Zinc reducing diarhhea

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http://www.vitasearch.com/CP/experts/GVGregorioAT09-28-07.htm

Diarrhea and Zinc Supplementation

Germana V. Gregorio, M.D.

Department of Pediatrics

University of the Philippines College of Medicine

Philippine General Hospital

 Taft Avenue, Manila, Philippines

 (632) 524 0892 / (632) 526 0150 (FAX)

germana1@...

“Zinc Supplementation Reduced Cost and Duration of Acute Diarrhea in

Children,”

J Clin Epidemiol, 2007 Jun;60(6):560-6. Epub 2006 Dec 11. 45975 (10/2007)

Kirk Hamilton: Can you please share with us your educational background and

current position?

Germana V. Gregorio: I am a Doctor of Medicine with specialty training in

the field of pediatric gastroenterology. I am presently a Clinical Associate

Professor in the Department of Pediatrics, University of the Philippines

College of Medicine, Philippine General Hospital.

KH:What got you interested in studying the role of zinc and acute diarrhea

in children?

GVG: It is not clear why some episodes of diarrhea persist for a longer

duration in some patients as compared with others but host factors, such as

nutritional deficiencies, which may increase susceptibility to enteric

infections and delay mucosal recovery would be expected to contribute to

this effect. Two well-documented determinants of diarrheal duration are low

weight-for-age and decreased cell-mediated immunity. Common to both of these

factors are zinc deficiency, which is prevalent in children in developing

countries.

KH:What is the biochemistry of zinc that might lead to a resolution in acute

diarrhea?

GVG: Zinc is an essential trace element for humans, being a constituent of

over 200 metalloenzymes. Zinc participates in major metabolic pathways

involving tissue and protein synthesis and turnover, carbohydrates and

energy metabolism, gene expression, embryogenesis and apoptosis. Zinc is

thus essential for growth, sexual maturation and immune function. Zinc

supplementation has been shown to improve immune function and to reduce the

incidence and prevalence of diarrhea among children in developing countries.

Possible roles for zinc include regulation of intestinal water and

electrolyte transport, improvement in the enzymatic function of the brush

borders and enhancement of the repair of the intestinal mucosa, leading to a

decreased duration of diarrhea.

 KH: What were the dose, frequency and type of zinc used? What was the

elemental amount of zinc given daily? Was it given in a liquid or tablet

form? With meals or away from meals?

GVG: The zinc tablets were in the form of zinc sulfate. It contains 20 mg

elemental zinc given once daily for 14 days. The zinc tablets were dissolved

in water or milk before administration or were taken as is by older

children. The tablets were taken 2 hours after food intake.

 KH: Were zinc levels sub-optimal in these children with acute diarrhea? If

so, did those supplemented with zinc and who recovered, have documented

improvement in zinc levels?

GVG: The present study did not measure the zinc levels of the patients

before and after administration. However, previous studies have documented

an improvement in the zinc levels (and a shorter duration of the diarrhea)

after supplementation

  

KH: Can you tell us about your study and the basic results?

GVG: The study included children aged between 2 to 59 months with a history

of diarrhea <7 days duration and no dehydration. Patients were randomized to

either the zinc supplemented or no treatment group. The clinical outcome of

interest was duration of diarrhea. The following data on resources used and

clinical outcomes were obtained during randomization and on follow-ups

during the first and second weeks: (1) direct medical costs (building space,

drugs, diagnostics and professional fees); (2) direct non-medical costs

(out-of-pocket expenditures); (3) indirect cost (salary lost for parents or

caregivers); (4) compliance with medications; and (5) date of cessation of

diarrhea. The mean duration of diarrhea was shorter and the mean total cost

of treatment was 5% cheaper in the zinc treated group than in the no

treatment group. After computing for the cost effectiveness ratio, it was

shown that zinc supplementation as compared to no treatment is more cost

effective in the treatment of acute childhood diarrhea.

KH: Were there any side effects with the zinc therapy? How was the patient

compliance?

GVG: The study did not observe any patient with vomiting after intake of

zinc, which is the known side effect of the drug. In a trial done in Nepal,

it was shown that the relative risk of vomiting increases by 3 to 4 times if

children are given 3 times the RDA (15 and 30 mg) for zinc. In this study,

non-compliance with intake of zinc was defined as < 80% intake of the

recommended dose. This was assessed by counting the number of remaining zinc

tablets during the follow-up visits of the patient and by asking the

caregivers if they had given the zinc tablets to someone else apart from the

study patient. In the study, no patient was considered non-compliant.

KH: In your opinion, should all cases of childhood diarrhea (acute) be

treated with a zinc supplement? How do you determine what dose to give and

who gets treated with zinc?

GVG: It is clear in different studies and in a meta-analysis that zinc

supplementation causes a reduction in the duration of diarrhea. In June

2004, a joint statement made by the WHO and UNICEF advocated the use of zinc

as an adjunctive therapy in acute childhood diarrhea. The WHO recommends

giving 20 mg/day of elemental zinc for 10-14 days in children with diarrhea

but the dose is reduced to 10 mg/day in infants less than 6 months.

KH:What would the savings be in morbidity and mortality from zinc therapy?

GVG: Based on the outcomes that were measured in the trial, it was not

possible to assess the savings in terms of morbidity and mortality from zinc

treatment in acute diarrhea. However, in another study, it was shown that

the mean incremental cost effectiveness ratio was reduced from US$113 to

US$73 per disability adjusted life years (DALY) averted when zinc is given.

KH: Do you have any further comments that you would like to make on this

very practical treatment?

GVG: It is recommended that further studies on cost-effectiveness analysis

of zinc supplementation in acute diarrhea be done using a different costing

method to validate the results of this study. The cost of the present study

was derived from the cost figures of an urban, government, tertiary

hospital. The cost figures of private hospitals or rural, government

hospitals could be used. Likewise, the cost in this study was done from the

society’s perspective. It will be of interest to do an evaluation from the

perspective of the patient or a health maintenance organization.

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