No impact of disease and its treatment on bone mineral density in survivors of childhood acute lymphoblastic leukemia.

BACKGROUND: Acute lymphoblastic leukemia (ALL) and its treatment are often implicated in adversely affecting bone health. Conflicting reports in the literature and a paucity of studies from the developing world prompted us to study bone mineral density (BMD) in childhood ALL survivors. METHODS: BMD lumbar spine (LS) and whole body (WB) were evaluated, using dual energy x-ray absorptiometry in 65 pediatric ALL survivors who had been off-therapy for at least 2 years. The control group constituted of 50 age- and sex-matched healthy siblings. Kernel density plots were used to compare BMD among cases and controls. The disease-, treatment-, hormone- and lifestyle-related factors likely to modulate BMD were analyzed using the Mann-Whitney U test and Student's t-test. RESULTS: At a median of 4.3 years (range, 2-14.8 years) since cessation of therapy, height-adjusted (HA) mean BMD Z-scores of LS (-0.67 ± 1.11, -0.607 ± 1.05, P = 0.759) and WB (-0.842 ± 0.92, -0.513 ± 0.97, P = 0.627) were comparable among the cases and controls. Disease, treatment (chemotherapy, cranial radiotherapy) and endocrine factors did not predict low BMD. However, survivors with calcium intake <800 mg/day (WB, P = 0.018) and hypovitaminosis D (≤25 nmol/L) had lower BMD values (HA-WB, P = 0.046) than the controls. A significant proportion of survivors were overweight or obese and had higher BMD Z-scores (HA-LS, P = 0.003; HA-WB, P = 0.028). CONCLUSION: BMD Z-scores were similar among ALL survivors and controls. It was reassuring that there was no detrimental impact of the disease or its treatment on BMD. Future studies are required to determine the best possible ways to target the modifiable risk factors (diet, vitamin D) to optimize bone health.

Classroom as the Site for Type 1 Diabetes Self-Care Activities.

Children and adolescents with Type 1 diabetes (T1D) require bolus insulin before each meal, necessitating self-care activities including blood glucose checking to determine insulin dose (or check for hypoglycemia) and injecting insulin during school hours. Though these activities are essential for optimizing glycemic control, they are met with reluctance from parents, the child, school authorities, and sometimes peers. This requires ongoing education and support for the child, school staff, and other students, by the diabetes care team. Many problems of performing self-care activities can be greatly reduced by allowing them in the child's classroom itself, a strategy which offers several logistical, safety, psychological and social benefits. The glucometer and strips, continuous glucose monitoring device, insulin in a cool case, and hypoglycemia kit are kept in the teacher's custody, and used by the child as needed, under supervision. This normalizes diabetes and its care, obviates concealment of diabetes, enhances the child's and teacher's confidence, optimizes diabetes care by ensuring timely and consistent insulin dosing, encourages hypoglycemia prevention and management, and reduces the chances of the child being bullied. It also promotes acceptance of diabetes by peers and greater community awareness. Other places for self-care like the medical room or the toilet have disadvantages. Possible limitations of this strategy could be objections occasionally raised by some school staff, lack of privacy needed by adolescents, or bullying by classmates: issues which need proactive handling. The diabetes care team may do well to emphasize performing self-care activities in the classroom, working with school staff and parents to this end.

Burden, risk factors and outcomes associated with adequately treated hypothyroidism in a population-based cohort of pregnant women from North India.

Hypothyroidism is the commonest endocrine disorder of pregnancy, with known adverse feto-maternal outcomes. There is limited data on population-based prevalence, risk factors and outcomes associated with treatment of hypothyroidism in early pregnancy. We conducted analysis on data from an urban and peri-urban low to mid socioeconomic population-based cohort of pregnant women in North Delhi, India to ascertain the burden, risk factors and impact of treatment, on adverse pregnancy outcomes- low birth weight, prematurity, small for gestational age and stillbirth. This is an observational study embedded within the intervention group of the Women and Infants Integrated Interventions for Growth Study, an individually randomized factorial design trial. Thyroid stimulating hormone was tested in 2317 women in early (9-13 weeks) pregnancy, and thyroxin replacement started hypothyroid (TSH ≥2.5mIU/mL). Univariable and multivariable generalized linear model with binomial family and log link were performed to ascertain risk factors associated with hypothyroidism and association between hypothyroidism and adverse pregnancy outcomes. Of 2317 women, 29.2% (95% CI: 27.4 to 31.1) had hypothyroidism and were started on thyroxin replacement with close monitoring. Overweight or obesity was associated with increased risk (adjusted RR 1.29, 95% CI 1.10 to 1.51), while higher hemoglobin concentration was associated with decreased risk (adjusted RR 0.93, 95% CI 0.88 to 0.98 for each g/dL) for hypothyroidism. Hypothyroid women received appropriate treatment with no increase in adverse pregnancy outcomes. Almost a third of women from low to mid socio-economic population had hypothyroidism in early pregnancy, more so if anemic and overweight or obese. With early screening and adequate replacement, adverse pregnancy outcomes may be avoided. These findings highlight the need in early pregnancy for universal TSH screening and adequate treatment of hypothyroidism; as well as for attempts to reduce pre and peri-conception overweight, obesity and anemia. Clinical trial registration: Clinical trial registration of Women and Infants Integrated Interventions for Growth Study Clinical Trial Registry-India, #CTRI/2017/06/008908; Registered on: 23/06/2017, (http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=19339&EncHid=&userName=society%20for%20applied%20studies).

