Therapeutic value of zinc supplementation in acute and persistent diarrhea: a systematic review

Cellular zinc metabolism and zinc signaling: from biological functions to diseases and therapeutic targets

Zinc metabolism at the cellular level is critical for many biological processes in the body. A key observation is the disruption of cellular homeostasis, often coinciding with disease progression. As an essential factor in maintaining cellular equilibrium, cellular zinc has been increasingly spotlighted in the context of disease development. Extensive research suggests zinc's involvement in promoting malignancy and invasion in cancer cells, despite its low tissue concentration. This has led to a growing body of literature investigating zinc's cellular metabolism, particularly the functions of zinc transporters and storage mechanisms during cancer progression. Zinc transportation is under the control of two major transporter families: SLC30 (ZnT) for the excretion of zinc and SLC39 (ZIP) for the zinc intake. Additionally, the storage of this essential element is predominantly mediated by metallothioneins (MTs). This review consolidates knowledge on the critical functions of cellular zinc signaling and underscores potential molecular pathways linking zinc metabolism to disease progression, with a special focus on cancer. We also compile a summary of clinical trials involving zinc ions. Given the main localization of zinc transporters at the cell membrane, the potential for targeted therapies, including small molecules and monoclonal antibodies, offers promising avenues for future exploration.

m-Follow up for zinc adherence by caretakers of children with acute watery diarrhoea: A randomized controlled trial

The standard of care for children with acute watery diarrhea (AWD) with no dehydration comprises oral rehydration solution, zinc, and feeding advice. Adherence to zinc therapy may be an issue in the management of acute watery diarrhoea. Mobile phones are used by over 90% of the population in Tanzania, thus good means to improve adherence to prescribed medication and/or attendance to follow-up visits. The objective of this study was to see whether m-follow-up improves adherence rate to zinc therapy, possible reasons for non-adherence, in children with diarrhea.: A randomized controlled trial was carried out in a suburban municipality in Dar-es-Salaam. Block randomization of participants was carried out with a block size of 4 and a 1:1 ratio of intervention: control. The intervention group comprised participants who were to be followed up using text messages and voice calls; the control group was to be followed up in outpatient. The outcome of interest was adherence to the full course of 10 days' oral zinc, reasons for nonadherence and acceptability. Chi-square was used to compare the categorical variables. δ, the targeted difference in adherence between arms, was pre-set at 20%. The total number of participants were 196, of which 98 participants were enrolled in each arm. Full adherence to the 10-day course of zinc sulphate in children with AWD and no dehydration was 84.1% in the control arm and 89.7% in the m-follow up group (P = 0.33). m-follow up significantly improved physical attendance at 14-day clinic visit compared to control group (39.8% vs. 60.2%; P = 0.006). Commonest reasons for non-adherence in both groups were related to vomiting (67%). Vomiting at enrolment due to gastroenteritis was significantly associated with vomiting zinc sulphate with RR 2.17 (95% CI 1.24-3.79, P = 0.007). The acceptability of m-follow-up was high (99%). In conclusion the idea of m-follow-up was well received by participants who considered it acceptable. In this study, the adherence to Zinc dosing was not significantly different between the intervention and control group, and we consider that for zinc in AWD, counselling alone was good enough to achieve high adherence. The trial was registered with the Pan-African Clinical Trial Registry. Trial number: PACTR201711002737120.

Zinc Deficiency and Therapeutic Value of Zinc Supplementation in Pediatric Gastrointestinal Diseases

The benefits of zinc in treating certain gastrointestinal (GI) diseases have been recognized for over two decades. This review aims to explore zinc deficiency (ZD) and the potential therapeutic value and safety of zinc supplementation in pediatric GI diseases. A systematic review of published articles on ZD and zinc as adjuvant treatments for GI diseases was conducted using various databases. Children with inflammatory bowel disease (IBD), celiac disease, and those receiving long-term proton pump inhibitor treatments are particularly susceptible to ZD. ZD in children with celiac disease and IBD is attributed to insufficient intake, reduced absorption, and increased intestinal loss as a result of the inflammatory process. Zinc plays a crucial role in maintaining the integrity of the gastric mucosa and exerts a gastroprotective action against gastric lesions. Although considerable evidence supports the use of zinc as adjuvant therapy for certain GI diseases in adults, its use is unspecified in children except for infectious diarrhea. Current evidence suggests that zinc supplementation with well-documented dosages helps reduce the duration of diarrhea in children with acute or persistent diarrhea, while there are no specific guidelines for zinc supplementation in children with IBD and celiac disease. Zinc supplementation appears to be beneficial in peptic ulcer disease or gastroesophageal reflux disease. The available evidence highlights the need for intervention programs to enhance zinc status and reduce the morbidity of certain GI diseases in children.

Effects of dietary supplementation with purple garlic powder and oregano essential oil on intestinal health in post-weaning piglets from commercial farms

This work studied the effects of the inclusion of Purple Garlic Powder (PGP) and Oregano Essential Oil (OEO) in the feed, at different doses and combinations, on intestinal health and the growth performance of 140 and 3000 piglets, respectively, weaned at 21 days of age. Seven dietary treatments were used: a negative control group (basal diet), a positive control group with ZnO (3000 mg/Kg of feed), two groups with OEO at 0.4% and 1.2% respectively, two groups with PGP at 0.4% and 2% respectively and one group with OEO at 1.2% combined with PGP at 2%. Only the positive control group received ZnO in the diet. Each group of piglets received the treatment for seven weeks, from weaning, and were later sacrificed to obtain jejunum and ileum samples for counting of goblet cells, intraepithelial lymphocytes, and IgA-producing cells. The growth performance were measured at the beginning and at the end of the seven weeks. In jejunum and ileum, the number of goblet cells increased in the groups with ZnO, PGP 2%, OEO 1.2% and PGP 2% + OEO 1.2%, presenting significant differences with the rest of the groups. The results obtained for the intraepithelial lymphocyte count were in line with those obtained for the count of goblet cells. Regarding IgA-producing cells, the groups that showed significantly favourable results in the jejunum and ileum were OEO 1.2%, PGP 2% and their combination, but the groups that showed the most similar means to ZnO were the OEO 0.4% and the PGP 0.4%. Regarding the growth performance, PGP 2%, OEO 1.2% and their combination had similar results to ZnO. The intestinal health of piglets could be improved, without harming the growth performance, by means of the supplementation of PGP 2%, OEO 1.2% and PGP 2% + OEO 1.2% offering a natural alternative to the use of ZnO.

