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PEDIATRICS Vol. 108 No. 6 December 2001, pp. 1366

COMMENTARY

Zinc Supplementation Saves the Lives of Children Living in Poverty

Abbreviations: SGA, small for gestational age • IUGR, intrauterine growth retardation

The study by Sazawal et al1 analyzes the effect of zinc supplementation, during the first 9 months of life, in preventing death in infants born small for gestational age (SGA) in slum areas of India. The study was randomized and controlled for most relevant confounding variables. The main finding is that supplemental zinc in conjunction with 1 or more of other micronutrients—riboflavin, folate, calcium, phosphorus, or iron—decreases the risk of death by two thirds during the supplementation period. The risk reduction was significant and of similar magnitude independent of whether the infant was breastfed or received artificial feeding. Unfortunately this analysis was not performed for the exclusively breastfed infant who had the lowest risk of dying (relative risk: 0.03; 95% confidence interval: 0.003–0.29). Zinc supplementation may in fact have benefited only those who were either artificially fed or partially breastfed.2 Zinc prevented deaths mainly from diarrheal disease and sepsis, but differential mortality by cause of death could not be fully assessed because the number of deaths was 20 out of 1154 SGA infants enrolled. The study was performed in SGA infants consuming breast milk or artificial feeding in an environment where infection, especially diarrhea, may be highly prevalent and complementary foods do not contain meat or other zinc-rich foods. Children living in poverty, particularly SGA infants, are at risk of severe zinc deficiency, which leads to repeated infections and growth failure. Stunting, the most prevalent manifestation of malnutrition, has been demonstrated to increase the risk of death.3 This study, and the existing body of literature of increased infant mortality in malnourished children, suggests that zinc deficiency may be an underlying cause in a large proportion of infant death in developing countries. The message is that malnutrition, whether in utero or after birth, is an important risk factor for dying early in life. Preventive strategies should include optimizing fetal as well as postnatal growth.

Countries where prevalence of low birth weight is high have a large proportion of low birth weight attributable to intrauterine growth retardation (IUGR). In communities where low birth weight rates are >30%, infant mortality is usually over 50 per 1000 live births. Global data analyzed by de Onis et al4 suggests that nearly 75% of all IUGR infants are born in Asia, mainly in south-central Asia, and 20% in Africa. Most of them are at higher risk of early protein-energy malnutrition, infections, early weaning, and death. Few studies demonstrate a beneficial effect of maternal nutritional interventions to prevent IUGR. A review by de Onis et al5 in 1998 found only 12 randomized, controlled trials, including protein-energy, vitamins (vitamin D, folate), minerals (calcium, magnesium, zinc, iron) and fish oil supplementation. A beneficial effect of marginal significance was found only with balanced protein-energy supplementation (odds ratio: 0.77; 95% confidence interval: 0.58–1.01). Studies on zinc supplementation during pregnancy failed to demonstrate an effect on prevention of IUGR.

This study demonstrates the importance of micronutrient malnutrition in determining high infant mortality in developing countries and the fact that this is further aggravated by fetal growth retardation. What this study fails to highlight is that exclusive breastfeeding provides greater protection from death than zinc supplementation.

Carlos Castillo-Durán, MD and Ricardo Uauy, MD, PhD

Institute of Nutrition and Food Technology (INTA)
Universidad de Chile
Macul 5540, Santiago, Chile

FOOTNOTES

Received for publication Oct 3, 2001; Accepted Oct 3, 2001.

Reprint requests to (C.C-D.) Institute of Nutrition and Food Technology (INTA), Universidad de Chile, Macul 5540, Santiago, Chile. E-mail: ccastd{at}uec.inta.uchile.cl

PEDIATRICS (ISSN 1098-4275). ©2001 by the American Academy of Pediatrics




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