Nigerian Journal of Paediatrics 2011;38 (4)159 - 164
Esezobor C I
Adeniyi OF
Knowledge, Acceptance and Practice of
Ekure EN
Zinc Therapy in Acute Diarrhoea Among
Paediatric Doctors in Nigeria
Received: 22nd May 2011
Abstract Background: WHO and
part of Nigeria (70.8%). About half
Accepted: 29th September 2011
UNICEF recommend zinc therapy
(44.3%) of the respondents
in children with acute diarrhoea,
managed more than 10 diarrhoeal
Esezobor C I (
cases every month. All except one
Adeniyi OF, Ekure EN
recommendation varies from
respondent (84 of 85) agreed with
Department of Paediatrics, College country to country.
t h e
W H O / U N I C E F
of Medicine, University of Lagos, Objectives:
To determine the
recommendation and 86.9% (73 of
PMB 12003, Lagos , Nigeria
knowledge, acceptance and
85) reported prescribing zinc for
practice of zinc use in childhood
acute diarrhoea in the past year;
Tel: +2348058440582
diarrhoea among paediatric
67.1% (49 out of 73) prescribed it
doctors in Nigeria.
always for acute diarrhoea.
Every third sitting
Knowledge of the effects of zinc on
participant during the 42
n d
acute diarrhoea was high.
Paediatric Association of Nigeria
was no significant difference
Conference was requested to
between the paediatric residents
complete a questionnaire if they
and the consultants in both
were either a paediatric resident
knowledge and practice of zinc
doctor or consultant working in
Conclusion: The use of zinc as an
Results: Of the 153 questionnaires
adjunct in the management of acute
distributed, 93 (60.8%) were
diarrhoea is acceptable and
returned and 85 met the study
practised by most paediatric
criteria. Over half (57.6%) of the
residents and consultants in
respondents were consultant
paediatricians and 84.7% (49 of
85) practise in tertiary or teaching
acute diarrhoea,
hospitals, mostly in the southern
knowledge, practice, WHO, zinc
recommendations, many countries have developed
guidelines on the management of acute diarrhoea
which include zinc However, it has been observed
Diarrhoea remains a leading cause of mortality and
morbidity in the paediatric population globally, and
that that adherence to treatment guidelines for the
also in Nigeria.
Most diarrhoeal deaths result from
management of common childhood illnesses such as
dehydration and take place at home or soon after
diarrhoea is low worldwide.
In Sudan,Cheragili et
arrival at the hospital. To combat this trend, WHO
al noted that the adherence of prescribers to standard
recommended the use of oral rehydration
treatment guidelines for treating diarrhoea in the
solution including continued oral feeding. Based on
public hospitals ranged between 45-64%. Similarly,
the reports of several studies
confirming the
arecent study in India found that only 22% of 843
beneficial effects of zinc therapy in acute watery
prescriptions for acute diarrhoea included zinc.
diarrhoea, the WHO and UNICEF, in 2004,
recommended its use for 10-14 days in children with
There appears to be little published information
acute diarrhoea. Since the publication of the
available on the use or prescription of this vital
Supplement for children with diarrhoea by
In diarrhoea where the options provided were 'Yes',
paediatricians in Nigeria. Thus this study aims to
'No' and 'Not sure', if none of the options was ticked it
describe the knowledge and practice of the use of
was assumed the respondent was not sure of the
zinc in the treatment of acute watery diarrhoea by
correct answer. Continuous variables were tested for
paediatric residents and consultants in the country.
normality and presented as mean (SD) or median
(IQR) as appropriate. Categorical variables were
presented as percentages. Test of differences in the
knowledge and practice of the residents and the
Materials and Methods
consultants was compared using odds ratio. The level
of statistical significance was set at 5%.
