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Sachdev H.P.S.,Sitaram Bhartia Institute of Science and Research | Gera T.,SL Jain Hospital
European Journal of Clinical Nutrition | Year: 2013

Childhood anemia has major adverse consequences for health and development. It's prevalence in India continues to range from 70 to 90%. Although anemia is multifactorial in etiology, preventative efforts have predominantly focused on increasing iron intake, primarily through supplementation in pregnant and lactating women. Policy thrust for childhood anemia is only recent. However, program implementation is dismal; only 3.8-4.7% of preschoolers receive iron-folate supplements. There is an urgent need for effective governance and implementation. Policy makers must distinguish anemia from iron deficiency, and introduce additional area-specific interventions as an integrated package.Increased iron intake may yield maximum benefit but will only address up to half the burden. In 6-59 months old children, instead of 100 days' continuous dosing with iron-folate syrup in a year, a directly supervised intermittent supplementation (biweekly; ∼100 days per year) merits consideration. Multiple micronutrient powders for home fortification of foods in 6-23 months old infants do not appear viable. Additional interventions include delayed cord clamping, earlier supplementation in low birth weight infants, appropriate infant and young child feeding guidelines, and intermittent supervised supplementation in children and adolescents through school health programs. Use of double (iron-folate)-fortified salt in mid-day meal programs deserves piloting.Important area-specific, non-iron interventions include targeted deworming, and prevention and treatment of hemoglobinopathies, malaria and other common infections. Routine addition of multi-micronutrients to iron-folate supplementation appears unjustified currently. There is a pressing need to conduct relevant research, especially to inform etiology, additional interventions and implementation issues. © 2013 Macmillan Publishers Limited.

Gera T.,Sl Jain Hospital | Sachdev H.S.,Sitaram Bhartia Institute of Science and Research | Boy E.,International Food Policy Research Institute
American Journal of Clinical Nutrition | Year: 2012

Background: The utility of iron fortification of food to improve iron deficiency, anemia, and biological outcomes is not proven unequivocally. Objectives: The objectives were to evaluate 1) the effect of iron fortification on hemoglobin and serum ferritin and the prevalence of iron deficiency and anemia, 2) the possible predictors of a positive hemoglobin response, 3) the effect of iron fortification on zinc and iron status, and 4) the effect of iron-fortified foods on mental and motor development, anthropometric measures, and infections. Design: Randomized and pseudorandomized controlled trials that included food fortification or biofortification with iron were included. Results: Data from 60 trials showed that iron fortification of foods resulted in a significant increase in hemoglobin (0.42 g/dL; 95% CI: 0.28, 0.56; P < 0.001) and serum ferritin (1.36 μg/L; 95% CI: 1.23, 1.52; P < 0.001), a reduced risk of anemia (RR: 0.59; 95% CI: 0.48, 0.71; P < 0.001) and iron deficiency (RR: 0.48; 95% CI: 0.38, 0.62; P < 0.001), improvement in other indicators of iron nutriture, and no effect on serum zinc concentrations, infections, physical growth, and mental and motor development. Significant heterogeneity was observed for most of the evaluated outcomes. Sensitivity analyses and meta-regression for hemoglobin suggested a higher response with lower trial quality (suboptimal allocation concealment and blinding), use of condiments, and sodium iron edetate and a lower response when adults were included. Conclusion: Consumption of iron-fortified foods results in an improvement in hemoglobin, serum ferritin, and iron nutriture and a reduced risk of remaining anemic and iron deficient. © 2012 American Society for Nutrition.

Gogia S.,Max Hospital | Sachdev H.S.,Sitaram Bhartia Institute of Science and Research
International Journal of Epidemiology | Year: 2010

Background: Maternal postpartum vitamin A supplementation (VAS) provides an opportunity to improve vitamin A nutriture of breast fed infants in developing countries and can possibly prevent infant mortality and morbidity attributable to vitamin A deficiency. Objective: To evaluate the effect of maternal postpartum VAS on infant mortality, morbidity and adverse effects. Design: Systematic review, meta-analysis and meta-regression of randomized controlled trials. Data sources: Electronic databases and abstracts and proceedings of micronutrient conferences. Review methods: Randomized or quasi-randomized, placebo-controlled trials evaluating the effect of postpartum, maternal synthetic VAS on mortality or morbidity within infancy (<1 year), or adverse effects. Results: The seven included trials were from developing countries. There was no evidence of a reduced risk of mortality during infancy [relative risk (RR) 1.05, 95% confidence interval (CI) 0.92-1.20, P = 0.438; I2 = 0%, P = 0.940]. No variable emerged as a significant predictor of mortality but data for high-risk groups (high maternal night blindness prevalence and low birth weights) was restricted. Neonatal mortality data was available from a single study, (RR 1.09, 95% CI 0.88-1.35; P = 0.422). In two trials, there was no evidence of a reduced risk of cause-specific mortality. In one trial, there was no evidence of a decrease in either diarrhoea or acute respiratory infection. No adverse effects were reported in the single relevant trial. Conclusions: There is no evidence of a mortality or morbidity benefit to the infant following postpartum maternal VAS. Only prevention of infant morbidity or mortality would be sufficient justification for initiating this intervention in public health programmes. Published by Oxford University Press on behalf of the International Epidemiological Association © The Author 2010; all rights reserved.

