Prevalence and predictors of vitamin D deficiency in five immigrant groups living in Oslo, Norway: the Oslo Immigrant Health Study.

OBJECTIVE: To study the prevalence of vitamin D deficiency and to identify possible predictors of vitamin D deficiency in five main immigrant groups in Oslo. DESIGN: Cross-sectional, population-based. SETTING: City of Oslo. SUBJECTS: In total, 491 men and 509 women with native countries Turkey, Sri Lanka, Iran, Pakistan and Vietnam living in the county of Oslo. RESULTS: Median serum 25(OH)D level (s-25(OH)D) was 28 nmol/l, ranging from 21 nmol/l in women born in Pakistan to 40 nmol/l in men born in Vietnam. Overall prevalence of vitamin D deficiency defined as s-25(OH)D<25 nmol/l was 37.2%, ranging from 8.5% in men born in Vietnam to 64.9% in women born in Pakistan. s-25(OH)D did not vary significantly with age. s-25(OH)D was higher in blood samples drawn in June compared to samples obtained in April, but not significantly for women. Reported use of fatty fish and cod liver oil supplements showed a strong positive association with s-25(OH)D in all groups. Education length was positively associated with s-25(OH)D in women, whereas body mass index (BMI) was inversely associated with s-25(OH)D in women. These two variables were not related to vitamin D deficiency in men. CONCLUSIONS: There is widespread vitamin D deficiency in both men and women born in Turkey, Sri Lanka, Iran, Pakistan and Vietnam residing in Oslo. The prevalence of vitamin D deficiency is higher in women than in men, and it is higher in those born in Pakistan and lower in those born in Vietnam compared to the other ethnic groups. Fatty fish intake and cod liver oil supplements are important determinant factors of vitamin D status in the groups studied. BMI and education length are also important predictors in women.

Low levels of serum calcidiol in an African population compared to a North European population.

OBJECTIVE: To compare vitamin D status in an African population living at 10 degrees N with a Norwegian population living at 60 degrees N. DESIGN: Serum samples from 30 healthy young Ethiopians and 31 full term pregnant women from Addis Ababa were collected in September, and from 24 healthy Norwegians in March and 23 pregnant women from Oslo in February to June. METHODS: Serum (s) levels of calcidiol and intact parathyroid hormone (iPTH) were measured. RESULTS: The median values for s-calcidiol were significantly lower in Ethiopians compared with Norwegians (young Ethiopians 23.5nmol/l vs young Norwegians 81nmol/l, P<0.001; pregnant Ethiopians 25nmol/l vs pregnant Norwegians 36nmol/l, P<0.05) while those for s-iPTH were significantly higher (young Ethiopians 5.7pmol/l vs young Norwegians 2.4pmol/l, P<0.001; pregnant Ethiopians 4.8pmol/l vs pregnant Norwegians 2.8pmol/l, P<0.02). CONCLUSION: In spite of abundant availability of ultraviolet radiation, the population from Addis Ababa had a high rate of biochemical vitamin D deficiency compared with the Norwegian group.

Diet and vitamin D status among pregnant Pakistani women in Oslo.

OBJECTIVES: In the present study the diet and the nutritional status of pregnant Pakistani immigrant women have been compared with a group of Norwegian women. DESIGN: A cross-sectional survey of women in the 18th week of pregnancy. SETTING: Women referred to routine ultrasound examination at Aker and Ullevål Hospitals in Norway. SUBJECTS: All (58) healthy women of Pakistani origin referred from October of 1991 to January of 1992 were included, of whom 38 (66%) participated. Forty-five Norwegian women were randomly included in the same period and 38 (84%) of these women participated. RESULTS: The serum levels of 25-hydroxyvitamin D3 were significantly lower in the Pakistanis compared with the Norwegians (median 19 nmol/l vs 55 nmol/l, P < 0.001) and 83% of the Pakistani women had 25-hydroxyvitamin D3 levels below the reference value (< 30 nmol/l). The Pakistanis had higher levels of serum parathyroid hormone (median 2.6 vs 1.6 pmol/l, P < 0.001). The Pakistanis also had a lower dietary intake of vitamin D than that of the Norwegians (median 2.2 vs 3.3 micrograms/day, P < 0.05), and a lower total intake, including supplements (median 2.9 vs 7.0 micrograms/day, P < 0.001). Among the Pakistanis a correlation was found between the dietary intake of margarine, the main source of vitamin D in the diet, and the concentration of 25-hydroxyvitamin D3 in serum, r = 0.48 (P = 0.01). In general, the Pakistanis avoided any direct sunshine exposure, and no relation between outdoor activity and serum level of 25-hydroxyvitamin D3 was found. The Pakistani women had a lower intake of calcium than the Norwegians (median 793 vs 1134 mg/day, P < 0.001). CONCLUSION: This study has shown that Pakistani women living in Oslo are at great risk of developing vitamin D deficiency during pregnancy. The main reasons for this are avoidance of sun exposure, a low dietary intake of vitamin D, and no or little use of supplementation.

