Associations of vitamin D status, bone health and anthropometry, with gross motor development and performance of school-aged Indian children who were born at term with low birth weight.

OBJECTIVES: There is little information regarding motor development of children born at term with low birth weight (LBW), a group that constitutes a large proportion of children in South Asia. We used data from infancy and at school age from a LBW cohort to investigate children's motor performance using causal inference. DESIGN: Cross-sectional follow-up study. SETTING: Delhi, India. PARTICIPANTS: We recruited 912 children aged 5 years who had participated in a trial of vitamin D for term LBW infants in the first 6 months of life. OUTCOME MEASURES: We focused on gross motor development, using the Ages and Stages Questionnaire (ASQ) gross motor scale and several measures of motor performance. We examined the effects on these of current anthropometry, vitamin D status and bone health, controlling for age, sex, season of interview, socioeconomic variables, early growth, recent morbidity, sun exposure and animal food intake. RESULTS: In adjusted analyses, stunted children (height-for-age Z (HAZ) <-2) took longer to run 20 m (0.52 s, 95% CI 0.35 to 0.70; p<0.001) and had greater odds of a failing score on the ASQ (OR 3.00, 95% CI 1.41 to 6.38, p=0.004). Greater arm muscle area was associated with faster run time, and the ability to perform more stands and squats in 15 s. Poorer vitamin D status was associated with the ability to perform more stands and squats. Lower tibia ultrasound Z score was associated with greater hand grip strength. Early growth and current body mass index had no associations with motor outcomes. CONCLUSIONS: Current HAZ and arm muscle area showed the strongest associations with gross motor outcomes, likely due to a combination of simple physics and factors associated with stunting. The counterintuitive inverse associations of tibia health and vitamin D status with outcomes may require further research.

Poor Vitamin D Status in Healthy Populations in India: A Review of Current Evidence.

Vitamin D deficiency is associated with rickets in children, with osteoporosis in the elderly, is thought to increase the risk of certain cancers and of cardiovascular diseases, and may have an impact on many other health conditions. Asians are reported to have a poor vitamin D status despite adequate sunshine in their regions. Data on the extent of vitamin D deficiency at the population level from most Asian countries, including India, are limited. Part of the reason for paucity regarding vitamin D status is the absence of clear recommendations on optimal vitamin D intakes and status, as well as clear consensus on the cut-offs for deficiency. With a large country covering several latitudes, ethnicities, cultures, traditions, and attitudes, the current data on vitamin D status in India is inadequate and classified in different ways, making interpretation difficult, and is unrepresentative as it comes only from four states, with about half the data from Delhi. Poor vitamin D status is almost universally reported across all age groups with as many as 95.7 % neonates, 75 % adults and 67 % pregnant women having serum 25 hydroxy vitamin D levels < 50 nmol/L (deficient). Children and adults exposed to sunlight, living in rural or less polluted areas have been reported to have a better vitamin D status, especially in summer months. Lack of conclusive information emphasizes the need for state-specific data on the vitamin D status and the extent of sun exposure to issue recommendations for vitamin D intake in the country.

Effects of vitamin D supplementation in infancy on growth, bone parameters, body composition and gross motor development at age 3-6 years: follow-up of a randomized controlled trial.

BACKGROUND: The long-term effects of infant vitamin D supplementation and status are unclear since there have been few controlled intervention trials and these have been small and contradictory. The Delhi Infant Vitamin D Supplementation (DIVIDS) trial found that supplementation of low-birthweight term infants with one recommended dietary allowance of vitamin D from 1 week to 6 months of age resulted in increased length and weight at 6 months. In the DIVIDS-2 study we followed up the DIVIDS children, now aged 3-6 years, to determine longer-term effects. METHODS: DIVIDS children, 446 from the vitamin D arm and 466 from the placebo arm, attended the follow-up visit. Data collection included anthropometry, blood pressure, bone structure and strength by quantitative ultrasound (QUS), gross motor tests, deuterium dilution test of body composition on a subset (n = 229) and blood samples for measurement of vitamin D status. RESULTS: Body mass index Z scores (BMIZ) were lower (adjusted P = 0.003)in the vitamin D Group [-1.18 (SD 0.92)] when compared with the placebo [-1.02 (SD 0.91)] group as a result of slightly lower weight and slightly greater height. The vitamin D group also had lower thigh circumference and arm muscle area and borderline lower mid-upper arm circumference. There were no group differences in body fat percentage, bone QUS or blood pressure and few differences in motor development measures. CONCLUSIONS: Vitamin D supplementation of low-birthweight infants in infancy resulted in children being thinner at age 3-6 years but in no differences in functional outcomes.

