education
Burns: modified metabolism and the
nuances of nutrition therapy
Objective: To review the effects of burn injury on nutritional
requirements and how this can best be supported in a
healthcare setting.
Method: A literature search for articles discussing nutrition and/or
metabolism following burn injury was carried out. PubMed, Embase
and Web of Science databases were searched using the key search
terms ‘nutrition’ OR ‘metabolism’ AND ‘burn injury’ OR ‘burns’. There
was no limitation on the year of publication.
Results: A total of nine articles met the inclusion criteria, the
contents of which are discussed in this manuscript.
body composition  ● burn ● metabolism ● nutrients ●  nutrition  ● requirements
T
hermal injuries are responsible for
generating the greatest metabolic response
of any disease process in critically ill
patients. 1 A number of alterations in
inflammatory, immune and endocrine
pathways are initiated upon injury.2 Immune cells are
stimulated to secrete cytokines that can induce an
unstable hypercatabolic state which, if left
unregulated, may lead to multiple organ failure and
systematic inflammatory response syndrome.3
Nutrition practice in burn injury requires a
multifaceted approach aimed at providing metabolic
support during a heightened inflammatory state,
while accommodating surgical and medical needs of
the patient. Nutritional assessment and determination
of nutrient requirements is challenging, particularly
given the metabolic disarray that frequently
accompanies inflammation. Nutritional therapy
*Madeline Houschyar,1 MSc; Mimi R Borrelli,2 MBBS, MSc; Christian Tapking,3,4
MD; Zeshaan N Maan,2 MD; Susanne Rein,5 MD; Malcolm P Chelliah,2 MD;
Clifford C Sheckter,2 MD; Dominik Duscher,2 MD; Ludwik K Branski,3 MD;
Christoph Wallner,7 MD; Bjö Behr,7 MD; Marcus Lehnhardt,7 MD;
Frank Siemers,8 MD; Khosrow S Houschyar,7 MD
*Corresponding author email: madeline_houschyar@gmx.de
1  Institute of Agricultural and Nutrition Sciences, Martin Luther University of Halle-
Wittenberg, Germany.  2  Division of Plastic and Reconstructive Surgery, Department
of Surgery, Stanford School of Medicine, Stanford, US.  3  Department of Surgery,
Shriners Hospital for Children-Galveston, University of Texas Medical Branch,
Galveston, US.  4  Department of Hand, Plastic and Reconstructive Surgery, Burn
Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Germany.
5  Department of Plastic and Hand Surgery, Burn Center, Sankt Georg Hospital,
Leipzig, Germany.  6  Department of Plastic Surgery and Hand Surgery, Technical
University Munich, Munich, Germany.  7  Department of Plastic Surgery and Burn
Centre, BG University Hospital Bergmannsheil GmbH, Ruhr University Bochum,
Bochum, Germany.  8  Department of Plastic and Hand Surgery, Burn Unit, Trauma
Center Bergmannstrost Halle, Germany.
18 4
Conclusion: Thermal injury elicits the greatest metabolic response,
among all traumatic events, in critically ill patients. In order to ensure
burn patients can meet the demands of their increased metabolic
rate and energy expenditure, adequate nutritional support is
essential. Burn injury results in a unique pathophysiology, involving
alterations in endocrine, inflammatory, metabolic and immune
pathways and nutritional support needed during the inpatient stay
varies depending on burn severity and idiosyncratic patient
physiologic parameters.
Declaration of interest: The authors have no conflicts of interest.
requires careful decision making, regarding the safe
use of enteral or parenteral nutrition and the
aggressiveness of nutrient delivery given the severity
of the patient’s illness and response to treatment.4,5
Nutritional support, defined as the provision of vital
and ancillary nutrients to maintain or improve the
patient’s nutritional status and permit wound
healing,6 is essential in the management of burns.7
Treatment protocols should be evidence-based,
originating from clinical and laboratory data.
Severely burned patients have much higher energy
requirements due to the magnitude and duration of
the hypermetabolic response as compared with non-
burned critically ill patients.8 The optimal dietary
parameters, including amount, route and composition,
are still unknown. The objectives of this literature
review are to discuss the effects of burn injury on
nutritional requirements, analyse how this can best be
supported in a healthcare setting and thus provide a
guideline for providing nutritional therapy to severely
burned patients throughout their care.
Methods
Literature search
To identify published articles discussing nutrition and/
or metabolism following burn injury, PubMed, Embase
and Web of Science databases were searched for
publications using the key search terms: ‘nutrition’ OR
‘metabolism’ AND ‘burn injury’ OR ‘burns’. Articles
published in English or German were included in this
© 2020 MA Healthcare ltd
review. There were no limitations regarding the year of
publication. Suitability for inclusion was based on
abstract and title screening. A total of nine publications
were selected for inclusion. The results from these nine
articles are discussed in the following sections.
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Results
A total of 18 publications were examined, of which
only nine met the inclusion criteria. The literature
search was carried out by two authors, the first and last
author. The years 2016–2018 were analysed.
Changes in metabolism and body
composition following severe burn injury
The management of metabolic problems secondary to
