S.A.M. Khairul Bashar  ( Department of Biochemistry, Dhaka University, Dhaka, Bangladesh. )
Lamia Sharmeen  ( Department of Biochemistry, Dhaka University, Dhaka, Bangladesh. )

Zinc (Zn), Copper (Cu) were measured in children suffering from Marasmic-Kwashiorkor with various infections. On admission to hospital Zn level was low in all patients (39.6 = 15.9 ug - 88.7 = 16.8 ug%). On nutritional rehabilitation without any Zn supplementation, Zn level showed improvement but in one group, who had initially very low level, subjects were still Zn deficient. Cu level was found low in 50% cases studied, and most of them had vit-B2 deficiency also. Cu level did not show significant rise on nutritional therapy without Cu supplementation (JPMA 33:251, 1983).

The role of trace elements in human health and nutrition has attracted interest in recent times. Among different trace elements some are being widely investigated and their role in various aspects of growth and metabolism has been established.
Zinc (Zn) is needed for tissue synthesis, it plays its role, both as a component of the new tissue and in the form of the Zinc metalloenzymes essential for nucleic acid and protein synthesis. Various studies on animals indicate that Zn is stored in negligible amount in the body so that there is a day to day requirement for dietary Zinc (William et al., 1972; Hurley and Swenerton, 1971). Children recovering from “Protein-energy” “malnutrition” gain weight more than normal, during recovery period (Golden and Golden, 1981). In that condition, more Zn is required for growth of new tissue. When this is the case, dietary Zinc may both limit the absolute rate of weight gain and determine the composition of new tissue laid down. Data from Jamaica (Brooke and Wheeler, 1976) and Peru (Maclean and Graham, 1980) show that children recovering from malnutrition tend to synthesize excessive amounts of adipose tissue, which has a low zinc content, at the expense of lean tissue which is rich in zinc. In another report (Vitter and Glazer, 1954), Zinc deficiency was reported in pre-School children in Egypt. There are also other reports which suggest that zinc has a very important role in vit-A transport and metabolism (Smith and Mc Daniel, 1973).
Although the role of Copper (Cu) in protein-energy malnutrition has been less discussed, its importance in various metabolic functions cannot be ignored. Cu is required for the optimal activity of many enzymes, the best known of which are cytochrome oxidase, lysyl oxidase, ferroxidase and tyrosinase. An inadequate supply of Cu will eventually lead to anemia, neutropenia, skeletal and connective tissue changes and developmental delay in growing children.
The studies reported here were undertaken to investigate the Zn and Cu levels in malnourished children in Bangladesh. This will further illustrate whether additional Zinc or copper supplementation is necessary for normal and satisfactory recovery of the children.

Fourteen malnourished Bangladeshi children, aged between 15 months to 48 months, were studied. In these children Zn level was measured on admission and release from hospital. In another 11 malnourished children, aged between 16 months to 48 months, copper levels were measured on admission and release from hospital. Nutritional status of these children was determined by the Mclaren’s points method (Donald et al., 1976). These children were admitted to a local hospital of “SAVE THE CHILDREN’S FUND, NUTRITION UNIT” for treatment.
On admission to the hospital, a standarized clinical examination was carried out. They were checked for conjunctival on cc teal signs of vit-A deficiency and associated infections like anaemia, upper respiratory tract infection (URTI), lower respifatory tract infection (LRTI) and tuberculosis. The degree of edema was assessed both clinically and by decrease in body weight with loss of edema. Vit-B2 deficiency in these children was determined from clinical symptoms of angular stomatitis.
After obtaining initial sera for the studies outlined below, the children were placed on a high protein diet (948 cal/6 kg body weight/day). Antibiotics and vitamin-A supplement were given according to the requirement and when clinically indicated. When their conditions improved in the next 10-15 days, second sample of sera were drawn from them. Children classified “as improved” were those children whose albumin levels showed tendency of increasing but had not yet returned to normal. The sera were collected in tubes, washed with deionized water, and kept frozen until analysis.
A  Estimation of serum levels of Zn:
Zn level in serum was determined by absorption spectroscopy (Dawson and Walker, 1969; Prasad et al., 1965).
B. Determination of copper level in serum:
Cu level in serum was measured by absorption spectroscopy (Parker et al., 1967; Underwood, 1977).

Most of the patients under our study had total protein 4.1 - 6.1 g/100 ml, weight/height 70-80% of the normal (of local standard) with oedema on admission. Using Mclaren’s classification of the severe form, patients under our study were found to have a nutritional status of Marasmic-Kwashiorkor


Table I shows that children suffering from severe and moderately severe vit-A deficiency (determined from the clinical symptoms of keratomalacia and Xerosis) had much low levels zinc compared to others. Children having no vit-A deficiency symptoms, but suffering from protein-energy malnutrition also had low levels of Zn. One report on Jamaican children (Dawson and Walker, 1969) shows that children suffering from Marasmic-Kwashiorkor have Zn level of 69.2 ug% in serum. Our results show that some of our children have extremely low levels of Zn (19 ug% - 36.5 ug%) which is one third to half of that found for Jamaican children. Mother report on Egyptian children suffering from protein energy malnutrition (Vitter and Glazer, 1954) showed that those children had Zn level of 42 ug% - 63 ug% on average against the standard literature value of 102 ± 13 ug%. Some of our children with only mild vit-A deficiency had Zn level of 84.8 ug% - 92.7 ug%.
On nutritional rehabilitation with protein rich diet (948 cal/6 kg/day) without any additional Zn supplementation in next ten to fifteen days, Zn level was improved. This Zn was coming from diet and some of unused Zn might have come to blood bound with proteins like retinol binding protein (REP) and prealbumin (PA).
Those patients who did not have very low levels of Zn initially (85 ug%-92.7 ug%) show better improvement. Almost in all cases, Zn had returned to normal or near to normal standard values. But those patients who had extremely low levels of Zn initially (19-32 ug%) were still Zn deficient. And most of these patients had severe or moderately severe vit-A deficiency.
As some reports suggest (Wilkins et al., 1972) that Zn supplementation improves vit-A transport and metabolism, supplementation with Zinc in the diet may be considered in these children.


In case of Cu (Table II) the picture was different from that found in case of Zn. About 50% patients studied had normal Cu levels, (110 ± 16 ug%), and these patients had various infections like URTI, LRTI, Ascariasis, Amebiasis, Xerosis, Anemia. Rest 50% had low levels of Cu (52 ug% 87 ug%). On nutritional rehabilitation with same diet and without any Cu supplementations, Cu level improved in all patients but the change was not very significant as found in case of Zn. Only 5 to 10 ug% Cu level increased on average in each patient. The patients who were Cu deficient initially had same type of infections like others but most of these patients had vit-B2 deficiency. Mter nutritional rehabffitation, the condition remained same with only slight improvement.
There are some suggestions that Cu and Zn play antagonist role; whether this is working here will be very interesting.

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