant increase
Supplementation Supplementation in the number of lymphocytes in the antioxidant sup-
Parameter (n ⴝ 15) (n ⴝ 17) P plementation group was detected (Table 3).

Age (mo) 54.3 ⫾ 44.9 54.1 ⫾ 51.8 .847 Antioxidant and Oxidative Stress
Subjects, n (%) Vitamin E levels were affected by the variables time and
Male 10 (66.6) 11 (64.7) .901
supplement use (P ⫽ .016). In both the groups, it was
Female 5 (33.3) 6 (35.3) .855
observed as an increase in serum levels of vitamin E;
Nutritional status, n (%)
Malnourished or 01 (6.7) 02 (11.8) .709 however, this increase was more evident in the antioxi-
nutritional dant supplementation group. Vitamin C level and zinc
risk showed no significant differences in all subjects, despite
Normal range 10 (66.7) 12 (70.6) .798 a nonsignificant decrease in zinc level in no supplemen-
Overweight or 04 (26.7) 03 (17.6) .699 tation group and an increase in antioxidant supplemen-
obese tation group after 7 days were observed (Table 4). The
% TBSA 16.2 ⫾ 5.3 15.0 ⫾ 7.4 .556 use of the antioxidant supplementation on lipid peroxi-
The results are represented by mean ⫾ SD. Unpaired Student’s t-test.
dation (P ⫽ .006) promoted a significant decrease in
levels of MDA (Table 4).

crease in prealbumin levels in the antioxidant supple- Wound Healing

mentation group but without significant differences. The number of days to complete tissue repair was
CRP levels, although no statistically significant significantly lower in the antioxidant supplementa-
change, were higher after 7 days in the no supplemen- tion group (P ⬍ .001; Figure 1).
tation group, whereas for the antioxidant supplemen-
Morbidity and Mortality
There was neither severe sepsis nor mortality in this
Table 2. Intake of macronutrients and micronutrients series, because life-threatening severe burns were not
enrolled for inclusion criteria.
No Antioxidant
Supplementation Supplementation
Variables (n ⴝ 15) (n ⴝ 17) P DISCUSSION
Food To our knowledge, this is the first study that ad-
Energy* 1373 ⫾ 650a 1385 ⫾ 665a .963 dressed a pediatric population in a double-blind fash-
(Kcal/d)
ion, employing large proportions of the three re-
Protein† 48 ⫾ 26a 48 ⫾ 26a .975
ported nutrients—vitamin C, vitamin E, and the trace
(g/d)
Vitamin C‡ 108.9 ⫾ 30.3a 94.5 ⫾ 37.7a .247
element zinc.
(mg/d) As clinical parameters for monitoring the health
Vitamin E‡ 8.3 ⫾ 5.1a 6.7 ⫾ 3.5a .323 status of patients, albumin, hematocrit, and hemo-
(mg/d) globin levels were those that showed significant
Zinc‡ 8.3 ⫾ 5.3a 6.9 ⫾ 3.7a .390 changes in both groups after 7 days. The decrease in
(mg/d) such parameters can be the result of the occurrence of
Food ⫹ supplement bleeding and the acute inflammatory process gener-
Vitamin C‡ 108.9 ⫾ 30.3a 1032.0 ⫾ 542.7b ⬍.001 ated by thermal trauma.30 Althought not significant,
(mg/d) a concomitant tendency of increase in prealbumin
Vitamin E‡ 8.3 ⫾ 5.1a 403.0 ⫾ 244.3b ⬍.001
values and the decrease of CRP values after antioxi-
(mg/d)
dant supplementation is probably associated with the
Zinc‡ 8.3 ⫾ 5.3a 15.3 ⫾ 7.9b .003
(mg/d)
decline of the acute phase of the metabolic stress, and
also with the lower period of wound healing observed
The results are represented by means ⫾ SD. Unpaired Student’s t-test. in the experimental group.31 Unchanged values of
* Curreri Junior; Day et al (1986).12
creatinine were also found in adult patients after se-
† Cunningham et al (1990)13; Voruganti et al (2005).14
‡ Recommended Dietary Allowance—Dietary Reference Intakes.15,16
vere burn injury.32
Within a row, values with a superscript not sharing a letter are significantly The combination of such antioxidant supplementa-
different (P ⬍ .01). tion appears to decline lipid peroxidation in burned chil-
Journal of Burn Care & Research
Volume 30, Number 5 Barbosa et al 863

