Indian Academy of Pediatrics Revised Guidelines on Evaluation, Prevention and Management of Childhood Obesity

JUSTIFICATION

The last guidelines for pediatric obesity were released in 2004 by Indian Academy of Pediatrics (IAP). Since then, there has been an alarming increase in prevalence and a significant shift in our understanding in the pathogenesis, risk factors, evaluation, and management of pediatric obesity and its complications. Thus, it was decided to revise and update the previous recommendations.

OBJECTIVES

To review the existing literature on the burden of childhood obesity and its underlying etiology and risk factors. To recommend evaluation of childhood obesity and suggest optimum prevention and management strategies of childhood obesity.

PROCESS

The following IAP chapters (Pediatric and Adolescent Endocrinology, Infant and Young Child feeding, Nutrition, Non-Communicable Disease and Adolescent Health Academy) were invited to nominate members to become part of the writing committee. The Committee held discussions on various aspects of childhood obesity through online meetings between February and August, 2023. Recommendations were then formulated, which were analyzed, revised and approved by all members of the Committee.

RECOMMENDATIONS

Exogenous or primary obesity accounts for the majority of cases of childhood obesity. It is important to differentiate it from endogenous or secondary obesity as evaluation and management changes depending on the cause. In Indian, in children under 5 years of age, weight for length/height using WHO charts, and in children 5-18 years, BMI using IAP 2015 charts is used to diagnose overweight and obesity. Waist circumference should be routinely measured in all overweight and obese children and plotted on India specific charts, as it is a key measure of cardio-metabolic risk. Routine evaluation for endocrine causes is not recommended, except in short and obese children with additional diagnostic clues. All obese children more than ten years old should be evaluated for comorbidities like hypertension, dyslipidemia, hyperglycemia and non-alcoholic fatty liver disease/metabolic dysfunction associated steatotic liver disease (NAFLD/ MASLD). Prevention and management of childhood obesity mainly involves healthy diet practices, daily moderate to vigorous physical activity and reduced screen time. Pharmacotherapy may be offered as an addition to lifestyle interventions only in cases of class 3 obesity or if there are any life-threatening comorbidities. Finally, surgical management may be offered in children older than 12 years of age with class 2 obesity and associated comorbidities or class 3 obesity with/without comorbidities, only after failure of a proper trial of intense lifestyle modifications and pharmacotherapy for at least 6 months.

Diagnosis, Treatment and Prevention of Nutritional Anemia in Children: Recommendations of the Joint Committee of Pediatric Hematology-Oncology Chapter and Pediatric and Adolescent Nutrition Society of the Indian Academy of Pediatrics

JUSTIFICATION

Anemia in children is a significant public health problem in our country. Comprehensive National Nutrition Survey 2016-18 provides evidence that more than 50% of childhood anemia is due to an underlying nutritional deficiency. The National Family Health Survey-5 has reported an increase in the prevalence of anemia in the under-five age group from 59% to 67.1% over the last 5 years. Clearly, the existing public health programs to decrease the prevalence of anemia have not shown the desired results. Hence, there is a need to develop nationally acceptable guidelines for the diagnosis, treatment and prevention of nutritional anemia.

OBJECTIVE

To review the available literature and collate evidence-based observations to formulate guidelines for diagnosis, treatment and prevention of nutritional anemia in children.

PROCESS

These guidelines have been developed by the experts from the Pediatric Hematology-Oncology Chapter and the Pediatric and Adolescent Nutrition (PAN) Society of the Indian Academy of Pediatrics (IAP). Key areas were identified as: epidemiology, nomenclature and definitions, etiology and diagnosis of iron deficiency anemia (IDA), treatment of IDA, etiology and diagnosis of vitamin B12 and/or folic acid deficiency, treatment of vitamin B12 and/or folic acid deficiency anemia and prevention of nutritional anemia. Each of these key areas were reviewed by at least 2 to 3 experts. Four virtual meetings were held in November, 2021 and all the key issues were deliberated upon. Based on review and inputs received during meetings, draft recommendations were prepared. After this, a writing group was constituted which prepared the draft guidelines. The draft was circulated and approved by all the expert group members.

