Body Fat Indices for Identifying Risk of Hypertension in Indian Children.

Background: High adiposity is major risk factor for hypertension. Various anthropometric indices are used to assess excess fatness. Objectives: (1) To examine relationship of body mass index (BMI), waist circumference (WC), waist to height ratio (WHtR), triceps skin fold thickness (TSFT) and wrist measurements with blood pressure in children and adolescents 2) to suggest age- and gender-specific cutoffs for these indices in Indian children. Methods: Cross-sectional school-based study on a random sample of 6380 children (6-18 yr old, 3501 boys) from five major cities in India. Height, weight, waist and wrist circumference, TSFT, and blood pressure were recorded. Children with systolic blood pressure (BP) and/or Diastolic BP >95th percentile were classified as hypertensive. Results: Prevalence of overweight and obesity was 23.5% and 9.7%, respectively. Hypertension was observed in 5.6%. Multiple logistic regression (adjustments: age, gender) indicated double risk of hypertension for overweight and 7 times higher odds for obese than normal-weight children. Children with TSFT >95th centile for US children showed three times risk and with TSFT from 85th to 95th double risk of hypertension. Higher WC and WHtR exhibited 1.5 times risk and larger Wrist 1.3 times higher risk of hypertension (P<0.001). Receiver operating curve (ROC) analysis provided age-gender specific cut offs for the five indices to detect the risk of high BP. Area under ROC curves (AUC) for five indices were similar and greater in older age groups indicating equal sensitivity and specificity. Conclusion: Using age- and gender-specific cutoffs for BMI, TSFT, WC or WHtR may offer putative markers for early detection of hypertension.

Body Mass Index Cut-offs for Screening for Childhood Overweight and Obesity in Indian Children.

Objective: To develop age and sex specific cut- offs for BMI to screen for overweight and obesity in Indian children linked to an adult BMI of 23 and 28 kg/m2 respectively, using contemporary Indian data. Design: Cross-sectional. Setting: Multicentric, School based. Participants: 19834 children were measured from 11 affluent schools from five major geographical regions of India. Data were analyzed using the LMS method, which constructs growth reference percentiles adjusted for skewness. Results: Compared to the cut-offs suggested for European populations and those by the Indian Academy of Pediatrics 2007 Guidelines, the age and sex specific cut off points for body mass index for overweight and obesity for Indian children suggested by this study are lower. Conclusions: Contemporary cross-sectional age and sex specific BMI cut-offs for Indian children linked to Asian cutoffs of 23 and 28 kg/m2 for the assessment of risk of overweight and obesity, respectively are presented.

Growth Performance of Affluent Indian Preschool Children: A Comparison with the New WHO Growth Standard.

This study was conducted to evaluate the nutritional status of 2-5 year old affluent, urban children using the new WHO 2006 standards. A cross-sectional, multicentric preschool-based study was conducted on 1493 children (727 boys). Mean Z scores for height, weight, body mass index and weight for height (-0.75(1.1), - 0.59(1.1), –0.19(1.22) and -0.26(1.18), respectively) were below the WHO standard median.

KCNJ11 activating mutation in an indian family with remitting and relapsing diabetes.

Objective. To identify the genetic cause of transient neonatal diabetes mellitus in three siblings from an Indian family. Methods. Case reports with clinical and molecular evaluation of an activating mutation in the KCNJ11 gene are presented. We describe an Indian family with two asymptomatic parents with 3 children presenting with hyperglycemia at 6, 1.5 and 1 month of age respectively. Blood glucose levels at presentation were 22.2, 18.3 and 20 mmol/L and the diabetes remitted in all three children by 5 years of age. None of the affected siblings had dysmorphism or neurological abnormalities. Diabetes relapsed in the oldest sibling at 9.4 years of age and she is now euglycemic on 1mg/Kg of Glibenclamide twice a day. Results. A novel heterozygous missense mutation (G53V) in the KCNJ11 gene was identified in all 3 affected children and the father. Conclusions. The report suggests that screening for KCNJ11 mutations is appropriate in patients diagnosed with neonatal diabetes as it provides valuable information concerning possible course of the disease and choice of treatment.

Sunlight exposure and development of rickets in indian toddlers.