Intestinal absorption pathways of lisinopril: Mechanistic investigations

Lisinopril is an antihypertensive drug with poor intestinal permeability. Enhancement of intestinal absorption depends on a clear understanding of the permeation pathways and absorption mechanisms. Unfortunately, these are not fully elucidated for lisinopril. Accordingly, the aim was to determine lisinopril permeation pathways and obstacles limiting membrane transport with subsequent nomination of appropriate permeation enhancers. This employed an in situ rabbit intestinal perfusion technique, which revealed site-dependent absorptive clearance (PeA/L) from a lisinopril simple solution (5 μg/ml), with paracellular absorption playing a role. Regional drug permeability ranked as colon> duodenum> jejunum> ileum opposing intestinal expression rank of P-glycoprotein (P-gp) efflux transporters. Duodenal and jejunal perfusion of a higher lisinopril concentration (50 μg/ml) reflected saturable absorption, suggesting carrier-mediated transport. The effect of piperine and verapamil as P-gp inhibitors on intestinal absorption of lisinopril was investigated. Coperfusion with either piperine or verapamil significantly enhanced lisinopril absorption, with enhancement being dominant in the ileum segment. This supported the contribution of P-gp transporters to poor lisinopril permeability. On the other hand, coperfusion of lisinopril with zinc acetate dihydrate significantly multiplied lisinopril PeA/L by 2.3- and 6.6-fold in duodenum and ileum segments, respectively, through magnifying intestinal water flux. The study explored the barriers limiting lisinopril intestinal absorption. Moreover, the study exposed clinically relevant lisinopril interactions with common coadministered cargos that should be considered for an appropriate lisinopril regimen. However, this requires further in vivo verification.

Maternal supplementation of different trace mineral sources on broiler breeder production and progeny growth and gut health

Trace mineral minerals Zn, Cu, and Mn play important roles in breeder production and progeny performance. The objective of this study was to determine maternal supplementation of trace mineral minerals on breeder production and progeny growth and development. A total of 540 broiler breeders, Cobb 500 (Slow feathering; 0–66 weeks old) were assigned to one of three treatment groups with the same basal diet and three different supplemental trace minerals: ITM–inorganic trace minerals in sulfates: 100, 16, and 100 ppm of Zn, Cu, and Mn respectively; MMHAC -mineral methionine hydroxy analog chelate: 50, 8, and 50 ppm of bis-chelated MINTREX®Zn, Cu and Mn (Novus International, Inc.), and TMAAC - trace minerals amino acid complex: 50, 8, and 50 ppm of Zn, Cu, and Mn. At 28 weeks of age, eggs from breeder treatments were hatched for progeny trial, 10 pens with 6 males and 6 female birds per pen were fed a common diet with ITM for 45 days. Breeder production, egg quality, progeny growth performance, mRNA expression of gut health associated genes in breeder and progeny chicks were measured. Data were analyzed by one-way ANOVA; means were separated by Fisher’s protected LSD test. A p-Value ≤ 0.05 was considered statistically different and 0.1 was considered numerical trend. Breeders on ITM treatment had higher (p < 0.05) body weight (BW), weight gain and lower (p < 0.05) feed conversion ratio (FCR) from 0 to 10 weeks, when compared to birds fed MMHAC. MMHAC significantly improved egg mass by 3 g (p < 0.05) and FCR by 34 points (0.05 < p < 0.1) throughout the reproductive period (26–66 weeks) in comparison to ITM. MMHAC improved (p < 0.01) egg yolk color versus (vs.) ITM and TMAAC in all periods, except 28 weeks, increased (p < 0.01) eggshell thickness and resistance vs. TMAAC at 58 weeks, and reduced (p < 0.05) jejunal NF-κB gene expression vs. TMAAC at 24 weeks. There was a significant reduction in tibial dry matter weight, Seedor index and resistance for the breeders that received MMHAC and/or TMAAC when compared to ITM at 18 weeks. Lower seedor index but numerically wider tibial circumference was seen in hens fed MMHAC at 24 weeks, and wider tibial circumference but lower tibial resistance in hens fed TMAAC at 66 weeks. Maternal supplementation of MMHAC in breeder hens increased (p < 0.0001) BW vs. ITM and TMAAC at hatching, reduced (p < 0.05) feed intake vs. ITM at d14 and d28, and improved (p < 0.01) FCR and performance index vs. TMAAC at d28, reduced (p < 0.01) NF-κB gene expression and increased (p < 0.05) A20 gene expression vs. TMAAC on d0 and vs. ITM on d14, reduced (p < 0.05) TLR2 gene expression vs. ITM on d0 and vs. TMAAC on d14, increased (p < 0.05) MUC2 gene expression vs. both ITM and TMAAC on d45 in progeny jejunum. Overall, these results suggest that supplementation with lower levels of MHA-chelated trace minerals improved breeder production and egg quality and reduced breeder jejunal inflammation while maintaining tibial development in comparison to those receiving higher inorganic mineral supplementation, and it also carried over the benefits to progeny with better growth performance, less jejunal inflammation and better innate immune response and gut barrier function in comparison to ITM and/or TMAAC.

Childhood diarrhoea: a cross-sectional survey on maternal knowledge, hygienic practices and use of oral zinc for home management in a Nigerian community

Introduction

diarrhoea is the second leading cause of morbidity and mortality in young children. The aim was to assess maternal knowledge, hygienic practices and home management (HM) of diarrhoea with oral rehyrdation therapy (ORT) and oral zinc in children aged 6-23 months in western Nigeria. Predictors of good knowledge and practice were also assessed.

Methods

this was a community based analytic cross-sectional study. Multistage sampling was used to select mothers of children 6-23 months of age. Data were collected using pre-tested, interviewer administered questionnaires and analyzed using SPSS version 20. Bivariate analysis and multiple logistic regression for predictor variables were done. Level of significance was set at 0.05.

Results

three hundred and seventy one (371) respondents were interviewed (mean age 30.4 ± 5.02 years). 305 (82.2%) had good knowledge of diarrhoeal diseases, 208(56.1%) had good knowledge of home management of childhood diarrhoea, 274 (73.9%) had good maternal hygienic practices and 161 (61.2%) of the 263 mothers who had managed diarrhoea in their children, had good practice. Only 34 (12.9%) of them used zinc tablets and 11 (32.4%) did not complete the full course. Maternal age 30-39 years predicted good knowledge (AOR 3.19 CI 2-6.05). Predictors of good home management practices were: maternal age 30-39 years (AOR 2.78 CI 1.44-5.37), >40 years (AOR 5.55 CI 1.54-20.01) and younger age of the index child, 6-11 months (AOR 4.83 CI 2.29-10.18).

Conclusion

mothers had poor knowledge of the role of zinc supplementation in childhood diarrhoea and use of zinc tablets for diarrhoea was very low. Community based health education should be carried out.

Childhood diarrhoea in southwestern Nigeria: Predictors of low osmolarity ORS and zinc use among mothers

Objectives

Diarrhoea is a leading cause of mortality among children in resource-limited countries. However, very scarce literature exists regarding the factors influencing the awareness and use of low osmolarity oral rehydration salts (Lo-ORS) and zinc supplementation in the management of childhood diarrhoea among mothers of children under 5 years of age in southwestern Nigeria. This study, performed in Lagos, Nigeria, aimed to address this lack of knowledge.

Methods

Through a cross-sectional survey design, 336 mothers of children under 5 years of age were selected through a multi-stage sampling procedure. Data were collected with a pretested, semi-structured interviewer administered questionnaire and analysed in SPSS version 23. Descriptive and inferential statistical techniques were used for data analysis.

