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Brief Reports Indian Pediatrics 2000;37: 647-650 |
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Outcome of Nutritional Rehabilitation with and without Zinc Supplementation |
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P. Sreedevi S. Noel Narayanan
Micronutrient deficiency especially that of zinc is one of the causes for growth retardation and morbidity among children(1). Zinc deficiency is known to produce growth retardation, skin changes, persistent diarrhea, acrodermatitis enteropathica, defects in dark adaptation, delayed wound healing, thymic atrophy, altered immune function, candidial superinfection, abnormalities of taste sensation, neuropsychiatric disturbances like irritability and tremors and a syndrome of dwarfism, anemia, hepatosplenomegaly, dry skin, geophagia and hypogonadism(2–5). Maternal zinc deficiency has been reported to result in low birth weight (LBW) babies(6). Zinc is essential for life and is the component of over 100 metalloenzymes with catalytic, regulatory or structural role. Excess of zinc may produce gastrointestinal upset, gastric erosion, dizziness, lethargy, copper deficiency and renal failure(4). Serum zinc levels tend to reduce in acute infections and liver disorders. The normal range is between 60-150 mg/dl(7). In the serum, zinc is mostly bound to albumin (80%), a2 macroglobulin (15%), transferrin and metalloenzymes(4). Even though zinc is present in cereals, nuts, meat, fruits, etc., the absorption is low due to phytates(7) and interaction with folic acid, iron and copper(8). Zinc supplementation has been suggested to result in better catch up growth in those with PEM and LBW(9,10). However, recent studies have shown that catch up in weight is comparable in the zinc supplemented and unsupplemented groups(11,12). But, catch up in height has not been evaluated in these studies. The present study was undertaken to assess the extent of zinc deficiency among children with PEM and to evaluate the outcome of zinc supplementation in weight and height gain.
Sixty underfives with varying grades of PEM who attended the Nutrition follow up clinic of a tertiary referral center were included in the study. Those with congenital malforma-tion, genetic, metabolic and chromosomal diseaes, liver and kidney diseases and those already on zinc supplements were excluded from the study. These children were evaluated using a detailed proforma that included socio-demographic profile and dietary habits. Anthropometric parameters like weight, length/height, midarm circumference and head circumference were recorded using stand-ardized procedures ensuring inter and intra-observer reliability(3). These parameters were compared to NCHS reference(14). Grading of PEM was done according to IAP classifica-tion(15) and grading of stunting and wasting was done according to Waterlow’s classifica-tion(16). They were stratified according to the grade of PEM and were randomized into two groups with and without zinc supplementation. Both the groups were rehabilitated using a comprehensive package that included nutrition and health education (NHE), growth monitoring, treatment of intercurrent infections, food supplementation and multivitamins and iron supplements. A palatable ready to mix cereal pulse mixture (SAT mix) was made available to the children. Intake of 150-200 Calories and 3-4 g protein per kg body weight were ensured during rehabilitation. The zinc supplemented group was given 2 mg/kg of elemental zinc in syrup form along with multivitamins for 3 months in addition to the above package. Others were given multivitamin syrup without zinc. Venous blood was collected in deionized tubes after controlling the acute infections and serum zinc level was estimated using atomic absorption spectrophotometer (IL 556) in the Division of Cellular and Molecular Cardiology, SCTIMST, Thiruvananthapuram. Normal control values were established on 10 well nourished children belonging to the same age group. Serum protein and albumin were also assessed. Zinc levels were reassessed after 3 months and anthropometric parameters were reassessed after 6 months. There were three drop outs in the study and there were no deaths. The mean increase in serum zinc level and the various anthropometric parameters were analyzed using paired t-test and the comparison of effectiveness among the two groups were analyzed using the Student t-test.
Majority of subjects (68%) with PEM were above 1 year of age and there were 27 boys. Ninety three per cent were consuming rice and 86% were consuming milk daily in their diet. Their diet was mostly deficient in legumes, vegetables, fruits and meat group leading to micronutrient deficiency. Twenty nine per cent of them had severe (PEM grades III and IV), 18% had severe stunting and 21% had severe wasting. The distribution of the study group according to the nutritional status is given in Table I. The serum protein, albumin and zinc levels among the controls were 7.1±0.6 g/dl, 4.7±0.3 g/dl and 140.0±6.2 mg/dl, respectively. The mean serum protein, albumin and zinc levels in the study group were 6.3±0.4 g/dl, 3.4±0.2 g/dl and 49.8±10.6 mg/dl, respectively. These levels were significantly lower compared to the controls. The reduction was more marked in those with severe PEM and severe stuning (P <0.001). Only those without stunting had serum zinc in the normal range. At the end of 3 months, serum protein and albumin levels improved to the normal range and were comparable in both the groups. Serum zinc level showed improvement in both the groups; it improved 2˝ times and reached on par with the controls in the zinc supplemented group, but in the unsupplemented group, it improved only 1˝ times the initial level (Table II). This difference between the two groups was statistically significant (Table III). After 6 months of nutritional rehabilitation, there was significant improvement in mean weight for age, height for age and weight for height in both the groups (Table II). The improvement was more marked in the zinc supplemented group. This difference between the groups was statistically significant except for weight for height (Table III). Table I: Distribution According to Nutritional Status
None of the differences between the two groups were significant Table II: Outcome Measures [Mean (SD)] Before and After Rehabilitation.
Group I comprised zinc supplemented subjects and
Group II comprised controls. Table III: Comparison of Mean Increase in Outcome Measures>
* p <0.01 ** p <0.001
Majority with PEM were above the age of 1 year as PEM is more rampant in the post weaning phase(17). The daily diet of children is mostly deficient in micronutrients and the intake of cereals and milk alone in the daily diet is likely to aggravate micronutrient deficiency due to the high phytate and phosphate content in them interfering with micronutrient absorption(7). The high association of severe stunting in those with PEM is attributable to chronic malnutrition and micronutrient deficiency and this is of concern as stunting tends to remain permanent(18). Even after controlling acute infection, serum zinc levels were very low in those with PEM compared to the controls. Serum zinc levels may fall to 40-60 mg/dl during acute infections. A marked reduction in serum zinc levels in those with severe PEM and severe stunting has been observed earlier(19,20). It is of concern that among majority in the zinc unsupplemented group, the serum zinc levels remained low even after 3 months of nutritional rehabilitatin and serum protein and albumin returned to normal levels. The increase in serum zinc level in the supplemented group was remarkable.A fourfold increase in serum zinc level in the supplemented group has been observed in a previous study(11). This points to the need for zinc supplementation during nutritional rehabilitation. Improvement in zinc status has been reported to affect body composition favourably and dietary zinc has been concluded to be inadequate to replenish zinc stores in deficient children(12). As documented in the Baroda(11) and Hyderabad(12) studies, the present report also observed overall improvement in both the groups. However increase in height was not evaluated in the above studies. The improvement in anthropometric parameters especially height in the zinc supplemented group was significantly greater than that in the unsupplemented group. Hence zinc supplementation may be beneficial in the rehabilitation package for children with PEM.
The help rendered by Dr. C.C. Kartha and Dr. John T. Eapen Divison of Cellular and Molecular Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Trivandrum and Mr. N. Shyamalan, Associate Professor of Statistics, Medical College, Trivandrum and the financial support rendered by the SAT Endowment Scheme are gratefully acknowledged. Contributors:
EKE Co-ordinated the study and drafted the paper; she will act as
guarantor for the paper. SP participated in data collection and
follow up. SNS supported the study and permitted publication.
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