Role of zinc in severe pneumonia: a randomized double bind placebo controlled study

A systematic review and meta-analysis on nutritional and dietary interventions for the treatment of acute respiratory infection in pediatric patients: An EAACI taskforce

Acute respiratory infections are a major cause of morbidity and mortality in children worldwide. Dietary and nutritional interventions, including minerals and vitamin supplementation, have been explored as potential treatments for these infections. However, the evidence on their efficacy is limited and inconclusive. This systematic review and meta-analysis aim to provide a comprehensive summary of the available evidence on the effectiveness of dietary and nutritional interventions for treating acute respiratory tract infections in children. A systematic review was conducted according to the PRISMA 2020 guidelines in April 2022 and updated in April 2023. Clinical trials focusing on dietary or nutritional interventions, including supplementations, in children with acute respiratory tract infections were included. The selection of interventions and outcomes was based on biological plausibility. Data were extracted using a standardized form, and the risk of bias was assessed using the Cochrane Risk of Bias Tool. Meta-analysis was performed using random-effect models. A total of 50 studies were included in the review. Four trials were conducted in low, 32 in lower-middle, 12 in upper-middle, and only two in high-income countries. The studies evaluated various dietary interventions, including zinc, vitamin A, vitamin E, vitamin D, and probiotics. The results of individual studies on the efficacy of these interventions were mixed, with some showing positive effects on clinical outcomes such as duration of symptoms, while others showed no significant impact. Meta-analysis was conducted for zinc supplementation in children with pneumonia, and the pooled results suggested a potential limited benefit in terms of reduced hospital length of stay but not time to recovery. Meta-analyses on vitamin D did not show any effect in children with pneumonia. This systematic review fills a critical gap in the literature by synthesizing the available evidence on the efficacy and safety of nutritional or dietary interventions for acute respiratory tract infections in children. The findings indicate no dietary or nutritional intervention can currently be recommended for the routine treatment of respiratory tract infections in children based on single supplement studies. The metanalysis suggests that zinc supplementation might have a beneficial effect on length of hospitalization in children with pneumonia. New studies are needed to establish more conclusive evidence for pediatric acute respiratory diseases especially for children living in a context of high-income countries.

Investigating the Efficacy of Zinc and Vitamin A in Treating Pediatric Community-Acquired Pneumonia

BACKGROUND

Community-acquired pneumonia (CAP) poses a significant global health challenge, even more so for children less than five years old. Nutritional interventions, such as zinc and vitamin A supplementation, are gaining attention for their therapeutic potential in enhancing recovery and minimizing pneumonia severity in pediatric patients.

OBJECTIVE

To assess the therapeutic benefits of zinc and vitamin A supplementation in pediatric CAP patients under five years old and to advocate for their use in clinical settings.

METHODOLOGY

Three groups were formed in a randomized controlled trial conducted from October 2022 to September 2023, to address zinc and vitamin A supplementation in pediatric patients under five years old in the intensive care unit with severe pneumonia. Group 1 received zinc supplementation, group 2 received vitamin A supplementation, and group 3 served as the control group, receiving antibiotic treatment exclusively for pneumonia. This treatment comprised either a β-lactam (amoxicillin-clavulanate, commonly referred to as Augmentin) administered orally at 500 mg/125 mg three times a day, Augmentin 875 mg/125 mg orally twice daily, or Augmentin 2000 mg/125 mg orally once daily. Additionally, the control group received a macrolide (azithromycin or clarithromycin) or doxycycline at a dosage of 100 mg orally twice daily. Linear regression analysis identified statistically significant decreases in both length of hospital stay and active pneumonic effusion.

RESULTS

The study encompassed 90 pediatric pneumonia patients with an age range of six to 55 months. Multiple linear regression analysis showed that both vitamin A and zinc led to a significant decrease in hospitalization length by 2.39 days (p < 0.01, 95% CI: 4.19-0.47) and 3.17 days (p < 0.01, 95% CI: 5.19-1.31), respectively. In comparison to the control group, both the vitamin A and zinc supplementation groups were linked to a shorter pneumonic effusion duration (p < 0.001).

CONCLUSION

Both interventions significantly reduced the duration of hospitalization (2.39 days for vitamin A and 3.17 days for zinc) and pneumonic effusion compared to the control group. These findings highlight the potential of zinc and vitamin A as valuable additions to standard CAP treatment regimens, potentially leading to improved clinical outcomes and reduced healthcare burdens.

Effect of zinc versus vitamin A supplementation on pediatric patients with community-acquired pneumonia

Background: Community-acquired pneumonia (CAP) is one of the most common infectious diseases affecting the respiratory tract and is responsible for a high mortality rate in children less than 5 years of age. The mortality rate due to CAP is much higher in low/middle-income countries than in high-income countries due to malnutrition and different micronutrient deficiencies that weaken the immune system.

Aim: The aim of this study was to compare the effects of zinc and vitamin A, as two elements of micronutrient agents, on the recovery rate of children suffering from CAP aged from 6 months to 5 years. The length of hospital stays was also investigated.

Method: A comparative, randomized, open-label, controlled, interventional study was carried out among children less than 5 years of age in the pediatric intensive care unit (PICU) diagnosed with CAP who were randomly divided into three groups. In addition to the standard therapy, group 1 was given zinc, group 2 was given vitamin A, and group 3 was the control group, given the standard therapy only. We compared the three groups in terms of recovery rate and hospital stay.

