Oral zinc for treating diarrhoea in children

Effect of probiotics plus zinc supplementation on clinical outcomes of infants and children with acute infectious diarrhea: a randomized controlled trial

BACKGROUND

Findings are conflicting regarding the effect of zinc supplementation on disease severity in children with acute gastroenteritis.

PURPOSE

To examine the effects of probiotics and zinc on the clinical outcomes of infants and children with acute infectious diarrhea.

METHODS

In this randomized controlled trial, children with mild or moderate to severe acute gastroenteritis in the Kurdistan Region from November 2021 to June 2022 were diagnosed clinically and randomly assigned to the experimental or control group. The experimental group (n=50) received probiotics and zinc, whereas the control group (n=51) received probiotics alone for 1 week. The product contained live Bifidobacterium infantis, Lactobacillus paracasei, and Lactobacillus rhamnosus (10×106 colony-forming units/day for 7 days). Zinc syrup was administered to the probiotic plus zinc group. Each 5 mL of syrup contained 15 mg of zinc sulfate. Dehydration and disease severity in both groups were measured using the Clinical Dehydration Scale and the Modified Vesikari Scale, respectively. An illness episode was defined as an episode of gastroenteritis with a total score of ≥9 on the Modified Vesikari Scale (range, 0-20).

RESULTS

The probiotic and probiotic plus zinc groups were similar in age (1.79 years vs. 1.69 years, respectively; P= 0.645), sex (male/female ratio: 1.43 and 1.0, respectively; P=0.373), and medical characteristics. The groups had similar mean dehydration and disease severity scores and a similar incidence of dehydration recovery (some dehydration, 3.92% and 4.00%, respectively; P=1.000), and recovery from mild gastroenteritis (0.0% and 2.0%, respectively; P=0.495) at 2 weeks. Significant decreases in mean dehydration severity and disease severity score (1.80 to 0 and 6.66 to 0, respectively; P<0.001) and the development of dehydration (some dehydration, from 94.0% to 4.0%; P<0.001) from baseline to 2 weeks were noted in the probiotics plus zinc group. The probiotics group responded similarly. The development of mild gastroenteritis was significantly reduced from baseline to 2 weeks (90.2% to 0% and 78.0% to 2.0% in the probiotics and probiotics plus zinc groups, respectively; P<0.0001). The probiotics plus zinc group had a shorter mean recovery time (1.34 days vs. 2.00 days, respectively; P<0.001).

CONCLUSION

Taking probiotics plus zinc did not significantly affect disease severity in children with gastroenteritis at 2 weeks. However, the probiotics plus zinc group recovered more quickly than the probiotics group.

Preventing and Controlling Zinc Deficiency Across the Life Course: A Call to Action

Through diverse roles, zinc determines a greater number of critical life functions than any other single micronutrient. Beyond the well-recognized importance of zinc for child growth and resistance to infections, zinc has numerous specific roles covering the regulation of glucose metabolism, and growing evidence links zinc deficiency with increased risk of diabetes and cardiometabolic disorders. Zinc nutriture is, thus, vitally important to health across the life course. Zinc deficiency is also one of the most common forms of micronutrient malnutrition globally. A clearer estimate of the burden of health disparity attributable to zinc deficiency in adulthood and later life emerges when accounting for its contribution to global elevated fasting blood glucose and related noncommunicable diseases (NCDs). Yet progress attenuating its prevalence has been limited due, in part, to the lack of sensitive and specific methods to assess human zinc status. This narrative review covers recent developments in our understanding of zinc's role in health, the impact of the changing climate and global context on zinc intake, novel functional biomarkers showing promise for monitoring population-level interventions, and solutions for improving population zinc intake. It aims to spur on implementation of evidence-based interventions for preventing and controlling zinc deficiency across the life course. Increasing zinc intake and combating global zinc deficiency requires context-specific strategies and a combination of complementary, evidence-based interventions, including supplementation, food fortification, and food and agricultural solutions such as biofortification, alongside efforts to improve zinc bioavailability. Enhancing dietary zinc content and bioavailability through zinc biofortification is an inclusive nutrition solution that can benefit the most vulnerable individuals and populations affected by inadequate diets to the greatest extent.

