Diarrhea, Stunting
Conditions
Keywords
Zinc, Multiple micronutrient powders, Diarrhea, Stunting
Brief summary
This is a randomized, double-blind, community-based efficacy trial of different doses, forms, and frequencies of zinc supplementation for the prevention of diarrhea and promotion of linear growth among children 9-11 months of age in Dhaka, Bangladesh.
Detailed description
Zinc is essential to support growth in young children especially for tissues undergoing rapid cellular differentiation and turnover, such as those in the immune system and gastrointestinal tract. Therapeutic zinc supplementation has been initiated in low-income countries as part of diarrhea treatment programs to support these needs for young children but, the effects of preventive supplemental zinc as a tablet or as a multiple micronutrient powder (MNP) on child growth and diarrheal disease are mixed and pose programmatic uncertainties. Thus, a randomized, double-blind community-based efficacy trial of five different doses, forms, and frequencies of preventive zinc supplementation vs. a placebo was designed for a study in children aged 9-11 months in an urban community in Dhaka, Bangladesh. The primary outcomes of this 24-week study are incidence of diarrheal disease and linear growth. Study workers will conduct in-home morbidity checks twice weekly; anthropometry will be measured at baseline, 12 weeks and 24 weeks. Serum zinc and other related biomarkers will be measured in a subsample along with an estimate of the exchangeable zinc pool size using stable isotope techniques in a subgroup. Therapeutic zinc will be provided as part of diarrhea treatment, in accordance with Bangladesh's national policy. Therefore, the proposed study will determine the additional benefit of a preventive zinc supplementation intervention.
Interventions
DIETARY_SUPPLEMENTStandard MNP
Standard MNP, 15 micronutrients (Vitamin A 400 µg, vitamin D 5 µg, vitamin E 5 mg, vitamin C 30 mg, thiamine 0.5 mg, riboflavin 0.5 mg, niacin 6 mg, pyridoxine 0.5 mg, vitamin B12 0.9 mg, folate 150 µg, iron 10 mg, zinc 4.1 mg, copper 0.56 mg, selenium 17.0 µg and iodine 90 µg). Daily supplementation for 24 weeks.
DIETARY_SUPPLEMENTHigh zinc, low iron MNP
Same as group 1, except with 10 mg zinc instead of 4.1 mg and 6 mg iron instead of 10 mg. Daily supplementation for 24 weeks.
DIETARY_SUPPLEMENTHigh zinc, low/no iron on alternating days
Same as study group 1, except with 10 mg zinc instead of 4.1 mg, and 6 mg iron and no iron on alternating days instead of 10 mg. Daily supplementation for 24 weeks.
DIETARY_SUPPLEMENTDispersible zinc supplement
10 mg zinc in a dispersible tablet. Daily supplementation for 24 weeks.
DIETARY_SUPPLEMENTIntermittent zinc supplement
10 mg zinc in a dispersible tablet. Daily supplementation for 14 days at baseline and 3 months, placebo tablet on all other days.
DIETARY_SUPPLEMENTPlacebo powder
Daily provision of a placebo powder for 24 weeks.
Sponsors
International Centre for Diarrhoeal Disease Research, Bangladesh
Johns Hopkins Bloomberg School of Public Health
University of Colorado, Denver
UCSF Benioff Children's Hospital Oakland
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
PREVENTION
Masking
QUADRUPLE (Subject, Caregiver, Investigator, Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
9 Months to 11 Months
Healthy volunteers
Yes
Inclusion criteria
* 9-11 months of age * Weight-for-length Z score \>= -3 according to the 2006 World Health Organization Growth Standards * Hemoglobin concentration \> = 7.0 g/dL
Exclusion criteria
* Presence of severe acute malnutrition, defined as a WLZ \<-3 and/or the presence of bipedal edema and/or mid-upper arm circumference \<115 mm; * Presence of severe anemia, defined as a hemoglobin concentration \< 7.0 g/dL * Congenital anomalies (e.g. cardiac defects, cleft lip or palate) or any other conditions that interfere with feeding; * Chromosomal anomalies and other organic problems (e.g. jaundice, tuberculosis) * Currently consuming MNPs with no intention of stopping
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Incidence of diarrhea | Incidence over the 24-week follow-up period | Incidence of diarrhea is defined as the number of diarrheal episodes per person-weeks of follow-up |
| Change in length-for-age Z score | Measured at enrollment and the end of the 24-week follow-up period | Change in length-for-age Z score from enrollment to the end of the 24-week follow-up period |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Incidence of dysentery | Measured twice weekly for 24 weeks | Dysentery is defined as any diarrheal episode in which the loose or watery stools contain visible red blood |
| Incidence of diarrhea with dehydration | Measured twice weekly for 24 weeks | Incidence of diarrhea with dehydration over the 24-week follow-up period |
| Incidence of hospitalizations | Assessed twice weekly for 24 weeks | Hospitalization is defined as an overnight stay in the hospital due to illness |
| Change in mean serum zinc concentration | Measured at enrollment and at the end of the 24-week follow-up period in a subgroup of participants in all 6 intervention groups | Change in mean serum zinc concentration among children in the biochemistry sub-group over the 24-week follow-up period |
