Rethinking Zinc Supplementation as a Treatment for Pediatric Pneumonia

Study provides insight into anemia treatment and prevention in young children.

By Jessica Mitchell, ND

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Sazawal S, Dhingra U, Hiremath G, et al. Effects of Bifidobacterium lactis HN019 and prebiotic Oligosaccharide added to milk on iron status, anemia, and growth among children 1 to 4 years old. J Pediatr Gastroenterol Nutr. 2010 Jun 30. [Epub ahead of print]


Double-blind, randomized, controlled, community-based trial.


624 children aged 1–4 years in New Dehli were randomized to receive either control or fortified milk. Hematological parameters were evaluated at baseline and end of study. Height and weight were measured at baseline, mid-study and end of study.

Study Medication and Dosage

Participants received either control milk or milk fortified with an additional 1.9 x107 colony-forming units of Bifidobacterium lactis HN019 and 2.4g/day of prebiotic oligosaccharides for 1 year.

Key Findings

The consumption of the prebiotic- and probiotic-fortified milk reduced the risk of being anemic and iron-deficient by 45%, and increased weight gain by 0.13 kg/year when compared to controls.

Practice Implications

According to the World Health Organization (WHO), 47.4% of preschool-age children and 25.4% of school-age children worldwide are anemic. Approximately half these anemias are thought to be due to iron deficiency. In the United States, WHO does not consider anemia to be a public health problem, as only 3.1% of preschool age children were found to be anemic.1 However, poor, minority and immigrant children and toddlers are still at risk for iron deficiency with and without anemia.2

This study by Sazawal points to a potential solution to the global concern of nutritional deficiencies, and it specifically provides a new insight to anemia treatment and prevention. The beneficial effects of probiotics have been well-documented in the treatment of diarrhea, though it seems they may have a more far-reaching physiological impact than previously thought.3 In a concurrent study, prebiotic- and probiotic-fortified milk reduced the number of episodes of dysentery, severe illness, and high fever.

In a concurrent study, prebiotic- and probiotic-fortified milk reduced the number of episodes of dysentery, severe illness, and high fever.

It has also been shown that a healthy ratio of beneficial gut bacteria in infancy is protective against overweight and obesity later in life,4, 5 and associated with a decreased risk of gestational diabetes.6

With respect to the role of probiotics in treating anemia, related studies show that children given an iron-fortified fermented milk beverage with supplemental Lactobacillus acidophilus had higher red blood cell measurements and were more likely improve hemoglobin levels with increased iron intake.7 These studies provide evidence to support the use of both Lactobacillus acidophilus and Bifidobacterium lactis to prevent anemias in children.

What may be more relevant to our patients in the United States and the growing trend toward obesity is the link between increased BMI and decreased iron status. According to a 2004 Pediatrics article, children who are overweight and obese are approximately twice as likely to be iron-deficient.8 It is reasonable to assume that supplementing children with probiotics will confer many benefits, including a stronger immune system, as well as decreasing risks of both obesity and iron deficiency. One explanation is that the large amounts of calcium in milk may have a protective effect against the development of overweight, type 2 diabetes, metabolic syndrome, and ischemic cardiovascular disease by reducing the absorption of fat in the intestines.9 It may be worth considering a similar intervention of fortified milk to obese children to address not only the development of such conditions, but also the associated risk of iron deficiency.

While anemia certainly affects cognitive development, Lozoff et al have also shown a correlation between iron deficiency both with and without anemia and poorer infant behaviors.10 A relatively simple intervention such as the one described in this study could have profound effects on the social and emotional development of infants.

This study not only highlights the importance of intestinal bacteria, but serves as a reminder of the importance of prebiotics as well. A trial of infant formula with probiotics only did not improve infant growth, and Laparra et al showed that the addition of inulin as a prebiotic to Lactobacillus acidophilus increased iron absorption from beans, but decreased iron absorption when added to Bifidobacterium infantis.11, 12

Probiotics continue to be a safe and noninvasive intervention worth considering not only in cases of gastrointestinal disturbances but also as an adjunctive therapy in cases anemia or where there is a risk of anemia.

About the Author

Jessica Mitchell, ND, graduated from Southwest College of Naturopathic Medicine in 2005. During her general practice residency she discovered her passion for pediatric medicine. In 2007, she became the first naturopathic pediatric resident. During her residencies, she participated in 2 double-blind, placebo-controlled studies on biomedical treatments of autism. Articles from this research have been published in the Journal of Toxicology and BioMed Central Clinical Pharmacology. She has worked in conjunction with the Arizona branch of the American Academy of Pediatrics on its obesity committee and is a founding member and treasurer of the Pediatric Association of Naturopathic Physicians. Mitchell is currently an assistant professor and residency director at Southwest College of Naturopathic Medicine. She oversees student medical rotations at the medical center and at 2 free clinics in Phoenix and maintains a private practice at Southwest Naturopathic Medical Center.


1. de Benoist B, McLean E, Egli I and Cogswell M, eds. Worldwide Prevalence of Anaemia 1993–2005: WHO global database on anaemia. Geneva, Switzerland: World Health Organization; 2006

2. Brotanek JM, Halterman J, Auinger P, Flores G, Weitzman M. Iron deficiency, prolonged bottle-feeding, and racial/ethnic disparities in young children. Arch Pediatr Adolesc Med. 2005;159:1038-1042.

3. Sazawal S, Dhingra U, Hiremath G, et al. Prebiotic and probiotic fortified milk in prevention of morbidities among children: community-based, randomized, double-blind, controlled trial. PLoS One. 2010;5(8):e12164.

4. Ibid.

5. Ley RE, Turnbaugh PJ, Klein S, Gordon JI. Microbial ecology: human gut microbes associated with obesity. Nature. 2006;444(7122):1022-1023.

6. Luoto R, Laitinen K, Nermes M, Isolauri E. Impact of maternal probiotic-supplemented dietary counselling on pregnancy outcome and prenatal and postnatal growth: a double-blind, placebo-controlled study. Br J Nutr. 2010 Jun;103(12):1792-1799.

7. Silva MR, Dias G, Ferreira CL, Franceschini SC, Costa NM. Growth of preschool children was improved when fed an iron-fortified fermented milk beverage supplemented with Lactobacillus acidophilus. Nutr Res. 2008;28(4):226-232.

8. Nead KG, Halterman JS, Kaczorowski JM, Auinger P, Weitzman M. Overweight children and adolescents: a risk group for iron deficiency. Pediatrics. 2004;114(1):104-108.

9. Jaffiol C. Milk and dairy products in the prevention and therapy of obesity, type 2 diabetes and metabolic syndrome. Bull Acad Natl Med. 2008;192(4):749-758.

10. Lozoff B, Clark KM, Jing Y, Armony-Sivan R, Angelilli ML, Jacobson SW. Dose-response relationships between iron deficiency with or without anemia and infant social-emotional behavior. J Pediatr. 2008;152(5):696-702, 702.31-702.33.

11. Saavedra JM, Abi-Hanna A, Moore N, Yolken RH. Long-term consumption of infant formulas containing live probiotic bacteria: tolerance and safety. Am J Clin Nutr. 2004;79(2):261-267.

12. Laparra JM, Glahn RP, Miller DD. Assessing potential effects of inulin and probiotic bacteria on Fe availability from common beans (Phaseolus vulgaris L.) to Caco-2 cells. J Food Sci. 2009;74(2):H40-H46.