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Abstract Studies have found a substantial reduction in diarrhea and respiratory morbidity in young children receiving zinc supplementation. The impact of daily zinc supplementation administered with iron plus folic acid (IFA) in young children on all-cause hospitalizations and mortarity in comparison with IFA alone was evaluated. In a double blind cluster-randomized controlled trial, 94,359 subjects aged 1-23 mo were administered a daily dose of zinc plus IFA or IFA alone for a duration of 12 mo after enrollment. The intervention group tablet contained 10 mg of elemental zinc, 12.5 mg of iron, and 50 [micro]g of folic acid. The control group tablets were similar except that they contained a placebo for zinc. Infants aged

Complementary feeding practices are often inadequate in developing countries, resulting in a significant nutritional decline between 6 and 18 mo of age. We assessed the effectiveness of an educational intervention to promote adequate complementary feeding practices that would be feasible to sustain with existing resources. The study was a cluster randomized controlled trial in communities in the state of Haryana in India. We developed the intervention through formative research. Eight communities were pair matched on their baseline characteristics; one of each pair was randomly assigned to receive the intervention and the other to no specific feeding intervention. Health and nutrition workers in the intervention communities were trained to counsel on locally developed feeding recommendations. Newborns were enrolled in all of the communities (552 in the intervention and 473 in the control) and followed up every 3 mo to the age of 18 mo. The main outcome measures were weights and lengths at 6, 9, 12, and 18 mo and complementary feeding practices at 9 and 18 mo. All analyses were by intent to treat. In the overall analyses, there was a small but significant effect on length gain in the intervention group (difference in means 0.32 cm, 95% CI, 0.03, 0.61). The effect was greater in the subgroup of male infants (difference in mean length gain 0.51 cm, 95% CI 0.03, 0.98). Weight gain was not affected. Energy intakes from complementary foods overall were significantly higher in the intervention group children at 9 mo (mean [+ or -] SD: 1556 [+ or -] 1109 vs. 1025 [+ or -] 866 kJ; P < 0.001) and 18 mo (3807 [+ or -] 1527 vs. 2577 [+ or -] 1058 kJ; P < 0.001). Improving complementary feeding practices through existing services is feasible but the effect on physical growth is limited. Factors that limit physical growth in such settings must be better understood to plan more effective nutrition programs. KEY WORDS: * complementary feeding * educational intervention * child growth * gender * cluster randomization

Oral rehydration solution (ORS) programs for the treatment and prevention of diarrhea-associated rehydration, which has played a vital role in reducing the diarrhea death rate, are discussed. A randomized controlled trail established the superiority of reduced-osmolarity ORS over standard ORS in the management of diarrheal disease in children.

Vitamin A supplementation of lactating mothers and of infants at the time of diphtheria-pertussistetanus (DPT) and oral polio vaccine (OPV) immunizations have both been suggested as measures to prevent deficiency among infants. This multicenter randomized, double-blind, placebo-controlled trial was conducted in Ghana, India and Peru to determine the effect of maternal vitamin A supplementation on breast milk retinol and of maternal and infant supplementation on infant vitamin A status. Mothers in the intervention group received 60 mg vitamin A (as retinol palmitate) at 18-42 d postpartum; their infants were given 7.5 mg three times, i.e., at 6, 10 and 14 wk of age with DPT and OPV immunizations. Mothers and infants in the comparison group received a placebo. Maternal supplementation resulted in higher breast milk retinol at 2 mo postpartum [difference in means 7.1,95% confidence interval (CI), 3.4, 10.8 nmol/g fat] and lower proportion of mothers with breast milk retinol [less than or equal to] 28 nmol/g fat (15.2 vs. 26.6%, 95% CI of difference -16.6, -4.1%). At 6 and 9 mo, maternal supplementation did not affect breast milk retinol or the proportion of mothers with low breast milk retinol. Vitamin A supplementation of the mothers and their infants reduced the proportion of infants with serum retinol [less than or equal to] 0.7 [micro]mol/L (30.4 vs. 37%, 95% CI of difference -13.7, 0.6%) and that with low vitamin A stores as indicated by the modified relative dose response (MRDR) > 0.06 (44.2 vs. 52.9%, 95% CI of difference -16.6, -0.9%) at 6 mo. Supplementation had no effect at 9 mo. The beneficial effect of supplementation on breast milk retinol and infants' vitamin A status varied by site. It was greatest in India followed by Ghana and Peru. At the doses used, maternal supplementation improved breast milk retinol status at 2 mo (P < 0.001) and maternal and infant supplementation modestly increased (P = 0.03) infant vitamin A status at 6 mo of age. Additional strategies to improve vitamin A status of 6- to 9-mo-old infants must be considered. KEY WORDS: * human infants * vitamin A supplementation * breast milk retinol * serum retinol

