ABSTRACT
OBJECTIVE: Zinc may be a limiting factor in restricting catch-up growth in severely malnourished children. This study had two aims: (i) to examine the effect of different zinc supplementation regimens on IGF-I, its binding proteins and on markers of bone and collagen turnover in severely malnourished children and (ii) to investigate mechanisms underlying catch-up growth by examining changes in these markers during nutritional rehabilitation, their inter-relationships and their relationships with ponderal and linear growth. DESIGN: Double-blind randomized intervention study of three regimens of oral zinc supplementation. PATIENTS: One hundred and forty-one children, aged 6-36 months, mean (SD) age 15.4 (8.7) months, with day 1 weight-for-height SD score (whz) -2.6 (0.93) and height-for-age SD score (haz) -3.79 (1.29). MEASUREMENTS: Weight, height, lower leg length (by knemometry) at 15-day intervals from day 1 to day 90 of nutritional rehabilitation. Blood collection on days 1, 15 and 30 for IGF-I, IGFBP3, IGFBP2, bone alkaline phosphatase (BAP, osteoblast marker), procollagen type I C-terminal propeptide (PICP, marker of type I collagen synthesis), procollagen type III N-terminal propeptide (P3NP, marker of soft tissue type III collagen synthesis) and type I collagen telopeptide (ICTP, marker of type I collagen breakdown). RESULTS: There was early rapid weight gain during refeeding, whereas height gain occurred later in the trial. IGF-I, IGFBP3, BAP, PICP and P3NP were low or very low on day 1 compared to well-nourished age-matched European children, and all increased within 15 days (P < 0.001), with PICP and P3NP reaching levels higher than European norms. IGFBP2 and ICTP were high on day 1 and decreased over the same period (P < 0.001). There were no differences in anthropometric outcome or marker responses among zinc regimens. Day 1 whz was correlated with BAP, PICP and P3NP (P < 0.001). Changes in IGF-I, IGFBP3, BAP, PICP and P3NP over 30 days correlated with ponderal growth (whz change) over the same period (all P < 0.01). However, changes in these markers over 30 days correlated better with lower leg growth (all P < 0.01) and linear growth (haz change, P < 0.01 for PICP and P3NP, P < 0.05 for IGFBP3) measured over 90 compared with 30 days. At most time points, there were strong positive correlations (i) among IGF-I, IGFBP3, BAP, PICP and P3NP (P < 0.01) and (ii) between IGFBP2 and ICTP (P < 0.01). Conversely, IGFBP2 was negatively correlated with IGF-I, IGFBP3, BAP, PICP and P3NP at most time points (P < 0.01). CONCLUSIONS: We found no difference among zinc regimens in growth, IGF-I and its binding proteins or markers of bone and collagen turnover. Severe malnutrition was associated with low rates of bone and collagen synthesis and high rates of collagen degradation, and nutritional rehabilitation was associated with full or partial 'normalization' of the markers studied. Early weight gain and subsequent linear growth were associated with early increments in IGF-I, IGFBP3 and markers of bone and collagen formation. The study of these markers has provided additional insights into the mechanisms of the effects of malnutrition and refeeding on growth.