The study was carried out during the 42 Annual
Paediatric Association of Nigeria Conference
(PANCONF), held in Abuja, Nigeria between 12
and 14
January 2011. PANCONF is the largest
annual gathering of paediatricians, paediatric
residents and other health practitioners in the
Of the 153 questionnaires distributed 93 were
practice of child health in Nigeria. It attracted over
returned (60.8%). Eight questionnaires were
500 participants from Nigeria and the rest of the
discarded because they were completed by nurses (3),
world. A sample size of 158 was calculated using the
did not include the state where practice is located (3),
Cochran's formula with correction for finite
did not see any child with diarrhoea in the past one
population and a reported adherence of 75% from a
year (1) and was incompletely filled (1); leaving 85
previous study.
To increase the geographical
questionnaires for analysis. The median time since
spread of the survey and diversity of the participants,
graduation from medical school was 13 years and 45
every third sitting participant was recruited, because
(52.9%) of the respondents were females. Most of the
participants that share the same interests and location
respondents work in tertiary or teaching hospitals
of practice tend to sit togetherduring meetings.
(84.7%) located in the southern region of Nigeria
(70.8%). Consultants made up 57.6% (49 out of 85)
The questionnaire included sections on the
of the respondents with a median time since
demographics of the respondents such as gender,
attainment of fellowship of 4
years. About half
time since medical school graduation and fellowship
(44.3%) of the respondents attend to more than 10
in paediatrics, practice type and location; number of
diarrhoeal cases every months Table 1.
diarrhoea cases seen per month; agreement with the
WHO guidelines on the use of zinc for acute watery
All the respondents except one (84 out of 85) agreed
diarrhoea; zinc prescription pattern; and knowledge
with the WHO recommendation that zinc should be
about the function of zinc in acute diarrhoea. To
given to children with acute diarrhoea and 86.9% (73
encourage completion, each question except the
out of 85) prescribed zinc for acute watery diarrhoea
ones on time since graduation or fellowship and
in the past 1 year. Of those who prescribed zinc in the
practice location had 3 or more options to choose
past one year, 67.1% (49 out of 73) prescribed it all
from. To maximize retrieval, the questionnaires were
the time they managed a child with acute diarrhoea
distributed on the first day of the conference. Only
Table 2. Of the 88 respondents who agreed with the
questionnaires from resident doctors in paediatrics
WHO recommendation,more than 75% responded
and consultant paediatricians were analyzed.
that zinc in acute watery diarrhoea should be given
I n c o m p l e t e l y
f i l l e d
q u e s t i o n n a i r e s
o r
for 10-14 days, that it reduces diarrhoea duration,
questionnairesfilled byparticipantspractising
replaces body stores of zinc and re-epithelizes the
outside Nigeria were excluded
intestine. A smaller proportion (60.7%) agrees that it
reduces stool frequency. In contrast, less than half
The data was entered into Microsoft Excel 2007 and
(45.2%) reported that zinc reduces stool volume.
analyzed using EPI info version 3.4.3. One of the
There was no significant difference in the knowledge
authors checked the entered data for errors by going
and practice of paediatric residents and consultants
through all the questionnaires again. For
concerning zinc use in acute diarrhoea (Tables 2 and
theknowledge-based section on the benefits of zinc
