nrhm karnataka

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Key Child Survival ToolsZinc and Vitamin A : 

Key Child Survival ToolsZinc and Vitamin A Dr Sudeep Kumar, MBBS, MPH, Micronutrient Initiative

Slide 2: 

CANADIAN INTERNATIONAL DEVELOPMENT AGENCY – MICRONUTRIENT PROGRAM

Revised Guidelines on Management of Acute DiarrheaLow Osmolarity ORS and ZincFrom Evidence to Policy : 

Revised Guidelines on Management of Acute DiarrheaLow Osmolarity ORS and ZincFrom Evidence to Policy Dr. Sudeep Kumar, MBBS,MPH Micronutrient Initiative

Slide 4: 

Child mortality Global treatment policy on management of Acute Diarrhea WHO –UNICEF Joint Statement (2001) Low osmolarity ORS Zinc in Acute Diarrhea Indirect uses of Zinc Roles of functionaries

Let’s be clear ! : 

Let’s be clear ! In 2001 an estimated 1.8 million below 5 years died from diarrhea.

Where we stand? : 

Where we stand?

Objectives and Goals : 

Objectives and Goals Prevent /Treat Dehydration Improve the nutrition

Karnataka – NFHS III & DLHS III : 

Karnataka – NFHS III & DLHS III

Global Policy on Treatment of Diarrhea : 

Global Policy on Treatment of Diarrhea Treat dehydration with ORS (or IVF in severe dehydration) + ZINC Continual of Breastfeeding and increase feeding Use of Antibiotics only when appropriate No Antidiarrheals, antiemetic Health education to mothers on feeding practices

Why New ORS…? : 

Why New ORS…? Std.ORS did not reduce the duration/stop the episode 2 decades of multiple researches All results shown clinical benefits Better absorption with low Na and low Glucose levels

Why low osmolarity? : 

Why low osmolarity? Meta-analysis comparing LO-ORS with Standard ORS

Public Health Importance : 

Public Health Importance

Revised Recommendations… : 

Revised Recommendations… WHO – UNICEF (2001) GoI – IAP (2004 -2007) Citrate Introduction Universal Low osmolarity Zinc: 20 mg/day for 14 days Less than 6 months: 10mg/day orally NO INCREASED RISK OF HYPONATREMIA IN 2 studies (>100000 sample size)

Why Zinc in Diarrhea? : 

Why Zinc in Diarrhea? Zinc Deficiency Excessive loss in Diarrhea Critical in immune and non immune functions that resist infections and other consequences

Prevalence of Zinc Deficiency(serum Zinc in field trials) : 

Prevalence of Zinc Deficiency(serum Zinc in field trials)

Why Zinc Deficiency is so common? : 

Why Zinc Deficiency is so common? Breast Milk :Insufficient source, >4-5 months Low intake of complementary food Low consumption of Animal foods High fecal loss in diarrheal diseases Limited Bioavailability High Phytates in Cereals Zinc deficient soil

Risk among Zinc deficient children : 

Risk among Zinc deficient children Zinc deficiency in children aged <5 years increases the risk of incidence for Diarrhea 1.28 (95% CI 1.10–1.50) pneumonia 1.52 (95% CI 1.20–1.89) malaria 1.56 (95% CI 1.29–1.89). http://www.who.int/publications/cra/chapters/volume1/0257-0280.pdf

Prevention of diarrhea in children < 5 years with Zn supplementation : 

Prevention of diarrhea in children < 5 years with Zn supplementation Zinc Investigators Collaborative Group, J Pediatrics, 1999

Reduced incidence of severe and prolonged diarrhea in children (<35 months) with Zn supplementation in North India : 

Reduced incidence of severe and prolonged diarrhea in children (<35 months) with Zn supplementation in North India 1-2 of RDA for 4 months

Zinc in Acute Diarrhea : 

Zinc in Acute Diarrhea 26% 44% 24%

Additional Preventive Aspects of Zinc Treatment : 

Additional Preventive Aspects of Zinc Treatment

Therapeutic Effect of Zinc given in persistent Diarrhea : 

Therapeutic Effect of Zinc given in persistent Diarrhea Summery estimates from a pooled analysis of 4 trails; Zinc Investigators Collaborative Group, Am J Clin Nutr 2000

Jodi No.1 (ORS – Zinc) : 

Jodi No.1 (ORS – Zinc)

Zinc Administration : 

Zinc Administration Oral Dispersible with Plain water/ORS/Breast Milk Fixed time/morning time Not to be used with whole ORS preparation 20mg/d for > 6 months; 10mg/d for <6 months for 10-14 days Safety and benefits in HIV infection

Side effects and Overdose : 

Side effects and Overdose None Vomiting , very rare and minimal Use of tablet in case of vomiting Quality assured products have less metallic taste Over dosage, long term toxicity: 150mg/d smallest fatal dose : 15gm

Slide 27: 

How Does ZINC Work?

Slide 28: 

Correction of Zinc deficiency and Immune reconstitution Sazawel et al, Ind Pediatr 1997 Direct effect on Damaged epithelial barrier Major Apoptosis regulator Direct immunostimulatory effect Anti-secretary effect

Slide 29: 

Indirect Benefits of ZINC

Zn - Reduced overall death and hospitalization rates : 

Zn - Reduced overall death and hospitalization rates 20 mg of Zinc /day for 14 days for children with Acute Diarrhea Baqui et al, BMJ 2002

Zn- Reduced the use of Antibiotics : 

Zn- Reduced the use of Antibiotics

Zn- Increases the ORS Usage : 

Zn- Increases the ORS Usage

Bhandari et al, Pediatrics, 2008 : 

Bhandari et al, Pediatrics, 2008

Low Osmolarity ORS + Zinc : 

Low Osmolarity ORS + Zinc Low Osmolarity ORS shortens the duration of diarrhea Reduces stool output Reduces the need for unscheduled intravenous fluids Zinc supplementation Reduces the duration and Reduces severity of diarrhea Lowers the incidence of diarrhea in the following 2–3 months

Vitamin A Supplementation Programme : 

Vitamin A Supplementation Programme upplemenat Subclinical deficiency : 25%

Vitamin A : 

Vitamin A Overall Mortality Reduction: 23% (Sommer et al, Beaton’s meta analysis) Measles Mortality Reduction : 50% Mortality Reduction related to Diarrhea:40% Malaria and RTI?

Slide 38: 

Thank You skumar@micronutrient.org

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