Indian Academy of Pediatrics Revised (2021) Guidelines on Prevention and Treatment of Vitamin D Deficiency and Rickets

Justification: The emerging literature on prevalence of vitamin D deficiency in India, prevention and treatment strategies of rickets, and extra-skeletal benefits of vitamin D suggest the need for revising the existing guidelines for prevention and treatment of vitamin D deficiency in India. Objectives: To review the emerging literature on vitamin D prevalence and need for universal vitamin D supplementation. To suggest optimum vitamin D therapy for treatment of asymptomatic and symptomatic vitamin D deficiency, and rickets. To evaluate the extra-skeletal health benefits of vitamin D in children. Process: A National consultative committee was formed that comprised of clinicians, epidemiologists, endocrinologists, and nutritionists. The Committee conducted deliberations on different aspects of vitamin D deficiency and rickets through ten online meetings between March and September, 2021. A draft guideline was formulated, which was reviewed and approved by all Committee members. Recommendations: The group reiterates the serum 25- hydroxy vitamin D cutoffs proposed for vitamin D deficiency, insufficiency, and sufficiency as <12 ng/mL, 12-20 ng/mL and >20 ng/mL, respectively. Vitamin D toxicity is defined as serum 25OHD >100 ng/mL with hypercalcemia and/or hypercalciuria. Vitamin D supplementation in doses of 400 IU/day is recommended during infancy; however, the estimated average requirement in older children and adolescents (400-600 IU/day) should be met from diet and natural sources like sunlight. Rickets and vitamin D deficiency should be treated with oral cholecalciferol, preferably in a daily dosing schedule (2000 IU below 1 year of age and 3000 IU in older children) for 12 weeks. If compliance to daily dosing cannot be ensured, intermittent regimens may be prescribed for children above 6 months of age. Universal vitamin D supplementation is not recommended in childhood pneumonia, diarrhea, tuberculosis, HIV and non-infectious conditions like asthma, atopic dermatitis, and developmental disorders. Serum 25-hydroxy vitamin D level of >20 ng/mL should be maintained in children with conditions at high-risk for vitamin deficiency, like nephrotic syndrome, chronic liver disease, chronic renal failure, and intake of anticonvulsants or glucocorticoids.

Parental Education, Children’s Nutritional Status and Non-verbal Intelligence in Rural School-children

Objective: To assess non-verbal intelligence and its relationship with nutritional status,nutrient intakes and parents’ education in school-children. Methods: A cross-sectional,observational study was conducted in children between 6-11 years, without any knownchronic disorder or intellectual disability. Data were collected regarding parents’ education,anthropometry and dietary intakes. Non-verbal intelligence was assessed by Raven’sColoured Progressive Matrices (RCPM). Results: In 323 enrolled children (52.9% boys), asignificant positive association was observed between RCPM scores and parents’ education(father’s rs=0.14, mother’s rs=0.22), height Z-scores (rs=0.14) and dietary intakes of zinc(rs=0.14), iron (rs=0.12) and folate (rs=0.14). Conclusion: Height in normal range, higherzinc, iron and folate intakes, and parental higher educational levels were associated withhigher non-verbal intelligence scores

Height Velocity Percentiles in Indian Children Aged 5-17 Years

Objective: To assess height velocity and develop height velocitypercentiles in 5-17-year-old Indian children; and to study themagnitude and age at peak height velocity.Design: Mixed longitudinal study.Setting: Private schools at Pune and Delhi.Participants/patients: 2949 children (1681 boys) belonging toaffluent class aged 5-17 years (1473-Pune, 1476-Delhi).Methods: Annual height and weight measurements from 2007 to2013. Total 13214 height velocity measurements (7724 on boys).Outcome Measures: Height velocity percentiles (3rd, 10th, 25th,50th, 75th, 90th and 97th) constructed using LMS chart maker.Results: Age- and gender-specific height velocity percentileswere generated. Median height velocity in girls decreased from 5to 8 years, increased to a peak of 6.6 cm at 10.5 years and thendeclined to 0.3 cm at 17.5 years. In boys, median height velocityreduced till 10.5, increased to a peak of 6.8 cms at 13.5 years andthen declined to 1cm by 18 years.Conclusions: Height velocity percentiles in 5-17-year-old urbanIndian children were constructed

Longitudinal Growth in Children and Adolescents with Type 1 Diabetes.