Results

A total of 10.4% of the mothers were aware of Lo-ORS, whereas 6.5% had ever used it; 53.3% were aware of zinc supplementation, whereas 42% had ever used it. Awareness was influenced by educational level (AOR: 2.017; 95% CI: 1.123–3.626) and the age of the child (AOR: 2.257; 95% CI: 1.237–4.117) for Lo-ORS, and by average monthly income (AOR: 1.582; 95% CI: 1.144–2.187) for zinc supplementation. The utilisation level was associated with educational level (p = 0.039) and awareness (p < 0.001) for Lo-ORS, and with marital status (p = 0.018) and awareness (p < 0.001) for zinc supplementation.

Conclusion

Awareness and use of Lo-ORS was poorer than that of zinc supplementation among the mothers. Efforts to promote awareness regarding these treatments among mothers and health workers should be intensified to promote their use and help bridge the gap between policy change and effectiveness.

Mechanistic Impact of Zinc Deficiency in Human Development

Zinc (Zn) deficiency in humans is an emerging global health issue affecting approximately two billion people across the globe. The situation prevails due to the intake of Zn deficient grains and vegetables worldwide. Clinical identification of Zn deficiency in humans remains problematic because the symptoms do not appear until impair the vital organs, such as the gastrointestinal track, central nervous system, immune system, skeletal, and nervous system. Lower Zn body levels are also responsible for multiple physiological disorders, such as apoptosis, organs destruction, DNA injuries, and oxidative damage to the cellular components through reactive oxygen species (ROS). The oxidative damage causes chronic inflammation lead toward several chronic diseases, such as heart diseases, cancers, alcohol-related malady, muscular contraction, and neuro-pathogenesis. The present review focused on the physiological and growth-related changes in humans under Zn deficient conditions, mechanisms adopted by the human body under Zn deficiency for the proper functioning of the body systems, and the importance of nutritional and nutraceutical approaches to overcome Zn deficiency in humans and concluded that the biofortified food is the best source of Zn as compared to the chemical supplementation to avoid their negative impacts on human.

"Are We Feeding Them Enough?" Micronutrient Deficiency in Children Aged Six Months to Fourteen Years in India

In this study, we conducted a systematic literature review of the various micronutrient deficiencies (MNDs) that affect children in India and an examination of whether there is a geographic basis for MNDs.

MNDs are a common problem in the developing world, in particular, among children in South Asia. According to the United Nations Children’s Fund, millions of children suffer from stunted growth, cognitive delays, weakened immunity, and diseases because of MNDs. These physical ailments have several economic, social, and public health implications, and they can severely hamper a country’s growth. This study aims to clarify existing data on this topic and highlight the disparities between children living in urban and rural areas in India.

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed to conduct this systematic literature review of a total of five studies. Study quality was assessed using appropriate checklists, and the studies strengthened the hypothesis that MNDs are common among children in India. Because the selected studies were heterogeneous, no statistical conclusions are drawn here. However, a central premise is that MNDs in children are prevalent in India and are related to poverty. No link between geographic location and MNDs is established; rather, recommendations are made for further research on the topic.

Therapeutic supplementation with zinc in the management of COVID-19-related diarrhea and ageusia/dysgeusia: mechanisms and clues for a personalized dosage regimen

Zinc supplementation is indicated for diarrhea and taste disorders, which are both features of COVID-19. Nevertheless, this strategy has not been tested for the treatment of these secondary complications in the current pandemic. Through an updated review, a practical appraisal was considered as a means of providing a medical nexus of therapeutic zinc regimens as an adjunct in the management of COVID-19–related diarrhea and ageusia/dysgeusia. While diarrhea and taste disorders are consequences of COVID-19, zinc supplementation is useful for non–COVID-19 patients with these clinical problems. The overwhelming evidence for supplementing with zinc in diarrhea and pneumonia is associated with the treatment of children, while for taste disorders the use of supplementing with zinc is more examined in adults. Whereas COVID-19 is more prevalent in adults, precautions should be exercised not to translate the zinc dosage used for children with diarrhea and taste disorders into the current pandemic. Therapeutic doses of zinc used for adults (∼50–150 mg/day of elemental zinc) could be included in the treatment strategies for COVID-19, but this proposal should be examined through randomized studies.

Multielemental Analysis of Bee Pollen, Propolis, and Royal Jelly Collected in West-Central Poland

Beehive products possess nutritional value and health-promoting properties and are recommended as so-called "superfoods". However, because of their natural origin, they may contain relevant elemental contaminants. Therefore, to assess the quality of bee products, we examined concentrations of a broad range of 24 selected elements in propolis, bee pollen, and royal jelly. The quantitative analyses were performed with inductively coupled plasma-mass spectrometry (ICP-MS) and inductively coupled plasma optical emission spectrometry (ICP-OES) techniques. The results of our research indicate that bee products contain essential macronutrients (i.e., K, P, and S) and micronutrients (i.e., Zn and Fe) in concentrations depending on the products' type. However, the presence of toxic heavy metals makes it necessary to test the quality of bee products before using them as dietary supplements. Bearing in mind that bee products are highly heterogenous and, depending on the environmental factors, differ in their elemental content, it is necessary to develop standards regulating the acceptable levels of inorganic pollutants. Furthermore, since bees and their products are considered to be an effective biomonitoring tool, our results may reflect the environment's condition in west-central Poland, affecting the health and well-being of both humans and bees.

Effects of Dietary Supplementation of Garlic and Oregano Essential Oil on Biomarkers of Oxidative Status, Stress and Inflammation in Postweaning Piglets

The effects of two different concentrations of micro capsuled oregano essential oil (OEO) and purple garlic powder on biomarkers of oxidative status, stress, and inflammation, as well as on average daily gain (ADG) and feed conversion ratio (FCR), were evaluated in piglets during the postweaning period. The trial was carried out with 300 crossbred pigs of 21 days of age fed with different concentrations of OEO and purple garlic powder and ZnO. Saliva and serum samples were taken to evaluate a panel of biomarkers of oxidative status, stress, and inflammation. OEO and garlic powder at 0.4% did not produce significant changes in C-reactive protein (CRP) and cortisol and yielded higher levels of the antioxidant biomarker CUPRAC in serum than higher doses (p < 0.01); they yielded a better ADG than the control and ZnO diets. OEO and garlic powder at higher concentrations than 0.4% showed higher concentrations of CRP (p < 0.05). Overall, doses of OEO and garlic powder at 0.4% did not lead to inflammation, stress, or negative changes in oxidative biomarkers in piglets during the postweaning period and gave better productive performance than the control and ZnO diets. High doses of OEO and garlic powder were ineffective and could negatively affect the animals. Therefore, our results highlight the importance of the dose used when OEO or garlic are supplemented to piglets.

Factors associated with zinc utilization for the management of diarrhea in under-five children in Ethiopia

BACKGROUND

Zinc has a tremendous advantage to save the life of children. It reduces the mean duration of diarrhea and mortality due to diarrhea. Besides, it reduces the severity of the initial episode, and also it prevents future diarrhea episodes. But there is low utilization of zinc for the management of diarrhea in under-five children in Ethiopia and there is a paucity of literature regarding the factors associated with the utilization.