Table 1: Description of the studied population
n=85 (%)
n=36 (%)
n=49 (%)
40 (47.1)
15 (41.7)
25 (51.0)
45 (52.9)
21 (58.3)
24 (49.0)
Time since medical school graduation, median(IQR), years
13 (12)
8 (4.5)
17 (11)
Time since fellowship, median (IQR), years
4 (8)
Practice location:
13 (14.6)
9 (25.0)
4 (8.2)
9 (10.1)
2 (5.6)
7 (14.3)
1 (1.1)
1 (2.8)
0 (0.0)
24 (27.0)
7 (19.4)
17 (34.7)
19 (22.5)
12 (33.3)
7 (14.3)
19 (21.3)
5 (13.9)
14 (28.6)
Practice Type:
General hospitals
8 (9.4)
3 (8.3)
5 (10.2)
Tertiary/Teaching Hospitals
72 (84.7)
32 (88.9)
40 (81.6)
5 (5.9)
1 (2.8)
4 (8.2)
Diarrhoea cases/month:
49 (55.7)
19 (52.8)
30 (61.2)
20 (23.9)
10 (27.8)
10 (20.4)
16 (20.5)
7 (19.4)
9 (18.4)
19.NA: not appropriate
Table 2: Practice of zinc use in acute watery diarrhoea
Practice Variables*
Odds Ratio
P value
n (%)
n (%)
n (%)
Agrees with WHO
84 (98.9)
36 (100.0)
48 (98.0)
1 (1.1)
0 (0.0)
1 (2.0)
Teach student use of Zinc
1.09 (0.30-
67 (85.9)
29 (85.3)
38 (86.4)
11 (14.1)
5 (14.7)
6 (13.6)
Prescribed zinc in the past
1.03 (0.25-
73 (86.9)
32 (88.9)
41 (85.4)
9 (10.7)
4 (11.1)
5 (10.4)
How often is zinc prescribed
1.47 (0.54-
All the times
49 (67.1)
23 (71.9)
26 (63.4)
24 (32.9)
9 (28.1)
15 (36.6)
Duration zinc is prescribed
2.05 (0.49-
10 (13.7)
3 (9.4)
7 (17.1)
62 (84.9)
29 (90.6)
33 (80.5)
*The total respondents for each practice variables differs
Table 3: Knowledge of the Function of Zinc in Acute Diarrhoea
Knowledge Variables*
Odds Ratio
P value
n (%)
n (%)
n (%)
Does zinc reduce stool
1.06 (0.44-2.52)
38 (45.2)
16 (44.4)
22 (45.8)
46 (54.8)
20 (55.6)
26 (54.2)
No/not sure
Does zinc reduce
diarrhoea duration
1.24 (0.43-3.61)
67 (79.8)
28 (77.8)
39 (81.3)
No/not sure
17 (20.2)
8 (22.2)
9 (18.8)
Does zinc reduce stool
0.79 (0.33-1.93
51 (60.7)
23 (63.9)
28 (58.3)
33 (39.3)
13 (36.1)
20 (41.7)
Not/not sure
Does zinc re-epithelize
0.53 (0.12-2.22
the intestine
74 (88.1)
33 (91.7)
41 (85.4)
10 (11.9)
3 (8.3)
7 (14.6)
Not/not sure
Does zinc replace body
1.27 (0.45-3.54)
65 (77.4)
27 (75.0)
38 (79.2)
19 (22.6)
9 (25.0)
10 (20.8)
Not/not sure
*knowledge variables for the 84 respondents who agree with the WHO/UNICEF recommendation
found to be lower than adherence inferred from self
1 4
With widespread awareness of a
In this study an attempt was made to determine,
recommendation among health workers, adherence is
expected to increase ; hence the difference in study
using self-report, the level of adherence to the WHO-
UNICEF recommendation concerning the use of
periods could also have contributed to the varied
zinc in acute diarrhoea. All but one of the
adherence rates.
participating respondents agreed with the
recommendation with over 80% prescribing zinc for
The high prescription rate for zinc in the present study
acute diarrhoea in the past year. Of those who
may be explained by the demographics of the
prescribed zinc in the past one year, two-thirds
respondents. All the respondents were either
prescribed it all the time they managed a child with
specialist paediatricians or paediatric residents
acute diarrhoea. The high practice rate in this study is
practicing in tertiary or teaching hospitals with a
similar to the findings of two retrospective studies in
median duration since graduation from medical
India which reported that 65% of the children with
schools of 13 years. Because most of the respondents
acute diarrhoea received a prescription of
indicated that they teach students about diarrhoea, it
is expected that they were more likely to be current in
zinc. Inontrast, the prescription rate in the present
the knowledge and practice of common childhood
study is much higher than the 22% reported by
Pathak et al in another region in India.