Objective. To study the role of sunlight exposure in determining the vitamin D status of underprivileged toddlers. Methods. Height and weight were measured, clinical examination was performed, Food Frequency Questionnaire was administered and history of sunlight exposure was obtained in all (61) toddlers attending daytime crèche (Group B). Ionised calcium (iCa), inorganic Phosphorous (iP), alkaline phosphatase activity (ALP), serum parathyroid hormone (PTH) and 25 Hydroxy vitamin D (25OHD) were measured. Data were compared with results of a survey measuring similar parameters in 51 (of 251 eligible) toddlers from the same slum (Group A). Results. 111 children (mean age 2.6 yr (0.7), boys 56) were studied. Prevalence of hypovitaminosis D was 77% in group B toddlers (46 of 60) and 16.4% (10 of 61) had rickets, while none of the group A toddlers had 25OHD levels below 30nmol/L. Four children (7.8%) from Group A as against 24 (42.9%) from Group B, had sunshine exposure of < 30 minutes per day. Conclusion. Underprivileged toddlers who were deprived of sunlight had a much greater incidence of hypovitaminosis D and frank rickets. The study has important public health implications and underscores the necessity for sunlight exposure in young children.

Cross-sectional growth curves for height, weight and body mass index for affluent indian children, 2007.

Background: The assessment of growth is crucial in child care and reference data are central to growth monitoring. As the pattern of growth of a population changes with time it is recommended that references be updated regularly. Objective: To produce contemporary growth curves for Indian children from 5-18 years for height, weight and BMI. Design: Cross-sectional. Setting: Multicentric, School based. Participants: 19834 children were measured from 10 affluent schools from five major geographical regions of India. Data were analyzed on 18666 children (10496 boys and 8170 girls) using the LMS method and smoothed percentiles 2007 were produced. Results: Compared to the 1989 data, median height at 18 years was 0.6 cm greater for boys but unchanged for girls, while the 97th height percentile had increased by 1.7 cm for boys and 2 cm for girls. Boys and girls were heavier and taller at almost all ages. The study also showed that boys and girls were taller at a younger age. Conclusions: Contemporary cross sectional reference percentile curves for height, weight and body mass index for the assessment of physical growth of present day Indian children are presented.

Bone disease in preterm.

The survival rate of premature infants has significantly increased during the last few decades. As a consequence, new disorders such as osteopenia of prematurity have been emerging. We report 6 month evolution from diagnosis to recovery of a patient with metabolic bone disease of prematurity who showed a remarkable improvement on therapy with phosphate, calcium and vitamin D.

Allgrove syndrome.

Allgrove syndrome consists of triad of Adrenal hypoplasia, Achalasia cardia and Alacrimia. Often the first manifestation of adrenal hypoplasia is Addisonian crisis precipitated by infection or trauma. We present case of a 9-year-old boy who presented in shock due to adrenal failure later confirmed to have Allgove syndrome.

Management of diabetic ketoacidosis in PICU.

OBJECTIVE: This study was undertaken to analyze the outcome of children with DKA treated with a modified protocol at a tertiary level teaching hospital PICU in Pune, Maharashatra. METHODS: We retrospectively analyzed case records of 12 patients (8 males and 4 females) with DKA (11 new and 1 readmission) admitted in our PICU from January 2005 to June 2006. Patients were managed according to a modified protocol (that is with less intensive biochemical monitoring when compared with standard book protocols). Laboratory parameters measured were blood glucose, urinary ketones, electrolytes, urea creatinine, arterial blood gas (ABG) and infectious screen. Treatment included fluid therapy and insulin infusion- 0.1 u/Kg short acting intravenously followed by 0.1 u/Kg/hr. No bicarbonate was administered as a bolus. RESULTS: Total fluid deficit was corrected slowly over a period of 36 hr. The median time to normalize ABG was 19 hr (5.3-39) while the median time for the urinary ketones to disappear was 1day (1-3). The child to nurse ratio was 1:2, there were 2 pediatric residents in house all 24 hr with an intensivist and pediatric endocrinologist on call. CONCLUSION: We have shown that when DKA is managed in a PICU setting using modified protocol, the outcome is good and complications such as brain edema can be prevented.

Multicentric study of efficacy and safety of growth hormone use in growth hormone deficient children in India.

Growth Hormone being very expensive in India data on use of recombinant human growth hormone (rhGH) is scarce. The authors studied the effect and safety of one year of therapy with rhGH on growth velocity and predicted final height in Indian patients with growth hormone deficiency (GHD). A multicentric, prospective, open trial with rhGH was performed on 15 patients. Patients received rhGH in a dose of 0.7 IU (0.23 mg)/Kg/week. The mean pretreatment height was 111.2 cms {SD 12.4}, height velocity was 3.1 cms per year {1.2} and predicted height was 146.5 cms {10.4} at a mean age of 12.0 (2.8). At the end of therapy mean height was 123.4 {11.9}, height velocity was 12.1 cms per year {2.8} and the predicted height was 153.0 cm {9.4}. The increase in predicted height was thus 6.5 cm (4.2). The increment in height velocity with growth hormone therapy was statistically significant (p value= 0.001). The present study shows that children with growth hormone deficiency in India also benefit from therapy with rhGH even when treatment is started late as compared to the published Western data and there is a potential for increased final height.