METHOD

The 2016 Ethiopian demographic and health survey data were used as a data source. A total weighted sample of 1228 under-five children with diarrhea within 2 weeks preceding the survey were used. A mixed-effects logistic regression analysis was done to account for the complex sample design of the data. Variables with p-value < 0.20 in the bivariable analysis were eligible for multivariable analysis and those variables with p value< 0.05 in the multivariable analysis were declared to be determinants of zinc utilization for the management of diarrhea in under-five children.

RESULT

In this study, we found multiple determinants of zinc utilization. Mothers with formal education (adjusted odds ratio (AOR) = 1.83;95% CI; 1.30-2.58) and media exposure (AOR = 1.46;95% CI; 1.04-2.04) had higher odds of zinc utilization. But mothers from five and above household size (AOR = 0.57;95% CI; 0.39-0.82) had lower odds of zinc utilization for the management of diarrhea in under-five children.

CONCLUSION

In our study maternal education, media exposure, and household size were determinants of zinc utilization for the management of diarrhea in under-five children. Being having a formal education and being exposed to all or either of the three media (radio, TV, and newspaper) increases the likelihood of zinc utilization while being mothers from large household size decreases the likelihood of zinc utilization. Therefore, giving special attention to those mothers with no formal education, and mothers from high family size could increase the utilization of zinc for the management of diarrhea in under-five children. Also, media campaigns regarding diarrhea management could be scaled up to potentially achieve the desired impact.

Lower-Dose Zinc for Childhood Diarrhea - A Randomized, Multicenter Trial

BACKGROUND

The World Health Organization recommends 20 mg of zinc per day for 10 to 14 days for children with acute diarrhea; in previous trials, this dosage decreased diarrhea but increased vomiting.

METHODS

We randomly assigned 4500 children in India and Tanzania who were 6 to 59 months of age and had acute diarrhea to receive 5 mg, 10 mg, or 20 mg of zinc sulfate for 14 days. The three primary outcomes were a diarrhea duration of more than 5 days and the number of stools (assessed in a noninferiority analysis) and the occurrence of vomiting (assessed in a superiority analysis) within 30 minutes after zinc administration.

RESULTS

The percentage of children with diarrhea for more than 5 days was 6.5% in the 20-mg group, 7.7% in the 10-mg group, and 7.2% in the 5-mg group. The difference between the 20-mg and 10-mg groups was 1.2 percentage points (upper boundary of the 98.75% confidence interval [CI], 3.3), and that between the 20-mg and 5-mg groups was 0.7 percentage points (upper boundary of the 98.75% CI, 2.8), both of which were below the noninferiority margin of 4 percentage points. The mean number of diarrheal stools was 10.7 in the 20-mg group, 10.9 in the 10-mg group, and 10.8 in 5-mg group. The difference between the 20-mg and 10-mg groups was 0.3 stools (upper boundary of the 98.75% CI, 1.0), and that between the 20-mg and 5-mg groups was 0.1 stools (upper boundary of the 98.75% CI, 0.8), both of which were below the noninferiority margin (2 stools). Vomiting within 30 minutes after administration occurred in 19.3%, 15.6%, and 13.7% of the patients in the 20-mg, 10-mg, and 5-mg groups, respectively; the risk was significantly lower in the 10-mg group than in the 20-mg group (relative risk, 0.81; 97.5% CI, 0.67 to 0.96) and in the 5-mg group than in the 20-mg group (relative risk, 0.71; 97.5% CI, 0.59 to 0.86). Lower doses were also associated with less vomiting beyond 30 minutes after administration.

CONCLUSIONS

Lower doses of zinc had noninferior efficacy for the treatment of diarrhea in children and were associated with less vomiting than the standard 20-mg dose. (Funded by the Bill and Melinda Gates Foundation; ZTDT ClinicalTrials.gov number, NCT03078842.).

Efficacy of zinc supplementation in the management of acute diarrhoea: a randomised controlled trial

Background: Zinc has been recommended for the treatment of acute diarrhoea; however, there are heterogeneous reports regarding its efficacy.Aim: This study investigated the efficacy of zinc supplementation on the treatment outcomes of children admitted to hospital with acute diarrhoea.Methods: A double-blind, randomised, placebo-controlled trial was conducted in the Srinakharinwirot University Hospital's Paediatric Department, Thailand. Eligible children were randomly allocated to receive either zinc bisglycinate (15 mg elemental zinc) or a placebo. The study protocol was registered in the Thai Clinical Trials Registry (TCTR20190423004).Results: Of 86 patients, 50 (58.1%) were male and the mean age (range) was 2.5 years (6 months to 9.3 years). The median (IQR) number of hours to recovery from diarrhoea was significantly less in the zinc group than in the controls [44 (24-48) vs 52 (36-80) hours, respectively, p < 0.01]. The median (IQR) number of stools was significantly lower in the zinc group [5 (3-12)] than in the controls [7 (4-17), p = 0.02]. The median (IQR) duration of intravenous fluid therapy was 40 (24-56) hours in the zinc group and 56 (40-73) in the control group (p < 0.01). The duration of hospitalisation was 60 (44-72) hours in the zinc group and 84 (56-136) hours in the controls (p < 0.01). There was good compliance by all participants in both groups.Conclusion: Zinc supplementation can reduce the time to resolution of acute diarrhoea, the length of hospital stay and the frequency of stools. Zinc supplementation is recommended as a routine strategy for Thai children with acute diarrhoea.

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.

Effect of dose reduction of supplemental zinc for childhood diarrhoea: study protocol for a double-masked, randomised controlled trial in India and Tanzania

BACKGROUND

Diarrhoea-associated mortality and morbidity are highest in infants and young children in low-income and middle-income countries (LMICs). Zinc supplementation during acute diarrhoea has been shown to reduce the duration of illness and the risk of persistent diarrhoea. However, vomiting with zinc supplementation is a common side effect that may interfere with compliance and programmatic scale-up, and may be related to the dose prescribed.

METHODS/DESIGN

The Zinc Therapeutic Dose Trial (ZTDT) is a two-centre (Tanzania and India), three-arm randomised, double-blind controlled non-inferiority trial. Children 6-59 months of age with acute diarrhoea are eligible to participate. Enrolled children (1500 per arm; 4500 total) will be randomly allocated to receive 5, 10 or 20 mg of zinc sulfate daily for 14 days and will be followed up for 60 days after enrolment. All children will receive WHO/Unicef Integrated Management of Childhood Illness standard of care (oral or intravenous rehydration and zinc as indicated and feeding advice). The primary efficacy outcomes of the trial are the percentage of subjects with diarrhoea duration >5 days, the mean total number of loose or watery stools after enrolment and the proportion of children vomiting within 30 min of zinc administration.

DISCUSSION

The ZTDT trial will determine the optimal dose of therapeutic zinc supplements for treatment of acute diarrhoea in children aged 6-59 months in two LMICs. The results of the trial are likely to be generalisable to childhood acute diarrhoea in similar resource-limited settings and may influence global policy about zinc supplementation dosage during acute diarrhoea.

TRIAL REGISTRATION NUMBER

NCT03078842.

TRIAL STATUS

Enrolment began in January 2017 and follow-up is estimated to be completed by April 2019. As of 1 February 2019, 742 children are still contributing data to the ZTDT study.