major burn injuries is challenging.9 Elevated levels of
catecholamines, corticosteroids, dopamine and
cytokines are indicative of a hypermetabolic
response.10,11 The changes associated with the ‘ebb
phase’ occur within the first 48 hours of a burn injury.
This phase is characterised by decreased cardiac output,
oxygen consumption and metabolic rate, as well as
impaired glucose tolerance and hyperglycaemia.12 This
‘ebb’ phase is followed by an evolving ‘flow’ phase13 in
the weeks following injury.
Enhanced secretion of catecholamines, glucagon,
glucocorticoids and dopamine are closely associated
with an acute hypermetabolic response and the
associated catabolic metabolism, 14 resulting in
tachycardia, hyperthermia, increased caloric
consumption, proteolysis and neoglycogenesis.15
Hyper-metabolism starts approximately on day 5 post-
burn and can persist for up to 24 months. 16 Basal
metabolic rate (BMR) can double and result in extreme
loss of lean body mass.1 Inability to meet the body’s
energy and protein demands can lead to impaired
wound healing, inability to fight infection, organ
dysfunction and ultimately death. 17 The
pathophysiology behind this response remains elusive,
but involves a number of immune modulators
including cytokines, platelet-activating factor,
endotoxin, reactive oxygen species (ROS), nitric oxide
and complement cascade. 18 Additionally, acutely
burned patients have increased intestinal
permeability19 and secondary immunodeficiency,20
making them more susceptible to secondary infections.
Besides the hypermetabolic response, systemic
insulin resistance and altered glucose metabolism is
common following severe burns.21 This can, for
example, lead to alterations in wound healing.22
The hypermetabolic response leads to reductions in
bone and muscle mass. Several studies, especially in
paediatric patients, reported changes of body
composition following burn injury. 23–26 The most
common way to assess body composition in this and
other patient populations is dual X-ray absorptiometry
(DEXA). Cambiaso et al. reported a significant loss of
lean mass in paediatric patients during their stay in an
intensive care unit (ICU), especially in the upper
extremities. Furthermore, an increase of fat mass
© 2020 MA Healthcare ltd
was noticed.23
In long-term observations of paediatric burn
patients, a progressive increase of lean mass was
reported up to 36 months post-injury compared with
lean mass levels at discharge.24 Furthermore, an impact
JOURNAL OF WOUND CARE  VOL 29, NO 3, MARCH 2020
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of severe burn injury on the structure of bones with a
decrease of bone mineral content and bone mineral
density can be seen.26 Following these changes in body
composition, cardiorespiratory fitness often persist
several years after burn, structured programmes to
minimise changes during ICU stays have
been implemented.27
Strategies to attenuate the hypermetabolic response
include environmental management, early excision
and coverage of the burn wounds, nutritional support
and pharmacological management.28 When the skin,
with its major role in thermoregulation, is damaged,
the patient produces more heat (which means a higher
metabolic turnover) to maintain core body
temperature. By increasing the temperature in patient
and treatment rooms and performing early excision
and coverage of the burn wounds using occlusive
wound dressings, the hypermetabolic response can
be attenuated.29,30
Pharmacological modulation also has a critical role
in the management of the hypermetabolic response to
burns. Treatment with a β-adrenergic receptor
blockade, such as propranolol, is efficacious in
lowering heart rate and metabolic rate in the acute and
long-term recovery after burn.31,32 Evidence exists to
support a role for oxandrolone, a testosterone
analogue, in attenuating the hypermetabolic rate in
severely burned children for up to six months after the
injury.33 In addition, the use of insulin to treat
hyperglycaemia showed increased hospital attendance,
increased mortality and reduced bone mass in
paediatric burn patients.22 Metformin, a first-line
medication for the treatment of type 2  diabetes, has
been shown to attenuate hyperglycaemia and increase
muscle protein synthesis in adult burn patients when
compared with placebo-controls.34
Timing of nutritional support
of the severely burned patient
Providing nutrition is essential in the successful
management of the burn patient. The safety and
efficacy of initiating enteral feedings in burn patients
has been established, as is a trend toward decreased
infection rates and decreased calorie deficitis, however,
the optimal timing of initiating nutrition support is
debated.35 The American Burn Association practice
guidelines state that enteral nutrition should begin as
soon as possible, however there is no consensus among
experts regarding the best time to initiate oral/enteral
nutrition.36 Most advocate initiating enteral nutrition
within 24 hours of injury37 and research indicates
starting it six hours post-burn is safe, effective and can
reverse the detrimental metabolic and hormonal shifts.9
In human studies, early enteral nutrition can preserve
blood levels of catecholamines, cortisol and glucagon,
and consequently preserve intestinal mucosal integrity,
as well as its motility and blood flow.38–40
In the acute post-burn phase, patients experience a
state of haemodynamic instability which inhibits
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Table 1. Formulas for calculating nutritional needs in burn cases