Gulani A.,Sitaram Bhartia Institute of Science and Research
Cochrane database of systematic reviews (Online) | Year: 2012

Otitis media (OM) is inflammation of the middle ear and is usually caused by infection. It affects people of all ages but is particularly common in young children. Around 164 million people worldwide have long-term hearing loss caused by this condition, 90% of them in low-income countries. As zinc supplements prevent pneumonia in disadvantaged children, we wanted to investigate whether zinc supplements could also prevent OM. To evaluate whether zinc supplements prevent OM in adults and children of different ages. We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2012, Issue 1) which includes the Cochrane Acute Respiratory Infections Groups' Specialised Register, MEDLINE (1950 to February week 1, 2012) and EMBASE (1974 to February 2012). Randomised, placebo-controlled trials of zinc supplements given at least once a week for at least a month for preventing OM. Two review authors independently assessed the eligibility and methodological quality of the included trials and extracted and analysed data. We summarised results using risk ratios (RRs) or rate ratios for dichotomous data and mean differences (MDs) for continuous data. We combined trial results where appropriate. We identified 12 trials for inclusion, 10 of which contributed outcomes data. There was a total of 6820 participants. In trials of healthy children living in low-income communities, two trials did not demonstrate a significant difference between the zinc supplemented and placebo groups in the numbers of participants experiencing an episode of definite OM during follow-up (3191 participants); another trial showed a significantly lower incidence rate of OM in the zinc group (rate ratio 0.69, 95% confidence interval (CI) 0.61 to 0.79, n = 1621). A small trial of 39 infants undergoing treatment for severe malnutrition suggested a benefit of zinc for the mean number of episodes of OM (mean difference (MD) -1.12 episodes, 95% CI -2.21 to -0.03). Zinc supplements did not seem to cause any serious adverse events but a small minority of children were reported to have vomited shortly after ingestion of the supplements. The trial evidence included is generally of good quality, with a low risk of bias. Evidence on whether zinc supplementation can reduce the incidence of OM in healthy children under the age of five years living in low- and middle-income countries is mixed. There is some evidence of benefit in children being treated for marasmus (severe malnutrition) but this is based on one small trial and should therefore be treated with caution.

Sachdev H.P.S.,Sitaram Bhartia Institute of Science and Research
Indian Pediatrics | Year: 2012

This policy review highlights the need to focus on stunting as an indicator of under-five undernutrition and explores the major challenges and priority public health options for accelerating linear growth in children. Early childhood stunting predicts poor human capital including shorter adult height, lower attained schooling, reduced adult income, and decreased offspring birth weight. The current prevalence of stunting is disconcerting but there has been a relatively faster decline recently. It is imperative to intervene before birth to address stunting. Pertinent ongoing interventions (delaying early child birth, adequate antenatal care and maternal iron-folate supplementation) are beneficial but have sub-optimal coverage. There is only a narrow window of opportunity in early life - the first two years. Effective coverage of children below two years of age with a package of interventions (breastfeeding; immunization; appropriate complementary feeding; treatment of infections, especially diarrhea; safe water supply; and sanitation) merits urgent investigation for greater impact.

Kumar R.K.,Amrita Institute of Medical science and Research Center | Tandon R.,Sitaram Bhartia Institute of Science and Research
Indian Journal of Medical Research | Year: 2013

Rheumatic fever (RF) and rheumatic heart disease (RHD) continue to be a major health hazard in most developing countries as well as sporadically in developed economies. Despite reservations about the utility, echocardiographic and Doppler (E&D) studies have identified a massive burden of RHD suggesting the inadequacy of the Jones' criteria updated by the American Heart Association in 1992. Subclinical carditis has been recognized by E&D in patients with acute RF without clinical carditis as well as by follow up of RHD patients presenting as isolated chorea or those without clinical evidence of carditis. Over the years, the medical management of RF has not changed. Paediatric and juvenile mitral stenosis (MS), upto the age of 12 and 20 yr respectively, severe enough to require operative treatement was documented. These negate the belief that patients of RHD become symptomatic ≥20 years after RF as well as the fact that congestive cardiac failure in childhood indicates active carditis and RF. Non-surgical balloon mitral valvotomy for MS has been initiated. Mitral and/or aortic valve replacement during active RF in patients not responding to medical treatment has been found to be life saving as well as confirming that congestive heart failure in acute RF is due to an acute haemodynamic overload. Pathogenesis as well as susceptibility to RF continue to be elusive. Prevention of RF morbidity depends on secondary prophylaxis which cannot reduce the burden of diseases. Primary prophylaxis is not feasible in the absence of a suitable vaccine. Attempts to design an antistreptococcal vaccine utilizing the M-protein has not succeeded in the last 40 years. Besides pathogenesis many other questions remain unanswered.