RECOMMENDATIONS

We recommend use of World Health Organization (WHO) cut-off hemoglobin levels to define anemia in children and adolescents. Most cases suspected to have IDA can be started on treatment based on a compatible history, physical examination and hemogram report. Serum ferritin assay is recommended for the confirmation of the diagnosis of IDA. Most cases of IDA can be managed with oral iron therapy using 2-3 mg/kg elemental iron daily. The presence of macro-ovalocytes and hypersegmented neutrophils, along with an elevated mean corpuscular volume (MCV), should raise the suspicion of underlying vitamin B12 (cobalamin) or folic acid deficiency. Estimation of serum vitamin B12 and folate level are advisable in children with macrocytic anemia prior to starting treatment. When serum vitamin B12 and folate levels are unavailable, patients should be treated using both drugs. Vitamin B12 should preferably be started 10-14 days ahead of oral folic acid to avoid precipitating neurological symptoms. Children with macrocytic anemia in whom a quick response to treatment is required, such as those with pancytopenia, severe anemia, developmental delay and infantile tremor syndrome, should be managed using parenteral vitamin B12. Children with vitamin B12 deficiency having mild or moderate anemia may be managed using oral vitamin B12 preparations. After completing therapy for nutritional anemia, all infants and children should be advised to continue prophylactic iron-folic acid (IFA) supplementation as prescribed under Anemia Mukt Bharat guidelines. For prevention of anemia, in addition to age-appropriate IFA prophylaxis, routine screening of infants for anemia at 9 months during immunization visit is recommended.

Indian Academy of Pediatrics Guidelines on the Fast and Junk Foods, Sugar Sweetened Beverages, Fruit Juices, and Energy Drinks

JUSTIFICATION

In view of easy availability and increasing trend of consumption of fast foods and sugar sweetened beverages (fruit juices and drinks, carbonated drinks, energy drinks) in Indian children, and their association with increasing obesity and related non-communicable diseases, there is a need to develop guidelines related to consumption of foods and drinks that have the potential to increase this problem in children and adolescents.

OBJECTIVES

To review the evidence and formulate consensus statements related to terminology, magnitude of problem and possible ill effects of junk foods, fast foods, sugar-sweetened beverages and carbonated drinks; and to formulate recommendations for limiting consumption of these foods and beverages in Indian children and adolescents.

PROCESS

A National Consultative group constituted by the Nutrition Chapter of the Indian Academy of Pediatrics (IAP), consisting of various stakeholders in private and public sector, reviewed the literature and existing guidelines and policy regulations. Detailed review of literature was circulated to the members, and the Group met on 11th March 2019 at New Delhi for a day-long deliberation on framing the guidelines. The consensus statements and recommendations formulated by the Group were circulated to the participants and a consensus document was finalized.

CONCLUSIONS

The Group suggests a new acronym 'JUNCS' foods, to cover a wide variety of concepts related to unhealthy foods (Junk foods, Ultra-processed foods, Nutritionally inappropriate foods, Caffeinated/colored/carbonated foods/beverages, and Sugar-sweetened beverages). The Group concludes that consumption of these foods and beverages is associated with higher free sugar and energy intake; and is associated with higher body mass index (and possibly with adverse cardiometabolic consequences) in children and adolescents. Intake of caffeinated drinks may be associated with cardiac and sleep disturbances. The Group recommends avoiding consumption of the JUNCS by all children and adolescents as far as possible and limit their consumption to not more than one serving per week. The Group recommends intake of regional and seasonal whole fruits over fruit juices in children and adolescents, and advises no fruit juices/drinks to infants and young children (age <2y), whereas for children aged 2-5 y and >5-18 y, their intake should be limited to 125 mL/day and 250mL/day, respectively. The Group recommends that caffeinated energy drinks should not be consumed by children and adolescents. The Group supports recommendations of ban on sale of JUNCS foods in school canteens and in near vicinity, and suggests efforts to ensure availability and affordability of healthy snacks and foods. The Group supports traffic light coding of food available in school canteens and recommends legal ban of screen/print/digital advertisements of all the JUNCS foods for channels/magazines/websites/social media catering to children and adolescents. The Group further suggests communication, marketing and policy/taxation strategies to promote consumption of healthy foods, and limit availability and consumption of the JUNCS foods.

Prevention of Micronutrient Deficiencies in Young Children: Consensus Statement from Infant and Young Child Feeding Chapter of Indian Academy of Pediatrics

JUSTIFICATION

Micronutrient deficiencies have significant impact on the overall health and well-being of society and potential targets for supplementations. It is important to formulate a consensus statement in view of current evidence, and put in place strategies to meet targets.