Protocol of the study: the effectiveness of pleuran in the treatment of acute gastroenteritis in children-a randomised, placebo-controlled, double-blind trial (EPTAGE)

INTRODUCTION

Acute gastroenteritis is one of the most common causes of children's morbidity and mortality globally. Oral or intravenous rehydration was proven effective in reducing the mortality rates in acute gastroenteritis, although it does not affect the course of the disease. Attempts to identify new therapeutic methods effective in reducing the symptoms of diarrhoea are of interest. Pleuran's potential immunomodulatory effect in acute gastrointestinal infection relies on the stimulation of innate immunity. The effectiveness of pleuran (β-(1,3/1,6)-d-glucan) administration to treat acute infectious diarrhoea remains unknown. This study evaluates the efficacy of pleuran in reducing diarrhoea duration and the severity of acute gastroenteritis symptoms in children.

METHODS AND ANALYSIS

Our study is a randomised, double-blind, placebo-controlled superiority trial with two parallel groups and a 1:1 allocation ratio. A total of 120 children aged 2-10 years hospitalised or requiring a visit to the emergency department because of acute gastroenteritis will be randomly assigned to receive either pleuran oral suspension in the experimental group or matching placebo in the control group. The primary outcome measure will be the duration of diarrhoea. We will analyse the results in both intention-to-treat and per-protocol approaches.

ETHICS AND DISSEMINATION

The Bioethics Committee of The Medical University of Warsaw approved the study protocol (approval number: KB/45/2018). Written informed consent of the patients' caregivers participating in the study will be obligatory. The results of this study will be published in a medical journal, regardless of whether they confirm or deny the research hypothesis.

TRIAL REGISTRATION NUMBER

NCT03988257; Pre-results.

Association of nutritional support programs with zinc deficiency in Colombian children: a cross-sectional study

Background

Zinc is an essential trace element that plays a key role in the immune, gastrointestinal, respiratory and nervous systems. In Colombia, a vast percentage of children live in low-income households with food insecurity and nutritional deficiencies, including zinc. In an effort to improve children’s well-being, public health measures such as nutritional support programs that provide meals have targeted the poorest populations. The aim of the present study was to assess the role of nutritional support programs on zinc deficiency in Colombian children, while considering their wealth and food security.

Methods

Cross-sectional study using data from the 2010 Colombian National Nutrition Survey, a population-based study representative of Colombia. A total of 4275 children between 12 and 59 months of age were included in the study. Stepwise logistic regressions were modelled with SPSS, first for zinc deficiency on wealth and food security, then adding enrolment in a nutritional support program, and finally, adjusting for socio-demographic variables.

Results

A zinc deficiency prevalence of 49% was found. The adjusted models showed an association of wealth quintiles: very poor (OR = 1.48) and poor (OR = 1.39), food security (OR = 0.75) and enrolment in a nutritional support program (OR = 0.76) with zinc deficiency. Enrolment in nutritional programs did not modify the relationship of wealth and food security to zinc deficiency.

Conclusion

Zinc deficiency is associated with wealth, food security and enrolment in nutritional support programs. Nutritional programs may be a good alternative against zinc deficiency, if they focus appropriately on the needs of children according to their wealth and food security.

Examining the effectiveness of zinc treatment in children admitted with diarrhoea in Kenya's public hospitals: an observational comparative effectiveness study

Background

Kenyan paediatric treatment protocols recommend the use of zinc supplement for all children with diarrhoea. However, there is limited evidence of benefit for young children aged 1-5 months and those who are well-nourished. We examine effectiveness of zinc supplementation for children admitted with diarrhoea to Kenya’s public hospitals with different nutritional and age categories. This is to determine whether the current policy where zinc is prescribed for all children with diarrhoea is appropriate.