Formula Patients Formula

Harris and Benedict Estimated energy requirements:

BMR x activity factor x injury factor
Male 66 + (13.7 x w) + (5 x h) – (6.8 x age)
Female 665 + (9.6 x w) + (1.8 x h) – (4.7 x age)

Activity factor:
Confined to bed: 1.2
Minimal ambulation: 1.3
Injury factor:
<20% TBSA: 1.5
20–40% TBSA: 1.6
>40% TBSA: 1.7

Ireton-Jones Estimated energy requirements:

Spontaneously breathing 629 – (11 x years) + (25 x w) – (609 x O)
Ventilated-dependent 1784 – (11 x years) + (25 x w) + (244 x S) +( 239 x t) + (804 x B)

Toronto For all patients Estimated energy requirements:

[– 4343 + (10.5 x %TBSA) + (0.23 x kcals) + (0.84 x Harris Benedict) + (114 x
T (°C)) – (4.5 x days post-burn) ] x activity factors

Activity factors non-ventilated:

Confined to bed: 1.2
Minimal ambulation: 1.3
Moderate act: 1.4
Ventilated-dependent: 1.2

Schofield (modified) Men: Estimated energy requirements: BMR x injury factor

10–18 years (0.074 x w) + 2.754
18–30 years (0.063 x w) + 2.896
30–60 years (0.048 x w) + 3.653
>60 years (0.049 x w) + 2.459
Women:
10–18 years (0.056 x w) + 2.898
18–30 years (0.062 x w) + 2.036
30–60 years (0.034 x w) + 3.538
>60 years (0.038 x w) + 2.755

Injury factors:
<10% TBSA = 1.2
11–20% TBSA = 1.3
21–30% TBSA = 1.5
31–50% TBSA = 1.8
>50% TBSA = 2.0

ASPEN For all patients 25–35kcal/kg/day

Mayes For children Estimated energy requirements:

Male and female:
<3 years 108 + (68 x w) + (3.9 x %TBSA)
3–10 years 818 + (37.4 x w) + (9.3 x %TBSA)

World Health Organization For children:

Male:
<3 years (60.9 x w) – 54
3–10 years (22.7 x w) + 495
Female
<3 years (61.0 x w) – 51
3–10 years (22.5 x w) + 499

Galveston For children

Male and female:
0–1 year 2100 (BSA) + 1000 (BSA × TBSA)
1–11 years 1800 (BSA) + 1300 (BSA × TBSA)
© 2020 MA Healthcare ltd

12–18 years 1500 (BSA) + 1500(BSA × TBSA)

BMR—Basal metabolic rate; TBSA- total body surface area; w—weight in kg; h—height in cms; age in years; kcals—calorie intake in past 24 hours; Days post burn—the number of
days after the burn injury is sustained using the day itself as day zero; O–obesity (body mass index >27kg/m2); t—body temperature in degree Celcius; S—sex (male=1/female=0); B—
burn diagnosis (present=1/absent=0); BSA—body surface area; Harris Benedict—basal requirements in calories using the Harris Benedict formula with no stress factors or activity
factors; ASPEN—American Society for Parenteral and Enteral Nutrition

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Table 2. Recommended vitamin and trace elements replacement in burns patients*
Element (units)
Vitamin A (IU)
Vitamin C (IU)
Folate (mcg)
Copper (mg)
Selenium (mcg)
Zinc (mcg)
*Adapted from Clark et al. 20179; †administered three times weekly
intestinal motility and can an trigger paralytic ileus,
further contributing to impaired nutrition.41 If some
gastrointestinal function remains, enteral nutrition is
preferred over parenteral nutrition, with guidelines
promoting the use of enteral nutrition as soon as
possible after resuscitation. 36 Enteral nutrition
stimulates and directly nourishes the gastrointestinal
tract, and promotes release of intestinal hormones and
growth factors.42 In humans, enteral nutrition can
help preserve muscle mass and wound healing and
decrease the time patients spend in intensive care.35
Early enteral nutrition dampens the hypermetabolic
state and can reduce the occurrence of paralytic ileus.1
It is advised that enteral nutrition is initiated at a
continuous low flow rate which is gradually increased
to the goal volume at a rate tolerated by each patient.41
Continuous enteral nutrition is preferred over defined
timescales, though data are limited and there is no
conclusive evidence supporting the superiority of
either schedule.9 In the setting of prolonged ileus or
intolerance of enteral nutrition,16 however, parenteral
nutrition becomes necessary. Interestingly, reduced
immune response, impairment of liver function, and
increased mortality were observed when combining
both enteral and parenteral feeding compared with
enteral feeding alone.43
Nutritional evaluation and energy requirements
Nutritional support post-burn aims to supply additional
calories required by patients in their hypermetabolic
state while balancing the risk of overfeeding.9 Without
adequate nutrition, patients are at risk of impaired
immune function, delayed wound healing, increased
risk of infection, prolonged dependency on mechanical
ventilation and heightened mortality risk.16 Conversely,
overfeeding can cause hyperglycaemia, respiratory
system overload, steatosis and hyperosmolarity.16
Various equations have been developed to estimate
nutritional requirements and caloric needs in patients
© 2020 MA Healthcare ltd
with burns using biochemical markers, biometrics and
anthropometry.44 Body mass is considered the easiest
indicator to assess nutritional status.45
Based on the Curreri formula, adult patients should
receive about 25kcal/kg/day plus 40kcal/%total body
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0–13 years ≥13 years
2500–5000 10,000
250–500 1000
1000† 1000†
0.8–2.8 4
60–140 300–500
12.5–25 25–40
surface area (TBSA)/day.8 The requirement for children
is 1800kcal/day plus 2200kcal/m2 burn/day. Ideally,
this calorific intake should be via enteral nutrition.
Harris-Benedict, Ireton-Jones, Toronto, Schofield and
the American Society for Parenteral and Enteral
Nutrition (ASPEN) have all developed formulas to
guide nutritional support in critically ill and burn
patients.46 The most widely used formulas in children
are the Harris-Benedict, Mayes, and World Health