Trace Mineral Supplementation for the Intestinal Health of Young Monogastric Animals

Growth performance and feed efficiency are essential parameters when evaluating profitability of livestock. However, animal performance does not always reflect optimal gut health. Decades of research have supported the theory that improved animal performance such as average daily gain and feed efficiency can be impacted by intestinal health or the ability of the intestinal mucosa to absorb nutrients, but dysfunction may be found when the animal is stressed. Most of the early research focused on enteric infections causing diarrhea and nutritional alternatives to antibiotics which has led to findings related to pharmacological supplementation of trace minerals above the nutrient requirements for non-ruminants. While pharmacological concentrations of copper (Cu) have been shown to enhance growth, the mechanism in the gut is elusive. High concentrations of zinc (Zn) fed to newly weaned nursery pigs reduced the incidence of diarrhea from the proliferation of enterotoxigenic Escherichia coli (E. coli) and Clostridium and improve gut morphology. There are numerous publications where pharmacological supplementation of Zn as zinc oxide (ZnO) were fed to newly weaned pigs. Pharmacological Zn has been reported to shape the intestinal microflora as well as the diversity of the microflora during the first 2 weeks post-weaning. Both Fe deficiency and fortification impact bacterial growth in the intestine. Therefore, this paper will focus on the role of trace minerals that potentially impact optimal gut health of young monogastric animals.

Effect of Zinc Supplementation on the Frequency and Consistency of Stool in Children with Acute Diarrhea

Introduction

Acute diarrhea in young children is a prevalent and distressing pediatric illness. The role of zinc therapy in the improvement of stool consistency and the shortening of the duration of diarrhea is still controversial. The aim of this study is to assess the effect of oral zinc supplementation in acute diarrhea.

Methods

Children of age 28 days till five years presenting in the outpatient department with acute diarrhea were included. Oral zinc supplementation was included in the anti-diarrheal regime of half of the children (n=50); the other half (n=50) were not given zinc. Mean body weight and the frequency and consistency of stool were noted for both groups on Days 1 and 3.

Results

The zinc group showed a significantly reduced frequency of diarrheal episodes on the third day of intervention (p<.00001). More children in the zinc group had soft to firm stool consistency than in the non-zinc group (p=.01).

Conclusion

Oral zinc supplementation has a promising role in reducing the duration of diarrhea and improving stool consistency in children with acute diarrhea. Oral zinc supplementation should be made a mandatory part of the anti-diarrheal regime for Pakistani children.

Effectiveness of zinc-fortified water on zinc intake, status and morbidity in Kenyan pre-school children: a randomised controlled trial

OBJECTIVE

Zn deficiency and diarrhoea are prevalent and may coexist in children living in low-resource settings. Recently, a novel approach for delivering Zn via microbiologically treated, Zn-fortified water was shown to be effective in improving Zn status in West African schoolchildren. We assessed the effectiveness of Zn-fortified, microbiologically purified water delivered as a household intervention on Zn intake, status and morbidity in children aged 2-6 years from rural western Kenya.

DESIGN

Randomised controlled trial. Intervention included households assigned to water treatment device with (ZFW) or without (FW) Zn delivery capability SETTING: Rural households in Kisumu, western Kenya.

SUBJECTS

Children aged 2-6 years.

RESULTS

The ZFW group had higher dietary Zn intake compared with the FW group. ZFW contributed 36 and 31 % of daily requirements for absorbable Zn in children aged 2-3 and 4-6 years, respectively, in the ZFW group. Consumption of Zn-fortified water resulted in lower prevalence of reported illness (risk ratio; 95 % CI) in the ZFW group compared with the FW group: for cold with runny nose (0·91; 0·83, 0·99; P=0·034) and abdominal pain (0·70; 0·56, 0·89; P=0·003) in the intention-to-treat analysis and for diarrhoea (0·72; 0·53, 0·96; P=0·025) in the per-protocol analysis. We did not detect an effect of treatment on plasma Zn concentration.

CONCLUSIONS

Daily consumption of Zn-fortified, microbiologically treated water results in increased intake of absorbable dietary Zn and may help in preventing childhood infections in pre-school children in rural Africa.

Professor Lan Shu's experience of syndrome differentiation and prescription in treating infant diarrhea

This paper aims to clarify the theory of Chinese medicine for treating infant diarrhea by analyzing Professor Lan Shu's three representative cases of treating cold diarrhea, damp heat diarrhea, spleen diarrhea, and spleen and kidney deficiency diarrhea in infants with Huoxiang Zhengqi powder addition and subtraction, Gegen Qinlian decoction, Qiwei Baizhu powder addition and subtraction, and Fuzilizhong decoction. Due to the characteristics of the etiology and pathogenesis of infant diarrhea, Chinese medicine has a unique advantage in treating infant diarrhea. Based on the syndrome differentiation and according to the pathogenesis of cold and heat changes, adding or subtracting traditional Chinese medicine not only improves the clinical cure rate of infant diarrhea effectively, but also reduces the incidence of antibiotic-associated diarrhea.

Drug-development concepts as guides for optimizing clinical trials of supplemental zinc for populations at risk of deficiency or diarrhea

Studies on the efficacy of zinc supplementation for treatment or prevention of diarrhea have shown an inconsistent effect in populations at risk for zinc deficiency. Unlike drugs, which have no preexisting presence in the body, endogenous zinc must be assessed pharmacokinetically by isotope tracer studies. Although such methods have produced much data, very few studies have estimated the dose and the timing of dosing of zinc supplementation. This review examines drug kinetics used to establish the best dose, the timing of such doses, and the mechanism of action through pharmacodynamic markers and applies them, where possible, to zinc supplements. The findings reveal that little is known, especially in children at highest risk of zinc deficiency. Key data missing to inform proper dosing, whether for treatment of disease or for preventive nutrient supplementation, are noted. Addressing these uncertainties could improve study design, leading to future studies of zinc supplements that might be of greater benefit.

Factors Associated with the Duration of Moderate-to-Severe Diarrhea among Children in Rural Western Kenya Enrolled in the Global Enteric Multicenter Study, 2008-2012

Diarrheal disease is a leading cause of death among young children worldwide. As rates of acute diarrhea (AD; 1-6 days duration) have decreased, persistent diarrhea (PD; > 14 days duration) accounts for a greater proportion of the diarrheal disease burden. We describe factors associated with the duration of moderate-to-severe diarrhea in Kenyan children < 5 years old enrolled in the Global Enteric Multicenter Study. We found 587 (58%) children experienced AD, 360 (35%) had prolonged acute diarrhea (ProAD; 7-13 days duration), and 73 (7%) had PD. We constructed a Cox proportional hazards model to identify factors associated with diarrheal duration. Risk factors independently associated with longer diarrheal duration included infection with Cryptosporidium (hazard ratio [HR]: 0.868, P = 0.035), using an unimproved drinking water source (HR: 0.87, P = 0.035), and being stunted at enrollment (HR: 0.026, P < 0.0001). Diarrheal illness of extended duration appears to be multifactorial; given its association with adverse health and development outcomes, effective strategies should be implemented to reduce the duration and severity of diarrheal illness. Effective treatments for Cryptosporidium should be identified, interventions to improve drinking water are imperative, and nutrition should be improved through exclusive breastfeeding in infants ≤ 6 months and appropriate continued feeding practices for ill children.