Methods

We explore the effect of zinc treatment on time to discharge for children aged 1-5 and 6-59 months and amongst those classified as either severely – moderately under-nourished or well-nourished. To overcome the challenges associated with non-random allocation of treatments and missing data in these observational data, we use propensity score methods and multiple imputation to minimize bias.

Results

The analysis included 1645 (1-5 months) and 11 546 (6-59 months) children respectively. The estimated sub-distribution hazard ratios for being discharged in the zinc group vs the non-zinc group were 1.25 (95% confidence interval (CI) = 1.07, 1.46) and 1.17 (95% CI = 1.10, 1.24) in these respective age categories. Zinc treatment was associated with shorter time to discharge in both well and under-nourished children.

Conclusion

Zinc treatment, in general, was associated with shorter time to discharge. In the absence of significant adverse effects, these data support the continued use of zinc for admissions with diarrhoea including those aged 1-5 months and in those who are well-nourished.

Impact of Two Forms of Daily Preventive Zinc or Therapeutic Zinc Supplementation for Diarrhea on Hair Cortisol Concentrations Among Rural Laotian Children: A Randomized Controlled Trial

Zinc supplementation has been shown to reduce the morbidity burden among young children, and may reduce chronic stress. Hair cortisol has been promoted as an indicator of chronic stress. We assessed the impact of different strategies for delivering supplementary zinc on hair cortisol concentrations (HCC) in young Laotian children and examined risk factors associated with HCC. In a randomized double-blind controlled trial (NCT02428647), children aged 6⁻23 mo were randomized to one of four intervention groups and followed for ~36 weeks: daily preventive zinc (PZ) tablets (7 mg/day), daily multiple micronutrient powder (MNP) sachets (containing 10 mg zinc and 14 other micronutrients), therapeutic zinc (TZ) supplements for diarrhea treatment (20 mg/day for 10 days) or daily placebo powder. HCC of 512 children was assessed at baseline and endline. ANCOVA and linear regression models were used to assess group differences in HCC and to examine the risk factors associated with HCC, respectively. At enrollment, mean HCC was 28.8 ± 43.9 pg/mg. In models adjusted for age at enrollment, health district, and baseline HCC there was no overall effect of the interventions on endline HCC and change in HCC. When controlling for additional predetermined covariates, there was a marginally significant effect on change in HCC (p = 0.075) with a slightly lower reduction of HCC in TZ compared to PZ (mean change (95% CI): -4.6 (-7.0; -2.3) vs. -9.4 (-11.7; -7.0) pg/mg; p = 0.053). At baseline, consumption of iron rich foods was negatively associated with HCC, whereas AGP (α1-acid glycoprotein) levels, elevated AGP and C-reactive protein and high soluble transferrin receptor were positively associated with HCC. In young Laotian children, MNP, PZ and TZ had no impact on HCC. The marginal difference in change in HCC between the PZ and TZ groups was too small to be considered of health significance.

Importance of zinc for the human body in the aspect of zinc supplementation

Cynk jest jednym z głównych pierwiastków śladowych organizmu, spełniającym rolę katalityczną, strukturalną i regulacyjną. Jest niezbędny do podziałów komórkowych i różnicowania powstających komórek, uczestniczy w homeostazie, reakcjach odpornościowych, w apoptozie i starzeniu się organizmu. Cynk jest również składnikiem wielu enzymów i białek oraz odgrywa ważną rolę w spermatogenezie i syntezie hormonów steroidowych. Niedostateczna podaż cynku dotyczy ok. 30% ludności świata. Oprócz niedostatecznej podaży z pokarmem, przyczyną niedoboru cynku mogą być niektóre schorzenia oraz nieprawidłowe wchłanianie tego pierwiastka. Schorzenia, wynikające z niedoboru tego pierwiastka, mogą występować zarówno u dzieci, jak i dorosłych. Suplementacja diety preparatami cynku w wielu przypadkach jest niezbędna, jednak samodzielne jego stosowanie, bez stwierdzonego niedoboru i bez konsultacji z lekarzem, może doprowadzić do występowania działań niepożądanych w wyniku jego nadużywania, w tym także niebezpiecznych interakcji z innymi stosowanymi preparatami i żywnością.