Result: The duration of hospitalization following zinc and vitamin A supplementation was reduced by an average of 3.21 days (95% CI: 5.01–1.41, p = 0.01) and 2.43 days (95% CI: 4.29–0.57, p = 0.01), respectively, compared to the control group. In addition, the two groups of vitamin A and zinc supplementation were associated with a shorter duration of pneumonic effusion (p < 0.001) in comparison to the control group. Additionally, there was no significant difference between the effects of zinc and vitamin A when compared to each other in terms of duration of hospital stay and pneumatic effusion.

Conclusion: The administration of zinc or vitamin A supplementation proved to be useful as an add-on therapy in community-acquired pneumonia, where it reduced the length of hospital stay and the duration of pneumonic effusion in pneumonic children less than 5 years of age.

Review of the role of additional treatments including oseltamivir, oral steroids, macrolides, and vitamin supplementation for children with severe pneumonia in low- and middle-income countries

Background

Pneumonia is a major cause of death in children aged under five years. As children with severe pneumonia have the highest risk of morbidity and mortality, previous studies have evaluated the additional benefit of adjunctive treatments such as oseltamivir, oral steroids, macrolides, and vitamin supplementation that can be added to standard antibiotic management to improve clinical outcomes. The study reviewed the evidence for the role of these additional treatments for children with severe pneumonia in low- and middle-income countries (LMICs).

Methods

Four electronic databases were searched for English-language articles between 2000 to 2020. Systematic reviews (SRs) with meta-analyses, comparative cohort studies, and randomised controlled trials (RCTs) from LMICs that reported clinical outcomes for children with severe pneumonia aged between one month to 9 years who received adjunct treatment in addition to standard care were included. Risk of bias of included SRs was assessed using AMSTAR 2, and of individual studies using the Effective Public Health Practice Project (EPHPP) quality assessment tool for quantitative studies.

Results

Overall, the search identified 2147 articles, 32 of which were eligible, including 7 SRs and 25 RCTs. These studies evaluated zinc (4 SRs, 17 RCTs), Vitamin D (1 SR, 4 RCTs), Vitamin A (3 SRs, 1 RCT), Vitamin C (1 SR, 2 RCTs) and micronutrients (1 RCT). Most studies reported clinical outcomes of time to improvement, length of stay, and treatment failure (including mortality). No studies of oseltamivir, steroids, or macrolides fulfilling the inclusion criteria were identified. For zinc, pooled analyses from SRs showed no evidence of benefit. Similarly, a Cochrane review and one RCT found that Vitamin A did not improve clinical outcomes. For Vitamin D, an RCT evaluating a single high dose of 100 000 international units (IU) of vitamin D found a reduction in time to improvement, with 38%-40% documented vitamin D deficiency at baseline. However, two other studies of 1000 IU daily did not show any effect, but vitamin D status was not measured. For vitamin C, two studies found a reduction in time to symptom resolution in those with severe disease, with one reporting a shorter length of hospital stay. However, both studies were of weak quality. Most studies excluded malnourished children, and studies which included these children did not report specifically on the effect of micronutrients.

Conclusions

This review found that adjunctive zinc and vitamin A, in addition to standard care, does not improve clinical outcomes in children with severe pneumonia in LMICs (strong evidence). However, a reduction in time to symptom resolution was reported with high dose vitamin D supplementation in children with documented vitamin D deficiency (strong evidence from one study) and vitamin C (weak evidence), although further research is needed, especially in underweight children.

Dietary Micronutrients from Zygote to Senility: Updated Review of Minerals' Role and Orchestration in Human Nutrition throughout Life Cycle with Sex Differences

Micronutrients such as selenium, fluoride, zinc, iron, and manganese are minerals that are crucial for many body homeostatic processes supplied at low levels. The importance of these micronutrients starts early in the human life cycle and continues across its different stages. Several studies have emphasized the critical role of a well-balanced micronutrient intake. However, the majority of studies looked into or examined such issues in relation to a specific element or life stage, with the majority merely reporting the effect of either excess or deficiency. Herein, in this review, we will look in depth at the orchestration of the main element requirements across the human life cycle beginning from fertility and pregnancy, passing through infancy, childhood, adolescence, and reaching adulthood and senility, with insight on the interactions among them and underlying action mechanisms. Emphasis is given towards approaches to the role of the different minerals in the life cycle, associated symptoms for under- or overdoses, and typical management for each element, with future perspectives. The effect of sex is also discussed for each micronutrient for each life stage as literature suffice to highlight the different daily requirements and or effects.

Do Zinc Supplements Enhance the Clinical Efficacy of Hydroxychloroquine?: a Randomized, Multicenter Trial

No specific treatment for COVID-19 infection is available up till now, and there is a great urge for effective treatment to reduce morbidity and mortality during this pandemic. We aimed to evaluate the effect of combining chloroquine/hydroxychloroquine (CQ/HCQ) and zinc in the treatment of COVID-19 patients. This was a randomized clinical trial conducted at three major University hospitals in Egypt. One hundred ninety-one patients with a confirmed diagnosis of COVID-19 infection were randomized into two groups: group I (96) patients received both HCQ and zinc, and group II (95) received HCQ only. The primary endpoints were the recovery within 28 days, the need for mechanical ventilation, and death. The two groups were matched for age and gender. They had no significant difference regarding any of the baseline laboratory parameters or clinical severity grading. Clinical recovery after 28 days was achieved by 79.2% in the zinc group and 77.9% in zinc-free treatment group, without any significant difference (p = 0.969). The need for mechanical ventilation and the overall mortality rates did not show any significant difference between the 2 groups either (p = 0.537 and 0.986, respectively). The age of the patient and the need for mechanical ventilation were the only risk factors associated with the patients' mortality by the univariate regression analysis (p = 0.001 and < 0.001, respectively). Zinc supplements did not enhance the clinical efficacy of HCQ. More randomized studies are needed to evaluate the value of adding zinc to other therapies for COVID 19. ClinicalTrials.gov Identifier: NCT04447534.