OBJECTIVE

To formulate by endorsement or adoption and disseminate a consensus statement for prevention of micronutrients deficiencies in young children for office practices from an Indian perspective.

PROCESS

A National Consultative Meeting was convened by Infant and Young Child Feeding Chapter (IYCF) of Indian Academy of Pediatrics (IAP) on 17 December, 2016 at Mumbai. IYCF chapter, IAP, United Nations Children Fund, National Institute of Nutrition and Government of India were the participating agencies; and participants representing different parts of India were included.

CONCLUSIONS

Micronutrient deficiencies are widespread. For its prevention proper maternal and infant-young child feeding strategies need to be practiced. Encourage delayed cord clamping, dietary diversification, germinated foods, soaking and fermentation processes. Existing Iron, Vitamin A, Zinc supplementation and universal salt iodization programs need to be scaled up, especially in high risk groups. Universal vitamin D supplementation need to be in place; though, the dose needs more research. Vitamin B12 deficiency screening and supplementation should be practiced only in high-risk groups. Availability of appropriately fortified foods needs to be addressed urgently.

Multiple Nutritional Deficiencies in Cerebral Palsy Compounding Physical and Functional Impairments

Introduction:

Cerebral palsy (CP) refers to a spectrum of disorders causing physical and intellectual morbidity. Macro and micro nutrient deficiencies often contribute to the subnormal physical and mental capabilities of them.

Objectives:

To assess the growth, nutritional status, physical and functional ability and quality of life in cerebral palsy children and to determine any relation with their gross motor and functional capabilities.

Method:

The study was conducted at a Tertiary Care Centre, with the participants in the age group 1-16 years. A pretested evaluation tool was prepared which included Anthropometric measurements, tests for hemoglobin and Vitamin D estimation, evidence of micronutrient deficiencies, Dietary patterns, Epidemiological factors, Functional assessment using GMFM (Gross Motor Function Measure ) and FIM (Functional Independent Measurement) scales and Quality of life (QOL) assessment. The data was statistically analyzed.

Results:

Out of the 41 children, 30 had quadriplegia, 3 had hemiplegia and 8 had spastic diplegia. 34 (82.9%) were severely underweight, 35 (85.4%) had severe stunting and 38 (92.7%) had severe wasting. Micronutrient deficiencies were noted like vitamin B complex deficiency in 37 (90.2%), vitamin A deficiency in 31 (75.6%), low vitamin D levels in 27 (65.9%) and insufficient levels in 9 (22%), severe anemia in 5 (12.2%) and moderate anemia in 26 (63.4%). The gross motor and functional scores were suboptimum in the majority of patients and the care givers had significant impairment in the quality of life.

Conclusion:

Majority of children with cerebral palsy had multiple nutritional deficiencies, gross motor and functional disabilities. QOL of the children and their care givers were suboptimum. A comprehensive package that address dietary intake, correction of micronutrient deficiencies especially anemia and vitamin D deficiency, physical and emotional support is recommended for the wellbeing of the affected children.

Crusade against Malnutrition: Nutrition Education Program

A holistic approach in assessment and plan for intervention in childhood malnutrition is the need of the hour. This is in the context of nutrition education program (NEP), undertaken under the National IAP action plan, 2015. In the crusade against malnutrition, an ABCDEFQ assessment scale is recommended, with aspects covering anthropometric, biochemical, clinical, dietary, ecological/epidemiological, functional parameters and quality of life. In the dietary assessment, a scoring system based on the ten interventions related to infant and young child feeding (IYCF) practices recommended by UNICEF and the food frequency table score are incorporated. In the evaluation of quality of life and plan for intervention, a tool called IMPACT (IAP Malnutrition Proactive Assessment: A Comprehensive Tool) is proposed.

Disability Related to Self - care management among patients with Chronic Lymphatic filariasis in Kerala, India