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 different ecological niches of enterotoxigenic Escherichia coli

Enterotoxigenic Escherichia coli (ETEC) is a water and food-borne pathogen that infects the small intestine of the human gut and causes diarrhoea. Enterotoxigenic E. coli adheres to the epithelium by means of colonization factors and secretes two enterotoxins, the heat labile toxin and/or the heat stable toxin that both deregulate ion channels and cause secretory diarrhoea. Enterotoxigenic E. coli as all E. coli, is a versatile organism able to survive and grow in different environments. During transmission and infection, ETEC is exposed to various environmental cues that have an impact on survivability and virulence. The ability to cope with exposure to different stressful habitats is probably shaping the pool of virulent ETEC strains that cause both endemic and epidemic infections. This review will focus on the ecology of ETEC in its different habitats and interactions with other organisms as well as abiotic factors.

Zinc for Acute Diarrhea and Amoxicillin for Pneumonia, Do They Work? : Delivered at the AIIMS, IJP Excellence Award for the year 2013 on 7th September 2014

Acute diarrhea and pneumonia are the two largest killers of under-five children in the world. Zinc, used in management of acute diarrhea and Amoxicillin, used in community acquired pneumonia, feature in the list of 13 Life Saving Commodities for Women's and Children Health by the UN Commission. Zinc has caught wide scientific attention for the conceptual promise it has to offer for prevention, control and treatment of acute diarrhea. This presentation focuses on author's research on the mechanisms by which zinc might contribute to the pathogenesis of acute diarrhea and the degree of success achieved in diarrhea control and treatment by zinc supplementation including its impact on mortality. However, emerging evidence in terms of controlled studies in humans beckons a more complete understanding of the mechanistic basis for zinc supplementation. Current evidence indicates that studies specifically addressing the variability in response to zinc supplementation need to be undertaken to better comprehend these mechanisms. Similarly, the author presented her research that examined the role of oral amoxicillin in community management of severe pneumonia in children and the need to assess its universal efficacy in all children with severe pneumonia.

The epidemiology of global micronutrient deficiencies

Micronutrients are essential to sustain life and for optimal physiological function. Widespread global micronutrient deficiencies (MNDs) exist, with pregnant women and their children under 5 years at the highest risk. Iron, iodine, folate, vitamin A, and zinc deficiencies are the most widespread MNDs, and all these MNDs are common contributors to poor growth, intellectual impairments, perinatal complications, and increased risk of morbidity and mortality. Iron deficiency is the most common MND worldwide and leads to microcytic anemia, decreased capacity for work, as well as impaired immune and endocrine function. Iodine deficiency disorder is also widespread and results in goiter, mental retardation, or reduced cognitive function. Adequate zinc is necessary for optimal immune function, and deficiency is associated with an increased incidence of diarrhea and acute respiratory infections, major causes of death in those <5 years of age. Folic acid taken in early pregnancy can prevent neural tube defects. Folate is essential for DNA synthesis and repair, and deficiency results in macrocytic anemia. Vitamin A deficiency is the leading cause of blindness worldwide and also impairs immune function and cell differentiation. Single MNDs rarely occur alone; often, multiple MNDs coexist. The long-term consequences of MNDs are not only seen at the individual level but also have deleterious impacts on the economic development and human capital at the country level. Perhaps of greatest concern is the cycle of MNDs that persists over generations and the intergenerational consequences of MNDs that we are only beginning to understand. Prevention of MNDs is critical and traditionally has been accomplished through supplementation, fortification, and food-based approaches including diversification. It is widely accepted that intervention in the first 1,000 days is critical to break the cycle of malnutrition; however, a coordinated, sustainable commitment to scaling up nutrition at the global level is still needed. Understanding the epidemiology of MNDs is critical to understand what intervention strategies will work best under different conditions.

Zinc-fortified oral rehydration solution improved intestinal permeability and small intestinal mucosal recovery

A randomized double-blind placebo-controlled study was conducted in children admitted to hospital with gastroenteritis (≥3 loose stools per day). All were treated for 5 days following admission with either zinc (Zn, 3 mg) or without Zn-fortified rice-based oral rehydration solution (ORS). (13)C-sucrose breath test (SBT) and intestinal permeability (lactulose/rhamnose or L/R ratio) were performed concurrently prior to commencement of ORS with or without Zn and at day 5 post-admission. There was a significant improvement in the SBT results in both the Zn-fortified group, median (5th-95th percentile) 2.1% (0.4% to 8.3%) versus 4.4% (0.4% to 10.4%), P < .05, and control group, 1.4% (0.1% to 5.4%) versus 4.3% (0.4% to 11.4%), P < .05, between the day of admission and day 5 post-admission. In the Zn-fortified group, there was also a significant improvement in L/R ratio between the day of admission and day 5 post-admission, 53.0 (19.5-90.6) versus 17.7 (13.4-83.2), P < .05. Low levels of Zn improved intestinal permeability but did not enhance short-term recovery following diarrheal illness.

The potential for zinc stable isotope techniques and modelling to determine optimal zinc supplementation

It is well recognised that zinc deficiency is a major global public health issue, particularly in young children in low-income countries with diarrhoea and environmental enteropathy. Zinc supplementation is regarded as a powerful tool to correct zinc deficiency as well as to treat a variety of physiologic and pathologic conditions. However, the dose and frequency of its use as well as the choice of zinc salt are not clearly defined regardless of whether it is used to treat a disease or correct a nutritional deficiency. We discuss the application of zinc stable isotope tracer techniques to assess zinc physiology, metabolism and homeostasis and how these can address knowledge gaps in zinc supplementation pharmacokinetics. This may help to resolve optimal dose, frequency, length of administration, timing of delivery to food intake and choice of zinc compound. It appears that long-term preventive supplementation can be administered much less frequently than daily but more research needs to be undertaken to better understand how best to intervene with zinc in children at risk of zinc deficiency. Stable isotope techniques, linked with saturation response and compartmental modelling, also have the potential to assist in the continued search for simple markers of zinc status in health, malnutrition and disease.

Zinc supplementation in acute diarrhea

OBJECTIVE

To determine the effect of zinc supplementation on the duration of acute diarrhea in children.

METHODS

A search was conducted in PubMed, the Cochrane Library database, China Biology Medicine (CBM), CNKI, VIP, and Wanfang Data to find studies on zinc supplementation for children with acute diarrhea from the date of establishment of the respective databases to June 2013. Clinical trials were included, and reviews or other types of studies were excluded. Considering the inclusion criteria, articles were evaluated by two individual investigators. The Cochrane Handbook 5.0.2 was used to evaluate the methodological quality. RevMan 5.2 software was used for meta-analysis. Heterogeneity of the included studies was tested to select a proper effect model. Measurement data were expressed as standard mean difference (SMD), weighted mean difference (WMD), and 95 % confidence interval (CI).