Hydroxychloroquine can potentially interfere with immune function in COVID-19 patients: Mechanisms and insights

The recent global pandemic due to COVID-19 is caused by a type of coronavirus, SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2). Despite rigorous efforts worldwide to control the spread and human to human transmission of this virus, incidence and death due to COVID-19 continue to rise. Several drugs have been tested for treatment of COVID-19, including hydroxychloroquine. While a number of studies have shown that hydroxychloroquine can prolong QT interval, potentially increasing risk of ventricular arrhythmias and Torsade de Pointes, its effects on immune cell function have not been extensively examined. In the current review, an overview of coronaviruses, viral entry and pathogenicity, immunity upon coronavirus infection, and current therapy options for COVID-19 are briefly discussed. Further based on preclinical studies, we provide evidences that i) hydroxychloroquine impairs autophagy, which leads to accumulation of damaged/oxidized cytoplasmic constituents and interferes with cellular homeostasis, ii) this impaired autophagy in part reduces antigen processing and presentation to immune cells and iii) inhibition of endosome-lysosome system acidification by hydroxychloroquine not only impairs the phagocytosis process, but also potentially alters pulmonary surfactant in the lungs. Therefore, it is likely that hydroxychloroquine treatment may in fact impair host immunity in response to SARS-CoV-2, especially in elderly patients or those with co-morbidities. Further, this review provides a rationale for developing and selecting antiviral drugs and includes a brief review of traditional strategies combined with new drugs to combat COVID-19.

Zinc against COVID-19? Symptom surveillance and deficiency risk groups

A wide variety of symptoms is associated with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection, and these symptoms can overlap with other conditions and diseases. Knowing the distribution of symptoms across diseases and individuals can support clinical actions on timelines shorter than those for drug and vaccine development. Here, we focus on zinc deficiency symptoms, symptom overlap with other conditions, as well as zinc effects on immune health and mechanistic zinc deficiency risk groups. There are well-studied beneficial effects of zinc on the immune system including a decreased susceptibility to and improved clinical outcomes for infectious pathogens including multiple viruses. Zinc is also an anti-inflammatory and anti-oxidative stress agent, relevant to some severe Coronavirus Disease 2019 (COVID-19) symptoms. Unfortunately, zinc deficiency is common worldwide and not exclusive to the developing world. Lifestyle choices and preexisting conditions alone can result in zinc deficiency, and we compile zinc risk groups based on a review of the literature. It is also important to distinguish chronic zinc deficiency from deficiency acquired upon viral infection and immune response and their different supplementation strategies. Zinc is being considered as prophylactic or adjunct therapy for COVID-19, with 12 clinical trials underway, highlighting the relevance of this trace element for global pandemics. Using the example of zinc, we show that there is a critical need for a deeper understanding of essential trace elements in human health, and the resulting deficiency symptoms and their overlap with other conditions. This knowledge will directly support human immune health for decreasing susceptibility, shortening illness duration, and preventing progression to severe cases in the current and future pandemics.

The Role of Micronutrients in Support of the Immune Response against Viral Infections

Viral infections are a leading cause of morbidity and mortality worldwide, and the importance of public health practices including handwashing and vaccinations in reducing their spread is well established. Furthermore, it is well known that proper nutrition can help support optimal immune function, reducing the impact of infections. Several vitamins and trace elements play an important role in supporting the cells of the immune system, thus increasing the resistance to infections. Other nutrients, such as omega-3 fatty acids, help sustain optimal function of the immune system. The main aim of this manuscript is to discuss of the potential role of micronutrients supplementation in supporting immunity, particularly against respiratory virus infections. Literature analysis showed that in vitro and observational studies, and clinical trials, highlight the important role of vitamins A, C, and D, omega-3 fatty acids, and zinc in modulating the immune response. Supplementation with vitamins, omega 3 fatty acids and zinc appears to be a safe and low-cost way to support optimal function of the immune system, with the potential to reduce the risk and consequences of infection, including viral respiratory infections. Supplementation should be in addition to a healthy diet and fall within recommended upper safety limits set by scientific expert bodies. Therefore, implementing an optimal nutrition, with micronutrients and omega-3 fatty acids supplementation, might be a cost-effective, underestimated strategy to help reduce the burden of infectious diseases worldwide, including coronavirus disease 2019 (COVID-19).

Effect of traditional Chinese medicine injections on severe pneumonia: A protocol for systematic review and meta-analysis

BACKGROUND

Traditional Chinese medicine injections (TCMJ) used in the treatment of severe pneumonia have been widely implemented in clinical practice, but their overall efficacy and safety remain unclear. This paper aims to evaluate the efficacy and safety of TCMJ in the treatment of severe pneumonia.