Background Disability in self-care is a part of physical domain and is described as the inability to withstand bodily disruptions in normal functional performance. This study was conducted to determine the pattern of self-care management in patients with chronic lymphatic filariasis and to determine the disability in self-care on the basis of gender, duration of disease and stage of the disease in Kerala.  Materials and Methods This cross-sectional study was conducted from 2008 to 2009 among individuals suffering from chronic lymphatic filariasis in Kannur District, Kerala State, India. 200 individuals with chronic lymphatic filariasis participated in this research. An interviewer-administered questionnaire, which had structured closed-ended questions and semi-structured open-ended questions, was used for data collection. A door-to-door survey was conducted to recruit the required sample size. Data analysed using SPSS version 21. Results In the present study 200 individuals (151 females and 49 males) with chronic lymphatic filariasis were participated. The mean age observed was 58.8 years with a minimum of 25 years and a maximum of 85 years. The factors included under self-care were bathing, grooming, dressing, and bowel and bladder management. The severity of self-care management shows that more than 60% had no difficulty in any of the self-care activities. 40% reported having at least some problem in toileting. Among the total participants, 3.5% reported extreme difficulty in bathing, followed by 1% in grooming, 1% in dressing and 1% in toileting.   Some degree of bowel management problems was reported by 61.5% participants, and 67.5% had bladder management problems. Though males and females experienced bladder problems, former experienced them more. In both the groups the median score observed for bathing, grooming, dressing and toileting was ‘none’. There was no statistically significant difference in the median score observed between males and females. The leading difficulties related to self-care experienced by participants with duration of disease greater than 40 years were toileting (72.7%), bathing 39.4%, grooming 9.1%, and dressing (3.0%). Both bowel and bladder management problems were experienced by 85% of the participants having duration of disease greater than 40 years whereas 2.6% each experienced extremely severe bladder and bowel management problems. Statistically significant difference in median score was observed in bathing (p<0.05), grooming (p<0.05), Toileting (p<0.05) and bowel management (p<0.05), which shows as the duration of the disease increases; the difficulty for self-care management also increases.  Maximum respondents with difficulty in toileting were in stage seven, the intensity ranged from a little to a lot. All distributions were statistically not different except for self-care related to toileting (p<0.05).   Conclusion: The prevalence of difficulty in self-care management showed variations between the genders, duration of the disease and stage of the disease.  DOI: http://dx.doi.org/10.3126/nje.v5i1.12375

Immune reconstitution inflammatory syndrome in CNS tuberculosis

BACKGROUND

Immune Reconstitution Inflammatory Syndrome (IRIS), an exaggerated inflammatory response with clinical worsening due to immune recovery during treatment, is rare in the immune-competent population.

CASE CHARACTERISTICS

A 5-½-year old immune-competent girl with CNS tuberculosis without HIV who developed paradoxical IRIS.

OUTCOME

Response to supportive care along with Anti-tuberculosis treatment.

MESSAGE

IRIS can occur in tuberculosis, even in the immuno-competent.

Immortalized functional endothelial progenitor cell lines from umbilical cord blood for vascular tissue engineering

Endothelial progenitor cells (EPCs) play a significant role in multiple biological processes such as vascular homeostasis, regeneration, and tumor angiogenesis. This makes them a promising cell of choice for studying a variety of biological processes, toxicity assays, biomaterial-cell interaction studies, as well as in tissue-engineering applications. In this study, we report the generation of two clones of SV40-immortalized EPCs from umbilical cord blood. These cells retained most of the functional features of mature endothelial cells and showed no indication of senescence after repeated culture for more than 240 days. Extensive functional characterization of the immortalized cells by western blot, flow cytometry, and immunofluorescence studies substantiated that these cells retained their ability to synthesize nitric oxide, von Willebrand factor, P-Selectin etc. These cells achieved unlimited proliferation potential subsequent to inactivation of the cyclin-dependent kinase inhibitor p21, but failed to form colonies on soft agar. We also show their enhanced growth and survival on vascular biomaterials compared to parental cultures in late population doubling. These immortalized EPCs can be used as a cellular model system for studying the biology of these cells, gene manipulation experiments, cell-biomaterial interactions, as well as a variety of tissue-engineering applications.

Hopkins syndrome and phantom hernia: a rare association

Acute flaccid paralysis (AFP), other than paralytic poliomyelitis, are usually due to demyelination like Guillian Barre syndrome (GBS), transverse myelitis and traumatic neuritis. Poliomyelitis like illness, Hopkins syndrome or Post Asthmatic Amotrophy, associated with bronchial asthma and hyperIgEemia has been reported in literature. We present a two and a half year old child who developed AFP with phantom hernia following an episode of bronchial asthma.

