Diarrhoea and malnutrition in children
BMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7538.378 (Published 16 February 2006) Cite this as: BMJ 2006;332:378All rapid responses
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Baqui and Ahmed (1) highlighted the recent advances in the management
of diarrhoea in children. Despite scientific evidence, oral rehydration
solution (ORS) and adequate nutritional support are still under-provided
mainly due to restricted availability in developing countries, poor
palatability and care-giver scepticism in industrialised society. As a
consequence, mortality, severe dehydration, hospitalisation, malnutrition,
persisting diarrhoea, inappropriate administration of antibiotics or other
drugs and parental working absence are still worldwide frequent. Zinc
supplementation during diarrhoea have been recommended by WHO and Unicef
based on several trials in developing countries demonstrating significant
effect in reducing duration, severity and recurrence of diarrhoea even in
severe malnourished and immuno-compromised patients (2). Recent researches
pointed out that zinc may reduce ion secretion and nitric oxide synthesis
and improve appetite, absorption, regeneration of enterocytes, restoration
of enteric enzymes, and humoral and cellular immunity (3). Furthermore
zinc seems to offer anti-oxidant activities and promising effects on child
growth through a positive interaction with GH and IGF-1.
A randomised controlled trial reported that ORS with zinc significantly
reduces stool output, persistent episodes of diarrhoea and fluid
requirement (4).
Reduced osmolarity ORS with zinc is commercially available (in Italy) and
palatable, thus representing a precious alliance in treatment of
diarrhoea. Inadequate intake of zinc may be present in Europe (5). However
zinc supplementation is currently under-used and considered only for
developing countries, severe and malnourished patients. In view of its
wide clinical properties and safe profile (at recommended dosage) zinc
supplementation during diarrhoea should be supported in order to reduce
social cost and morbidity even in developed countries.
1. Baqui AH, Ahmed T. Diarrhoea and malnutrition in children. BMJ
2006;332:378
2. Bobat R,Covadia H,Stephen C, Naidoo KL, McKerrow N, Black RE, Moss WJ.
Safety and efficacy of zinc supplementation for children with HIV-1
infection in South Africa: a randomised double-blind placebo-controlled
trial. Lancet 2005; 366: 1862–67
3. Wapnir RA. Zinc Deficiency, Malnutrition and the Gastrointestinal
Tract. J Nutr 2000;130: 1388S-1392S
4. Bhatnagar S, Bahl R, Sharma PK, Kumar GT, Saxena SK, Bhan MK. Zinc With
Oral Rehydration Therapy Reduces Stool Output and Duration of Diarrhea in
Hospitalized Children: A Randomized Controlled Trial. J Pediatr
Gastroenterol Nutr 2004;38:34–40
5. Cruz JA. Dietary habits and nutritional status in adolescents over
Europe - Southern Europe. Eur J Clin Nutr 2000;(S1):S29-35
Competing interests:
None declared
Competing interests: No competing interests
Undergraduate teaching and infectious diseases in Africa
The teaching and facilitation of internal / general medicine at
undergraduate level presents a challenge in the era of HIV/AIDS in Africa
– and perhaps in other developing parts of the world.
Arguably, diarrhoea is the archetypical disease of poverty and
malnutrition in the same way that TB is.1 We wish to take this
opportunity to congratulate Abdulla H Baqui and Tahmeed Ahmed for
reminding readers that ‘Most episodes of diarrhoea are infectious and are
caused by a variety of bacteria, viruses, and parasites. Dehydration is
the most direct effect of diarrhoea, accounting for the majority of
deaths.‘2 As far as Africa is concerned and indeed any impoverished
country in the world, malnutrition is frequently associated with
immunodeficiency and infection “there is a three-way relationship between
malnutrition, immunodeficiency and infection. Protein Energy Malnutrition
leads to immunodeficiency, which predisposes to infection, which further
aggravates the nutritional state ………’ This condition has been termed
Nutritionally Acquired Immune Dysfunction Syndrome (NAIDS)’3, and as such
it should not be confused with HIV/AIDS.
Our current concern is that in Africa, despite known parasitic causes
of diarrhoea, the knee-jerk first answer given by medical students and
interns / housemen when asked for the most likely explanation, they
invariably say “HIV/AIDS”.
References:
1. The Editorial : The Lancet Vo. 366, December 17/24/31,2005
2. Abdullah H Baqui, Tahmeed: Diarrhoea and malnutrition in children:
BMJ Vol 332 18 Feb 2006.
3. HM Coovadia and DF Wittenberg: Paediatrics and child Health – A Manual
for Health Professionals in the Third World – Fourth Edition, OUP, Cape
Town 1998.
SWP Mhlongo, MBBS, LRCP, MRCS, MSc Med(London), MRCGP(UK)
Prof. & Head : Department of Family Medicine & Primary Health Care,
University of Limpopo (Medunsa Campus)
Dr. AJ Mbokazi
MBChB, MFam Med (Natal)
Deputy Dean, Faculty of Medicine, Polokwane Campus
Competing interests:
None declared
Competing interests: No competing interests