METHODS

PubMed, EMbase, Cochrane Library, Web of Science, China National Knowledge Infrastructure, WanFang, and the Chongqing VIP Chinese Science and Technology Periodical Database were all searched for randomized controlled trials focusing on the administration of TCMJ for severe pneumonia. Two researchers independently screened titles, abstracts, full texts, and extracted relevant data. The RevMan 5.3 software (The Cochrane Collaboration, Software Update, Oxford, UK) and Stata 14 software (STATA Corporation, College Station, TX) were used for statistical analysis.

RESULTS

This study summarizes the related randomized controlled trials to assess the effect and safety of TCMJ in the treatment of severe pneumonia.

CONCLUSION

This article provides theoretical support for the clinical application of TCMJ in the treatment of severe pneumonia.

PROSPERO REGISTRATION NUMBER

CRD42020185072.

Efficacy of Adjunctive Zinc in Improving the Treatment Outcomes in Hospitalized Children with Pneumonia: A Randomized Controlled Trial

BACKGROUND

The mortality rate of pneumonia is high, placing a huge burden on developing countries. Healthcare professionals use zinc as an adjunctive treatment for children with pneumonia; however, this contradicts with some published reports. Thus, this study aimed to assess the efficacy of zinc supplementation on the treatment outcomes of pneumonia.

METHODS

A randomized, double-blind, placebo-controlled trial was conducted on hospitalized children with pneumonia. The children randomly received either zinc bis-glycinate (15 mg elemental zinc) or placebo, twice per day. The primary outcome was the resolution time of pneumonia, and the secondary outcomes were the duration of hospitalization and the recovery times of each clinical symptom.

RESULTS

Out of the 91 children, 65 (71.4%) were males. The resolution period of clinical pneumonia was significantly shorter in the zinc group than the placebo group (48 and 72 h, respectively; hazard ratio = 0.585, 95% confidence interval 0.377-0.908). Similarly, the hospitalization period and the resolution period of fever were shorter in the zinc group [96 and 144 h (p = 0.008), and 24 and 42 h (p = 0.002), respectively]. Children receiving zinc needed a median of 28 h to reach the normal level of oxygen saturation compared to 48 h required by children under placebo (p = 0.014).

CONCLUSION

Zinc supplementation enhanced the treatment outcomes of pneumonia, by reducing the resolution period of pneumonia and normalizing oxygen levels and body temperature. The length of hospital stay for children receiving zinc was shorter than those receiving placebo.

Efficacy of zinc as adjunctive pneumonia treatment in children aged 2 to 60 months in low-income and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Despite advances in vaccination and case management, pneumonia remains the single largest contributor to early child mortality worldwide. Zinc has immune-enhancing properties, but its role in adjunctive treatment of pneumonia in low-income and middle-income countries (LMICs) is controversial and research still active.

METHODS

Systematic review and meta-analysis of randomised controlled trials of zinc and placebo in pneumonia in children aged 2 to 60 months in LMICs. Databases included MEDLINE, the Cochrane Library, EMBASE, LILACS, SciELO, the WHO portal, Scopus, Google Scholar and ClinicalTrials.gov. Inclusion criteria included accepted signs of pneumonia and clear measure of outcome. Risk of bias was independently assessed by two authors. ORs with 95% CI were used for calculating the pooled estimate of dichotomous outcomes including treatment failure and mortality. Time to recovery was expressed as HRs. Sensitivity analyses considering risk of bias and subgroup analyses for pneumonia severity were performed.

RESULTS

We identified 11 trials published between 2004 and 2019 fulfilling the a priori defined criteria, 7 from South Asia and 3 from Africa and 1 from South America. Proportional treatment failure was comparable in both zinc and placebo groups when analysed for all patients (OR 0.95 (95% CI 0.80 to 1.14)) and only for those with severe pneumonia (OR 0.93 (95% CI 0.75 to 1.14)). No difference was seen in mortality between zinc and placebo groups (OR 0.64 (95% CI 0.31 to 1.31)). Time to recovery from severe pneumonia did not differ between the treatment and control groups for patients with severe pneumonia (HR 1.01 (95% CI 0.89 to 1.14)). Removal of four studies with high risk of bias made no difference to the conclusions.

CONCLUSION

There is no evidence that adjunctive zinc treatment improves recovery from pneumonia in children in LMICs.

TRIAL REGISTRATION NUMBER

CRD42019141602.

Role of Zinc Supplementation in the Improvement of Acute Respiratory Infections among Iranian Children: A Systematic Review

BACKGROUND

Respiratory infectious disease is considered as one of the most serious problems among children in developing countries. The importance of zinc in the improvement of respiratory disease has been indicated. However, there are some unanswered questions and uncertainty. This systematic review aimed at assessing the therapeutic benefits of zinc supplementation on respiratory infections of Iranian children.

MATERIALS AND METHODS

Databases, such as PubMed, Scopus, Embase, Magiran, and IranDoc, were searched for randomized controlled trials published from January 1998 to December 2017 on Zinc supplementation for the treatment or improvement of acute respiratory disease among Iranian children, during March 2018. Studies were screened according to the PICO framework, and irrelevant studies were excluded.

RESULTS

A total of 5 studies conducted on 522 children were included in this review. Except for one study, others had indicated the beneficial effect of zinc supplement on improving signs and symptoms of respiratory infectious disease and earlier discharge from the hospital.