Table 3. Clinical characteristics of subjects at baseline and at after 7 d of supplementation

No Supplementation (n ⴝ 15) Antioxidant Supplementation (n ⴝ 17)

Reference
Parameter Values Baseline After 7 d of Study Baseline After 7 d of Study SE

Albumin (g/dL) 2.5–5.5 3.25 ⫾ 0.77 2.75 ⫾ 0.35

a
3.33 ⫾ 0.51 b
3.04 ⫾ 0.38 a c
T
Pre-albumin 20–40 9.97 ⫾ 3.47 9.98 ⫾ 4.77 10.86 ⫾ 2.88 11.32 ⫾ 3.84 NS
(mg/dL)
Hematocrit (%) 32–42 34.21 ⫾ 8.12a 29.35 ⫾ 2.44b 37.75 ⫾ 6.92c 29.65 ⫾ 3.83b,d T
Hemoblobin 10.5–14.0 10.79 ⫾ 3.38 a
9.56 ⫾ 0.65 b
12.66 ⫾ 2.41 c
9.73 ⫾ 1.60b,d T
(mg/dL)
C-reactive protein ⬍6 28.70 ⫾ 22.46 34.56 ⫾ 14.91 36.86 ⫾ 27.39 28.50 ⫾ 24.26 NS
(mg/L)
Urea (mg/dL) 15–40 25.71 ⫾ 6.78 17.50 ⫾ 5.04 20.13 ⫾ 14.17 19.00 ⫾ 6.60 NS
Creatinin 0.4–1.3 0.48 ⫾ 0.17 0.37 ⫾ 0.08 0.61 ⫾ 0.32 0.37 ⫾ 0.13 NS
(mg/dL)
Total Bilirubin ⬍1.5 0.81 ⫾ 0.35 0.74 ⫾ 0.12 0.76 ⫾ 0.09 0.64 ⫾ 0.14 NS
(mg/dL)
White blood cells 4,000–10,000 15,328.57 ⫾ 5,579.64 18,275.00 ⫾ 8,928.09 15,912.50 ⫾ 5,989.38 17,843.06 ⫾ 10,844.76 NS
(p/mm3)
Neutrophils 1,200–6,000 10,845.71 ⫾ 5,896.79 11,441.25 ⫾ 6,837.22 10,237.13 ⫾ 6,433.26 10,754.88 ⫾ 11,545.97 NS
(p/mm3)
Lymphocytes 4,000–6,000 3,995.74 ⫾ 1,783.38 4,214.63 ⫾ 2,243.69 3,390.75 ⫾ 1,693.19 4,805.88 ⫾ 1,932.94 NS
(p/mm3)

The results are represented by means ⫾ SD. Two-way ANOVA conducted after the data transformed in log10 with interaction between groups (no supplementation
group and antioxidant supplementation group) vs time (before vs after supplementation).
Within a row, values with a superscript not sharing a letter are significantly different (P ⬍ .05).
SE, significant effect; S, main effect of supplementation (P ⬍ .01); T, main effect of final-basal by group (P ⬍ .01); I, interaction effects.