RESULTS

A total of 860 relevant articles were found, and 8 randomized control trials that met the inclusion criteria were included. Meta-analysis showed a significant difference in the duration of acute diarrhea between treatment and control groups, with a WMD of -14.47 (95 % CI: -25.06 to -3.89; P = 0.007). However, significant heterogeneity was found among the studies. Sensitivity analysis and subgroup analyses based on admission condition, sample size and age group were also performed, for which heterogeneity cannot be completely eliminated.

CONCLUSIONS

Zinc supplementation can decrease the duration of acute diarrhea in children, but future studies should carry out a more thorough analysis in less heterogeneous subjects for a more definitive conclusion.

Cost-effectiveness analysis of zinc supplementation for treatment of acute diarrhea in children younger than 5 years in Colombia

OBJECTIVE

The objective of this study was to determine the cost-effectiveness of zinc supplementation for the treatment of acute diarrhea (AD) in children younger than 5 years in Colombia.

METHODS

The cost-effectiveness analysis was performed from the perspective of the Colombian health system. The standard treatment with the addition of zinc was compared with the standard treatment without zinc in children younger than 5 years. The time horizon was 1 month. Effectiveness was extracted from a systematic review of literature. The specific data for Colombia were taken from local databases and observational studies. To determine the costs, a typical case was constructed by reviewing guidelines and medical records and validated by experts. To evaluate the resources consumed, Colombian tariff manuals were used. Costs were stated in Colombian pesos (COP) and US dollar (USD) for 2010. Deterministic sensitivity analysis was performed to evaluate the impact of changes in cost and effectiveness of the strategies on the results from the model.

RESULTS

The results from the model indicate that zinc supplementation is a dominant strategy; it is less costly and more effective than standard treatment without zinc (reduction of $15,210 COP [8.14 USD] per child). The results are sensitive to changes in the probability of hospitalization and of persistent diarrhea.

CONCLUSIONS

Zinc for the treatment of AD is a highly cost-effective strategy and is recommended for inclusion in the benefit plan of the Colombian health system. This intervention is more cost-effective in children with a higher risk of persistent diarrhea and hospitalization.

Early childhood diarrhoeal diseases and cognition: are we missing the rest of the iceberg?

Risk factors which interfere with cognitive function are especially important during the first 2 years of life - a period referred to as early child development and a time during which rapid growth and essential development occur. Malnutrition, a condition whose effect on cognitive function is well known, has been shown to be part of a vicious cycle with diarrhoeal diseases, and the two pathologies together continue to be the leading cause of illness and death in young children in developing countries. This paper reviews the burden of early childhood diarrhoeal diseases globally and the emerging evidence of their relationship with global disparities in neurocognitive development. The strength of evidence which indicates that the severe childhood diarrhoeal burden may be implicated in cognitive impairment of children from low- and middle-income counties is discussed. Findings suggest that greater investment in multi-site, longitudinal enteric infection studies that assess long-term repercussions are warranted. Furthermore, economic analyses using the concept of human capital should play a key role in advancing our understanding of the breadth and complexities of the health, social and economic ramifications of early childhood diarrhoeal diseases and enteric infections. This broadened awareness can serve to help advocate for more effective interventions, particularly in developing economies.

Zinc deficiency in children with environmental enteropathy-development of new strategies: report from an expert workshop

Zinc deficiency is a major cause of childhood morbidity and mortality. The WHO/UNICEF strategy for zinc supplementation as adjunctive therapy for diarrhea is poorly implemented. A conference of experts in zinc nutrition and gastrointestinal disorders was convened to consider approaches that might complement the current recommendation and what research was needed to develop these approaches. Several key points were identified. The design of novel zinc interventions would be facilitated by a better understanding of how disturbed gut function, such as environmental (or tropical) enteropathy, affects zinc absorption, losses, and homeostasis. Because only 10% of zinc stores are able to be rapidly turned over, and appear to be rapidly depleted by acute intestinal illness, they are probably best maintained by complementary regular supplementation in a primary prevention strategy rather than secondary prevention triggered by acute diarrhea. The assessment of zinc status is challenging and complex without simple, validated measures to facilitate field testing of novel interventions. Zinc bioavailability may be a crucial factor in the success of primary prevention strategies, and a range of options, all still inadequately explored, might be valuable in improving zinc nutrition. Some therapeutic actions of zinc on diarrhea seem attributable to pharmacologic effects, whereas others are related to the reversal of deficiency (ie, nutritional). The distinction between these 2 mechanisms cannot be clarified given the insensitivity of serum zinc to identify subclinical deficiency states. Why zinc seems to be less effective than expected at all ages, and ineffective for secondary prevention of diarrhea in children <12 mo of age, remains unclear. It was concluded that a reframing of the current recommendation is warranted with consideration of how to better optimize and deliver zinc and whether to provide a complementary public health primary prevention zinc strategy. This requires careful consideration of the zinc product to be used as well as strategies for its delivery.

Zinc protects against Shiga-toxigenic Escherichia coli by acting on host tissues as well as on bacteria

BACKGROUND

Zinc supplements can treat or prevent enteric infections and diarrheal disease. Many articles on zinc in bacteria, however, highlight the essential nature of this metal for bacterial growth and virulence, suggesting that zinc should make infections worse, not better. To address this paradox, we tested whether zinc might have protective effects on intestinal epithelium as well as on the pathogen.

RESULTS

Using polarized monolayers of T84 cells we found that zinc protected against damage induced by hydrogen peroxide, as measured by trans-epithelial electrical resistance. Zinc also reduced peroxide-induced translocation of Shiga toxin (Stx) across T84 monolayers from the apical to basolateral side. Zinc was superior to other divalent metals to (iron, manganese, and nickel) in protecting against peroxide-induced epithelial damage, while copper also showed a protective effect.The SOS bacterial stress response pathway is a powerful regulator of Stx production in STEC. We examined whether zinc's known inhibitory effects on Stx might be mediated by blocking the SOS response. Zinc reduced expression of recA, a reliable marker of the SOS. Zinc was more potent and more efficacious than other metals tested in inhibiting recA expression induced by hydrogen peroxide, xanthine oxidase, or the antibiotic ciprofloxacin. The close correlation between zinc's effects on recA/SOS and on Stx suggested that inhibition of the SOS response is one mechanism by which zinc protects against STEC infection.

CONCLUSIONS

Zinc's ability to protect against enteric bacterial pathogens may be the result of its combined effects on host tissues as well as inhibition of virulence in some pathogens. Research focused solely on the effects of zinc on pathogenic microbes may give an incomplete picture by failing to account for protective effects of zinc on host epithelia.

Therapeutic effects of oral zinc supplementation on acute watery diarrhea with moderate dehydration: a double-blind randomized clinical trial

BACKGROUND

To assess the therapeutic effects of oral zinc supplementation on acute watery diarrhea of children with moderate dehydration.