Organization (WHO) formulas (Table 1). These
formulas only act as guides as energy expenditure
fluctuates after burn, and strictly following these
formulas can lead to underfeeding during the periods
of highest energy use and overfeeding later
during recovery.47
The current gold-standard for measuring energy
expenditure is indirect calorimetry.48 The volume of
expired gas and the concentrations of oxygen and
carbon dioxide in inhalation and exhalation are
recorded.49 This enables carbon dioxide production
(VCO2) and oxygen consumption (VO2), therefore, the
metabolic rate to be calculated.50 The respiratory
quotient is the ratio of carbon dioxide produced to
oxygen consumed (VCO2/VO2)51 and is used to detect
overfeeding or underfeeding. The normal metabolism
of mixed substrates yields a respiratory quotient of
0.75–0.90. Overfeeding, characterised by the synthesis
of fat from carbohydrate, results in a respiratory
quotient of >1.0, while in unstressed starvation fat is
used as a major energy source and the consequent
respiratoru quotient is under <0.7.
Indirect calorimetry also allows the resting energy
expenditure to be calculated using the Harris-Benedict
equation. Compared with an isocaloric-isoprotein
high fat enteral diet, a high carbohydrate diet with
82% carbohydrate, 15% protein and 3% fat, stimulates
protein synthesis by increasing endogenous insulin
production, resulting in improved lean body mass
accretion.52 In paediatric burn patients, 1.4 times the
esting energy expenditure (in kcal/m2/day) is needed
to maintain body weight.37 Few clinicians have access
to indirect calorimetry due to its high cost and the
training required, and therefore it is mainly performed
for research.
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Requirements of macronutrients
Metabolism of carbohydrates, proteins, and lipids
provides energy via different pathways.53
Carbohydrates are needed in abundance by burn
patients to provide the glucose required for many
metabolic pathways, promote wound healing, and
spare the use of amino acids as an alternative fuel
source.9,54 A randomised study of 14 severely burned
children found that high-carbohydrate diets resulted in
significantly less muscle protein degradation than high-
fat diet.55 However, the glucose requirement in severely
burned patients may exceed the amount of glucose that
can be safely administered. Severely burned patients
oxidise glucose at a maximum rate of 7g/kg/day,1 and
unmetabolised excess glucose can result in
hyperglycaemia, glycosuria, dehydration, respiratory
failure, or the conversion of glucose to fat.37 In addition,
acute injury can result in hormonal changes which lead
to insulin resistance.
Burn injuries lead to profound stress and
inflammation, which increase levels of catecholamines,
glucocorticoids, glucagon, and dopamine amounting to
a hyperdynamic circulatory response with raised body
temperature and a catabolic state with marked
glycolysis.10 Persistent hyperglycaemia results in insulin
resistance, with insulin release reported to be double
that of healthy patients in response to a glucose load.56
Supplementary insulin can promote wound healing
and muscle protein synthesis in burns patients.57 When
used in combination with a high-carbohydrate, insulin
infusion and high-protein diet site healing, lean body
mass and bone mineral density are all improved, and
length of stay in hospital reduced.58,59
Fat, in small quantities, can improve glucose
tolerance, reduce the volume of total carbohydrates
required,54 and prevent essential fatty acid deficiency.
However, fat is recommended only in limited amounts.60
Lipolysis is suppressed as part of the hypermetabolic
and catabolic response to severe burns, limiting the
degree to which lipids can be used for energy; only 30%
of available free fatty acids are degraded, while the
remainder undergo re-esterification and accumulate in
the liver (steatosis). Fats should comprise a maximum
of 30% of non-protein calories or 1mg/kg/day of
intravenous lipids in total parenteral nutrition. Various
studies have also suggested that increased fat intake
impairs immune function.61,62 As a result, several low-
fat enteral formulas have been created.63
The composition of fat in the diet of burn patients is
