National Association of Neonatal Nurses logo.
National Association of Neonatal Nurses logo.

enews-hero

Special Interest Group Update

In each issue, one of NANN's special interest groups shares information in their area of focus.

Disclaimer:  The information presented and opinions expressed herein are those of the author and do not necessarily represent the views of the National Association of Neonatal Nurses.

Recognizing, Diagnosing, and Managing Neonatal Zinc Deficiency

Tosha Harris, DNP APRN NNP-BC

Neonatal zinc deficiency is a condition characterized by insufficient levels of zinc in newborn infants. This edition’s Special Interest Group Update (SIG Update) article will review its causes, diagnosis, and management.

Zinc, a crucial trace element, is recognized for its pivotal roles in protein structure and function, including enzymes, transcription factors, hormonal receptor sites, and biological membranes. It plays vital roles in DNA and RNA metabolism, is crucial to cell division and growth, and is involved in signal transduction, gene expression, and apoptosis (Krebs & Hambidge, 2022).
This has been growing awareness of and concern regarding the occurrence of zinc deficiency in low-birth-weight (LBW) and very-low-birth-weight (VLBW) infants. This is in line with increasing recognition of the health benefits associated with zinc supplementation in VLBW infants. Going as far back as 1993, greater growth with zinc supplementation has been observed in the first 6 months of life and evidence of favorable neurodevelopment, even in formula-fed VLBW infants, has been seen.

However, reports of severe zinc deficiency in premature infants continue to emerge regularly in the literature, particularly in cases of very premature/VLBW infants and infants primarily receiving human milk. This underscores the pressing need to address this issue (Krebs & Hambridge, 2022).

Deficiency can have significant negative effects on growth, development, and overall health, particularly in neonates at a critical stage of development.

Causes of Neonatal Zinc Deficiency(Brion et al., 2021; Krebs & Hambridge, 2022)

  1. Maternal Zinc Deficiency
    • Inadequate Maternal Intake: Poor dietary intake during pregnancy can result in lower zinc stores in the infant.
    • Malabsorption: Digestivediseases in the mother can impair zinc absorption.
    • Pregnancy Complications: Conditions like sickle cell disease and chronic renal disease can affect zinc transfer from mother to fetus.
  2. Prematurity
    • Premature infants have less time to accumulate zinc stores from the mother, resulting in lower zinc levels at birth.
  3. Breastfeeding Issues
    • Low Zinc Levels in Breast Milk: Certain conditions in the mother can lead to lower zinc concentrations in breast milk.
    • Exclusive Breastfeeding without Supplementation: This is particularly an issue when maternal zinc levels are low.
  4. Genetic Disorders
    • Acrodermatitis enteropathica: This rare autosomal recessive disorder affects zinc absorption due to mutations in the SLC39A4 gene.
    • High Zinc Requirements
      • Rapid growth and development in neonates increase the demand for zinc, making them more susceptible to deficiency if intake is inadequate.

Symptoms and Signsof Neonatal Zinc Deficiency (Brion et al., 2021)

  1. Dermatological manifestations
    • Periorifical lesions often are found around the mouth and anus, and an erythematous scaly rash may appear on the extremities.
    • Alopecia (air loss) can occur in severe cases.
    • Delayed wound healing
  2. Growth Retardation
    • Poor weight gain and stunted growth
    • Decreased head growth
  3. Immune Dysfunction
    • Increased susceptibility to infections due to impaired immune response
  4. Gastrointestinal Symptoms
    • Diarrhea and poor appetite
    • Altered gut physiology and microbial composition
  5. Behavioral Changes
    • Irritability and lethargy

Diagnosis

  1. Clinical Presentation
    • Evaluation of symptoms and physical examination
  2. Laboratory Tests
    • Plasma Zinc Concentration: Plasma zinc levels below 50 μg/dL strongly indicate deficiency but are not a reliable biomarker for marginal deficiency (Karpen & Poindexter, 2024). The European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) recommends a normative zinc concentration of 0.74–1.46 mcg ml−1 (Brion et al., 2021).
    • Other Tests: Assessment of serum alkaline phosphatase and other markers of nutritional status. Serum alkaline phosphatase is an enzyme that relies on zinc for its function, so diminished activity may indicate a zinc deficiency (Karpen & Poindexter, 2024).
  3. Genetic Testing
    • For suspected cases of acrodermatitis enteropathica or other genetic conditions affecting zinc metabolism
  4. Dietary History
    • Evaluation of maternal and neonatal dietary intake

Treatment
Although there is no consensus regarding neonatal zinc requirements, Parker (2021) cited several recommended parenteral and enteral intake ranges for term and preterm infants based on the baby’s weight. They are as follows: 

July NANN enews SIG article zinc chart 550

Zinc deficiencies can be mitigated though dietary interventions and zinc supplementation.

Dietary interventions include:

  • Ensuring adequate maternal zinc intake by consuming zinc-rich foods, such as meat, shellfish, legumes, seeds, and nuts.
  • A multicomponent human milk fortifier is recommended for infants who are exclusively fed human milk.
  • Premature or term formulas
  • Zinc supplementation should be provided through parenteral nutrition support.

Promoting Neonatal Health

Neonatal zinc deficiency is a significant nutritional disorder with potential severe consequences for growth, development, and immune function. Early recognition, appropriate diagnosis, and timely intervention with zinc supplementation and dietary adjustments are essential for managing this condition effectively. Ensuring maternal and neonatal nutritional adequacy is crucial in preventing zinc deficiency and promoting overall neonatal health.

References
Brion, L. P., Heyne, R., & Lair, C. S. (2021). Role of zinc in neonatal growth and brain growth: Review and scoping review. Pediatric Research, 89(7), 1627–1640. https://doi.org/10.1038/s41390-020-01181-z

Karpen, H., & Poindexter, B. (2024). Enteral nutrition. In C. A. Gleason & T. Sawyer (Eds.), Avery’s diseases of the newborn (11th ed., pp. 871–887). Elsevier.

Krebs, N. F., & Hambridge, M. (2022). Zinc in the fetus and neonate. In R. A. Polin, S. H. Abman, D. H. Rowitch, W. W. Benitz, W. W. Fox (Eds.), Fetal and neonatal physiology (6th ed., pp. 282–286). Elsevier.

Parker, L. A. (2021). Nutritional management. In M. Terese Verklan, M. Walden, & S. Forest (Eds.), Core curriculum for neonatal intensive care nursing (6th ed., pp. 152–171). Elsevier.