Objective: To study longitudinal growth in children with type 1 diabetes mellitus. Methods: Anthropometry, disease duration, insulin regimens and HbA1C recorded from patients with diabetes enrolled in a specialty clinic. Results: 160 children (75 boys; mean (SD) age 9.4 (3.3) y) were enrolled. 35% children had low (<25th centile) height velocity. Disease duration and HbA1 C affected height velocity (adjusted for puberty). Children on basal-bolus had higher height velocity Z scores than those on a split mix regimen [(0.5(1.6) vs. -0.3(1.4), P<0.05)]. Children diagnosed before 5 years of age had lowest height velocity. Of the children who reached final height, 53% remained below target height. Conclusion: Children with type 1 diabetes mellitus have lower height velocity compared to healthy children; those diagnosed at younger age were at higher risk for growth failure.

Association of Dietary Calcium Intake and Body Fat with Hypertension in Indian Adolescents.

To explore association of dietary-calcium intake and body-composition with blood-pressure, 417 apparently healthy adolescents (218 boys) were studied for anthropometry, blood pressure, body composition and nutrient intakes using standard protocols. Blood pressure correlated negatively with dietary calcium (r= -0.120, P<0.01) and positively with body fat (r=0.56,P<0.001). Low dietary-calcium intakes and high adiposity may increase risk of hypertension in Indian adolescents.

Association Between Metabolic Control and Lipid Parameters in Indian Children with Type 1 Diabetes.

Objectives: To compare lipid parameters between diabetics and controls and to study association between metabolic control and lipid profile. Methods: Lipid profile and HbA1c were measured (n=80, 39 boys) in diabetic children [age 10.7(3.4) y] and 54 controls, tests repeated after 1 year (in 45 diabetics). Results: Diabetic children had higher mean (SD) LDL-C [95.3(27.7) vs 84.5(26.4) mg/dL], lower HDL-C [48.2 (13.1) vs 53.1(11.9) mg/dl]. Moderate physical activity (P=0.014) protected against high LDL-C levels. HbA1c (P=0.00) predicted total and LDL-C levels. At 1year, 63% showed reduced LDL-C with improving HbA1c; 72% showed increased LDL-C with deteriorated HbA1c. Conclusion: Improving metabolic control is cardinal to reduce cardiometabolic risk; physical activity is beneficial.

Reference Centile Curves for Triceps Skinfold Thickness for Indian Children aged 5–17 years and Cut-offs for Predicting Risk of Childhood Hypertension: A Multi-Centric Study.

Objective: To create age- and gender-specific Triceps Skinfold Thickness percentile curves for Indian children; and to determine cut-offs for predicting the risk of childhood hypertension. Design: Cross-sectional. Setting: Multicentric, school-based, 5 major Indian cities Participants: 13375 children (7590 boys) aged 5-17 years Procedure: Data on height, weight, blood pressure, triceps skinfold thickness (using Harpenden Skinfold caliper) were collected. Reference triceps skinfold thickness percentile curves were derived for boys and girls by LMS (lambda-mu-sigma) method. Receiver operating curve analyses were performed to determine the optimal cut-off of triceps skinfold thickness centile for predicting the risk of hypertension. Results: Percentile curves for boys plateau around 13 years whereas for girls the curves increase steadily till the age of 17 years. Median triceps skinfold thickness increased by 7% to 9% till the age of 9 years in boys and girls. After 12 years, median triceps skinfold thickness decreased by 1% to 2% in boys but increased by 3% to 4% in girls. The optimal cut-off percentile yielding maximal sensitivity (68%) and specificity (74-78%) for predicting high blood pressure was the 70th triceps skinfold thickness percentile in both genders. Conclusions: Percentile curves for triceps skinfold thickness developed in the present study would be useful in the assessment of adiposity and the risk of hypertension in Indian children.