Echocardiography for patent ductus arteriosus including closure in adults.

Patent ductus arteriosus (PDA) represents at least 5-10% of all congenital heart defects (CHDs) making it a very important commonly diagnosed lesion. Although spontaneous closure of the PDA occurs within 24 to 48 hours after birth in the majority, those children who do not have natural or surgical closure may have a persistent PDA into adulthood. The diagnosis is most often confirmed by echocardiography that also guides catheter-based interventions and surgeries. Echocardiography continues to be the most important tool in long-term follow-up of residua and sequelae.

Management of Pregnancy in Women With Repaired CHD or After the Fontan Procedure.

OPINION STATEMENT: Pregnancy carries varying risks in women with congenital heart defects even after repair. Preconception evaluation is essential for genetic consultation, identifying/optimizing medical and surgical issues before pregnancy in order to improve outcomes. Echocardiography is the preferred imaging modality for guiding management. A multidisciplinary approach with collaboration between obstetrics, perinatology, anesthesiology, cardiology/adult congenital heart disease and cardiac surgery, at a specialized center is required for comprehensive management. This concise review driven by the recommendations from published guidelines, outcome data and our own clinical experience, provides a synopsis of the complexities involved in the care of this special population.

Parachute mitral valve with severe mitral regurgitation in an adult patient.

Parachute mitral valve (PMV) is rarely seen in the adult population, in isolation or in association with other congenital heart defects, since most patients may have had milder lesions previously that were asymptomatic early in life, or were not detected due to lack of a comprehensive examination. We report a case of an 18-year-old woman with a history of exertional dyspnea, atypical chest pain, and cough for about 1 year. The echocardiographic examination identified a PMV with severe mitral regurgitation associated with bicuspid aortic valve and coarctation of the aorta. Most patients present with mitral stenosis of varying degree of severity, and rarely present with severe mitral regurgitation as seen in our patient.

Outcome of pulmonary valve replacements in adults after tetralogy repair: a multi-institutional study.

OBJECTIVE: The purpose of this study was to assess the outcome of pulmonary valve replacement (PVR) in adults with moderate/severe pulmonary regurgitation after tetralogy repair, with particular emphasis on patient outcome, durability of valve repair, and improvement in symptomatology. DESIGN/SETTING/PATIENTS: The project committee of the International Society of Congenital Heart Disease undertook a retrospective multi-institutional analysis of PVR. Seven centers participated in submitting data on 93 patients >18 years of age who had the operation performed and follow-up obtained. The average age of PVR was 26+/- years (median 27 years). Time of follow-up after replacement was 3 years (range 4 days-28 years). OUTCOMES/MEASURES/RESULTS: Kaplan-Meier estimates of durability of PVR showed approximately 50% replacement at 11 years. There were two deaths at 6 and 12 months after valve replacement. Right ventricular (RV) size estimated by echocardiography from pre- to postoperative studies decreased in 81% (P < 0.001 testing for equal proportions), but RV systolic function increased in only 36% (P = 0.09). Ability index improved in 59% (P < 0.001) and clinical heart failure status improved in 57% with this problem before PVR. PVR did not improve arrhythmia status in a small group of patients. CONCLUSIONS: PVR is associated with low mortality, decrease in RV size and improvement in ability index, and uncertain effects on RV systolic function. Average valve durability was approximately 11 years. Criteria for PVR that will preserve RV function are not clearly identified, and management of these patients remains a difficult enterprise.

Management of pregnancy in women with palliated and unpalliated congenital heart defects.

Medical advancements have made it possible for more women with congenital heart defects (CHDs) to carry successful pregnancies. Most CHD surgeries or interventions are palliative with persistent residua and sequelae exacerbated by the physiologic stresses of pregnancy. Preconception assessment, a tailored multidisciplinary approach during pregnancy, and a planned, elective delivery followed by careful postpartum monitoring may improve outcomes. Teratogenic medications should be stopped and changed to safer alternatives. Major hemodynamic changes in pregnancy, labor, and delivery may aggravate the underlying cardiovascular defects. Interventions or surgeries, when anticipated, should be performed before pregnancy. Antibiotic prophylaxis is indicated for nearly all palliated and unpalliated defects.

Extramural coronary arteries in adults with cyanotic congenital heart disease.

Dilatation and tortuosity of extramural coronary arteries are prevalent in cyanotic congenital heart disease. Two pathogenetic variables are operative, namely endothelial vasodilator substances and medial structural abnormalities.