dren. Although not significant, TAC levels presented a
low decrease in no supplementation group after 7 days,
whereas the antioxidant-supplemented group main-
tained the same baseline level, which may reflect a
greater intake of antioxidants by supplementation. In
particular, serum vitamin E showed significantly in-
creased levels after supplementation. Considering
that oxidative insult is tightly associated with the
pathophysiologic events observed in burn subjects, it
is not surprising that, despite the relatively high daily-
supplemented doses, vitamin C remained the same or
near the value found at the beginning of supplemen-
tation and also when compared with the subjects
from the no supplementation group. This concentra-
tion is probably reflecting the consumption of nutri-
tional antioxidants either to neutralize the generation
of oxyradicals or to participate in other processes re-
lated to burn healing, as already described by Bertin-
Maghit et al,32 Dissemond et al,33 and revised by
Shepherd.34

Table 4. Baseline and after 7 d values of antioxidants and biomarkers of oxidative stress after antioxidant supplementation

No Supplementation (n ⴝ 15) Antioxidant Supplementation (n ⴝ 17)

Reference
Parameter Values Baseline After 7 d Study Baseline After 7 d Study SE

Vitamin C (mg/dL) 0.4–1.5 0.76 ⫾ 0.35 0.76 ⫾ 0.26 0.59 ⫾ 0.15 0.71 ⫾ 0.37 NS
Vitamin E (mg/dL) 0.3–1.0 0.71 ⫾ 0.30a 0.89 ⫾ 0.36b 0.50 ⫾ 0.18a 1.09 ⫾ 0.53c T, S
Zinc (␮g/dL) 70–150 81.43 ⫾ 29.17 75.20 ⫾ 29.63 70.39 ⫾ 10.20 82.92 ⫾ 17.54 NS
TAC (mmol/L) 1.1–1.2 1.59 ⫾ 0.16a 1.49 ⫾ 0.30a 1.19 ⫾ 0.12b 1.22 ⫾ 0.16b NS
MDA (nmol/mL) Up to 4.8 2.66 ⫾ 1.30a 2.54 ⫾ 1.18a 4.49 ⫾ 1.14b 3.16 ⫾ 0,97c T, S

The results are represented by means ⫾ SD. Two-way ANOVA conducted after the data transformed in log10 with interaction between groups (no supplementation
group and antioxidant supplementation group) vs time (before vs after supplementation).
Within a row, values with a superscript not sharing a letter are significantly different (P ⬍ .05).
SE, significant effect; S, maineffect of supplementation (P ⬍ .01); T, main effect offinal-basal by group (P ⬍ .01); I, interaction effects; TAC, total antioxidant
capacity; MDA, malondialdehyde.