Oral zinc for treating diarrhoea in children

BACKGROUND

In developing countries, diarrhoea causes around 500,000 child deaths annually. Zinc supplementation during acute diarrhoea is currently recommended by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF).

OBJECTIVES

To evaluate oral zinc supplementation for treating children with acute or persistent diarrhoea.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (the Cochrane Library 2016, Issue 5), MEDLINE, Embase, LILACS, CINAHL, mRCT, and reference lists up to 30 September 2016. We also contacted researchers.

SELECTION CRITERIA

Randomized controlled trials (RCTs) that compared oral zinc supplementation with placebo in children aged one month to five years with acute or persistent diarrhoea, including dysentery.

DATA COLLECTION AND ANALYSIS

Both review authors assessed trial eligibility and risk of bias, extracted and analysed data, and drafted the review. The primary outcomes were diarrhoea duration and severity. We summarized dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD) with 95% confidence intervals (CI). Where appropriate, we combined data in meta-analyses (using either a fixed-effect or random-effects model) and assessed heterogeneity.We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

Thirty-three trials that included 10,841 children met our inclusion criteria. Most included trials were conducted in Asian countries that were at high risk of zinc deficiency. Acute diarrhoeaThere is currently not enough evidence from well-conducted RCTs to be able to say whether zinc supplementation during acute diarrhoea reduces death or number of children hospitalized (very low certainty evidence).In children older than six months of age, zinc supplementation may shorten the average duration of diarrhoea by around half a day (MD -11.46 hours, 95% CI -19.72 to -3.19; 2581 children, 9 trials, low certainty evidence), and probably reduces the number of children whose diarrhoea persists until day seven (RR 0.73, 95% CI 0.61 to 0.88; 3865 children, 6 trials, moderate certainty evidence). In children with signs of malnutrition the effect appears greater, reducing the duration of diarrhoea by around a day (MD -26.39 hours, 95% CI -36.54 to -16.23; 419 children, 5 trials, high certainty evidence).Conversely, in children younger than six months of age, the available evidence suggests zinc supplementation may have no effect on the mean duration of diarrhoea (MD 5.23 hours, 95% CI -4.00 to 14.45; 1334 children, 2 trials, moderate certainty evidence), or the number of children who still have diarrhoea on day seven (RR 1.24, 95% CI 0.99 to 1.54; 1074 children, 1 trial, moderate certainty evidence).None of the included trials reported serious adverse events. However, zinc supplementation increased the risk of vomiting in both age groups (children greater than six months of age: RR 1.57, 95% CI 1.32 to 1.86; 2605 children, 6 trials, moderate certainty evidence; children less than six months of age: RR 1.54, 95% CI 1.05 to 2.24; 1334 children, 2 trials, moderate certainty evidence). Persistent diarrhoeaIn children with persistent diarrhoea, zinc supplementation probably shortens the average duration of diarrhoea by around 16 hours (MD -15.84 hours, 95% CI -25.43 to -6.24; 529 children, 5 trials, moderate certainty evidence).

AUTHORS' CONCLUSIONS

In areas where the prevalence of zinc deficiency or the prevalence of malnutrition is high, zinc may be of benefit in children aged six months or more. The current evidence does not support the use of zinc supplementation in children less six months of age, in well-nourished children, and in settings where children are at low risk of zinc deficiency.

The effectiveness bundling of zinc with Oral Rehydration Salts (ORS) for improving adherence to acute watery diarrhea treatment in Ethiopia: cluster randomised controlled trial

BACKGROUND

Presumably bundling/co-packaging of zinc with ORS encourages the combined use of the products for diarrhea treatment; however, empirical evidences are scarce. The purpose of this work is to evaluate whether co-packing using a plastic pouch can enhance the joint adherence to the treatment or not. The study also compares the cost effectiveness (CE) of two co-packaging options: 'central' and 'health center (HC)' level bundling.