Developmental Evaluation Clinic--CDC experience

We describe our five year experience of conducting developmental evaluation clinic at CDC. We have also assessed the prevalence of developmental delay (defined as delay in any two areas in Denver Development Screening Test II [DDST II]), documented the possible prenatal, natal, postnatal risk factors for developmental delay and, also identified the pattern of developmental disorders. A total of 2111 children were screened. DDST II results were abnormal for 953 (45.1 %) children. On multivariate analysis, delayed cry at birth, increasing age of the child, presence of feeding problems, assisted delivery, and birth injury were found to be associated with increasingly abnormal DDST II results. Nearly 50 % of referred babies had developmental delay without a specific clinical diagnosis, 13.9 % had speech problems, 9.5 % had neurological problems and 5.2 % had chromosomal anomalies. Birth related events are important risk factors for developmental delay.

Umbilical cord blood nutrients in low birth weight babies in relation to birth weight & gestational age

BACKGROUND & OBJECTIVE

Low birth weight (LBW) babies are a vulnerable group and represent two outcomes--preterm birth (preterm LBW) and term with intrauterine growth retardation (term LBW). LBW babies are considered to have low nutrient reserve, but the extent of deficiency as compared to the normal babies and the differences between preterm LBW and term LBW are unclear. This study was carried out to look at key anthropometric, biochemical and clinical (ABC) parameters of LBW babies, both preterm and term, in comparison to a control group of term normal weight babies.

METHODS

A group of 500 babies was selected at birth from a tertiary care teaching hospital and categorized into LBW (n = 251) with preterm LBW (n = 59), term LBW (n = 192) and term controls (n = 249). Two controls were dropped as tests could not be performed in the available cord blood sample. Key anthropometric and biochemical parameters were measured. Socio-economic status, age, parity, height and pre-delivery haemoglobin of the mothers were also recorded.

RESULTS

The maternal characteristics were comparable in the three groups. Socio-economically, majority of them belonged to lower middle or upper lower class (Class III and IV) representing the non affluent. All the anthropometric measurements and nutrients measured namely total protein, albumin, cholesterol, triglycerides, calcium, magnesium, zinc and iron were significantly lower in LBW babies compared to term control babies. These values were lowest in preterm LBW followed by term LBW. Total iron binding capacity (TIBC) showed inverse association with iron. Some of the babies including control babies had protein, albumin, calcium and iron below the normal range and mean albumin, calcium and iron levels were below the normal range in all the three subsets.

INTERPRETATION & CONCLUSION

Preterm and term LBW babies are born with significantly lower nutrient reserves at birth compared to term control babies. Normal weight babies from the non affluent sections also have low nutrients especially albumin, calcium and iron. As these levels are liable to be further lowered by recurrent infections and inappropriate feeding habits, nutritional surveillance, extra feeding and supplements like calcium and iron are recommended for such vulnerable babies to promote optimum growth and to prevent deficiencies. This is important as currently, there are no clear or uniform recommendations for extra feeding and nutrient supplements to LBW babies and no supplements other than exclusive breast feeding are recommended for term normal birth weight babies. Extra nutritional inputs for LBW and selected non affluent babies along with care of the prospective and prenatal mothers for ensuring adequate transfer of nutrients to the offspring seem necessary. Such interventions can be integrated with the existing health care programmes to reach all the beneficiaries.

Auxologic, biochemical and clinical (ABC) profile of low birth weight babies- a 2-year prospective study

INTRODUCTION

Low Birth Weight (LBW) is a key determinant of neonatal mortality, morbidity, subsequent growth and development as well as early onset of adulthood diseases. It represents a conflation of two outcomes-preterm- and term 'light for date' (LFD) babies. This study looks at key auxologic, biochemical and clinical (ABC) parameters of a cohort of LBW babies, both preterm- and term in comparison to a group of normal-term (control) babies. An attempt was also made to see how these parameters were at the end of a 2 year follow-up period with the currently available interventions.

MATERIALS AND METHODS

A cohort of 500 babies was selected at birth from a tertiary care teaching hospital in Kerala, India, key ABC indices were measured including relevant maternal data. The initial biochemical measurements were done using umbilical cord blood. Currently recommended nutritional interventions were provided to all the normal and LBW babies. At the end of 2 years, the measurements were repeated in a subset of babies available for follow-up (n = 147).