CONCLUSION

Although studies on the efficacy of zinc on respiratory infectious disease of children in Iran have not widely considered and more studies should be conducted, all published articles (except for one of them) had indicated the effectiveness of zinc supplementation on respiratory infections among children. Other criteria, such as age, gender, birth weight, diet, and type of respiratory infections, should be considered during zinc therapy. Controlling these confounding variables and measuring the level of blood zinc are necessary to understand how much zinc should be prescribed for respiratory treatment of children.

Low serum zinc level: The relationship with severe pneumonia and survival in critically ill children

BACKGROUND

Zinc deficiency is common among children in developing countries; but, there is still conflicting evidence on whether the alteration in zinc metabolism is the predictive of disease severity in the setting of critical illness.

OBJECTIVES

To assess serum zinc levels in children admitted with pneumonia, and also to study the relationship between zinc levels and severity and mortality from pneumonia.

METHODS

In a prospective cohort study, we enrolled 320 critically ill children admitted to the paediatric intensive care unit (PICU) with severe pneumonia (group 1) in addition to 160 children admitted into wards with pneumonia (group 2). Serum zinc measured in all patients on admission.

RESULTS

Serum zinc level was significantly lower among patients admitted to PICU (group 1) compared with patients admitted to wards (group 2) (P < .001). There was a highly statistically significant decrease in zinc level in critically ill children complicated by sepsis, mechanically ventilated cases and those who died. Regarding the diagnosis of sepsis, zinc had an area under the curve (AUC) of 0.81 while C-reactive protein (CRP) had an AUC of 0.83. Regarding the prognosis, zinc had an AUC of 0.649 for prediction of mortality, whereas the AUC for Pediatric risk of mortality (PRISM), Pediatric index of mortality2 (PIM2) and CRP were 0.83, 0.82 and 0.78, respectively. The combined zinc with PRISM and PIM2 has increased the sensitivity of zinc for mortality from 86.5% to 94.9%.

CONCLUSION

Zinc has both a diagnostic and a prognostic value for children with pneumonia.

Efficacy of zinc given as an adjunct to the treatment of severe pneumonia: A meta-analysis of randomized, double-blind and placebo-controlled trials

BACKGROUND

Pneumonia is a major cause of morbidity and mortality of children. Zinc is known to play a central role in the immune system. The deficiency of zinc increased susceptibility to infectious diseases.

OBJECTIVE

To investigate the clinical efficacy of zinc given as an adjunct therapy to the treatment of severe pneumonia.

METHODS

The PubMed, Embase, MEDLINE^TM and the Cochrane Central Register of Controlled Trials were searched to identify all randomized, double-blind and placebo-controlled (DBPC) trials which evaluated the clinical efficacy of zinc given as an adjunct in the treatment of severe pneumonia and published between January 1966 and October 2015.

RESULTS

Six randomized DBPC trials including 2216 patients with severe pneumonia were eligible. The results suggested that zinc given as an adjunct therapy to the treatment of severe pneumonia had no significant improvement of treatment failure (RR = 0.97, P = .71) and change of antibiotic therapy (RR = 1.09, P = .52). We also found a favorable trend for clinical deterioration of severe pneumonia but with no statistical significance (RR = 0.88, P = .55). Zinc produced a significant reduction in mortality caused by severe pneumonia (RR = 0.43, P = .01).

CONCLUSIONS

Zinc given as an adjunct to the treatment of severe pneumonia is effective in reducing the mortality of severe pneumonia, and has no significant effects on treatment failure and change of antibiotic therapy.

Zinc Supplementation in Adult Mechanically Ventilated Trauma Patients is Associated with Decreased Occurrence of Ventilator-associated Pneumonia: A Secondary Analysis of a Prospective, Observational Study

BACKGROUND

Ventilator-associated pneumonia (VAP) is a type of lung infection that typically affects critically ill patients undergoing mechanical ventilation (MV) in the Intensive Care Unit (ICU). The aim of this analysis is to determine potential association between zinc supplementation with the occurrence of VAP in adult mechanically ventilated trauma patients.

SUBJECTS AND METHODS

This secondary analysis of a prospective observational study was carried out over a period of 1 year in ICUs of one teaching hospital in Iran. A total of 186 adults mechanically ventilated trauma patients, who required at least 48 h of MV and received zinc sulfate supplement (n = 82) or not (n = 104) during their ICU stay, were monitored for the occurrence of VAP until their discharge from the ICU or death.

RESULTS

Forty-one of 186 patients developed VAP, 29.09 days after admission (95% confidence interval [CI]: 26.27-31.9). The overall incidence of VAP was 18.82 cases per 1000 days of intubation (95% CI: 13.86-25.57). Patients who received zinc sulfate supplement have smaller hazard of progression to VAP than others (hazard ratio: 0.318 [95% CI: 0.138-0.732]; P < 0.0001).

CONCLUSION

The findings show that zinc supplementation may be associated with a significant reduction in the occurrence of VAP in adult mechanically ventilated trauma patients. Further well-designed randomized clinical trials to confirm the efficacy of this potential preventive modality are warranted.

Relationship between Plasma Levels of Zinc and Clinical Course of Pneumonia

BACKGROUND

Pneumonia is a common disease and is more prevalent among children and the elderly. Zinc (Zn) is an essential substance for the human body and plays an important role in regulating the immune system. Studies have shown a possible relation between the Zn plasma levels and pneumonia.

