Sunday, January 19, 2014

Premature infants on parenteral nutrition among the casualties in zinc shortage

During the ongoing nationwide shortage of injectable zinc, hospitals should keep what stocks they have in reserve for patients who need them most, particularly infants on parenteral nutrition, investigators advised in the Jan. 17 Morbidity and Mortality Weekly Report.

Seven infants, five of them premature, developed severe zinc deficiencies in late 2012 while on parenteral nutrition (PN) secondary to extreme cholestasis. Zinc is normally added to PN for premature or medically compromised infants, but the hospitals – one in Washington, the other in Houston – had run out because of the shortage (MMWR 2014;63:35-7).

Six infants developed zinc-deficiency dermatitis – and three concomitant bacterial infections – after being on zinc-deficient PN from 4-34 weeks. Serum zinc levels in those tested were well below normal. One child died of causes possibly related to zinc deficiency. The other six children improved after the Food and Drug Administration helped arrange emergency shipments to the hospitals, but another child subsequently died of unrelated causes, said the investigators led by Dr. Duke J. Ruktanonchai, a Centers for Disease Control and Prevention epidemic intelligence service officer.

Injectable zinc has been scarce in the United States since late 2012. By mid-January 2013, 17 hospitals in 10 states had reported shortages.

The situation is slowly improving. FDA has allowed Baxter Healthcare to import injectable zinc from Laboratoire Aguettant, a foreign manufacturer. One U.S. manufacturer is ramping up production after addressing manufacturing problems, including particulate matter in injectable products. The other domestic supplier is already operating at maximum capacity. FDA is posting updates on the situation on its drug shortage website.

There might have been more zinc-deficiency cases in infants. Serum zinc levels aren’t routinely checked in infants; the amount of blood needed might pose a risk, especially to the premature. That "might explain, in part, why no other cases were reported," the investigators said.

Infants are particularly vulnerable to deficiencies because their systemic zinc reserves are not fully developed, so they depend totally on zinc from breast milk or formula.

Whenever administering PN without the standard micronutrients, it’s wise to monitor for signs and symptoms of deficiency. Dermatitis and growth impairment are the most common signs of zinc deficiency. The three zinc-deficient infants in Washington had erosive diaper-area dermatitis and blisters on their extremities, according to the report.

The funding source for the investigation and investigator disclosures were not reported.

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