Title: Low Serum Zinc Level- a Possible Marker of Severe Pneumonia
Authors: Dr N. Kumar, MD, Dr S. Jayaprakash, MD, Dr D. Kavitha, MD
DOI: https://dx.doi.org/10.18535/jmscr/v5i5.53
Abstract
Pneumonia is one of the main causes of death in under five children1. Zinc deficiency is associated and may lead to the cause of pneumonia. In our region we have no data about serum zinc levels in under five children and in the hospitalized children with pneumonia. Aim of the study is to compare the serum zinc levels among children 6 months to 60 months of age hospitalized with severe pneumonia with the same age matched controls. This could give us an idea about the necessary for zinc supplementation in under five children and also the need for serum zinc level estimation in children with severe pneumonia as a routine investigation in pneumonia management. This is a case control study conducted at the department of pediatrics, Coimbatore Medical College Hospital from July 2014-June2015. All hospitalized children 6 to 60 months of age with severe pneumonia (both bronchopneumonia and lobar pneumonia) as per WHO criteria, with x-ray finding are selected. Children with clinical features of congenital zinc deficiency, PEM grade III and IV, immunodeficiency, ADD, hospital acquired pneumonia; on zinc containing supplements were excluded. Age matched healthy controls included for comparison. Children with clinical features of congenital zinc deficiency, PEM grade III and IV, on zinc containing supplemental were excluded in control group. 50 cases and 50 controls are included for study. Serum zinc levels are estimated using atomic absorption spectrometry and compared. All children were from lower socioeconomic class. Zinc level – “cut off value taken as “For males and females less than 10 years in South Asian population is 65Kg/dl. All data were analyzed with a statistical software package (SPSS, version 16.0 for windows)”. About 80% of children with severe pneumonia had low serum zinc levels (P= 0.001). Slight preponderance of male is seen in the study group (p>0.5). No association between low serum zinc level and variables like age, sex, place of residence, duration of breast feeding, time of weaning, preterm/twin pregnancy, calorie and protein gap, developmental milestones, immunization history and family history of seizures were noted. There was strong association between low serum zinc level and mixed feeds. So exclusive breast feeding seems to be protective against zinc deficiency. Low birth weight has strong association with low serum zinc level. Low serum zinc levels have significant association with febrile seizures. Increased frequency of illness in past 6 months is associated with low serum zinc levels. Strong association of low serum zinc levels with vegetarian diet. Non vegetarian diet is protective against zinc deficiency. As 68% of study population is less than 2 years of age, intake of tubers does not have significant association with low serum zinc level. In this study low serum zinc is associated with tachypnea, increased respiratory distress and low oxygen saturation. Low serum zinc level is associated with leucocytosis significantly and this may be due to increased susceptibility to infection. Low serum zinc level does not have significant association with type of pneumonia that is lobar pneumonia or bronchopneumonia. There is no association between low serum zinc level and hospital stay. In conclusion, children with severe pneumonia have low serum zinc levels and thus “Low serum zinc level is a marker of severe pneumonia. Also lower the serum zinc level the higher the respiratory distress and associated significantly with low oxygen saturation.
Keywords: Serum, Zinc level, severe pneumonia
References
1. 1. Saeed Akhtar.Zinc status in south asian populations – an update.J Health popul nutr 2013 June; 31(2):139-149”World health organisation Pneumonia fact sheet N331, November 2014.
2. Sandora, Thomas J, and Theodore C.Sectish, Community acquired pneumonia" Nelson textbook of Paediatrics, 2011.
3. Sandstead HH. Understanding zinc: recent observations and interpretations. J Lab Clin Med 1994;124: 322-7.
4. Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. Washington, DC: National Academy Press, 2001.
5. Solomons NW. Mild human zinc deficiency produces an imbalance between cell-mediated and humoral immunity. Nutr Rev 1998;56: 27-8.
6. Heyneman CA. Zinc deficiency and taste disorders. Ann Pharmacother1996;30:186-7.
7. Fabris N, Mocchegiani E. Zinc, human diseases and aging. Aging (Milano) 1995;7:77-93
8. Maret W, Sandstead HH. Zinc requirements and the risks and benefits of zinc supplementation. J Trace Elem Med Biol 2006;20:3-18.
9. Prasad AS, Beck FW, Grabowski SM, Kaplan J, Mathog RH. Zinc deficiency: changes in cytokine production and T-cell subpopulations in patients with head and neck cancer and in noncancer subjects. Proc Assoc Am Physicians 1997;109:68-77.
10. Rink L, Gabriel P. Zinc and the immune system. Proc Nutr Soc 2000;59:541-52.
11. U.S. Department of Agriculture, Agricultural Research Service. 2011. USDA National Nutrient Database for Standard Reference, Release 24. Nutrient Data Laboratory Home Page,http://www.ars.usda.gov/ba/bhnrc/ndl
12. Sandstrom B. Bioavailability of zinc. Eur J Clin Nutr 1997;51 (1 Suppl):S17-9.
13. Wise A. Phytate and zinc bioavailability. Int J Food Sci Nutr 1995;46:53-63.
14. Jafek BW, Linschoten MR, Murrow BW. Anosmia after intranasal zinc gluconate use. Am J Rhinol 2004;18:137-41
15. Alexander TH, Davidson TM. Intranasal zinc and anosmia: the zinc-induced anosmia syndrome. Laryngoscope 2006;116:217-20.