MATERIALS AND METHODS

In a cross-sectional study, 100 patients with pneumonia, who were referred to the Educational-Medical Centers of Tabriz University of Medical Sciences, were included in the study. The plasma levels of Zn of all patients were measured. The patients were divided into two groups of normal and low plasma levels of Zn. The severity and clinical course of pneumonia, including the durations of fever, tachycardia, and tachypnea were evaluated and compared between the two groups.

RESULTS

The plasma levels of Zn were normal in 56 patients and low in 44 patients. The mean duration of fever, tachycardia, and tachypnea in the group with normal plasma levels of Zn were 1.58±0.68, 2.04±0.81, and 2.78±0.84 days, respectively; and those in the group with decreased Zn plasma levels were 1.72±0.70, 2.18±0.90, and 2.97±0.91 days, respectively. There were no statistically significant differences between the two groups (P>0.05). However, the incidence of severe pneumonia was significantly less in the group with normal Zn plasma levels (P=0.001).

CONCLUSION

Based on the findings of the present study, there was no statistically significant relationship between the plasma levels of Zn and the clinical course of pneumonia. However, Zn lowered the incidence of severe pneumonia.

Effect of zinc supplementation on infants with severe pneumonia

BACKGROUND

Pneumonia is a common respiratory infectious disease in infancy. Previous work shows controversial results on the benefit of zinc supplementation in patients with pneumonia. We conducted this study to investigate serum zinc status amongst infants with severe pneumonia and the clinical impact that zinc supplementation has on those patients with low serum zinc levels.

METHODS

This study design was a non-blinded prospective randomized controlled trial. The study is approved by the Ethics Committees of Beijing Children's Hospital. A total of 96 infants diagnosed with severe pneumonia and hospitalized in the pediatric intensive care unit between November 2011 and January 2012 were enrolled. Enrolled patients were divided into low serum zinc and normal serum zinc group. The low serum zinc group was randomized into treatment and control groups. Only the treatment group received zinc supplementation within 48-72 hours after hospitalization.

RESULTS

The prevalence of zinc deficiency on admission was 76.0%. The low zinc level was most apparent in infants between 1 and 3 months of age. The serum zinc level increased in the zinc treatment group and returned to a normal level (median, 53.20 μmol/L) on day 12±2. There was no statistical difference in the pediatric critic illness score, lung injury score, length of hospital stay, and duration of mechanical ventilation between the zinc treatment group and control group.

CONCLUSION

Zinc deficiency is common in infants with severe pneumonia. Normalization of zinc levels with zinc supplementation did not improve clinical outcomes of infants with pneumonia.

Is type 2 diabetes mellitus in mechanically ventilated adult trauma patients potentially related to the occurrence of ventilator-associated pneumonia?

BACKGROUND

Ventilator-associated pneumonia (VAP) is a type of lung infection that typically affects critically ill patients undergoing mechanical ventilation (MV) in the intensive care unit (ICU). Patients with type 2 diabetes mellitus (T2DM) are considered to be more susceptible to several types of infections including community-acquired pneumonia. However, it is not clear whether T2DM is a risk factor for the development of VAP. The purpose of this study was to determine the risk of VAP for diabetic and nondiabetic mechanically ventilated trauma patients.

MATERIALS AND METHODS

This study is a secondary analysis of a prospective observational study of the history of T2DM in the ICU over a period of 1 year at Imam Khomeini Hospital in Iran. A total of 186 critically ill trauma patients who required at least 48 h of MV were monitored for the occurrence of VAP by their clinical pulmonary infection score (CPIS) until ICU discharge, VAP diagnosis, or death.

RESULTS

Forty-one of the 186 patients developed VAP. The median time from hospitalization to VAP was 29.09 days (95% CI: 26.27-31.9). The overall incidence of VAP was 18.82 cases per 1,000 days of intubation (95% CI: 13.86-25.57). Risk of VAP in diabetic patients was greater than nondiabetic patients after adjustments for other potential factors [hazard ratio (HR): 10.12 [95% confidence interval (CI): 5.1-20.2); P < 0.0001)].

CONCLUSION

The findings show that T2DM is associated with a significant increase in the occurrence of VAP in mechanically ventilated adult trauma patients.

Zinc as an adjunct to antibiotics for the treatment of severe pneumonia in children <5 years: a meta-analysis of randomised-controlled trials

The effect of Zn, as an adjunct to antibiotics, on the treatment of severe pneumonia in young children is still under debate; therefore, we performed a meta-analysis to evaluate the therapeutic role of Zn for severe pneumonia in children younger than 5 years. PubMed, Cochrane library and Embase databases were systematically searched from inception until October 2015 for randomised-controlled trials (RCT) that assessed the effect of Zn as an adjunct to antibiotics for severe pneumonia. Random-effects model was used for calculating the pooled estimates, and intention-to-treat principle was also applied. Nine RCT involving 2926 children were included. Overall, the pooled results showed that adjunct treatment with Zn failed to reduce the time to recovery from severe pneumonia (hazard ratios (HR)=1·04; 95% CI 0·90, 1·19; I(2)=39%; P=0·58), hospital length of stay (HR=1·04; 95% CI 0·83, 1·33; I(2)=57%; P=0·74), treatment failure (relative risk (RR)=0·95; 95% CI 0·79, 1·14; I(2)=20%; P=0·58) or change of antibiotics (RR=1·07; 95% CI 0·79, 1·45; I(2)=44%; P=0·67). In addition, continuous outcomes were consistent while meta-analysed with standard mean difference, and all outcomes remained stable in intention-to-treat analysis. No significant differences were observed in the two groups between death rate, adverse events or recovery times of severe pneumonia indicators. Our results suggested that adjunct treatment with Zn failed to benefit young children in the treatment of severe pneumonia. Considering the clinical heterogeneity, baseline characteristics of children, definition of severe pneumonia and Zn supplement way should be taken into consideration in future research. This study was registered at PRESPERO as CRD42015019798.

