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ORIGINAL ARTICLE
Year : 2014  |  Volume : 27  |  Issue : 4  |  Page : 727-732

Comparative study of the efficiency of zinc integration in acute diarrhea


Department of Pediatrics, Menofiya University, Faculty of Medicine, Menofiya, Egypt

Date of Submission03-Dec-2014
Date of Acceptance03-Apr-2014
Date of Web Publication22-Jan-2015

Correspondence Address:
Nabil A Gad
MenietSammanoud, Aga, Dakahlehia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.149713

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  Abstract 

Objective
The aim of this study was to compare different forms of zinc supplementation in acute diarrhea.
Background
Diarrheal diseases pose a public health problem on a global scale, especially in developing countries. In 2004, zinc and oral rehydration solution (ORS) were recommended by WHO for the treatment of diarrhea.
Materials and methods
This study was conducted on 40 patients with acute diarrhea, who were able to accept oral fluids or feeds (both sexes, aged 3-53 months), hospitalized in the pediatric department of Aga Hospital, between May 2012 and May 2013, and 20 healthy infants/children as controls. The study included three groups: group 1 comprised 20 infants/children with acute diarrhea who received zinc syrup and were rehydrated with ORS only; group 2 comprised 20 infants/children who presented with diarrhea and received zinc incorporated in ORS; and group 3 comprised 20 normal infants/children. Venous blood samples were collected before and after zinc supplementation in groups 1 and 2 and only one sample was collected for control group 3. All patients had some level of dehydration. Colorimetric test for the determination of zinc level in serum was used, and statistical analysis of the data was carried out using Excel for figures and SPSS version 16.
Results
No significant difference was found in the zinc effect between zinc syrup and zinc incorporated in ORS in acute diarrhea treatment. Zinc level in the group that received zinc syrup was 79.7 ± 14.4 and that in the group that received zinc powder was 73.5 ± 13.2.
Conclusion
The study concluded that there was no significant difference in zinc effect between zinc syrup and zinc incorporated in ORS in cases with acute diarrhea.

Keywords: Acute diarrhea, zinc syrup, zinc with oral rehydration solution


How to cite this article:
Elnemr FM, El Lahony DM, Gad NA. Comparative study of the efficiency of zinc integration in acute diarrhea. Menoufia Med J 2014;27:727-32

How to cite this URL:
Elnemr FM, El Lahony DM, Gad NA. Comparative study of the efficiency of zinc integration in acute diarrhea. Menoufia Med J [serial online] 2014 [cited 2020 Feb 17];27:727-32. Available from: http://www.mmj.eg.net/text.asp?2014/27/4/727/149713


  Introduction Top


Diarrheal diseases pose a significant public health problem on a global scale, especially in developing countries. It is estimated that there are 1.5 billion episodes of diarrhea per year and that diarrheal disease accounts for 21% of all deaths in children younger than 5 years. This is equivalent to 2.5 million deaths in the same age group [1].

Studies conducted in the 1950s, 1960s, and 1970s estimated that 4.6 million children died annually from diarrhea [2]. Data from the WHO show that diarrheal disease accounts for 18% of the 10.6 million deaths in children younger than 5 years [3]. Diarrhea was defined as three or more loose stools in a 24-h period or one or more loose stool containing blood. A diarrheal episode was considered new if the episode was preceded by three or more diarrhea-free days [4].

One of the major advances in the reduction of mortality from diarrhea was the introduction of WHO oral rehydration solution (ORS) [5]. However, WHO ORS does not significantly decrease stool output and the duration of diarrhea; therefore, other approaches to add to or enhance the available ORS have been sought. Several newer approaches have included the addition of zinc to the treatment regimen [6]. Zinc is an essential micronutrient and protects cell membranes from oxidative damage. Zinc is not stored in the body, and therefore the level of zinc is determined by the balance of dietary intake, absorption, and losses. Zinc deficiency state may exist in children with acute diarrhea as a result of intestinal loss. A comprehensive review on this subject was recently published [6].

The efficacy of zinc in the treatment of diarrhea shows a reduction in diarrheal duration, stool output, and stool frequency [7]. The efficacy of zinc treatment on diarrhea duration included an improved absorption of water and electrolytes by the intestine and quicker regeneration of gut epithelium [8].


  Materials and methods Top


The study included infants/children of both sexes with acute diarrhea. The patients were hospitalized in the pediatric department of Aga Hospital and presented with some dehydration according to the WHO criteria [9] and were not suffering from vomiting. These patients were divided into three groups.