'Old Is Gold': How Traditional Indian Dietary Practices Can Support Pediatric Diabetes Management.

Nutrition is crucial for maintaining normal growth, development, and glycemic control in young people with diabetes (PwD). Undue restrictions cause nutrient deficiencies as well as poor adherence to meal plans. Widespread availability of low-cost, ultra-processed, and hyperpalatable food is further damaging. Most families struggle to find ways to provide nutritious, yet attractive, food with a low glycemic index (GI). India is one of the oldest continuous civilizations with a rich and diverse cultural and culinary heritage. Traditional dietary practices, including the centuries-old 'Thali' (meaning plate) concept, emphasize combinations (grains, lentils, vegetables, dairy, spices, prebiotics and probiotics, and fats) of local, seasonal, and predominantly plant-based ingredients. These practices ensure that all of the necessary food groups are provided and fit well with current evidence-based recommendations, including the International Society for Pediatric and Adolescent Diabetes (ISPAD) 2018 Guidelines. Techniques for the preparation, cooking, and preservation of food further impact the GI and nutrient availability. These practices benefit nutrient density, diet diversity, and palatability and thus improve adherence to meal plans and glycemic control. This narrative review describes the ancient wisdom, food composition, and culinary practices from across India which are still valuable today. These may be of benefit worldwide to improve glycemic control as well as quality of life, especially in PwD.

A Case for Expanding Thermochromic Vial Monitor Technology to Insulin and Other Biologics.

Insulin quality and efficacy determine glycemic control, which determines quality of life for people with diabetes. Insulin efficacy is reduced by heat exposure, especially in tropical climates, remote areas, and with improper handling. Insulin doses can be adjusted based on blood glucose monitoring, which may compensate for lack of viability. However, a measured response may be difficult with other biopharmaceuticals. Thermochromic vial monitor technology developed for oral polio vaccines (vaccine vial monitors) is an inexpensive, easily available, visible modality which can be used for insulin and other biopharmaceuticals to detect excessive heat exposure and thus reduced potency at any point in the cold-chain, till the end-users, thus improving patient care. Regulatory authorities must urgently consider the need to impose mandatory use of this technology for all biopharmaceuticals, including insulin, to ensure efficacy till end usage.

Growth disorders in type 1 diabetes: an Indian experience.

Though children with type 1 diabetes mellitus (T1DM) are often tall at the time of diagnosis, they may experience growth retardation, pubertal delay or both, which may be due to poor glycemic control, associated diseases or chronic complications. Factors affecting growth include: gender, genetic environment, age at diagnosis, diabetes duration, puberty, metabolic control, and status of growth hormone (GH), insulin-like growth factors (IGFs), and IGF binding proteins (IGFBPs). Insulin regulates expression of hepatic GH receptors, affects IGFs and IGFBPs synthesis by modulating GH postreceptor events, and significantly increases IGF-I bioactivity. Low portal insulin seen in T1DM leads to GH hypersecretion, low circulating IGF-I and IGFBP-3, and high circulating IGFBP-1. Newly diagnosed T1DM patients have decreased GHBP which can be restored with insulin therapy. Growth velocity should be appropriate for the age of the child/adolescent, and the mid-parental height. Height, weight and blood pressure (BP) should be measured and plotted on a growth chart at least 2-3 times a year. Puberty should also be assessed annually. Following precautions are to be taken in T1DM children: checking for pubertal onset and ensuring it is not delayed, testing early when growth falters (hypothyroidism/celiac disease/puberty/other conditions), aiming for best possible metabolic control (multidose regimens, regardless of type of insulin), and encouraging dietary calcium and protein, exposure to sunlight, Vitamin D supplements and exercise.

Deferasirox in Indian children with thalassemia major: 3 years experience.

OBJECTIVE: To evaluate the efficacy and safety of the oral iron chelator deferasirox in treating transfusional hemosiderosis in a cohort of Indian children with thalassemia major with high iron load. MATERIALS AND METHODS: The first 50 children (age 2-18 yrs) with thalassemia major to commence deferasirox at our center were enrolled and followed up for a period of 36 months between April 2008 and March 2011. The dose of deferasirox was determined by their baseline serum ferritin and was adjusted to a maximum of 40 mg/kg/day depending on response. Ferritin levels, SGOT, SGPT, serum creatinine and urine albumin were regularly monitored. RESULTS: Of the 50 patients, 76% documented a significant decline in serum ferritin (P<0.05). Seven (14%) patients had a stable ferritin whilst 5 patients (10%) documented an increase over the study period. The mean serum ferritin at baseline, 12, 24 and 36 months was 4354, 3260, 3290 and 3042, respectively (P<0.05). The median serum ferritin at the same time points was 3555, 2810, 2079 and 2271, respectively (P<0.05). No severe toxicity was seen. CONCLUSIONS: Deferasirox, when given in doses ≥30 mg/kg, was found to be an effective and safe drug in reducing transfusional hemosiderosis. Thirty five (70%) needed dose escalation upto 40 mg/kg/day. Fifteen (30%), however did not achieve a negative iron balance despite maximally permissible doses.

Diabetes in young: Beyond type 1.

Although majority of diabetes in children is type1 diabetes, childhood type2 diabetes prevalence is rapidly increasing due to changing lifestyle. Most patients can be definitely grouped into either of the two but some present diagnostic difficulty due to overlapping and non specific clinical features and laboratory findings. MODY and several other diseases affecting the pancreas also result in childhood diabetes. Treatment of diabetes in children presents unique challenges and primary prevention is of prime importance.