Oral zinc and common childhood infections--An update

Zinc is an essential micronutrient important for growth and for normal function of the immune system. Many children in developing countries have inadequate zinc nutrition. Routine zinc supplementation reduces the risk of respiratory infections and diarrhea, the two leading causes of morbidity and mortality in young children worldwide. In childhood diarrhea oral zinc also reduces illness duration and risk of persistent episodes. Oral zinc is therefore recommended for the treatment of acute diarrhea in young children. The results from the studies that have measured the therapeutic effect of zinc on acute respiratory infections, however, are conflicting. Moreover, the results of therapeutic zinc for childhood malaria also are so far not promising.This paper gives a brief outline of the current evidence from clinical trials on therapeutic effect of oral zinc on childhood respiratory infections, pneumonia and malaria and also of new evidence of the effect on serious bacterial illness in young infants.

Zinc supplements for preventing otitis media

BACKGROUND

Otitis media is inflammation of the middle ear and is usually caused by infection. It affects people of all ages but is particularly common in young children. Around 164 million people worldwide have long-term hearing loss caused by this condition, 90% of them in low-income countries. As zinc supplements prevent pneumonia in disadvantaged children, we wanted to investigate whether zinc supplements could also prevent otitis media.

OBJECTIVES

To evaluate whether zinc supplements prevent otitis media in adults and children of different ages.

SEARCH METHODS

We searched CENTRAL (2014, Issue 1), MEDLINE (1950 to February week 4, 2014) and EMBASE (1974 to March 2014).

SELECTION CRITERIA

Randomised, placebo-controlled trials of zinc supplements given at least once a week for at least a month for preventing otitis media.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility and methodological quality of the included trials and extracted and analysed data. We summarised results using risk ratios (RRs) or rate ratios for dichotomous data and mean differences (MDs) for continuous data. We combined trial results where appropriate.

MAIN RESULTS

No new trials were identified for inclusion in this update. We identified 12 trials for inclusion, 10 of which contributed outcomes data. There were a total of 6820 participants. In trials of healthy children living in low-income communities, two trials did not demonstrate a significant difference between the zinc-supplemented and placebo groups in the numbers of participants experiencing an episode of definite otitis media during follow-up (3191 participants); another trial showed a significantly lower incidence rate of otitis media in the zinc group (rate ratio 0.69, 95% confidence interval (CI) 0.61 to 0.79, n = 1621). A small trial of 39 infants undergoing treatment for severe malnutrition suggested a benefit of zinc for the mean number of episodes of otitis media (mean difference (MD) -1.12 episodes, 95% CI -2.21 to -0.03). Zinc supplements did not seem to cause any serious adverse events but a small minority of children were reported to have vomited shortly after ingestion of the supplements. The trial evidence included is generally of good quality, with a low risk of bias.

AUTHORS' CONCLUSIONS

Evidence on whether zinc supplementation can reduce the incidence of otitis media in healthy children under the age of five years living in low- and middle-income countries is mixed. There is some evidence of benefit in children being treated for marasmus (severe malnutrition), but this is based on one small trial and should therefore be treated with caution.

Effect of zinc supplementation on duration of hospitalization in Tanzanian children presenting with acute pneumonia

BACKGROUND

Zinc supplementation prevents incident pneumonia in children; however, the effect for pneumonia treatment remains unclear.

METHODS

A randomized, double-blind, placebo-controlled trial of zinc supplements (daily 25 mg) adjunct to antibiotic treatment of radiology-confirmed acute pneumonia was conducted among hospitalized children (6-36 months) in Dar es Salaam, Tanzania.

RESULTS

The trial was stopped early due to low enrollment, primarily owing to exclusion of children outside the age range and >3 days of prior illness. Among children enrolled (n = 94), zinc supplementation indicated no beneficial effect on the duration of hospitalization (IRR: 0.69; 95% CI 0.45-1.06; p = 0.09) or the proportion of children who were hospitalized for <3 days (RR: 0.85; 95% CI: 0.57-1.25; p = 0.40) or <5 days (RR: 1.01; 95% CI: 0.83-1.23; p = 0.92) (IRRs and RRs >1.0 favor zinc).

CONCLUSIONS

Although underpowered, this randomized trial provided no evidence for a beneficial effect of zinc supplementation adjunct to antibiotics for hospitalized children.

Zinc as an adjunct to the treatment of severe pneumonia in Ecuadorian children: a randomized controlled trial

BACKGROUND

Studies of zinc as an adjunct to treatment of severe pneumonia in children have shown mixed results, possibly because of poor information on zinc status and respiratory pathogens.

OBJECTIVE

We evaluated the effect of zinc given with standard antimicrobial treatment on the duration of respiratory signs in children with severe pneumonia. Zinc status and pathogens were assessed.