Group 1 comprised 20 infants/children (eight boys and 12 girls; mean age 24.2 ± 4.4 months) with acute diarrhea who received zinc syrup. The zinc supplement contained zinc sulfate equivalent to 15 mg/5 ml of elemental zinc (aqua ream syrup), 2.5 ml three times daily (22.5 mg zinc/day) for patients aged 6 months or less, and 5 ml three times daily (45 mg zinc/day) for patients older than 6 months. These patients were rehydrated with ORS without zinc (Hydrosafe sachets). Each sachet was dissolved in 200 ml water and the child received it at a dose of 75 ml/kg.

Group 2 comprised 20 infants/children (eight boys and 12 girls; mean age 22 ± 9.7 months) who presented with diarrhea and received ORS with zinc (rehydrozinc sachets in which every sachet contained 11 mg zinc acetate anhydrous). Each sachet was dissolved in 200 ml of water and the child received it at a dose of 75 ml/kg.

Group 3 comprised 20 normal infants/children of matched age and sex who were not suffering from diarrhea.

Children with any gastrointestinal abnormalities, children taking zinc for therapeutic purposes or receiving multivitamins, and malnourished children were excluded from the study.

All infants/children in this study were subjected to full history and clinical examination concentrating on sex, age, weight, temperature (°C), frequency of diarrhea/24 h, total amount of fluids/day (ml), zinc amount/day (mg/dl), and the mean length of hospital stay (day).

Venous blood samples were collected and immediately centrifuged and transported to the laboratory for colorimetric test for the determination of serum zinc level [10]. For groups 1 and 2, two blood samples were collected: the first sample at the time of admission before zinc supplementation, and the second sample at the time of discharge after zinc supplementation, after complete cure (<3 formed stools/day). For group 3, only one venous blood sample was collected and used as control.


  Results Top


The results of this study are illustrated in [Table 1],[Table 2],[Table 3] and [Table 4].
Table 1: Comparison between group 1 and group 2 as regards zinc amount administrated/day (mg)

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Table 2: Comparison between group 1 and group 2 as regards serum zinc level before admission

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Table 3: Comparison between group 1 and group 2 as regards serum zinc level at discharge

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Table 4: Comparison of group 1 and group 2 as regards serum zinc level before admission and serum zinc level at discharge with serum zinc level of the healthy control group 3

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With respect to the demographic data of the studied infants/children, there was no significant difference between group 1, group 2, and group 3 as regards sex, age, and weight. The mean age in groups 1, 2, and 3 was 24.2 ± 14.4, 22 ± 9.7, and 23 ± 10.4 months, respectively. The percentage of boys in groups 1, 2, and 3 was 40, 40, and 70%, respectively. The weight in group 1, group 2, and group 3 was 11.5 ± 3.1, 11.1 ± 2, and 11.6 ± 2 kg, respectively.

In this study there was no significant difference between group 1 and group 2 as regards the stool frequency at admission, temperature (°C), fluid amount consumption/day (ml), and hospital stay (day). The stool frequency at admission was 5.2 ± 0.9 times/day in group 1 and 4.9 ± 0.9 times/day in group 2, with temperature of 38.3 ± 0.6°C in group 1 and 38.1 ± 0.6°C in group 2. Fluid amount consumption/day (ml) was 897.8 ± 252.2 ml in group 1 and 838.5 ± 149 ml in group 2, with hospital stay (days) of 3.9 ± 0.9 in group 1 and 4 ± 1.1 in group 2.

As regards the laboratory investigation in this study, there was no significant difference (P > 0.05) between group 1 and group 2 with respect to zinc amount administrated/day (mg) [Table 1]. Zinc amount administrated/day (mg) was 43.9 ± 5 in group 1 and 46 ± 8.2 in group 2 [Figure 1]. As regards the serum zinc level at admission (mg/dl), there was no significant difference (P > 0.05) between group 1 and group 2 [Table 2]. It was 57.2 ± 18.4 in group 1 and 55.7 ± 20.7 in group 2 [Figure 2].
Figure 1: Zinc amount administrated/day (mg): group 1 = 43.9; group 2 = 46.

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Figure 2: Serum zinc level before admission (μg/dl): group 1 = 57.2; group 2 = 55.7.

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As regards the serum zinc level before discharge (mg/dl), there was no significant difference (P > 0.05) between group 1 and group 2 [Table 3]. It was 79.7 ± 14.4 in group 1 and 73.5 ± 13.2 in group 2 [Figure 3].
Figure 3: Serum zinc level at discharge (μg/dl): group 1 = 79.7; group 2 = 73.5.