practitioners. The small number of respondents in
facilities other than teaching/tertiary hospital did not
The higher rate in the present study compared to that
allow for comparison in the present study. Moreover,
of Pathak et al may be due to several factors. While
since about half of the respondents manage more than
the study by Pathak et al involved mostly general
10 cases of acute diarrhoea per month, it is likely that
practitioners the present study involved
this would have contributed to their knowledge and
paediatricians and paediatric residents whose
practice of the standard management of acute
knowledge of the current management of diarrhoea
is expected to be higher. Secondly, the huge
difference in adherence rates to the WHO
The majority of the respondents reported that
recommendation could also be due to the methods
prescribing zinc in acute diarrhoea was associated
used to access adherence. As expected, adherence
with shorter diarrhoea duration, fewer stool
measure by actual observation is commonly
frequency and helps in the re-epithelization of the
Intestinal mucosa. The high proportion of the
Association of Nigeria. Like in most c ountries where
respondents with the correct knowledge of the
effects of zinc on the course of acute diarrhoea may
the recommendations have been implemented,
have contributed to the high zinc prescription rate
support by paediatric associations has been important
to the implementation.
(elicited by self-report) documented in the present
study. In contrast, less than half of the respondents
reported that zinc use leads to reduction in stool
The findings of the present study may not be
volume. This low response may be due to the
extrapolated to the general population of paediatric
conflicting findings from various studies on the
doctors in Nigeria, because the respondents may be a
effect of zinc on stool volume.
selection bias of doctors that are abreast with current
medical practice.The lower sample size may also have
In agreement with the WHO recommendation, the
reduced the generalizability of our findings. However
vast majority of the respondents in the present study
the conference provided an opportunity to improve
reported prescribing zinc for 10-14 days to children
response rate and coverage to a country-wide study.
with acute diarrhoea; about 14%, most of whom are
For unknown reason(s) respondents from the north
consultant paediatricians, prescribed zinc for 5 days.
east region of Nigeria were poorly represented in the
Plausible explanation for the practice of zinc
study. However we are not aware of any reason why
prescription for 5 days was not explored in the study
their acceptance and practice of zinc use in acute
but may be due to reports of studies supporting than
diarrhoea should be significantly different from the
zinc therapy for less than 10-14 days was equally
results of the present study. Because the questionnaire
with the instruction 'for doctors only' was handed to
For instance, in a randomized
every third sitting participant, some of whom may not
community trial in Bangladesh a 5-day regimen was
be medical doctors, the response rate in this study
not different from a 10-day regimen when the
could be higher than the 60% response rate recorded.
primary outcome was incidence and duration of
We were not able to comment on the demographics of
diarrhoea over the subsequent 90 days.
those who did not return the questionnaires.
In terms of knowledge and practice of zinc use in
acute diarrhoea, there was no significant difference
between the resident doctors and consultant
paediatricians. This finding is not unexpected for
several reasons. Being a fairly common childhood
The use of zinc in the management of acute diarrhoea
condition both the residents and consultants would
is acceptable and practiced by most paediatricians and
have had ample opportunities to participate in the
paediatric resident doctors in Nigeria, most of whom
management of acute diarrhoea and as a result
posses the correct knowledge about the effects of zinc
improve knowledge and practice. Also, as most of
on the clinical course of a bout of acute diarrhoea.
the respondents are from teaching/tertiary hospitals
they are exposed regularly to academic activities that
Author's contribution: ECI and AOF conceived the
provide opportunities to update knowledge and
study but all the authors participated in the design and
practice of common health conditions including
implementation of the study. In addition all the
authors approved the submitted manuscript.
Conflict of interest: none declared
The 42 PANCONF provided a unique opportunity
Role of funding source: No funding was received for
to determine knowledge and practice of zinc use, not
this work
only in one centre or region, but among paediatric
doctors from all the regions of Nigeria. Our findings
support a country-wide practice of the prescription
of zinc during a bout of acute diarrhoea in children,
although the north east region was sparsely
We wish to thank the resident doctors from Lagos
represented in the sample. The result of the present
University Teaching Hospital who helped in the
study implies acceptance of the recommendations of
distribution and retrieval of the questionnaires during
WHO and UNICEF concerning the use of zinc in
PANCONF. We are also grateful to Dr Oladepo for
acute diarrhoea to most members of the Paediatric
entering the data into Microsoft Excel software.