METHODS

This cluster-randomised controlled trial was conducted in 2015 in eight districts of Ethiopia. Thirty two HCs were randomly assigned to one of the following four intervention arms: (i) 'Central bundling' (zinc and ORS bundled using a pouch that had instructional message, distributed to HCs); (ii) 'HC level bundling' (zinc, ORS and a similar pouch distributed to the HCs and bundled by health workers); (iii) 'Bundling without message' (zinc, ORS and plain pouch distributed and bundled by the health workers); and, (iv) 'Status quo' (zinc and ORS co-administered without bundling). In each of the four arms, 176 children 6-59 months of age, presented with acute diarrhea were enrolled. Twelve days after enrollment, level of adherence was assessed. A composite scale of adherence was developed and modeled using mixed effects linear regression analysis. The unit costs associated with the arms were estimated using secondary data sources. Incremental CE analysis was made by taking the cost and level of adherence in fourth arm as a base value.

RESULTS

The follow-up rate was 95.6 %. As compared with the 'status quo' arm, the joint adherences in the 'central' and 'HC level' bundling arms raised substantially by 14.8 and 15.7 percentage points (PP), respectively (P < 0.05). No significant difference was observed between 'bundling without message' and the 'status quo' arms. The unit cost incurred by the 'central bundling' is relatively higher (USD 0.658/episode) as compared with the 'HC level bundling' approach (USD 0.608/episode). The incremental CE ratio in the 'central bundling' modality was two times higher than in the 'HC based bundling' approach.

CONCLUSION

Bundling zinc with ORS using a pouch with instructional messages increases adherence to the treatment. 'HC level bundling' is more CE than the 'central bundling' approach.

Effect of vitamin A and Zn supplementation on indices of vitamin A status, haemoglobin level and defecation of children with persistent diarrhea

To investigate the effect of vitamin A and Zn supplementation on vitamin A status, haemoglobin level and defecation of children with persistent diarrhea, a total of 160 paediatric patients were randomly assigned to one of four intervention groups: daily supplementation of 1,500 IU VA for 14 days; daily Zn supplementation for 14 days; daily supplementation with both VA and Zn for 14 days; no supplementation. One hundred twenty-seven children with persistent diarrhea finished intervention (33 were lost to follow-up). Among the 127 children, 41 (32.28%) had anaemia, 104 (81.89%) had a VA deficiency and 38 (29.92%) had an iron insufficiency. Supplementation with VA or VA + Zn enhanced the serum VA levels and ameliorated anaemia. Supplementation with Zn and VA + Zn for 5 days significantly improved defecation, where the VA + Zn treatment resulted in superior outcomes. After 14 days of intervention, the total effectiveness rates were 93.94%, 96.77% and 96.67% in the three groups, significantly greater than that of the non-supplementation group (72.73%). These results indicate that single VA or concurrent VA + Zn supplementation can improve vitamin A status, haemoglobin level and defecation. However, concurrent VA + Zn supplementation is the optimal option and can shorten the duration of persistent diarrhea and markedly improve nutritional status. (www.clinicaltrials.gov registration number: ChiCTR-IOR-14005498)

Zinc supplementation for the treatment of measles in children

BACKGROUND

Measles is still an important cause of childhood morbidity and mortality globally, despite increasing vaccine coverage. Zinc plays a significant role in the maintenance of normal immunological functions, therefore supplements given to zinc-deficient children will increase the availability of zinc and could reduce measles-related morbidity and mortality.

OBJECTIVES

To assess the effects of zinc supplementation in reducing morbidity and mortality in children with measles.