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The comparison of group 1 and group 2 as regards serum zinc level before admission and at discharge with the healthy control group 3 (mg/dl) showed low levels in group 1 (57.2 ± 18.4) and group 2 (55.7 ± 20.7) compared with group 3 (95.6 ± 16.2) at the time of admission [Table 4] and [Figure 4] and [Figure 5], which increased to 79.7 ± 14.4 and 73.5 ± 13.2 in group 1 and group 2, respectively, at discharge.
Figure 4: Serum zinc level before admission (μg/dl): group 1 = 57.2; group 2 = 55.7. Serum zinc level in control group 3 = 95.6.

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Figure 5: Serum zinc level at discharge (μg/dl): group 1 = 79.7; group 2 = 73.5. Serum zinc level in control group 3 = 95.6.

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  Discussion Top


Diarrhea remains the second leading cause of death among children under 5 years in the developing world [3]. Zinc for the treatment of diarrhea has been recommended by the WHO and United Nations Children's Fund (UNICEF) since 2004; yet, access to this essential treatment remains limited. When given for 10-14 days during and following the diarrheal episode, zinc has been shown to decrease the duration and severity of the episode [11].

In our study, there was no significant difference (P > 0.05) between the three groups as regards sex, weight, age, temperature, stool frequency/day, total amount of oral fluids consumption/day, and zinc amount/day. As regards the laboratory investigations of this study, the serum zinc level at admission and before zinc treatment in patients with diarrhea in group 1 (zinc syrup) and group 2 (zinc+ORS) was significantly low compared with the control group. There was no significant difference (P > 0.05) between group 1 and group 2 with respect to zinc level at admission, but the level was lower compared with group 3 (the control group), with significant difference (P < 0.05) between groups 1 and 2 and group 3 (the control group), which showed that diarrhea caused a reduction in serum zinc level. The serum zinc level at admission was 57.2 mg/dl in group 1 (zinc syrup) and 55.7 mg/dl in group 2 (zinc+ORS), which was lower compared with group 3 (the control group) (95.6 mg/dl). Fawzi et al. [12] agreed with our study. They found a low serum zinc level (62.5 mg/dl) in diarrheal children at first sample of admission. Another study conducted by Sangita et al. [13] also showed a low serum zinc level at the time of admission of diarrheal children. Baqui et al. [14] also agreed with our study; their study showed low serum zinc in 44% of children at the first blood sample (61.44 mg/dl) compared with healthy controls (65.37 mg/dl), who had lower threshold for zinc deficiency. Arora et al. [15] found that children suffering from acute diarrhea showed a significant decrease of 13.1% in serum zinc level. This level further decreased by 22.6% after treatment with standard ORS therapy compared with normal healthy controls. They recommended zinc supplementation to standard ORS therapy for the reduction in morbidity and mortality associated with acute diarrhea in children. Strand et al. [16] observed a reduction in the mean plasma zinc level by 3.8 mg/dl per degree increase in axillary temperature when they studied the relation between serum zinc level in acute diarrhea and its relation with axillary temperature in 1757 cases of acute diarrhea in 6-35-month-old Nepalese children. In addition, Bhutta et al. [17] found zinc depletion in the body during diarrhea.

As regards serum zinc level at discharge and after zinc treatment in diarrheal children in groups 1 and 2, the level was above admission with no significant difference between the two groups. Serum zinc level increased from 57.2 to 97.7 mg/dl after zinc syrup treatment in group 1 and increased from 55.7 to 73.5 mg/dl in group 2 after zinc+ORS treatment, showing an increase in serum zinc level by zinc treatment. Karamyyar et al. [18] agreed with our study. They showed the beneficial effects of therapeutic zinc supplementation in patients with acute diarrhea and moderate dehydration in Iran. They found increase in serum zinc level after zinc treatment in diarrheal children. Fawzi et al. [12] found that serum zinc level increased from 62.5 mg/dl at first sample at admission to 92.1 mg/dl on the third day after zinc treatment. Abdullah et al. [14] found that serum zinc level increased from 61.44 mg/dl at first sample at admission to 85.6 mg/dl on the third day after zinc treatment. This also agreed with the results of Sangita et al. [13], who showed significant increase in serum zinc on the third day of supplementation with zinc syrup. Arora et al. [15] also found significant elevation of serum zinc level in the zinc-supplemented group. Bahl et al. [19] suggested that zinc supplementation as an adjunct therapy to ORS has beneficial effects on the clinical course of dehydrating acute diarrhea. This was in discordance with the results of Bhatnagar et al. [20], who found that there was failure of elevation in serum zinc level after its administration, although a beneficial effect on the outcome of diarrhea was observed. In addition, Patel et al. [21] reported that the most important predictor for zinc level was the severity of the disease and not the supplementation. In addition, Wadhna et al. [22] found that ORS containing zinc does not reduce the duration or stool volume of acute diarrhea in hospitalized children and showed that study findings do not support a change from using zinc syrup or dispersible tablets for the treatment of acute diarrhea in children.