DESIGN

Children aged 2-59 mo with severe pneumonia who were admitted to the main children's hospital in Quito, Ecuador, were given standard antibiotics and randomly allocated to receive zinc supplements twice daily or a placebo. Measurements included anthropometric variables, breastfeeding, hemoglobin, plasma zinc, and common bacteria/viral respiratory pathogens. The primary outcome was time to resolution of respiratory signs. The secondary outcome was treatment failure.

RESULTS

We enrolled 225 children in each group. There was no difference between groups in time to resolution of respiratory signs or treatment failure; pathogens were not associated with outcomes. Tachypnea and hypoxemia resolved faster in older children (P = 0.0001) than in younger ones. Higher basal zinc concentration (P = 0.011) and better height-for-age z score (HAZ) (P = 0.044) were associated with faster resolution of chest indrawing. Better weight-for-height z score (WHZ) (P = 0.031) and HAZ (P = 0.048) were associated with faster resolution of tachypnea. Increased C-reactive protein was associated with a longer duration of tachypnea (P = 0.044).

CONCLUSIONS

Zinc did not affect time to pneumonia resolution or treatment failure, nor did type of respiratory pathogens affect outcomes. Higher basal zinc and better HAZ and WHZ were associated with reduced time to resolution of respiratory signs. These results suggest the need for prevention of chronic zinc deficiency and improvement of general nutritional status among Ecuadorian children.

Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost?

Maternal undernutrition contributes to 800,000 neonatal deaths annually through small for gestational age births; stunting, wasting, and micronutrient deficiencies are estimated to underlie nearly 3·1 million child deaths annually. Progress has been made with many interventions implemented at scale and the evidence for effectiveness of nutrition interventions and delivery strategies has grown since The Lancet Series on Maternal and Child Undernutrition in 2008. We did a comprehensive update of interventions to address undernutrition and micronutrient deficiencies in women and children and used standard methods to assess emerging new evidence for delivery platforms. We modelled the effect on lives saved and cost of these interventions in the 34 countries that have 90% of the world's children with stunted growth. We also examined the effect of various delivery platforms and delivery options using community health workers to engage poor populations and promote behaviour change, access and uptake of interventions. Our analysis suggests the current total of deaths in children younger than 5 years can be reduced by 15% if populations can access ten evidence-based nutrition interventions at 90% coverage. Additionally, access to and uptake of iodised salt can alleviate iodine deficiency and improve health outcomes. Accelerated gains are possible and about a fifth of the existing burden of stunting can be averted using these approaches, if access is improved in this way. The estimated total additional annual cost involved for scaling up access to these ten direct nutrition interventions in the 34 focus countries is Int$9·6 billion per year. Continued investments in nutrition-specific interventions to avert maternal and child undernutrition and micronutrient deficiencies through community engagement and delivery strategies that can reach poor segments of the population at greatest risk can make a great difference. If this improved access is linked to nutrition-sensitive approaches--ie, women's empowerment, agriculture, food systems, education, employment, social protection, and safety nets--they can greatly accelerate progress in countries with the highest burden of maternal and child undernutrition and mortality.

Progress in Pediatrics in 2012: choices in allergy, endocrinology, gastroenterology, hematology, infectious diseases, neurology, nutrition and respiratory tract illnesses

In this review, we summarize the progresses in allergy, endocrinology, gastroenterology, hematology, infectious diseases, neurology, nutrition and respiratory tract illnesses that have been published in The Italian Journal of Pediatrics in 2012. The induction of Treg activity by probiotics might be effective for promoting tolerance towards food allergens. Nasal cytology is useful in patients with rhinitis for diagnosing chronic non-allergic non-infectious diseases. Atopic eczema is associated both with an aberrant skin matrix and impaired systemic immune response. Therefore, isolated topical treatment may have suboptimal effect. Diagnostic work-up of exercise-induced anaphylaxis, including exercise challenge test, is necessary to reach a diagnosis. Studies may support a role for nutrition on prevention of asthma and cardiovascular diseases. Clinicians need to early identify adolescent menstrual abnormalities to minimize sequelae, and to promote health information. In Multiple Endocrine Neoplasia type 2B investigations include acetylcholinesterase study of rectal mucosa followed by the molecular analysis of RET mutation. Low adherence to gluten-free diet and osteopenia are common problems in children with diabetes mellitus type 1 and celiac disease. In infantile colic, laboratory tests are usually unnecessary and the treatment is based on reassurance. Prevalence of obesity and stunting is elucidated by several studies. Evidences are growing that dietetic measures are needed to prevent obesity in children with acute leukemia. Treatment studies for infectious diseases show promise for probiotics along with standard triple therapy in children with Helicobacter pilori infection, while zinc has no effect on pneumonia. Educational programs about the proper management of the febrile child are warranted. A new hour-specific total serum bilirubin nomogram has been shown to be able to predict newborns without hyperbilirubinemia after 48 to 72 hours of life. Newborns with hypoxic-ischemic encephalopathy present ECG and cardiac enzymes alterations leading to reduced neonatal survival. Rehabilitation programs including sensory integration therapy and motor performance, may improve activities of daily life in children with developmental coordination disorder. Aerobic exercise training in addition to chest physiotherapy might be useful in children with cystic fibrosis. Studies on effectiveness of leukotriene receptor antagonists, alone or with other drugs in preschool wheezing are needed.