Pediatric zinc

FROM DISCOVERY TO DELIVERY Zinc in the management of diarrhoea Dr. B. K. Iyer 3 Mar 2011

The important question for today ,[object Object],3 Mar 2011 ,[object Object],[object Object],[object Object],[object Object],[object Object]

Global Revised Diarrhoea Treatment Strategy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],3 Mar 2011 Source: WHO/UNICEF. Joint statement on the clinical management of acute diarrhea. 2004.

Why changes in ORS formulation? ,[object Object],[object Object],[object Object],[object Object],3 Mar 2011 Source: Kosek et al. Bulletin of the WHO 2003; 81:197-204 ,[object Object],[object Object],[object Object],Standard formulation of ORS New formulation of ORS Sodium 90 MEq/L Sodium 75 mEq/L Osmolarity of 311 mmol/L Osmolarity 245 mmol/L

Why the need to give zinc? ,[object Object],[object Object],3 Mar 2011 ,[object Object],[object Object],[object Object],[object Object],[object Object]

Zinc deficiency regions 3 Mar 2011 Hotz & Brown. Food Nutr Bull 2004. < 14.9% < 15-24.9% > 25%

Zinc deficiency outcomes ,[object Object],3 Mar 2011 ,[object Object],[object Object],[object Object]

Zinc in diarrhoea management ,[object Object],[object Object],[object Object],3 Mar 2011 Source: Kosek et al. Bulletin of the WHO 2003; 81:197-204 ,[object Object],[object Object],[object Object],[object Object]

Zinc in diarrhoea management - trials 3 Mar 2011 13 trials in acute diarrhoea 5 trials in persistent diarrhoea Age groups = 3 to 60 months Trials evaluating the therapeutic effect of zinc supplementation on acute diarrhoea have been subjected to a meta-analysis Hospital based studies Community based studies Studies in which Zinc was mixed with ORS Additional studies on zinc supplementation in acute diarrhoea have been divided in 3 groups

Zinc in diarrhoea management - role ,[object Object],[object Object],3 Mar 2011 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Zinc in diarrhoea management-outcome 3 Mar 2011 Recovery from diarrhoea Continuation of diarrhoea for >7 days Stool volume / frequency Morbidity / Mortality Outcomes of Zinc interventions in diarrhoea have been studies on the following parameters

Evidence-based interventions ,[object Object],[object Object],[object Object],[object Object],[object Object],3 Mar 2011 The Zinc Investigators Collaborative Group: Therapeutic effects of oral Zinc in acute and persistent diarrhea in children in developing countries: Pooled analysis and randomized controlled trials. Am J Clin Nut 2000; 72:1516-22

Zinc in acute diarrhoea 3 Mar 2011 Effect on recovery Study No. of subjects Relative Hazards (95% CI) Sazawal, 1995 931 0.79 (0.69, 0.90)* Hidayat, 1998 1368 0.92 (0.83, 1.02) Roy, 1997 101 0.85 (0.57, 1.28) Strand, 2002 891 0.79 (0.68, 0.93)* Bahl, 2002 805 0.89 (0.80, 0.99)* Baqui, 2002 1252 0.75 (0.65, 0.90)* Bhatnagar, 2004 266 0.76 (0.59, 0.97)* Combined estimate (Meta-analysis) 0.84 (0.78 to 0.89)*

Zinc in acute diarrhoea 3 Mar 2011 Effect on continuation > 7 days Study No. of subjects Odds ratio (95% CI) Sazawal, 1995 931 0.85 (0.60, 1.19) Hidayat, 1998 1368 0.72 (0.48, 1.07) Roy, 1997 101 0.77 (0.33, 1.79) Strand, 2002 891 0.57 (0.38, 0.86)* Bahl, 2002 805 0.61 (0.33, 1.12) Bhatnagar, 2004 266 0.09 (0.01, 0.73)* Combined estimate (Meta-analysis) 0.66 (0.52 to 0.83)*

Zinc in acute diarrhoea 3 Mar 2011 Effect on stool frequency Study No. of subjects Difference in means/ Rate ratio(95% CI) Sazawal, 1995 931 -2.0 (-3.6, -0.4)* Sachadev, 1988 50 -1.7 (-4.1, 0.7)* Cuevas, 2001 74 -5.9 (-9.5, -2.3)* Strand, 2002 891 0.91 (0.85, 0.97)* Bahl, 2002 805 0.73 (0.63, 0.84)*