As regards hospital stay duration, there was no significant difference between group 1 and group 2. The mean hospital stay duration in group 1 was 3.9 days and that in group 2 was 4 days. This was in accordance with the results of Simpson et al. [23] as they found that there was no difference in diarrheal duration between the zinc tablet group and zinc syrup group.

In addition, Simpson et al. [23] found that zinc reduced the duration and frequency of diarrhea in children treated with zinc. This was in discordance with the study by Patel et al. [24], who found that the duration of diarrhea was not different in zinc and placebo groups; the main duration in the zinc group was 4.34 days and that in the placebo group (which received ORS only) was 4.48 days. Bahl et al. [19] also found that there was no significant effect of zinc on diarrheal duration.

As regards serum zinc level at discharge, there was no significant difference (P > 0.05) between group 1 and group 2. The serum zinc level in group 1 was 79.7 mg/dl and that in group 2 was 73.5 mg/dl. This showed that there was equal effectiveness in treating patients with zinc syrup or ORS+zinc. This agreed with the results of Simpson et al. [22], who found that there was no significant difference between different forms of zinc and reported a very high level of satisfaction with zinc treatment, either in tablet or in syrup form. Further, Habib et al. [25] showed that zinc reduces the frequency and improves recovery rates of diarrhea in any form and has better compliance and outcomes with the use of suspension form. Both groups also received WHO-recommended treatment for diarrhea. In this study, the serum zinc level of groups 1 and 2 at discharge was observed to be within normal level but was lower than that of group 3 (the control group), with significant difference (P > 0.05) between groups 1 and 2 and group 3. The serum zinc level in group 3 (the control group) was 95.6 mg/dl compared with 79.7 mg/dl in group 1 and 73.5 mg/dl in group 2. The serum zinc level at discharge in groups 1 and 2 was significantly lower than serum zinc level in the healthy control group 3. This agreed with WHO recommendations about the use of zinc in the treatment of diarrhea. The WHO recommended daily zinc supplements at 20 mg/day for 10-14 days for children with acute diarrhea and 10 mg/day for infants under 6 months to decrease the severity of the episode and prevent further occurrence in the next 2-3 months, thereby decreasing the morbidity [11].


  Conclusion Top


These data confirm that zinc supplementation is useful for treating acute diarrhea in children, with no difference between zinc syrup and zinc incorporated in ORS in terms of effect.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet 2003; 361 :2226-2234.  Back to cited text no. 1
    
2.
Snyder JD, Merson MH. The magnitude of the global problem of acute diarrhoeal disease: a review of active surveillance data. Bull World Health Organ 1982; 60 :605-613.  Back to cited text no. 2
    
3.
Bryce J, Boschi-Pinto C, Shibuya K, Black REWHO Child Health Epidemiology Reference Group. WHO estimates of the causes of death in children Lancet 2005; 365 :1147-1152.  Back to cited text no. 3
    
4.
Baqui AH, Black RE, Arifeen SE, et al. Community randomized trial of zinc supplementation started during diarrhea reduces morbidity and mortality in Bangladeshi children. Br Med J 2002; 325 :1059-1062.  Back to cited text no. 4
    
5.
Claeson M, Merson MH. Global progress in the control of diarrheal diseases. Pediatr Infect Dis J 1990; 9 :345-355.  Back to cited text no. 5
    
6.
Hoque KM, Binder HJ. Zinc in the treatment of acute diarrhea: current status and assessment. Gastroenterology 2006; 130 :2201-2205.  Back to cited text no. 6
    
7.
Bhutta ZA, Bird SM, Black RE, Brown KH, Gardner JM, Hidayat A, et al. Therapeutic effects of oral zinc in acute and persistent diarrhea in children in developing countries: pooled analysis of randomized controlled trials. Am J Clin Nutr 2000; 72 :1516-1522.  Back to cited text no. 7
    
8.
Bettger WJ, O′Dell BL. A critical physiological role of zinc in the structure and function of biomembranes. Life Sci 1998; 28 :1425-1438.  Back to cited text no. 8
    
