IAP GUIDELINES FOR THE USE OF ZINC IN DIARRHEA
Diarrhea is a major cause of morbidity and mortality in children in developing countries. Many of these children are also malnourished and have associated micro nutrient deficiency (1-3). Children with marginal nutritional status are at significant risk of developing zinc depletion with an episode of diarrhea (4). Castillo-Duran et al have reported that daily losses of zinc in the intestinal fluid during acute diarrhea are as high as 159 µg/kg/day compared with 47 µg in control children (5). Zinc deficiency is known to impair cellular and humoral immune function (6, 7) and zinc supplementation improves immunity (8, 9). Zinc deficiency also has direct effects on the gastrointestinal tract such as impaired intestinal brush border, increased secretion in response to bacterial enterotoxins and perturbations in intestinal permeability (10, 11). Zinc supplementation improves the transport of water and electrolytes across the intestinal mucosa in experimental zinc deficiency (10, 12).
There have been several studies that have shown that use of zinc in treatment of acute diarrhea reduces the episode duration and severity.
ZINC PORTIFIED ORS
A double blind randomized controlled trial in India analysed efficacy of zinc fortified oral rehydration salts solution (ORS) as compared to ORS without zinc in 6 to 35 month old in 1219 children. Total number of stools was lower in the zinc - ORS group (rate ratio: 0.83; 95% Cl, 0.71-0.96) as well as there was less watery stools (odds ratio, 0.61; 95% Cl, 0.39-0.95) as compared to the control group. However, there was no significant effect on diarrheal duration. Children who received zinc syrup had lower diarrheal duration (relative hazard, 0.89; 95% Cl, 0.80-0.99) and decreased total stools (rate ratio, 0.73; 95% Cl, 0.70-0.77) than control children. (Ref: - Bahl R, Bhandari N, Saksena M et al. Efficacy of zinc fortified oral rehydration solution in 6 to 35 month old children with acute diarrhea. Journal Pediatr 2002;141:677-682).
It has been found that these beneficial effects of zinc are not dependent upon the type of zinc salts (22). Also there is no added advantage when commonly used 20 mg of daily dose of elemental zinc is increased to 30-40 mg daily (23, 24). Also zinc fortified ORS does not seem have any additional benefit as compared to plain zinc preparations.
WHO / Unicef Joint Statement
Clinical Management of Acute Diarrhea (2004). The revised recommendations state that in addition to ORS, zinc supplementation should be given for 10-14 days in dose of 20 mg/day (10 mg/day for infants under six months) to curtail the severity of the acute diarrhea and prevent further occurrences in the ensuing 2-3 months (25).
Consensus statement of IAP National Task Force : Status report on Management of Acute Diarrhea (2004) (26).
Zinc Investigators Collaborative Group (2000) (23) have also recommended zinc supplementation as part of routine, standard case management in persistent diarrhea and in those with severe malnutrition.
Cost-effectiveness of zinc supplementation as an adjunct therapy to diarrhea in children.
Robberstad B et al demonstrated that use of zinc as adjunct therapy significantly improved the cost-effectiveness of standard management of diarrhea with particular benefits in mortality rates in non-dysenteric diarrhea (27).
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