16. Alaimo K, McDowell MA, Briefel RR, et al. Dietary intake of vitamins, minerals, and fiber of persons ages 2 months and over in the United States: Third National Health and Nutrition Examination Survey, Phase 1, 1986-91. Advance data from vital and health statistics no 258. Hyattsville, Maryland: National Center for Health Statistics. 1994.
17. Interagency Board for Nutrition Monitoring and Related Research. Third Report on Nutrition Monitoring in the United States. Washington, DC: U.S. Government Printing Office, 1995.
18. Hambidge KM, Mild zinc deficiency in human subjects. In: Mills CF, ed. Zinc in Human Biology. New York, NY: Springer-Verlag, 1989:281-96.
19. King JC, Cousins RJ. Zinc. In: Shils ME, Shike M, Ross AC, Caballero B, Cousins, RJ, eds. Modern Nutrition in Health and Disease, 10th ed. Baltimore, MD: Lippincott Williams & Wilkins, 2005:271-85.
20. Krasovec M, Frenk E. Acrodermatitis enteropathica secondary to Crohn's disease. Dermatology 1996;193:361-3.
21. Ploysangam A, Falciglia GA, Brehm BJ. Effect of marginal zinc deficiency on human growth and development. J Trop Pediatr 1997;43:192-8.
22. Nishi Y. Zinc and growth. J Am Coll Nutr 1996;15:340-4.
23. Hunt JR. Bioavailability of iron, zinc, and other trace minerals from vegetarian diets. Am J Clin Nutr 2003;78 (3 Suppl):633S-9S.
24. Van Wouwe JP. Clinical and laboratory assessment of zinc deficiency in Dutch children. A review. Biol Trace Elem Res 1995;49:211-25.
25. Hambidge KM, Krebs NF. Zinc deficiency: a special challenge. J Nutr 2007; 137:1101-5. [PubMed abstract]
26. Prasad AS. Zinc deficiency in women, infants and children. J Am Coll Nutr 1996;15:113-20.
27. Naber TH, van den Hamer CJ, Baadenhuysen H, Jansen JB. The value of methods to determine zinc deficiency in patients with Crohn's disease. Scand J Gastroenterol 1998;33:514-23.
28. Valberg LS, Flanagan PR, Kertesz A, Bondy DC. Zinc absorption in inflammatory bowel disease. Dig Dis Sci. 1986 Jul;31(7):724-31.
29. Prasad AS. Zinc deficiency. BMJ 2003;326:409-10
30. American Dietetic Association, Dietitians of Canada. Position of the American Dietetic Association and Dietitians of Canada: vegetarian diets. J Am Diet Assoc 2003;103: 748-65.
31. Caulfield LE, Zavaleta N, Shankar AH, Merialdi M. Potential contribution of maternal zinc supplementation during pregnancy to maternal and child survival. Am J Clin Nutr 1998; 68 (2 Suppl):499S-508S.
32. Krebs NF. Zinc supplementation during lactation. Am J Clin Nutr 1998;68 (2 Suppl):509S -12S.
33. Brown KH, Allen LH, Peerson J. Zinc supplementation and children's growth: a meta-analysis of intervention trials. Bibl Nutr Dieta 1998; 54:73-6.
34. Leonard MB, Zemel BS, Kawchak DA, Ohene-Frempong K, Stallings VA. Plasma zinc status, growth, and maturation in children with sickle cell disease. J Pediatr 1998;132:467-71
35. Zemel BS, Kawchak DA, Fung EB, Ohene-Frempong K, Stallings VA. Effect of zinc supplementation on growth and body composition in children with sickle cell disease. Am J Clin Nutr 2002;75:300-7.
36. Prasad AS. Zinc deficiency in patients with sickle cell disease. Am J Clin Nutr 2002;75: 181-2.
37. Kang YJ, Zhou Z. Zinc prevention and treatment of alcoholic liver disease. Mol Aspects Med 2005;26: 391-404.
38. Menzano E, Carlen PL. Zinc deficiency and corticosteroids in the pathogenesis of alcoholic brain dysfunction review. Alcohol Clin Exp Res 1994;18:895-901.
39. Shankar AH, Prasad AS. Zinc and immune function: the biological basis of altered resistance to infection. Am J Clin Nutr 1998;68:447S-63S.
40. Wintergerst ES, Maggini S, Hornig DH. Contribution of selected vitamins and trace elements to immune function. Ann Nutr Metab 2007; 51:301-23.
41. Prasad AS. Effects of zinc deficiency on Th1 and Th2 cytokine shifts. J Infect Dis 2000;182 (Suppl):S62-8.
42. Brooks WA, Santosham M, Naheed A, Goswami D, Wahed MA, Diener-West M, et al. Effect of weekly zinc supplements on incidence of pneumonia and diarrhoea in children younger than 2 years in an urban, low-income population in Bangladesh: randomised controlled trial. Lancet 2005;366: 999-1004.
43. Hulisz D. Efficacy of zinc against common cold viruses: an overview. J Am Pharm Assoc (2003) 2004; 44:594-603.
44. Caruso TJ, Prober CG, Gwaltney JM Jr. Treatment of naturally acquired common colds with zinc: a structured review. Clin Infect Dis 2007; 45:569-74.
45. Willis MS, Monaghan SA, Miller ML, McKenna RW, Perkins WD, Levinson BS, et al. Zinc-induced copper deficiency: a report of three cases initially recognized on bone marrow examination. Am J Clin Pathol 2005;123:125-31.
46. Lewis MR, Kokan L. Zinc gluconate: acute ingestion. J Toxicol Clin Toxicol 1998; 36: 99-101.