The efficacy of zinc as adjunct therapy in the treatment of severe pneumonia in children admitted to Mulago Hospital
Maheswari, Srinivasan G.
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Acute respiratory tract infection(ARI) is the most common cause of morbidity and mortality in children less than 5 years worldwide. It accounts for 10-30% of all childhood deaths. The burden of lower respiratory infections (ALRI) is 2-10 times more common in developing countries than developed countries. In 2004, the World Helth Organsation (WHO) documented that pneumonia accounted for 20% of all the overall childhood death worldwide and pneumonia was the leading cause of deaths in children under five years. In 2000, ALRI accounted for 23-34% of all admissions in mulago hospital with case fatality ranging between 10-25%. Zinc deficiency is a global nutritional problem affecting populations of low socioeconomic status in both developing and developed countries. The prevalence of zinc deficiency in Uganda ranges between 20-69% in children and 21-29% in adults. Randomised controlled studies from Bangaladesh and India by Brooks et al and Dillip et al respectively showed significant improvement with zinc supplementation in severe pneumonia. Its benefit regarding severe pneumonia is still unknown in Uganda. OBJECTIVES: To determine the efficancy of zinc supplementation as adjunct therapy in the treatment of severe pneumonia in children admitted to Mulago hospital paediatric wards STUDY DESIGN: A double blind randomized placebo-controlled clinical trail. STUDY SETTING: The acute care unit (ACU) and paediatric wards of mulago hospital, uganda’s national referral and teaching hospital. INTERVENTION: Either zinc or placebo was given as adjunct therapy to children with severe pneumonia who were followed up for seven days. METHODS: Children aged 6-59 months who fulfilled the WHO case definition of severe pneumonia were randomized to receive either zinc or placebo in addition to an antibiotic . Chest x-rays were taken to confirm the diagnosis of pneumonia and to identify complications. HIV sero-status of the children was established. A blood slide for malaria parasite was done, since severe malaria could simulate pneumonia. The main outcomes included were the proportions of children who showed clinical improvement on time taken for normalization of respirator y rate, time taken for chest in-drawing to disappear and time taken for oxygen saturation to normalize, death and adverse effects. RESULTS: Three hundred and fifty two children were enrolled into this study, treated and followed up. Each treatment arm consisted of 176 children. The difference in mean time taken for normalization of respiratory rate, chest in-drawing and oxygen saturation in both intervention arms was not statistically significant. Twenty eight children died, 7 in the zinc group (3.9%) and 21 (11.9%) in placebo group, the difference was statistically significant (p=0.005). Relative risk (RR) was 0.33 (95% CI of 0.15-0.76). Number needed to treat was 13. This means that we need to treat 13 children with zinc as adjunct therapy to avert one death. Zinc supplementation was well tolerated even though two children developed vomiting initially, subsequent doses were tolerated well. CONCLUSION: 1. Zinc given as adjunct therapy in the treatment of childhood severe pneumonia significantly reduced mortality with efficancy of 0.67 as compared to the placebo. 2. There was no difference in time taken for normalization of respiratory rate, chest in-drawing and oxygen saturation in the intervention and placebo arms 3. There were no serious adverse events reported and zinc was well tolerated. RECOMMENDATIONS: All children aged 6-59 months admitted with severe pneumonia in Uganda should receive zinc supplementation as adjunct therapy in order to reduce mortality.