SEARCH METHODS

We searched CENTRAL (2014, Issue 5), MEDLINE (1946 to June week 3, 2014), EMBASE (1974 to June 2014), CINAHL (1981 to June 2014), LILACS (1982 to June 2014), Web of Science (1985 to June 2014) and BIOSIS Previews (1985 to June 2014). We also searched ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) to identify unpublished and ongoing studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs evaluating the effects of zinc in reducing morbidity and mortality in children with measles.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the studies for inclusion and extracted data on outcomes, details of the interventions and other study characteristics using a standardised data extraction form. We used the risk ratio (RR) and hazard ratio as measures of effect with 95% confidence intervals (CI). We included only one study and we did not conduct any meta-analysis.

MAIN RESULTS

One RCT met our inclusion criteria. The study was conducted in India and included 85 children diagnosed with measles and pneumonia. The trial showed that there was no significant difference in mortality between the two groups (risk ratio (RR) 0.34, 95% confidence interval (CI) 0.01 to 8.14). Also, there was no significant difference in time to absence of fever between the two groups (hazard ratio (HR) 1.08, 95% CI 0.67 to 1.74). No treatment-related side effects were reported in either group. The overall quality of the evidence can be described as very low.

AUTHORS' CONCLUSIONS

We cannot draw any definite conclusions from this review about the effects of zinc supplementation on clinical outcomes of children with measles due to the very low quality of the evidence available. There is insufficient evidence to confirm or refute the effect of zinc supplementation in measles.

Severe acute malnutrition and infection

Severe acute malnutrition (SAM) is associated with increased severity of common infectious diseases, and death amongst children with SAM is almost always as a result of infection. The diagnosis and management of infection are often different in malnourished versus well-nourished children. The objectives of this brief are to outline the evidence underpinning important practical questions relating to the management of infectious diseases in children with SAM and to highlight research gaps. Overall, the evidence base for many aspects covered in this brief is very poor. The brief addresses antimicrobials; antipyretics; tuberculosis; HIV; malaria; pneumonia; diarrhoea; sepsis; measles; urinary tract infection; nosocomial Infections; soil transmitted helminths; skin infections and pharmacology in the context of SAM. The brief is structured into sets of clinical questions, which we hope will maximise the relevance to contemporary practice.

Village-randomized clinical trial of home distribution of zinc for treatment of childhood diarrhea in rural Western kenya

Background

Zinc treatment shortens diarrhea episodes and can prevent future episodes. In rural Africa, most children with diarrhea are not brought to health facilities. In a village-randomized trial in rural Kenya, we assessed if zinc treatment might have a community-level preventive effect on diarrhea incidence if available at home versus only at health facilities.

Methods

We randomized 16 Kenyan villages (1,903 eligible children) to receive a 10-day course of zinc and two oral rehydration solution (ORS) sachets every two months at home and 17 villages (2,241 eligible children) to receive ORS at home, but zinc at the health–facility only. Children’s caretakers were educated in zinc/ORS use by village workers, both unblinded to intervention arm. We evaluated whether incidence of diarrhea and acute lower respiratory illness (ALRI) reported at biweekly home visits and presenting to clinic were lower in zinc villages, using poisson regression adjusting for baseline disease rates, distance to clinic, and children’s age.

Results

There were no differences between village groups in diarrhea incidence either reported at the home or presenting to clinic. In zinc villages (1,440 children analyzed), 61.2% of diarrheal episodes were treated with zinc, compared to 5.4% in comparison villages (1,584 children analyzed, p<0.0001). There were no differences in ORS use between zinc (59.6%) and comparison villages (58.8%). Among children with fever or cough without diarrhea, zinc use was low (<0.5%). There was a lower incidence of reported ALRI in zinc villages (adjusted RR 0.68, 95% CI 0.46–0.99), but not presenting at clinic.

Conclusions

In this study, home zinc use to treat diarrhea did not decrease disease rates in the community. However, with proper training, availability of zinc at home could lead to more episodes of pediatric diarrhea being treated with zinc in parts of rural Africa where healthcare utilization is low.