also an important consideration. Omega-6 fatty acids
(ω-6 FFAs), like linoleic acid, are metabolised through
the synthesis of arachidonic acid, a precursor of
pro‑inflammatory cytokines such as Prostaglandin E2.
Omega-3 fatty acids (ω-3 FFAs), on the other hand, are
metabolised without generating pro-inflammatory
molecules. In patients with burns, ω-3 FFA-rich diets are
associated with a reduced incidence of hyperglycaemia,
improved inflammatory response and improved
outcomes in general.64 Therefore, immune-enhancing
18 8
diets have a ω6:ω3 ratio closer to 1:1, while most enteral
formulas have a ratio between 2.5:1 and 6:1. The ideal
composition and amount of fat in nutritional support
for patients with burns warrants further investigation
and remains a topic of controversy.
Protein supplementation is essential to meet the
ongoing nutritional demands, maintain lean body
mass, and to supply a substrate for immune function
and wound healing. Increased proteolysis is a hallmark
of the hypermetabolic response to severe burn resulting
in degradation of a 0.2kg of skeletal muscle per day.65
Healthy individuals require 1g/kg/day of protein,66 and
based on in vivo kinetics measuring oxidation rates of
essential and non-essential amino acids, burn patients
are calculated to use 50% more protein per day than
healthy individuals in the fasting state.8,37,67 Protein
requirements are estimated at 1.5–2.0g/kg/day for
adults with burns, and 2.5–4.0g/kg/day for children
with burns.68
Several amino acids are essential to recovery
following burn injury.69 Glutamine, alanine, and
arginine efflux from skeletal muscle and solid organs
following a burn injury,70 and provide a source of
energy for the liver and help in wound healing.71,72
Glutamine helps to maintain the integrity of the small
bowel and to preserve the immune function of the gut
by directly fueling lymphocytes and enterocytes.73
Glutamine also increases the synthesis heat shock
proteins and is as a precursor of glutathione, a critical
antioxidant, which can help to protect cells under
stress.74 The American and European Societies of
Parenteral and Enteral Nutrition (ESPEN) recommend
maximal administration of 0.57g/kg/day of glutamine
can reduce mortality and length of hospitalsation in
burn patients. 75 A recent meta-analysis reported
reduced in-hospitality mortality rates and
complications related to bacteremia with gram-
negative bacteria in patients receiving glutamine
supplementation.76 Evidence also supports arginine
supplements in patients with burns,77 which is
associated with promotion of wound healing and
immune function. Arginine acts to stimulate
T-lymphocytes, augment the function of natural killer
cells and accelerate the synthesis of nitric oxide.78
However, data from non-burn critically ill patients
suggest that arginine can be harmful79 and further
study is warranted before its use can be recommended.
Requirements of micronutrients
A number of vitamins and micronutrients can help to
facilitate wound healing and immune function
following burn6 (Table 2). Severe burns lead to intense
oxidative stress combined with substantial
inflammatory response, which accelerate the depleion
© 2020 MA Healthcare ltd
of endogenous antioxidant defenses. 9 Levels of
vitamins A, C, D, iron, zinc, selenium and calcium can
also drop following burns, which has resultant
detrimental effects on wound healing, the immune
system and skeletal muscle function.81 Vitamin A is
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Table 3. Recommendations for daily micronutrient supplementation*
Micronutrient (dose per day)
Vitamin A (mg/d)
Vitamin C (mg/d)
Vitamin E (mg/d)
Selenium (ug/d)
Zinc (mg/d)
*Adapted from Sriram and Lonchyna80; d—day; PN—parenteral nutrition; EN—enteral nutrition
required for wound healing and epithelial growth.
Vitamin C (also known as ascorbic acid) functions as
an antioxidant and is needed for collagen production
and cross-linking. Vitamin D is essential in the
prevention of further bone catabolism post-burn,
though its exact role and optimal dose after severe
burn remains to be determined. 82 Paediatric burn
patients often have altered calcium and vitamin D
homeostasis83 as well as osteoblast apoptosis, bone
