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Zinc deficiency in the newborn

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Background

Zinc is a cofactor for many enzymes and essential for optimal immune function1. Most zinc is accumulated during the 3rd trimester of pregnancy, placing preterm infants at high risk of zinc deficiency. After iron it is the most likely trace element to be deficient. Zinc is predominately (95%) found in muscle, bone, skin, and hair. Only 5% is in the liver and plasma. This leads to significant limitations to the assessment of zinc status based on the measurement of plasma or serum zinc. As zinc deficiency is difficult to diagnose accurately, it is better to err on the side of early zinc supplementation.2

Risk factors

  • Premature birth 
  • Male gender 
  • Vegan/vegetarian mother (or a mother who has stopped eating red meat during pregnancy) 
  • Accelerated growth - growth is the major determinant of zinc requirement 
  • Thiazide diuretics - hydrochlorthiazide increases excretion of zinc 
  • Dexamethasone - may impair zinc absorption 
  • Unusually low ALP3,4 (a zinc dependent enzyme important for bone metabolism, which is often high in premature babies with osteopenia) 
  • Low albumin-zinc is transported bound to albumin so mild hypoalbuminaemia may alter serum zinc concentration 
  • Large stool or ostomy output - short bowel syndrome etc. 

Signs of Zinc Deficiency

  • Serum zinc <7.5 mmol/L is highly suggestive of deficiency (reference range 9-17) but it is acknowledged there are problems with reliability of measuring zinc 
  • Growth failure in the presence of adequate energy and protein intake 
  • Diminished food intake usually due to reduced ability to taste and smell 
  • Poor wound healing 
  • Hair loss 
  • Decreased protein synthesis 
  • Poor immune function 
  • If severe - diarrhoea, behaviour changes, skin lesions, poor growth 

NB: The only definite method of diagnosing Zinc deficiency is to note the clinical and biochemical responses to Zinc supplementation.

Guidelines for the Treatment of Zinc Deficiency

If poor growth and serum zinc is <8 mmol/L Tsang recommends double or triple the RDI (1.2mg/kg/day X 2 or 3)

  1. Prescribe orally - 1 to 2 mg elemental Zinc/kg/day 
  2. Ensure an adequate intake of Zinc from feeds; 
    If <2.5kg Fortified EBM or Preterm formula 
    If >2.5kg Unfortified EBM or Term formula (not Soy) 
  3. Monitor serum Zinc weekly
  4. Treatment is continued until biochemical indexes are normal and growth has improved 

References

  1. Doherty CP, Weaver LT, Prentice AM: Micronutrient supplementation and infection: a double-edged sword? J Pediatr Gastroenterol Nutr 2002, 34(4):346-352. 
  2. Rao R, Georgieff M: Microminerals. In: Nutrition of the Preterm Infant. 2 edn. Edited by Tsang R, Uauy R, Koletzko B, Zlotkin S. Cincinati: Digital Educational Publishing; 2005: 277-310. 
  3. Weismann K, Hoyer H: Serum alkaline phosphatase and serum zinc levels in the diagnosis and exclusion of zinc deficiency in man. The American journal of clinical nutrition 1985, 41(6):1214-1219. 
  4. Zlotkin SH, Atkinson S, Lockitch G: Trace elements in nutrition for premature infants. Clin Perinatol 1995, 22(1):223-240. 
  5. National Women's Health Clinical Guidelines Zinc Deficiency in Neonates http://www.adhb.govt.nz/newborn/Guidelines/Nutrition/Zinc.htm. (accessed on 2/12/2012) 
  6. Groh-Wargo S: Recommeded Enteral Nutrient Intakes. In: Nutritional Care for High-Risk Newborns. 3 edn. Edited by Groh-Wargo S, Thompson M, Hovasi Cox J, Hartline J. llinois: Precept Press; 2000: 231-263. 
  7. Tsang RC, Uauy R, Koletzko B, Zlotkin SH: Nutrition of the Preterm Infant: Scientific Basis and Practical Guidelines 2edn. Cincinnati: Digital Education Publishing, Inc.; 2005.

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Document Control

  • Date last published: 06 September 2018
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Author(s): Barbara Cormack
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years