After a report of reduced seroconversion to measles in infants, aged 6 mo, given vitamin A with their measles vaccination, serious concerns were raised regarding the safety of the WHO's recommendation that infants be supplemented with vitamin A at the time of measles immunization. To determine the impact of coadministered vitamin A on the antibody response to measles vaccine given to infants aged 9 mo, the more common age for immunization in developing countries, we conducted a randomized, double-blind, placebo-controlled trial in an urban slum community in Delhi. Infants (618) were randomly allocated to receive 30 mg vitamin A or a placebo with the measles immunization. Antibodies to measles were measured by ELISA in serum samples obtained at before (baseline) and 12 wk after immunization. Overall, the seroconversion rates did not differ between vitamin A (89.5%) and placebo (87.6%) groups. There were no significant differences in the geometric mean titers in the two groups (ratio of geometric means, 1.19; 95% confidence interval, 0.97-1.46). Among malnourished infants, the geometric mean titer was significantly greater in the vitamin A group compared to the placebo group (ratio of geometric means, 1.57; 95% confidence interval, 1.18-2.0), but seroconversion rates did not differ. There were no differences in seroconversion rates and geometric mean titers in the two study groups among the well-nourished children. These results indicate that 30 mg vitamin A does not reduce the immune response to the coadministered vaccine and, therefore, can be continued to be given safely in public health programs. KEY WORDS: vitamin A; measles immunization; infants; immune response

Adding a zinc supplement to the diet of infants and preschool children significantly reduced the number of lower respiratory infections. In a double blind trial of 609 children between the ages of six months and three years and a month, 298 took a zinc supplement and 311 did not. Those who had the zinc added to their diets had 45% less lower respiratory ailments than the others. This suggests that use of zinc supplements would be useful for the health of children in developing countries., Background. Increased acute lower respiratory infection incidence, severity, and mortality are associated with malnutrition, and reduced immunological competence may be a mechanism for this association. Because zinc deficiency results in impaired immunocompetence and zinc supplementation improves immune status, we hypothesized that zinc deficiency is associated with increased incidence and severity of acute lower respiratory infection. Methods. We evaluated the effect of daily supplementation with 10 mg of elemental zinc on the incidence and prevalence of acute lower respiratory infection in a double-blind, randomized, controlled trial in 609 children (zinc, n = 298; control, n = 311) 6 to 35 months of age. Supplementation and morbidity surveillance were done for 6 months. Results. After 120 days of supplementation, the percentage of children with plasma zinc concentrations [is less than] 60 [micro] g/dL decreased from 35.6% to 11.6% in the zinc group, whereas in the control group it increased from 36.8% to 43.6%. Zinc-supplemented children had 0.19 acute lower respiratory infection episodes/child/year compared with 0.35 episodes/child/year in the control children. After correction for correlation of data using generalized estimating equation regression methods, there was a reduction of 45% (95% confidence interval, 10% to 67%) in the incidence of acute lower respiratory infections in zinc-supplemented children. Conclusions. A dietary zinc supplement resulted in a significant reduction in respiratory morbidity in preschool children. These findings suggest that interventions to improve zinc intake will improve the health and survival of children in developing countries. Pediatrics 1998;102:1-5; experimental trial, nutrition, pneumonia, respiratory infections, zinc. ABBREVIATIONS. ALRI, acute lower respiratory infection; WHO, World Health Organization; RR, respiratory rate; LCI, lower chest indrawing; GEE, generalized estimating equations; OR, odds ratio; CI, confidence interval., Acute lower respiratory infections (ALRIs), predominantly pneumonia, cause approximately 4 million deaths every year, accounting for one-third of all childhood deaths in developing countries.[1-3] Community-based trials have documented that a [...]