resorption and urinary calcium wasting.84 Additionally,
burned skin can no longer function to activate
vitamin D.3 A study in the paediatric burns population
found that multivitamins containing 400IU of vitamin
D2 did not correct vitamin D insufficiency.84 Methods
to combat calcium and vitamin D deficiency need
further investigation.
Vitamin C
Vitamin C has a fundamental role in the recovery of
patients with burns, related to its role as an electron
donor and a cofactor in the synthesis of collagen,
peptides and catecholamines.85 Following burns, there
is excessive production of ROS.86 ROS contain unpaired
high energy electrons that damage tissue by causing
dysfunction of mitochondria and lipid peroxidation.
These changes cause cell damage and thus increased
vascular permeability, and consequently generation of
ROS are largely responsible for the high fluid
requirements in burns patients.87 Indeed, the generation
of free radicals following burn is proportional to the
severity of injury. Vitamin C reduces ROS and hence
supplies are exhausted in critically ill burns patients.
Administration of ascorbate can lessen morbidity of
burns patients associated with resuscitation of large
volumes of fluid. A randomised controlled trial
demonstrated that high-dose ascorbic acid (66mg/kg
per hour for 24 hours) during the first 24  hours are
associated with a reduction of fluids required
for stabilisation.88
Reflective questions
© 2020 MA Healthcare ltd
● What are the characteristics of patients with burns in nutrition therapy?
● Why do patients with burns lose weight?
● Why is early enteral nutrition important in patients with burns?
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Additional supplementation
PN: 3.5, EN: 8.6
500–3000
PN: 400, EN: 40–1000
100-400
10-30
Trace elements
The trace elements iron (Fe), copper (Cu), selenium (Se),
and Zinc (Zn) play important roles in cellular and humoral
immunity, but are lost in large quantities during burn
wound exudation.89 Selenium is important for cell-
mediated immunity and iron is a cofactor for
oxygen-carrying proteins.9 Zinc is critical for protein
synthesis, wound healing, DNA replication, and
lymphocyte function.90 Copper deficiency has been
implicated in arrhythmias, decreased immunity and
worse outcomes after burn.9 Supplementing these
micronutrients can improve morbidity for severely burned
patients (Table 3). Like vitamin C, copper, selenium and
zinc also have antioxidant activity, and there is evidence
that strengthening the antioxidant defences by replacing
selenium, copper and zinc is beneficial.91 A combination
of copper, selenium and zinc, vitamin C in doses 5–10
times the parenteral nutrition recommended doses added
to the standard multi-micronutrients are provided
intravenously during the first 2–3 weeks and result in
normalisation of antioxidant function.92
Pharmacologic modalities
Current methods of nutritional support, although
perceived to be effective, may fail to replenish all
nutritional deficiencies. Pharmacological nutrition is the
concept whereby nutritional support is ‘tailor made’ for
the specific disease and/or organ involved and involves
administration of two to seven times the usual amounts
of selected normal dietary constituents with reduction of
the remaining components to avoid overfeeding. Dietary
supplementation with pharmacological levels of specific
amino acids and fatty acids, alone or in combination,
can improve immunologic function, reduce the intensity
and number of infections, stimulate the proliferation of
ileal and colonic mucosa, thereby also improving their
barrier functions, and maintain muscle anabolism and
nitrogen balance. Pharmacological nutrition can thus
significantly altering the clinical course of critically ill
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 education
patients.20 According to Häusinger’s hypothesis,
pharmacological nutrition regulates cell hydration.93
Among the nutritional supplements most frequently used
in pharmacological nutrition for patients with burns are
glutamine, arginine and (ω-3) fatty acids.20
Conclusions
Effective assessment and management of nutritional
References
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