METHODS

All 9-month to 5-year-old children who were admitted with acute watery diarrhea and moderate dehydration to the Children Ward of Motahari Hospital, Urmia, Iran in 2008 were recruited. After the application of the inclusion and exclusion criteria, the patients were randomly allocated to two groups: one group to receive zinc plus oral rehydration solution (ORS) and the other one to receive ORS plus placebo. All the patients were rehydrated using ORS and then receiving ORS for ongoing loss (10 ml/kg after every defecation). Additionally, the patients in the intervention group received zinc syrup (1 mg/kg/day) divided into two doses. A detailed questionnaire was filled daily for each patient by trained pediatrics residents; it contained required demographic characteristics, nutrition and hydration status, and disease progression. The primary outcome (frequency and consistency of diarrhea) and the secondary outcomes (duration of hospitalization and change in patients' weight) were compared between the two groups.

RESULTS

The mean diarrhea frequency (4.5±2.3 vs. 5.3±2.1; P=0.004) was lower in the group receiving zinc +ORS; however, the average weight was relatively similar between the two groups (10.5±3.1 vs. 10.1±2.3; P=0.14). The qualitative assessment of stool consistency also confirmed earlier improvement in the treatment group in the first three days of hospitalization (P <0.05). The mean duration of hospitalization was significantly lower in the patients receiving zinc supplements (2.5±0.7 vs. 3.3±0.8 days; P=0.001).

CONCLUSION

Our results imply the beneficial effects of therapeutic zinc supplementation on disease duration and severity in patients with acute diarrhea and moderate dehydration in Iran.

TRIAL REGISTRATION NUMBER

IRCT201201241580N2.

Review article: the management of acute gastroenteritis in children

BACKGROUND

In 2008, the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society of Paediatric Infectious Disease (ESPID) developed evidence-based guidelines for the management of acute gastroenteritis (AGE) in children in Europe.

AIM

To summarise data published subsequently to the ESPGHAN/ESPID guidelines.

METHODS

MEDLINE and The Cochrane Library were searched in August 2012 for randomised controlled trials (RCTs) or their meta-analyses published after 2008.

RESULTS

Efforts to improve the taste and/or efficacy of oral rehydration solution (ORS) continue, and some interventions are promising. While standard (over 24 h) nasogastric rehydration is still being used, new evidence confirms that rapid (over 4 h) rehydration is also effective. For intravenous rehydration, new evidence is available regarding rapid or ultrarapid and large-volume vs. standard-volume rehydration; as the new evidence is not consistent, until more data are available, the administration of 20 mL/kg seems appropriate. Convincing evidence has accumulated showing that ondansetron reduces the risk for vomiting; however, a clearance on safety in children is needed. New evidence has reconfirmed that in Europe, where zinc deficiency is rare, there is no benefit from the use of zinc. New data, although mainly from outside of Europe, have reconfirmed that either smectite or racecadotril is an effective adjunctive therapy to oral rehydration. There is a clear effect of using certain probiotics, such as Lactobacillus GG or S. boulardii.

CONCLUSIONS

The update of current ESPGHAN/ESPID recommendations is warranted.

Oral zinc for treating diarrhoea in children

BACKGROUND

In developing countries, diarrhoea causes around two million child deaths annually. Zinc supplementation during acute diarrhoea is currently recommended by the World Health Organization and UNICEF.

OBJECTIVES

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

SEARCH METHODS

In February 2012, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2011, Issue 11), MEDLINE, EMBASE, LILACS, CINAHL, mRCT, and reference lists. We also contacted researchers.

SELECTION CRITERIA

Randomized controlled trials comparing 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 authors assessed trial eligibility and risk of bias, extracted and analysed data, and drafted the review. Diarrhoea duration and severity were the primary outcomes. 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 the fixed- or random-effects model) and assessed heterogeneity.The quality of evidence has been assessed using the GRADE methods

MAIN RESULTS

Twenty-four trials, enrolling 9128 children, met our inclusion criteria. The majority of the data is from Asia, from countries at high risk of zinc deficiency, and may not be applicable elsewhere. Acute diarrhoea. There is currently not enough evidence from well conducted randomized controlled trials to be able to say whether zinc supplementation during acute diarrhoea reduces death or hospitalization (very low quality evidence).In children aged greater than six months with acute diarrhoea, zinc supplementation may shorten the duration of diarrhoea by around 10 hours (MD -10.44 hours, 95% CI -21.13 to 0.25; 2175 children, six trials, low quality 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, six trials, moderate quality evidence). In children with signs of moderate malnutrition the effect appears greater, reducing the duration of diarrhoea by around 27 hours (MD -26.98 hours, 95% CI -14.62 to -39.34; 336 children, three trials, high quality evidence).Conversely, In children aged less than six months, the available evidence suggests zinc supplementation may have no effect on mean diarrhoea duration (MD 5.23 hours, 95% CI -4.00 to 14.45; 1334 children, two trials, low quality evidence), and may even increase the proportion of children whose diarrhoea persists until day seven (RR 1.24, 95% CI 0.99 to 1.54; 1074 children, one trial, moderate quality evidence).No trials reported serious adverse events, but zinc supplementation during acute diarrhoea causes vomiting in both age groups (RR 1.59, 95% 1.27 to 1.99; 5189 children, 10 trials, high quality evidence). Persistent diarrhoea. In children with persistent diarrhoea, zinc supplementation probably shortens the duration of diarrhoea by around 16 hours (MD -15.84 hours, 95% CI -25.43 to -6.24; 529 children, five trials, moderate quality evidence).

AUTHORS' CONCLUSIONS

In areas where the prevalence of zinc deficiency or the prevalence of moderate 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 below six months of age.

Diosmectite-zinc oxide composite improves intestinal barrier function, modulates expression of pro-inflammatory cytokines and tight junction protein in early weaned pigs

The study evaluated whether feeding diosmectite-ZnO composite (DS-ZnO) at 500 mg Zn/kg to early weaned pigs would alleviate the weaning-related intestinal disorders as a substitute for high concentration of ZnO (2250 mg Zn/kg). The pigs weaned at an age of 21 ± 1 d were allotted to four treatments groups as follows: (1) control; (2) DS-ZnO, 500 mg Zn/kg diet; (3) ZnO, 2250 mg Zn/kg diet; and (4) mixture of 2·0 g DS/kg and 500 mg Zn/kg from ZnO (equal amount of DS and ZnO in the DS-ZnO treatment group). The results showed that, compared with the control on days 7 and 14 post-weaning, addition of DS-ZnO at 500 mg Zn/kg improved (P<0·05) daily gain and feed intake, decreased (P<0·05) post-weaning scour scores, increased (P<0·05) jejunal villus height and the ratio of villus height and crypt depth, decreased (P<0·05) jejunal paracellular permeability of fluorescein isothiocyanate dextran 4 kDa and up-regulated (P<0·05) tight junction protein expression of occludin, claudin-1 and zonula occludens-1 in jejunal mucosa. The mRNA levels of TNF-α, IL-6 and interferon-γ (IFN-γ) on day 7 post-weaning were also decreased (P<0·05). The piglets fed DS-ZnO at 500 mg Zn/kg did not differ in the above parameters from those fed ZnO at 2250 mg Zn/kg, while they had better performance than those fed the mixture of DS and ZnO. Supplementation with DS-ZnO at 500 mg Zn/kg was effective in alleviating diarrhoea, barrier dysfunction and inflammatory cytokine expression and up-regulating tight junction protein expression.