Ovarian and uterine ultrasonography in healthy girls between birth to 18 years.

The aim of our study was to determine the pattern of female reproductive organ growth in Indian girls from birth to 18 years of age and to correlate the uterine length, mean ovarian volume (MOV) and Fundo Cervical Ratio (FCR) with chronological age, bone age and pubertal breast staging. A cross sectional study was performed on 218 girls from birth to 18 years of age. Height, weight, stage of puberty, X-ray for bone age and transabdominal ultrasounds were performed on all girls. Higher chronological age, bone age and increase in breast stage significantly predicted higher MOV (P < 0.001) and higher uterine length (P < 0.001). The MOV, uterine length and FCR are positively correlated with chronological age, bone age, height, weight and breast staging. Data from present study may be useful in screening cases of precocious puberty and other disorders that may need further evaluation.

Growth hormone in turner syndrome.

We assessed the effect of one year of therapy with recombinant Human Growth Hormone (rhGH) on growth velocity of 16 Indian girls with Turner Syndrome (TS) in a prospective, open trial. Patients received rhGH in a dose of 1 IU (0.3 mg)/kg/week. The mean pretreatment height was 117.1 cms (Z score minus 3.4), height velocity was 3.8 cm per year (Z score minus 2.4), and predicted height was 140 cm. At the end of therapy mean height was 123.9 (Z score minus 3.1), height velocity was 6.7 cm per year (Z score + 1.7), and the predicted height was 142.4 cm. The increment in height velocity with growth hormone therapy was statistically significant (P value = 0.001) and the mean increment in predicted height was 2.4 cm. Our study shows that girls with TS in India benefit from therapy with rhGH.

Concomitant use of insulin glargine and NPH in type I diabetes.

In a prospective study on 11 patients with Type 1 diabetes we evaluated the glycaemic control and hypoglycaemic episodes on a combination therapy of pre-mixed and glargine insulin. Glycosylated hemoglobin (HbA1C), fasting (FPG) and Post Prandial blood glucose (PPG) levels were recorded at baseline and three monthly intervals for a period of 6 months. The mean HbA1C reduced from 9.5 to 7.3 %, incidence of hypoglycemias from 1.6 to 0.8, mean FPG from 146.5 to 90.4 and mean PPG from 258.4 to 184 over a six-month observation period. This regimen also helps to avoid injection of insulin before lunch so that child's school schedule is minimally disturbed and yet the incidence of hypoglycemia is not increased.

Impact of availability of oral hydrocortisone on growth of children with CAH.

OBJECTIVES: 1. To compare growth parameters of patients with Congenital Adrenal Hyperplasia (CAH) managed on Prednisolone (PR) before and on Hydrocortisone (HC) after its availability in India. 2. To compare growth parameters of patients with CAH who have been on treatment with HC since diagnosis with patients managed on PR. METHODS: Growth parameters of twelve children (8 m, 4 f) with congenital adrenal hyperplasia were retrospectively studied while on treatment with prednisolone (PR) earlier and then hydrocortisone (HC) after it became freely available in India. RESULTS: Patients treated with PR had height Z score of -0.42, weight Z score of - 0.45, and height velocity Z score of -2.06. On HC these scores were -0.27, +0.16 and + 2.27. Patients treated with HC from the begining had a height Z Score of + 0.08, weight Z score of +0.22, and height velocity Z score of +0.68. CONCLUSION: Hydrocortisone has a less growth effect than prednisolone and patients treated with HC from the beginning showed near normal growth.

Growth hormone and GnRHa combination therapy in the management of precocious puberty.

Growth hormone when used in precocious puberty in combination with Gonadotropin releasing hormone analogue (GnRHa) instead of using GnRHa alone has been shown to improve final height prognosis. We report here a two-year follow-up of three cases of precocious puberty, two of whom were treated with a combination of GH and GnRHa and the third treated with GnRHa alone.

Acalvaria.

Acalvaria is a rare congenital malformation in which the flat bones of the cranial vault, duramater and associated muscles are absent but the central nervous system is usually unaffected. Acalvaria has usually been described as a fatal anomaly and reports are rare in the Indian literature. We report a living case of acalvaria.