Role And Barriers of Using Zinc And ORS Combined in Diarrheal Diseases among Under Five Children: A Narrative Review

Introduction:

Diarrheal diseases remain as a most common public health problem in children throughout the world, especially in developing countries with approximately 1.5 billion diarrheal cases per year. Of these cases, 1.5-2.5 million deaths occur per year among children younger than age of five and malnutrition occurs among surviving children.⁽¹⁾To mitigate the diarrheal diseases, the World Health Organization (WHO) has recommended oral rehydration therapy in the year 1970.⁽²⁾Despite the huge success rate of oral rehydration solution (ORS), diarrheal diseases still remains to be the overall burden of childhood mortality accounting for more than 2 million deaths every year.⁽³⁾ To reduce the incidence and prevalence of diarrheal diseases, WHO and United Nations Children Fund(UNICEF)in year 2004recommended zinc (daily 20 mg zinc supplements for 10-14 days for children with acute diarrheaof age more than 6 months and 10 mg per day for infants below six months of age) with ORS in treatment and preventionof diarrheal episodes.⁽⁴⁾Though some contradictory results have been published by about the zinc supplementation for acute infectious diarrhea.⁽⁵⁾ Still various studies have shown that more than three-quarters of all diarrhea deaths could be reduced with combined utilization of Oral Rehydration Salt (ORS) and adjunct zinc supplementation.⁽⁶⁾Despite of these recommendations, the most recent National Family Health Survey (NFHS 4) reported ORS coverage of 26% and zinc coverage of less than 1%.⁽⁷⁾ so the present narrative review was undertaken to determine role and barriers of using zinc and ORS combined in diarrheal diseases among under 5 children.

Methodology :

Searching: We conducted aliterature search of full text articles which included observational studies and Randomized control trails which were evaluating the use of ORS and Zinc for the treatment and prevention of diarrhea in children under 5 years of age. Literature search was done on search platform like PubMed, Cochrane libraries and Google Scholar. Key words such as Role, Barriers, Zinc, ORS, Diarrhea, Under 5 children and theirMeSH term were used in combinations for searching the literature. Additional studies were identified through hand searches of key references lists and WHO Regional databases. Studies in English were included and the literature search covered studies published over ten years from 2009 to 2018. The search strategy included combinations of the terms: roles and effects, oral rehydration solution, diarrhea, community health workers, knowledge,attitudes and practices, health promotion, zinc therapeutic use.

Inclusion/exclusion criteria:We included randomized controlled trials and observational studies focused on ORS &Zinc in under 5 years of age population and barriers associated with usage. Studies which concentrated on knowledge, attitude and practices of caregivers and healthcare providers were also included. We limited our search to studies conducted in low- and middle-income countries, as diarrhea not a problem in developed countries. Only studies using WHO defined ORS and correct dosage of Zinc were considered eligible for this review. We excluded studies which related about cost effectiveness of the regimen.

Results:

18 full text articles were reviewed. As per the required objectives, review on two categories as Effects of zinc and ORS and barriers associated in using ORS was noted. For the first objective -seven original research articles were included as per the inclusion criteria and for the second objective eight original research articles were reviewed. The results of this review highlights the following results in Africa, Asia, India and Telangana state.

Discussion:

Role and effects of Zinc and ORS: Zinc supplementation has shown a substantial decline in the proportion of children who experienced recurrent diarrhea, suggesting that zinc is an important underlying factor in preventing and controlling diarrhea. Previous studies have shown that the diarrheal mortality has a skewed distribution and also many children experience exceptionally high diarrhea morbidity.⁽²²⁾The mechanisms in which Zinc acts- a)improves the absorption of water and electrolytes, improves regeneration of the intestinal epithelium, increases the levels of brush border enzymes, and enhances the immune response, allowing for a better clearance of the pathogens.⁽²³⁾b)It also plays a critical role in metallo enzymes, polyribosomes and the cell membrane and cellular function, giving credence to the belief that it plays a central role in cellular growth and in the function of the immune system.⁽²⁴⁾c)Zinc also acts as a potassium channel blocker, inhibiting cyclic adenosine monophosphate-mediated chlorine secretion.⁽¹⁾

This has also been supported by studies which revealed that zinc plays a major role in the regulation of intestinal fluid transport, mucosal integrity and modulation of expression of genes encoding important zinc-dependent enzymes like cytokines which play important roles in the immune system and in modulation of oxidative stress.⁽¹²⁾ Zinc sulfate is available as tablets, suspensions and may be dispersed in breast milk, in oral rehydration solutions or in water.⁽²⁵⁾ Some studies also showed that children with diarrhea and fever tended to be less likely to receive antimicrobial medication with usage of zinc with ORS.⁽¹⁹⁾Christa et al in their systematic review found that usage of zinc with ORS reduces the mortality by 23%, and reduction in diarrhoeal prevalence by 19%. In the same review also found mortality reduction in moderate and low income countries with relative risk of 66%.⁽²⁶⁾

Barriers associated with Use of Zinc and ORS: Although Oral Rehydration Salts (ORS) was recommended and made available for the prevention and treatment of diarrhea since the 1980s, yet the most recent national survey reports says that only 26% children with diarrhea were given ORS.⁽¹⁵⁾ Lack of awareness and training were found to be the main reason for not using or delaying the use of zinc supplement during diarrhea. A positive impact was observed on training the caretakers and healthcare workers.⁽¹⁷⁾ Another significant finding was lack of knowledge regarding importance of breast feeding as a tool in prevention of diarrhea.⁽¹⁸⁾ More than half of surveyed women reported that their first intervention was some kind of home remedy such as homemade sugar/salt solution, foods, liquids, or herbs. In addition, antibiotics were first or second choice of 46% of caregivers. For about half of women, zinc was the third or fourth intervention.⁽¹⁰⁾Behavior and practices of caretakers was not adequate: no participants used ORS for full duration of diarrheal episode and very few prepared ORS solution correctly.^(8,11) Training of private sector Registered Medical Practioners(RMPs) had no effect on prescribing practices and continued prescribing antibiotics and antimicrobials despite of having knowledge of Zinc and ORS for the treatment of diarrhea.⁽¹⁴⁾

Present study stands good in explaining about the roles and barriers in consumption of ORS and Zinc combined in diarrhea in children but limits in number of studies covered as we only focused in free full text. Its also advised that fortified zinc ORS should not be used, rather they should be administered separately when specifically considering for reduction of diarrhea and its complication. As Cochrane review suggested that effects of fortification of foods with zinc on other outcomes including zinc deficiency, children's growth, cognition, work capacity of adults, or on hematological indicators are unknown⁽²⁷⁾ but effects of zinc syrup is known to be beneficial in diarrhea. ⁽²⁸⁾

Conclusion :

Reduction in diarrheal disease burden can be achieved by improving coverage of zinc and ORS particularly amongst the poorest. There is an urgent need to train caretakers, healthcare providers on the initial fluid replacement and hygienic practices to be followed during an episode of diarrhea and also to improve the availability of ORS with zinc supplementation.Awareness of mothers about health, disease and preventive services is a key measure by which the progression at the level of family, community and the country can be measured.