RESULTS

From the cohort of 500 babies, two had to be eliminated as biochemical parameters could not be done due to technical reasons from the available umbilical cord blood. They were categorized into three groups: preterm-LBW (11.85%), term-LBW (38.55%) and normal-term controls (49.6%). The maternal characteristics like socio-economic status, maternal weight, height, BMI and hemoglobin levels were comparable in the three subsets. All of them belonged to middle or low-socio-economic status representing the non-affluent. In the initial group (n = 498), all the auxologic measurements and the nutrients measured namely, total protein, albumin, total cholesterol, triglycerides, calcium, magnesium, zinc and iron levels were significantly lower (p < 0.05) among LBW, lowest in preterm followed by term-LBW, compared to term controls. Total iron binding capacity showed inverse correlation with iron level. Protein, albumin, calcium and iron levels were low in many babies, and mean calcium and iron levels were below the normal range in all the three subsets reflecting reduced transfer from the mother. At the end of 2 years, calcium, magnesium, zinc and iron were significantly lower in preterm- and term-LBW (p < 0.05) compared to controls and mean value of serum calcium continued to be below the normal range in all the three subsets. At final follow-up, majority of the LBW babies had varying grades of malnutrition and only 1 (7%) of preterm-LBW subset and 13 (28%) of term-LBW subset had optimum catch up growth resulting in normal nutritional status with the existing interventions. Three (3.5%) of the normal babies were noted to slip down to malnutrition at the end of 2 years.

CONCLUSIONS

Preterm- and term-LBW babies are born with significantly lower nutrient reserves at birth compared to term-normal babies, this was lowest among the preterm babies. As this reserve may be further lowered by recurrent infections and inappropriate feeding habits, there is a need for special feeding and nutrient supplements in this group. Calcium and iron levels were suboptimum at birth and calcium levels remained suboptimum even at the end of 2 years in all three subsets including controls in this non-affluent group. Currently available interventions may prevent the occurrence of overt clinical nutrient deficiencies, but do not ensure optimum growth, even among normal birth weight babies as some of these babies were seen to slip into the pool of malnutrition subsequently. Specialized nutritional surveillance and supplements are recommended for LBW babies to promote optimum growth and prevent subclinical nutrient deficiencies. Infant feeding practices should be strengthened and integrated with the existing health care programs to reach all the beneficiaries. Along with the existing special supplementation programs like iron folic acid, vitamin A, iodine etc., calcium supplementation should also be considered. It is also essential to concentrate on the girl child, the adolescent girl, prospective mother and prenatal mother to ensure optimum nutrition and nutrient transfer to future offsprings.

Atypical relapsing course of Kawasaki disease with hemorrhagic serous effusions and hepatic dysfunction

Kawasaki disease (KD) is a multisystem vasculitis of childhood with cardiac, renal, pulmonary and neurological complications. Hemorrhagic serous effusions, liver dysfunction and relapsing course in spite of treatment are rare. We report an atypical case of KD with a relapsing course, hemorrhagic effusions and hepatic dysfunction, that required two repeated courses of intravenous immunoglobulin (IVIG) and methylprednisolone.

Mid arm circumference (MAC) and body mass index (BMI)--the two important auxologic parameters in neonates

Even though birth weight is the most sensitive predictor of health and outcome, accurate weighing and proper recording are not done in most developing countries. Most neonates lose 10% of body weight soon after birth and when such babies subsequently come for medical care, it becomes difficult to know whether the baby was low birth weight (LBW) at birth or not, to predict the outcome. Among the many surrogate auxologic parameters to identify LBW babies, mid arm circumference (MAC) was found to be the most useful and simplest. At a cut off of 9 cm, with a sensitivity of 92% and a specificity of 90.5% to identify LBW, MAC is recommended as an alternative measurement. Ponderal index is measured in neonatal period to identify growth retardation. Body mass index (BMI) is a very useful index in children and adults to identify obesity/chronic energy deficiency (CED). Tracking of BMI from neonatal period to adulthood is recommended to plan intervention and predict outcome. The mean BMI observed in the present study was 12.86 kg/m2 close to the expected of 13.