Vitamin A administration in children reduces the incidence of severe diarrhea during the subsequent few months. We therefore examined the effect of treatment with vitamin A during acute diarrhea on the episode duration and severity. In a double-blind controlled field trial, 900 children 1 to 5 y of age with acute diarrhea of [less than or equal to]7 d duration were randomly assigned to receive vitamin A (60 mg) or a placebo. Children were followed up at home every alternate day until they recovered from the diarrheal episode. In all study children, those treated with vitamin A had a significantly lower risk of persistent diarrhea [odds ratio (OR) 0.30, 95% confidence interval (CI) 0.07-0.97], but there was no effect on the mean diarrheal duration or the mean stool frequency. In the subgroup of children who were not breast-fed, the mean diarrheal duration [ratio of geometric means (GM) 0.84, 95% CI 0.72-0.97], mean number of stools passed after the intervention (ratio of GM 0.73, 95% CI 0.56-0.95), the proportion of episodes lasting [greater than or equal to] 14 d (P = 0.002) and the percentage of children who passed watery stools on any study day (OR 0.40, 95% CI 0.21-0.77) were significantly lower in those treated with vitamin A. We conclude that administration of vitamin A during acute diarrhea may reduce the severity of the episode and the risk of persistent diarrhea in non-breast-fed children. Similar benefit was not seen in breast-fed children. KEY WORDS: vitamin A * acute diarrhea * severity * breast-feeding * children

Zinc supplementation may improve activity levels in malnourished children. New Delhi researchers evaluated activity level in 93 impoverished children aged 12 to 23 months. Evidence suggests that correcting zinc deficiency improves mental skills and muscular development. All children had been receiving multivitamin supplements for at least one month. Half had been randomly assigned to receive zinc supplementation in addition. Children receiving zinc spent 72% more time in the high-movement group, their activity rating score was 12% higher, and their energy expenditure score was 8% higher than the control group., ABSTRACT. Objectives. To investigate whether supplementation of zinc in preschool children is associated with improvement in observed activity levels. Methods. On 2 consecutive days, we performed 5-hour observations with momentary time sampling (instant activity every 10 minutes) in children selected from an ongoing double-blind, randomized trial of zinc supplementation. The study was conducted in Kalkaji, a low-socioeconomic urban population of New Delhi with high diarrheal incidence and rates of malnutrition. A total of 93 children (48 zinc and 45 control) 12 to 23 months of age from an ongoing community-based, randomized, controlled trial received supplements for at least 1 month before study; 71%, had received supplementation for more than 120 days. Zinc gluconate (10 mg of elemental zinc) was given daily, with both zinc and control groups receiving vitamins A, B1, B2, B6, D3, and E and niacinamide in addition. Results. Outcomes were percentages of time spent in each of five activity levels and two groups representing high and low movement and overall rating by two activity scores. Children in the zinc group spent 72% more time performing activities in the high-movement group. Among the zinc-supplemented children, the activity rating by the children&apos;s activity rating score was 12% higher and by the energy expenditure score was 8.3% higher than in the control group. Conclusions. In conclusion, zinc supplementation, given along with selected vitamins, was associated with significantly greater activity levels in children. The relationship between the activity increase and locomotor development needs to be investigated, as do the long-term implications of zinc supplementation in terms of developmental status and school performance., Malnutrition in early childhood is associated with decreased activity and developmental delay.[1-4] Some of these effects in malnourished children may be the result of deficiencies of individual micronutrients. Zinc may [...]