864 Barbosa et al
Figure 1. Number of days needed for wound healing. Val-
ues in mean ⫾ SD. ***P ⬍ .001: statistically significant
difference between groups. Unpaired Student’s t-test.
Interestingly, adult patients from a French hospital
with severe (⬃54% of total burn area) burn injury,29
who were not supplemented with antioxidants micro-
nutrients, showed a persistent and strikingly en-
hanced (roughly 10 –30 times) lipoperoxidation
(thiobarbituric acid reactive substances) levels in
plasma, as well as induced superoxide dismutase ac-
tivity, and also a remarkable depletion of nutritional
antioxidants in plasma, such as ␤-carotene (around
10-fold), lycopene (between 10-fold and 30-fold),
vitamin E (4 –5-fold), and vitamin C (4 –10-fold).
However, no variation in zinc, albumin, and creati-
nine levels was detected.32
Therefore, we believe that the antioxidant supple-
mentation used in patients since the second day of
admittance into the hospital was able to keep lipoper-
oxidation at relatively low levels, and such antioxidant
compensation was performed by the consumption of
vitamins C and E and the trace element zinc.
Zinc and vitamin C are simultaneously immune-
enhancing and anti-inflammatory relevant molecules,
being also important for synthesis in tissue re-
pair.3,9,35 Vitamin E, besides being a scavenger of
oxyradicals, especially the peroxyl radical (LOO●) in
membranes, is endowed with properties concerning
hemorheology and endothelial function, including
prevention of breakdown of lipid membranes and mi-
crovascular barrier.3,4,6 Burn injury is accompanied
by a massive oxyradical overgeneration that causes
distant organ damage, which suggests a direct cause-
effect relationship.36,37
The observed maintenance of the nutritional anti-
oxidant defenses together with a parallel decrease of
lipoperoxidation (MDA levels) attack on lipids, and
also with an additional strengthening of the immune
system and time of wound healing, is probably a con-
sequence of the antioxidant supplementation offered
Journal of Burn Care & Research
September/October 2009
to the burned children. The participation of vitamins
E and C and zinc in the healing process deserves a
special mention, because these nutrients perform a
key role in collagen synthesis, growth, and cell repli-
cation and also in the immune system.38
More importantly, it seems that a time-course de-
cline of antioxidants associated with the increase in
lipoperoxidation occurs after burn injury,36 reinforc-
ing the recommendation of micronutrients therapy
after burn injury.
Vitamin C levels were maintained in treated pa-
tients only, indicating that the basic target of absorp-
tion and systemic replenishment was achieved. A gen-
erous average 900 mg/d was here adopted; therefore,
it is doubtful whether further increased values are
worthwhile. In this regard, there is a concentration
limit in plasma (⬃100 ␮M) for supplementations of
vitamins C and E, irrespective of higher intakes of
both antioxidants.39
Tanaka et al9 successfully administered 66 mg/kg/h
of ascorbic acid in the first 24 hours after burns
(around 11 g for a 70-kg adult), demonstrating no
toxicity together with decreased fluid requirement
probably because of less capillary leakage. Other au-
thors have signaled that to be even more effective,
rapid pool-filling doses for 3 or more days are to be
preferred.4
Vitamin E supplementation apparently reached the
goal as well, but the risk of overdose deserves some
remarks, because an average of not less than 400 mg
was added to the children’s regimen. Two huge car-
diovascular trials have supplemented40,41 a more
modest 300 mg/d to adults, but for periods of up to
5 years, without complications. Nathens et al,15 also
in a study involving adults, used ␣-tocopherol (dl-␣-
tocopheryl acetate) replenishment in amounts com-
parable with this study for up to 28 days without side
effects.
Although not significant, zinc concentration in se-
rum improved after treatment in antioxidant supple-
mentation group but not in controls. An average in-
crement of 7 mg/d was introduced in the diet, and
there is room for more robust utilization.42 Only
massive values in the range of 50 mg/d have been
shown to be immune suppressive in a pneumonia
protocol.43
Agay et al37 showed that early burn injury pro-
motes several changes in trace elements such as zinc,
selenium, and copper, including their mobilization
and reallocation in distinct tissues from rats. Such
changes might be also responsible for changes found
in the activities of antioxidant enzymes that use these
trace elements (superoxide dismutase and glutathi-
one peroxidase).37 Also, high serum levels of copper
Journal of Burn Care & Research
Volume 30, Number 5
might produce an overgeneration of oxyradicals via
the Fenton reaction.
The small number of patients in the series could be
justified by the stringent admission criteria. Unfortu-
nately, this fact, together with the moderate nature of
the thermal trauma, precluded analysis of morbidity
and mortality.
However, there are sufficient reasons to affirm that
the antioxidant molecules here examined in the re-
ported doses were useful for the pediatric burn pop-
ulation and could be safely prescribed, especially con-
sidering the significant decrease found in the period
of wound healing. Further studies are necessary to
refine the prescription with regards to zinc and other
trace elements, to include variables of clinical out-
come, and also to take into consideration more oxi-
dative stress variables, which were lacking in this pre-
liminary protocol.
CONCLUSIONS
The antioxidant supplementation apparently promoted
the maintenance of antioxidant defense against free rad-
ical oxidative stress mediated by burn injury, through
elevated vitamin E contents in plasma, the decrease of
lipoperoxidation (MDA levels), and a significant de-
crease in the time for wound healing. The results here
obtained reinforce the concept that oxidant damage is
involved in burn injuries and that an antioxidant therapy
is beneficial in attenuating such injuries.
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