Three-in-one weight, height and body mass index charts for children and adults

The aim of the study was to develop four appropriate three-in-one weight, height and built in body mass index (BMI) charts, for under-fives, 0-5-year-olds, > 5-10-year-olds, > 10-18-year-olds, and adults and to delineate the normal range, underweight, overweight and obesity on the above charts. Four different charts were designed for the various age groups as indicated above. Height was made available on the x-axis, weight on the y-axis, and corresponding BMI values on the right margin. Shading of the normal range to denote the health path and marking of the cut-off curves to denote normal status, overweight, and obesity were done selecting appropriate round figures to suit both sexes in accordance with the International Obesity Task Force (IOTF) recommendations for the various age groups. Field trials were done on appropriate subjects belonging to various age groups. 500 in each group with equal male to female ratio. The field trials showed that all the studied subjects belonging to both sexes came within the purview of the chart and those with normal nutritional status, underweight, overweight, and obesity could easily be identified looking at the chart without doing any further calculation. Early intervention also could be advised as the chart could demonstrate how much weight should be gained or reduced to come within the health path. In conclusion, the charts are applicable to both sexes and are user friendly. These are appropriate for general screening of nutritional status and to determine underweight, overweight, and obesity from birth to adulthood. They give a visual display of the ideal health path with respect to weight, height, and BMI and the adjustment in weight required to reach the normal range.

Correlation of age and birth order of parents with chromosomal anomalies in children

One hundred children with suspected congenital and/or malformation and their parents who reported to SAT hospital, Medical College, Trivandrum, India formed the test group. Fifty children with no obvious anomalies or abnormalities and their parents formed the control group. The criteria for selection of the control was 1) the maternal age at delivery was below 30 years and 2) the parents belong to 1st or 2nd birth order. The chromosomal analysis was carried out in all the subjects using peripheral blood lymphocyte microculture to investigate for any constitutional chromosomal markers and quantitate the mutagen (bleomycin) sensitivity of the chromosomes. All the subjects were evaluated clinically and a complete family history was recorded. Chromosome anomalies were noted in 41 out of the one hundred children and in 4 out of the 200 parents of the test group. No constitutional aberrations were seen either in the parents or in the children of the control group. Bleomycin sensitivity study revealed a high b/c value in 35 children (24 hypersensitive and 11 sensitive) of the test group whereas in the control group the b/c values were low denoting hyposensitivity and very good DNA repair mechanism. This study reveals that the incidence of chromosome aberrations is higher when the age and birth order of parents are higher. A direct correlation was noted with parental order and b/c value. This was also true with the parental age and birth defects.

The role of developmental stimulation in nutritional rehabilitation

OBJECTIVE

To evaluate the role of developmental stimulation and nutritional supplementation in rehabilitation of malnourished children in the hospital and community settings.

DESIGN

Prospective follow up study.

SETTINGS

(i) Nutrition clinic of a teaching hospital; and (ii) Community Nutrition Project in coastal Kerala.

SUBJECTS

(i) Hospital study: 100 children aged 6-24 months with moderate and severe Protein Energy Malnutrition (PEM) constituted the study group. The control group consisted of well nourished children matched for age and sex, 50 from high (Control I) and 50 from low socioeconomic (SE) status (Control II). The study group was randomized into two subgroups to administer the interventions namely composite stimulation package (STIM) or nutritional management (NUT). (ii) COMMUNITY STUDY: A cohort of 332 children aged 6-24 months with varying grades of PEM were studied. As per the area of residence, they were divided into three subgroups; 2 study groups to administer the two interventions namely STIM or NUT and a control group.

METHODS

In both the hospital and community studies, environmental parameters, growth and development were assessed initially. After two years, the study groups were reassessed in comparison with the control groups. A final IQ assessment was done in each subgroup by a tester blinded to the grouping.

RESULTS

(i) Hospital study: Control children from high SE status (Control I) had the highest overall scores compared to those from low SE status (Control II) as well as the study groups with PEM even after administering either STIM or NUT. Both the interventions produced a significant positive impact on growth and development, but STIM was found superior to NUT. (ii) Community study: There was a high prevalence of PEM in the community, which reduced significantly after the interventions. STIM was found superior in its positive impact on growth and development. In both studies, direct correlation was observed between environmental parameters and anthropometric scores and between anthropometric scores and IQ.

CONCLUSIONS

The benefit of developmental stimulation in nutritional rehabilitation and the need for providing better environment for deprived children are brought out in this study.

Growth faltering and developmental delay in children with PEM

Anthropometric measurements, Somatic Quotient (SQ), Development Quotient (DQ), Motor Quotient (MoQ) and Mental Quotient (MeQ) in 136 children in the age group 1-24 months with varying degrees of protein energy malnutrition (PEM) were compared with an equal number of comparable well nourished children. There was a progressive reduction in SQ, DQ, MoQ and MeQ as the degree of PEM advanced. There was a direct linear correlation between SQ and DQ and between height and DQ in 4 degrees PEM. However, there was no direct correlation between head circumference and either DQ or MeQ.