1. Black RE, Cousens S,
6. Bhandari N, Bahl R, Taneja S,
13. Balasubramanian S, Ganesh R.
Johnson HL, Lawn JE, Rudan
Strand T, Molbak K, Ulvik
Prescribing pattern of zinc and
I, Bassani DG, et al : Global,
RJ, Sommerfelt H, Bhan MK:
antimicrobials in acute
regional, and national causes
Substantial reduction in
diarrhea. Indian Pediatr. 2008;
of child mortality in 2008: a
severe diarrheal morbidity by
systematic analysis. Lancet
daily zinc supplementation in
14. Farley J, Hines S, Musk A,
2010, 375(9730):1969-1987.
young north Indian children.
Ferrus S, Tepper V.
2. Bryce J, Boschi-Pinto C,
Pediatrics2002, 109(6):e86.
Assessment of adherence to
Shibuya K, Black RE. WHO
7. Clinical management of acute
antiviral therapy in HIV-
estimates of the causes of
infected children using the
death in children. Lancet.
4.07). Geneva & New York:
Medication Event Monitoring
World Health Organization &
System, pharmacy refill,
3. Baqui AH, Black RE, El
United Nations Children's
provider assessment, caregiver
Arifeen S, Yunus M,
Fund; 2004.
self-report, and appointment
Chakraborty J, Ahmed S, et
8. Fischer Walker CL, Fontaine
keeping. J Acquir Immune
al. Effect of zinc
O, Young MW, Black RE.
DeficSyndr. 2003;33(2):211-8.
supplementation started
Zinc and low osmolarity oral
15. Patel A, Mamtani M, Dibley
during diarrhoea on morbidity
rehydration salts for
MJ, Badhoniya N, Kulkarni H.
and mortality in Bangladeshi
diarrhoea: a renewed call to
Therapeutic value of zinc
children: commun ity
action. Bull World Health
supplementation in acute and
randomised trial. BMJ 2002,
Organ. 2009; 87(10):780-6.
persistent diarrhea: a
9. Pathak D, Pathak A, Marrone
systematic review. PLoS One.
4. Bhutta ZA, Bird SM, Black
G, Diwan V, Lundborg CS.
RE, Brown KH, Gardner JM,
Adherence to treatment
16. Lukacik M, Thomas RL,
Hidayat A, et al : Therapeutic
guidelines for acute diarrhoea
Aranda JV. A meta-analysis of
effects of oral zinc in acute
in children up to 12 years in
the effects of oral zinc in the
and persistent diarrhea in
Ujjain, India--a cross-
treatment of acute and
children in developing
sectional prescription
persistent diarrhea. Pediatrics .
countries: pooled analysis of
analysis. BMC Infect Dis .
randomized controlled trials.
17. Patro B, Golicki D, Szajewska
Am J ClinNutr2000,
10. Hoekstra JH. Acute
H. Meta-analysis: zinc
gastroenteritis in
supplementation for acute
5. Sazawal S, Black RE, Bhan
industrialized countries:
gastroenteritis in children.
MK, Jalla S, Sinha A,
compliance with guidelines
Aliment PharmacolTher. 2008;
Bhandari N: Efficacy of zinc
for treatment. J
supplementation in reducing
18. Alam DS, Yunus M, El Arifeen
the incidence and prevalence
2001;33 Suppl 2:S31-5.
S, Chowdury HR, Larson CP,
of acute diarrhea--a
11. Cheraghali AM, Idries AM.
Sack DA, Baqui AH, Black
community-based, double-
Availability, affordability, and
RE: Zinc treatment for 5 or 10
blind, controlled trial. Am J
prescribing pattern of
days is equally efficacious in
ClinNutr1997, 66(2):413-418 .
medicines in Sudan. Pharm
preventing diarrhea in the
World Sci 2009;31(2):209-
subsequent 3 months among
Bangladeshi children. J
12. Cochran WG. Sampling
Nutr.2011, 141(2):312-315.
techniques, 2 Ed., New
York: John Wiley and Sons,
Inc. 1963