Revised IAP Growth Charts for Height, Weight and Body Mass Index for 5- to 18-year-old Indian Children.

Justification: The need to revise Indian Academy of Pediatrics (IAP) growth charts for 5- to 18-year-old Indian children and adolescents was felt as India is in nutrition transition and previous IAP charts are based on data which are over two decades old. Process: The Growth Chart Committee was formed by IAP in January 2014 to design revised growth charts. Consultative meeting was held in November 2014 in Mumbai. Studies performed on Indian children’s growth, nutritional assessment and anthropometry from upper and middle socioeconomic classes in last decade were identified. Committee contacted 13 study groups; total number of children in the age group of 5 to 18 years were 87022 (54086 boys). Data from fourteen cities (Agartala, Ahmadabad, Chandigarh, Chennai, Delhi, Hyderabad, Kochi, Kolkata, Madurai, Mumbai, Mysore, Pune, Raipur and Surat) in India were collated. Data of children with weight for height Z scores >2 SD were removed from analyses. Data on 33148 children (18170 males, 14978 females) were used to construct growth charts using Cole’s LMS method. Objectives: To construct revised IAP growth charts for 5-18 year old Indian children based on collated national data from published studies performed on apparently healthy children and adolescents in the last 10 years. Recommendations: The IAP growth chart committee recommends these revised growth charts for height, weight and body mass index (BMI) for assessment of growth of 5-18 year old Indian children to replace the previous IAP charts; rest of the recommendations for monitoring height and weight remain as per the IAP guidelines published in 2007. To define overweight and obesity in children from 5-18 years of age, adult equivalent of 23 and 27 cut-offs presented in BMI charts may be used. IAP recommends use of WHO standards for growth assessment of children below 5 years of age.

Molecular characterization in a case of isolated growth hormone deficiency and further prenatal diagnosis of an unborn sibling.

Familial isolated growth hormone deficiency (GHD) type 1 is characterized by an autosomal recessive pattern of inheritance with varying degrees of phenotypic severity. We report a proband, with isolated GHD (IGHD) with very early growth arrest and undetectable levels of GH. Homozygous complete deletion of the GH1 gene was identified by real‑time/quantitative polymerase chain reaction (RT/q‑PCR) and confirmed by an independent molecular genetic method; the multiplex ligation‑dependent probe amplification (MLPA) technique. Prenatal diagnosis was offered for the subsequent pregnancy in the mother of our proband. Identical heterozygous deletion of the GH1 gene was detected in both parents. The fetus had a similar homozygous deletion of the GH1 gene. We thus report a unique case with a confirmed mutation in GH1 gene in the proband followed by prenatal detection of the same mutation in the amniotic fluid which to our knowledge hitherto has not been documented from India.

Growth of Short Children Born Small for Gestational Age and Their Response to Growth Hormone Therapy.

Growth hormone [GH] is licensed for use in children born small for gestational age (SGA) who fail to catch-up. We retrospectively compared the response of twenty children born SGA (who satisfied the auxological criteria) to growth hormone (Group I) versus randomly selected age and sex matched controls from a group of SGA children with growth related complaints, not treated with GH (Group II). After 2 years of GH therapy the HAZ increased from -2.8 to -1.6 in Group I, compared 2.2 to -1.7 in group II (P-value < 0.05). The percentage of pubertal children rose from 55% to 65% in cases versus 60% to 75% in the controls (P>0.05). GH resulted in increase in growth velocity Z-score during the first year and (4.3±0.5 in Group-I versus - 0.5±0.6 in Group-II, P<0.05) second year of treatment (1.7±0.4 in cases versus -0.6±0.7 in controls, P<0.05).Thus, GH improves height of short SGA children without accelerating pubertal progression.