Tandon R.,Sitaram Bhartia Institute of Science and Research
Annals of Pediatric Cardiology | Year: 2012

Despite identifying that rheumatic fever (RF) is the result of an immunological reaction following group-A beta-hemolytic streptococcal infection, the pathogenesis remains elusive. RF has been incorrectly designated as causing pancarditis, since it does not cause myocarditis. Research directed toward myocarditis, targeting myosin to unravel the pathogenesis has not succeeded in more than 60 years. RF causes permanent damage to cardiac valves. The mitral valve (MV), derived from the wall of the left ventricle, is composed of a central core of connective tissue, covered on both sides by endothelium. The left ventricle does not have either myocardial or intermyocardial connective tissue involvement in RF. By exclusion, therefore, the primary site of RF damage appears to be the endothelium. Evaluation of the histopathology and immunopathology indicates that RF is a disease of the valvular and vascular endothelium. It is not a connective tissue disorder. Research to identify pathogenesis needs to be focused toward valvular endothelium.

Tandon R.,Sitaram Bhartia Institute of Science and Research
Indian Heart Journal | Year: 2014

Group A beta hemolytic streptococcus (GAS), the organism which initiates rheumatic fever (RF) continues to be sensitive to penicillin. However, penicillin cannot prevent RF if the preceding sore throat is asymptomatic in more than 70 percent children. Prevention of rheumatic fever (RF) may be possible only with the use of a vaccine. Efforts to design a vaccine based on emm gene identification of GAS, M-protein going on for more than 40 years, is unlikely to succeed. M-protein is strain specific. Infection with one strain does not provide immunity from infection with another strain. Based on the emm gene identification, of 250 or more identified strains of GAS, the distribution is heterogenous and keeps changing. The M-protein gene sequence of the organism tends to mutate. A vaccine prepared from available strains may not be effective against a strain following mutation. Lethal toxic shock syndrome due to GAS infection has been described with organisms without identifiable or functional M-protein. M-protein has been excluded as the antigen responsible for acute glomerulonephritis (GN). Therefore M-protein plays no role in one suppurative (toxic shock syndrome) and one non-suppurative (acute GN) manifestation due to GAS infection. Lastly there is no direct evidence to indicate that M-protein is involved in inducing RF. The role of M-protein and the GAS component resulting in the suppurative manifestations of GAS infections like pyoderma, septic arthritis or necrotizing fasciitis etc is unknown. For a vaccine to be effective, an epitope of the streptococcus which is stable and uniformly present in all strains, needs to be identified and tested for its safety and efficacy. The vaccine if and when available is expected to prevent GAS infection. Preventing GAS infection will prevent all the suppurative as well as non-suppurative manifestations including RF. Copyright © 2013, Cardiological Society of India. All rights reserved.

Sinha S.,Sitaram Bhartia Institute of Science and Research | Kumar M.,Institute of Liver and Biliary science
Hepatology Research | Year: 2010

The combination of chronic hepatitis B virus (HBV) infection and pregnancy presents unique management questions. Aspects of care that need to be considered include effects of hepatitis B on pregnancy, effects of pregnancy itself on the course of hepatitis B infection, treatment of hepatitis B during pregnancy and prevention of mother-to-infant transmission. Chronic HBV infection is usually mild in pregnant women, but may flare shortly after delivery. Effect of HBV infection on pregnancy outcomes are generally favorable, but may depend on severity of liver disease. Mother-to-infant transmission can be minimized by current immunoprophylaxis strategies, however, high levels of viremia in mothers may be a factor in the small but reproducible failure rate of current immunoprophylaxis strategies. Use of antivirals during pregnancy needs to be individualized. Careful planning and management of pregnancy must be done among patients with chronic HBV infection. © 2010 The Japan Society of Hepatology.

Objective: To determine whether home visits for neonatal care by community health workers can reduce infant and neonatal deaths and stillbirths in resource-limited settings. Methods: We conducted a systematic review up to 2008 of controlled trials comparing various intervention packages, one of them being home visits for neonatal care by community health workers. We performed meta-analysis to calculate the pooled risk of outcomes. Findings: Five trials, all from south Asia, satisfied the inclusion criteria. The intervention packages included in them comprised antenatal home visits (all trials), home visits during the neonatal period (all trials), home-based treatment for illness (3 trials) and community mobilization efforts (4 trials). Meta-analysis showed a reduced risk of neonatal death (relative risk, RR: 0.62; 95% confidence interval, CI: 0.44-0.87) and stillbirth (RR: 0.76; 95% CI: 0.65-0.89), and a significant improvement in antenatal and neonatal practice indicators (> 1 antenatal check-up, 2 doses of maternal tetanus toxoid, clean umbilical cord care, early breastfeeding and delayed bathing). Only one trial recorded infant deaths (RR: 0.41; 0.30-0.57). Subgroup analyses suggested a greater survival benefit when home visit coverage was ≥ 50% (P < 0.001) and when both preventive and curative interventions (injectable antibiotics) were conducted (P = 0.088). Conclusion: Home visits for antenatal and neonatal care, together with community mobilization activities, are associated with reduced neonatal mortality and stillbirths in southern Asian settings with high neonatal mortality and poor access to facility-based health care.

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