| Change in the prevalence of zinc deficiency | Measured at enrollment and at the end of the 24-week follow-up period in subgroup of participants in all 6 intervention groups | Change in the prevalence of zinc deficiency (serum zinc concentration \<9.9 umol/L) in the biochemistry subgroup from baseline to the end of the 24-week follow-up period |
| Change in the exchangeable zinc pool size | Measured at enrollment and at the end of the 24-week follow-up period in a subgroup of participants randomized to the high zinc, low-iron MNP, dispersible zinc supplement, and placebo groups. | Change in the exchangeable zinc pool size from enrollment to the end of the 24-week follow-up period in a subgroup of participants randomized to the high zinc, low-iron MNP group, dispersible zinc supplement group, and placebo group |
| Change in ferritin concentrations | Measured at enrollment and at the end of the 24-week follow-up period in a subgroup of participants in all 6 intervention groups | Change in mean concentrations of ferritin from enrollment to the end of the 24-week follow-up period among participants in the biochemistry subgroup. |
| Change in stunting prevalence | Measured at enrollment and the end of the 24-week follow-up period | Change in the prevalence of stunting (LAZ \<-2) in the study population over the 24-week follow-up period |
| Change in gut microbiota | Measured at enrollment and at the end of the 24-week follow-up period in a subgroup of participants randomized to the high zinc, low-iron MNP, dispersible zinc supplement, and placebo groups. | Change in the composition of gut microbiota from enrollment to the end of the 24-week follow-up period among a subgroup of participants randomized to the high zinc, low-iron; dispersible zinc supplement; and placebo powder groups. |
| Change in amino acid metabolites associated with gut permeability | Measured at enrollment and at the end of the 24-week follow-up period in a subgroup of participants randomized to the high zinc, low-iron MNP, dispersible zinc supplement, and placebo groups. | To compare the change in amino acid metabolites associated with gut permeability from enrollment to the end of the 24-week follow-up period among a subgroup of participants randomized to the high zinc, low-iron MNP; dispersible zinc supplement; and placebo groups. |
| Change in lipid metabolites associated with gut permeability | Measured at enrollment and at the end of the 24-week follow-up period in a subgroup of participants randomized to the high zinc, low-iron MNP, dispersible zinc supplement, and placebo groups. | To compare the change in lipid metabolites associated with gut permeability from enrollment to the end of the 24-week follow-up period among a subgroup of participants randomized to the high zinc, low-iron MNP; dispersible zinc supplement; and placebo groups. |
| Change in genome wide gene expression by RNA-sequencing | Measured at enrollment and at the end of the 24-week follow-up period in a subgroup of participants randomized to the high zinc, low-iron MNP, dispersible zinc supplement, and placebo groups. | To compare the change in genome wide gene expression, measured with RNA-sequencing, from enrollment to the end of the 24-week follow-up period among a subgroup of participants randomized to the high zinc, low-iron MNP; dispersible zinc supplement; and placebo groups. |
| Change in specific gene expression by quantitative Polymerase Chain Reaction | Measured at enrollment and at the end of the 24-week follow-up period in a subgroup of participants randomized to the high zinc, low-iron MNP, dispersible zinc supplement, and placebo groups. | To compare the change in specific gene expression, measured by quantitative Polymerase Chain Reaction, from enrollment to the end of the 24-week follow-up period among a subgroup of participants randomized to the high zinc, low-iron MNP; dispersible zinc supplement; and placebo groups. |
| Change in cellular immune function by leukocyte profiles | Measured at enrollment and at the end of the 24-week follow-up period in a subgroup of participants randomized to the high zinc, low-iron MNP, dispersible zinc supplement, and placebo groups. | To compare the change in cellular immune function by leukocyte profiles, from enrollment to the end of the 24-week follow-up period among a subgroup of participants randomized to the high zinc, low-iron MNP; dispersible zinc supplement; and placebo groups. |
| Change in serum cytokines | Measured at enrollment and at the end of the 24-week follow-up period in a subgroup of participants randomized to the high zinc, low-iron MNP, dispersible zinc supplement, and placebo groups. | To compare the change in serum cytokines, measured by Luminex analysis, from enrollment to the end of the 24-week follow-up period among a subgroup of participants randomized to the high zinc, low-iron MNP; dispersible zinc supplement; and placebo groups. |
| Change in concentrations of soluble transferrin receptor | Measured at enrollment and at the end of the 24-week follow-up period in a subgroup of participants in all 6 intervention groups | Change in mean concentrations of soluble transferrin receptor from enrollment to the end of the 24-week follow-up period among participants in the biochemistry subgroup. |
| Change in wasting prevalence | Measured at enrollment and at the end of the 24-week follow-up period | Change in the prevalence of wasting (WLZ \<-2) in the study population over the 24-week follow-up period |
Countries
Bangladesh
Outcome results
None listed