Trial Registration

ClinicalTrials.gov NCT00530829

Management strategies in the treatment of neonatal and pediatric gastroenteritis

Acute gastroenteritis, characterized by the onset of diarrhea with or without vomiting, continues to be a major cause of morbidity and mortality in children in mostly resource-constrained nations. Although generally a mild and self-limiting disease, gastroenteritis is one of the most common causes of hospitalization and is associated with a substantial disease burden. Worldwide, up to 40% of children aged less than 5 years with diarrhea are hospitalized with rotavirus. Also, some microorganisms have been found predominantly in resource-constrained nations, including Shigella spp, Vibrio cholerae, and the protozoan infections. Prevention remains essential, and the rotavirus vaccines have demonstrated good safety and efficacy profiles in large clinical trials. Because dehydration is the major complication associated with gastroenteritis, appropriate fluid management (oral or intravenous) is an effective and safe strategy for rehydration. Continuation of breastfeeding is strongly recommended. New treatments such as antiemetics (ondansetron), some antidiarrheal agents (racecadotril), and chemotherapeutic agents are often proposed, but not yet universally recommended. Probiotics, also known as "food supplement," seem to improve intestinal microbial balance, reducing the duration and the severity of acute infectious diarrhea. The European Society for Paediatric Gastroenterology, Hepatology and Nutrition and the European Society of Paediatric Infectious Diseases guidelines make a stronger recommendation for the use of probiotics for the management of acute gastroenteritis, particularly those with documented efficacy such as Lactobacillus rhamnosus GG, Lactobacillus reuteri, and Saccharomyces boulardii. To date, the management of acute gastroenteritis has been based on the option of "doing the least": oral rehydration-solution administration, early refeeding, no testing, no unnecessary drugs.

Zinc, vitamin A, and glutamine supplementation in Brazilian shantytown children at risk for diarrhea results in sex-specific improvements in verbal learning

OBJECTIVE

To identify the impact of supplemental zinc, vitamin A, and glutamine, alone or in combination, on long-term cognitive outcomes among Brazilian shantytown children with low median height-for-age z-scores.

METHODS

A randomized, double-blind, placebo-controlled trial was conducted in children aged three months to nine years old from the urban shanty compound community of Fortaleza, Brazil. Demographic and anthropometric information was assessed. The random treatment groups available for cognitive testing (total of 167 children) were: (1) placebo, n = 25; (2) glutamine, n = 23; (3) zinc, n = 18; (4) vitamin A, n = 19; (5) glutamine+zinc, n = 20; (6) glutamine+vitamin A, n = 21; (7) zinc+vitamin A, n = 23; and (8) glutamine+zinc+vitamin A, n = 18. Neuropsychological tests were administered for the cognitive domains of non-verbal intelligence and abstraction, psychomotor speed, verbal memory and recall ability, and semantic and phonetic verbal fluency. Statistical analyses were performed using SPSS, version 16.0. ClinicalTrials.gov: NCT00133406.

RESULTS

Girls receiving a combination of glutamine, zinc, and vitamin A had higher mean age-adjusted verbal learning scores than girls receiving only placebo (9.5 versus 6.4, p = 0.007) and girls receiving zinc+vitamin A (9.5 versus 6.5, p = 0.006). Similar group differences were not found between male study children.

CONCLUSIONS

The findings suggest that combination therapy offers a sex-specific advantage on tests of verbal learning, similar to that seen among female patients following traumatic brain injury.

Integrating global and national knowledge to select medicines for children: the Ghana National Drugs Programme

David Sinclair and colleagues discuss their experience at the Ghana National Drugs Programme reviewing the international evidence base for five priority pediatric medicines and report that applying the global recommendations to Ghana was not straightforward for any of the five medicines. Please see later in the article for the Editors' Summary

Treatment of chronic diarrhoea

The treatment of chronic diarrhoea can be challenging. While Oral Rehydration Solution is an important step in treating diarrhoeal illnesses, various medications can be used to alleviate the symptoms while the patient is undergoing diagnostic work up or to target the underlying mechanism responsible for their diarrhoea. Medications are also being prescribed in cases when there is a strong suspicious about a diagnosis or when there is no specific treatment for an underlying aetiology. This chapter discusses the treatment options for diarrhoeal disorders.