9.
World Health Organization; WHO. The treatment of diarrhea. A manual for physicians and other senior health workers. World Health Organization; 2005.  Back to cited text no. 9
    
10.
Johnsen O, Eliasson R. Evaluation of a commercially available kit for the colorimetric determination of zinc in human seminal plasma. Int J Androl 1987; 10 :435-440.  Back to cited text no. 10
    
11.
World Health Organization and United Nations Children′s Fund (WHO/UNICEF)Clinical management of acute diarrhea2004World Health Organization and United Nations Children′s Fund, 2004.  Back to cited text no. 11
    
12.
Fawzi H, Fathi S, Hosni A, Ibrhim N. Therapeautic effect of zinc supplementation in children with acute diarrhea. Zagazik Med J 2011; 77-79.  Back to cited text no. 12
    
13.
Sangita S, Rajesh K,Mrukowicz J, et al. Effect of zinc supplementation in children with acute diarrhea: randomized double blind controlled trial. J Pediatr Gastroenterol Nutr 2009; 06-1298.  Back to cited text no. 13
    
14.
Baqui AH, Black RE, Fischer Walker CL, Arifeen S, Zaman K, Yunus M, et al. Zinc supplementation and serum zinc during diarrhea. Indian J Pediatr 2006; 73 :493-497.  Back to cited text no. 14
    
15.
Arora R, Kulshreshtha S, Mohan G, Singh M, Sharma P Estimation of serum zinc and copper in children with acute diarrhea. Biol Trace Elem Res 2006; 114 :121-126.  Back to cited text no. 15
    
16.
Strand TA, Adhikari RK, Chandyo RK, Sharma PR, Sommerfelt H. Predictors of plasma zinc concentrations in children with acute diarrhea. Am J Clin Nutr 2004; 79 :451-456.  Back to cited text no. 16
    
17.
Bhutta ZA, Bird SM, Black RE, Brown KH, Gardner JM, Hidayat A, et al. Therapeutic effects of oral zinc in acute and persistent diarrhea in children in developing countries: pooled analysis of randomized controlled trials. Am J Clin Nutr 2000; 72 :1516-1522.  Back to cited text no. 17
    
18.
Karamyyar M, Gheibi S, Noroozi M, Kord Valeshabad A. Therapeutic effects of oral zinc supplementation on acute watery diarrhea with moderate dehydration: a double-blind randomized clinical trial. Iran J Med Sci 2013; 38 :93-99.  Back to cited text no. 18
    
19.
Bahl R, Bhandari N, Saksena M, Strand T, Kumar GT, Bhan MK, Sommerfelt H Efficacy of zinc-fortified oral rehydration solution in 6-to 35-month-old children with acute diarrhea. J Pediatr 2002; 141 :677-682.  Back to cited text no. 19
    
20.
Bhatnagar S, Bahl R, Sharma PK, Kumar GT, Saxena SK, Bhan MK. Zinc with oral rehydration therapy reduces stool output and duration of diarrhea in hospitalized children: a randomized controlled trial. J Pediatr Gastroenterol Nutr 2004; 38 :34-40.  Back to cited text no. 20
    
21.
Patel AB, Dhande LA, Rawat MS. Therapeutic evaluation of zinc and copper supplementation in acute diarrhea in children: double blind randomized trial. Indian Pediatr 2005; 42 :433-442.  Back to cited text no. 21
    
22.
Wadhwa N, Natchu UC, Sommerfelt H, Strand TA, Kapoor V, Saini S, et al. ORS containing zinc does not reduce duration or stool volume of acute diarrhea in hospitalized children. J Pediatr Gastroenterol Nutr 2011; 53 :161-167.  Back to cited text no. 22
    
23.
Simpson E, Zwisler G, Moodley M. Survey of caregivers in Kenya to assess perceptions of zinc as a treatment for diarrhea in young children and adherence to recommended treatment behaviors. J Glob Health 2013; 3 :010405.  Back to cited text no. 23
    
24.
Patel AB, Dhande LA, Rawat MS. Economic evaluation of zinc and copper use in treating acute diarrhea in children: a randomized controlled trial. Cost Eff Resour Alloc 2003; 1 :7.  Back to cited text no. 24
    
25.
Habib MA, Soofi SB, Bhutta ZA. Effect of zinc in tablet and suspension formulations in the treatment of acute diarrhoea among young children in an emergency setting of earthquake affected region of Pakistan. J Coll Physicians Surg Pak 2010; 20 :837-838.  Back to cited text no. 25
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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