A moderate amount of animal milk in the diets of children with persistent diarrhea (PD) does not appear to make the diarrhea worse or more persistent. In third-world countries, withholding milk withholds a cheap, easy to administer, highly nutritious food. Indian researchers randomly assigned 116 children with PD aged 3 to 24 months old to an equal calorie diet of puffed rice cereal, sugar, and oil with either milk or egg white as the protein source. Stool output, weight gain, duration of diarrhea, and the percentage of treatment failures did not differ between the groups., Objective. Previous studies have shown increased stool output when children with persistent diarrhea (PD) received milk as the predominant source of nutrition. Methods. We evaluated the efficacy of milk given in modest amounts as a part of a mixed diet in children with PD. One hundred sixteen children 3 to 24 months of age with diarrhea for between 14 days and 12 weeks were allocated to milk-based (n = 60) or milk-free (n = 56) cereal dietary regimens. The two diets were isocaloric (86.9 calories/100 g for [less than or equal to] 9 months; 95.6 cal/100 g for >9 months) consisting of puffed rice cereal, sugar, and oil differing in only their source of protein, which was either milk or egg white, respectively. An average of 30% of the calories were constituted by milk in the milk-cereal diet. Both diets were offered at the rate of 150 kcal/kg per day. Children receiving milk-cereal consumed an average of 1.9 g/kg lactose per day. Results. The baseline characteristics in the two groups were similar. Comparable amounts of diet were consumed in both groups. The milk-cereal group did not have higher median (range) stool output (g/kg/h) compared with the milk-free group during a 0- to 48-hour (milk-cereal, 1.7 [0.2 to 8.7]; milk-free, 1.5 [0.1 to 6.6] or 0-to 120-hour (milk-cereal, 1.6 [0.4 to 7.2]; milk-free, 1.0 [0.1 to 7.6]) period. The percentage of weight gain was similar in the two groups, and there were no significant differences in the duration of diarrhea. Overall, 23 children had treatment failures, 10 (17%) in the milk-cereal and 13 (23.6%) in the milk-free groups. Conclusions. Our findings suggest that modest intakes of milk are well tolerated as a part of mixed diet during PD., ABBREVIATIONS. PD, persistent diarrhea; AIIMS, All India Institute of Medical Sciences; WHO, World Health Organization; ORS, oral rehydration solution; KBW, kilogram of body weight. It is well established that persistent [...]

Persistent diarrhea (PD) and dysentery (DD) account for most diarrhea-associated deaths among children in developing countries. Zinc deficiency can cause stunting and impaired immune function, both of which are risk factors for these diarrheal illnesses. We investigated the effect of zinc supplementation on the incidence of PD and DD in a community-based, double-blind randomized trial in children 6-35 mo of age. Increase over baseline in plasma zinc concentrations in the supplemented group compared with a control group (3.61 vs. 0.009 [micro][mol][center dot][L.sup.-1]) indicated successful supplementation. The overall reductions in the zinc supplemented group of 21% in the incidence of PD (95% CI -6 to 42%) and 14% in the incidence of dysentery (95% CI -15 to 36%) were not significant. There was a significant interaction of treatment effect with baseline plasma zinc concentration and age for PD and with gender for DD. In the zinc-supplemented group compared with the control group, the incidence of PD was reduced by 73% (P < 0.05; 95% CI 34 to 91%) in children with a baseline zinc 11 mo of age. Zinc supplementation resulted in a 38% (P < 0.05 95%CI 8 to 59%) reduction in the incidence of DD in boys. There was no effect on PD among children 6-11 mo old or on DD in girls. In conclusion, zinc supplementation had a significant impact on the incidence of persistent diarrhea in children > 1 y old and in children with low plasma zinc, as well as on dysentery in boys. These findings may have important implications for reducing diarrhea-related morbidity and mortality. INDEXING KEY WORDS: * diarrhea * diarrhea infantile * dysentery * zinc * humans

Zinc supplementation in young children may be effective in treating severe diarrhea. In New Delhi, India, 462 children with severe diarrhea received 20 milligrams a day of zinc supplement along with a vitamin mixture including vitamins A, B, D, and E. An additional 485 children with diarrhea received a placebo. The parents of dehydrated children in both groups were encouraged to give water and dissolved salts to their children. The risk that the diarrhea would continue on any given treatment day was reduced by 23% in the zinc group. In addition, the frequency of diarrhea episodes lasting over seven days was reduced by 39% in the zinc group. The average number of watery stools per day was reduced by 39% with zinc treatment. Zinc supplementation reduced both the intensity and the time span of diarrhea.