Zinc in acute diarrhoea 3 Mar 2011 Effect on stool volume Study No. of subjects Difference in means/ Ratio of GM(95% CI) Roy, 1997 101 -91g Dutta, 2000 80 -900 (-1200, -590)* Bhatnagar, 2004 266 0.69 (0.48, 0.99)*

Zinc in acute diarrhoea [for 14 days] 3 Mar 2011 Effect on mortality and hospitalization Study Intervention Controls Rate Ratio (95% CI) Child-years of follow up 5866 6015 0.49 (0.25 to 0.94)* Diarrhoea hospitalizations 8.15 10.34 0.76 (0.59 to 0.98)* ALRI hospitalizations 5.05 5.99 0.81 (0.53 to 1.23) Baqui et al, 2002

Zinc in acute diarrhoea [community based trial] ,[object Object],[object Object],[object Object],[object Object],3 Mar 2011

Zinc in diarrhoea [community based efficacy studies] ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],3 Mar 2011

Zinc add-vantages ,[object Object],[object Object],3 Mar 2011 Source: BMJ VOLUME 325 9 NOVEMBER 2002 Indicated for diarrhea, regardless of duration or type (acute or persistent; bloody or watery) Reduces mortality in children Reduces admissions to hospitals for diarrhoea

Zinc bonus advantages ,[object Object],[object Object],3 Mar 2011 Source: BMJ VOLUME 325 9 NOVEMBER 2002 34% reduction in incidence of diarrhoea 26% reduction the incidence of pneumonia

Zinc – specifications for use in diarrhoea ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],3 Mar 2011

Zinc – specifications for use in diarrhoea ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],3 Mar 2011 Source: BMJ VOLUME 325 9 NOVEMBER 2002

Zinc in diarrhoea- questions that need answers ,[object Object],3 Mar 2011 Source: BMJ VOLUME 325 9 NOVEMBER 2002 ,[object Object],[object Object],[object Object],[object Object],[object Object],Yes Yes Yes Yes

Zinc in diarrhoea- questions that need answers ,[object Object],[object Object],[object Object],3 Mar 2011 Source: BMJ VOLUME 325 9 NOVEMBER 2002 ,[object Object],[object Object]

Zinc in diarrhoea- questions that need answers ,[object Object],3 Mar 2011 Source: BMJ VOLUME 325 9 NOVEMBER 2002 ,[object Object],[object Object]

Zinc in diarrhoea- questions that need answers ,[object Object],3 Mar 2011 Source: BMJ VOLUME 325 9 NOVEMBER 2002 ,[object Object],[object Object],[object Object]

Zinc in diarrhoea- questions that need answers ,[object Object],3 Mar 2011 Source: BMJ VOLUME 325 9 NOVEMBER 2002 Yes, but studies have revealed that efficacy does not remain the same and hence there is no combination of the 2.

Zinc in diarrhoea- questions that need answers ,[object Object],3 Mar 2011 Source: BMJ VOLUME 325 9 NOVEMBER 2002 ,[object Object],[object Object],[object Object],Source: WHO/UNICEF JOINT STATEMENT - CLINICAL MANAGEMENT OF ACUTE DIARRHOEA, MAY 2004

Zinc in diarrhoea- questions that need answers ,[object Object],3 Mar 2011 Source: BMJ VOLUME 325 9 NOVEMBER 2002 Studies show that - To enable the "protective" benefit of Zinc on preventing future episodes for 2 to 3 months. it is important to insist on compliance for 10 to 14 days therapy. Source: WHO/UNICEF JOINT STATEMENT - CLINICAL MANAGEMENT OF ACUTE DIARRHOEA, MAY 2004

Probiotics and zinc in infantile diarrhoea ,[object Object],[object Object],3 Mar 2011 Source: Journal of the American College of Nutrition, Vol. 24, No. 5, 370-375 (2005)

Conclusions ,[object Object],[object Object],[object Object],3 Mar 2011 Source: Robberstad, Strand, Sommerfelt, and Black. Bull WHO 2004. Baqui, Black, Arifeen. J Health Pop Nutr (In Press).

Conclusions ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],3 Mar 2011

References ,[object Object],[object Object],[object Object],[object Object],[object Object],3 Mar 2011

References ,[object Object],[object Object],[object Object],[object Object],3 Mar 2011

References ,[object Object],[object Object],[object Object],3 Mar 2011

Pediatric zinc

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