Vitamin D deficiency and fetal growth.

Vitamin D deficiency in pregnancy has been associated with decreased fetal growth, but previous studies have found no direct relation between the weight of the new-born child and the maternal serum level of 25-hydroxyvitamin D3 (calcidiol). The aim of this study was to evaluate the relation between maternal serum calcium and parathyroid hormone with reduced fetal growth in vitamin D deficient pregnant women. Thirty Pakistani women were included in the study at delivery. Only mothers without known chronic diseases who delivered vaginally after an uncomplicated pregnancy were included. Anthropometric data were recorded, and blood samples were drawn from the mothers 1-4 h after delivery. Nearly all (29/30) the Pakistani women had low (< 30 nmol/l) serum levels of 25-hydroxyvitamin D3. Thirteen of the mothers had high serum parathyroid hormone (PTH) levels (> 5.5 pmol/l). The median (range) level of ionised calcium in serum was 1.23 (1.15-1.28) nmol/l. A positive correlation was found between the level of ionised calcium in maternal serum and the crown-heel length of the infant (Spearman's rho = 0.65, P = 0.002, n = 20). The maternal serum PTH was related inversely to the crown-heel length (Spearman's rho = -0.47, P = 0.01, n = 30). No confounding effect of gestational age, sex of the infant, maternal height and body mass index (BMI) was found. The study indicates that vitamin D deficiency affects fetal growth through an effect on maternal calcium homeostasis.

Tissue Doppler imaging in very preterm infants during the first 24 h of life: an observational study.

BACKGROUND: Very preterm newborn infants often need cardiovascular support. More knowledge about myocardial function and factors that influence the immature myocardium may be helpful for optimising cardiovascular support in these infants. OBJECTIVE: Serial assessment of global myocardial function by means of colour tissue Doppler imaging (cTDI) in very and extremely preterm infants during the first 24 h of life. STUDY DESIGN: One-centre, prospective, observational longitudinal cohort study in a third level Neonatal Intensive Care Unit. Sixty-five infants with median (range) gestational age (GA) 27 (24-31) weeks and birth weight (BW) 1049 (484-1620) g underwent echocardiographic examinations including cTDI at 5, 12 and 24 h after birth. MAIN OUTCOME MEASURES: Peak systolic and peak diastolic annular velocity and peak annular displacement of the left and right ventricle. RESULTS: There was a significant reduction in systolic and diastolic velocities and displacement of both ventricles from 5 to 12 h age. From 12 to 24 h, there was a non-significant increase in myocardial velocities and displacement. At 5 h, babies with haemodynamically significant patent ductus arteriosus (PDA) had significantly higher systolic and diastolic velocities in both ventricles than those with non-significant PDA. CONCLUSIONS: Myocardial tissue velocities decrease significantly from 5 to 12 h after birth in very preterm infants. Further studies are needed to confirm these results and to determine their clinical implications.

Superior vena cava flow: feasibility and reliability of the off-line analyses.

BACKGROUND: Superior vena cava (SVC) flow has become a surrogate measure of systemic blood flow in neonates. OBJECTIVE: The aim of this study was to establish normal SVC flow values in healthy term infants the first 3 days of life and to evaluate the feasibility and reliability of the off-line analyses. DESIGN: Doppler echocardiography of SVC flow was performed in 48 healthy term infants the first 3 days of life. Off-line analyses were thereafter performed by one cardiologist to investigate the changes in SVC flow from day 1 to day 3 and to establish normal values. Intra- and inter-observer variability was analysed in a subset of 20 infants by three paediatric cardiologists. RESULTS: The authors found a decrease in mean SVC flow from 99 ml/kg/min at day 1 to 77 ml/kg/min at day 3. Reliable diameter images were obtained in 85% and velocity recordings in 81%. The mean variability of SVC flow was 17% in the intra-observer analysis and 29% in the inter-observer analysis. CONCLUSION: The main challenge of the method is the measurement of SVC diameter. The same observer should ideally perform sequential analyses. Special caution should be taken when making clinical implications from non-optimal pictures.

[Iron deficiency anemia among immigrant children from developing countries]. / Jernmangelanemi hos innvandrerbarn fra utviklingsland.

All children with haemoglobin below 9.0 g/100 ml and iron deficiency treated in the Paediatric Department, Ullevål Hospital, from 1.1.1988 to 6.10.1992, were studied. 26 of the 29 registered children had parents born in developing countries. Median age was 16 months (9-134 months) and median haemoglobin was 6.8 g/100 ml (3.5-9.0 g/100 ml) at admission. There was a negative correlation between platelet count and haemoglobin concentration in blood (correlation coefficient -0.67, p < 0.0001, n = 23). The main causes of the observed nutritional iron deficiency were high consumption of cow's milk and sweet beverages.

Vitamin D deficiency amongst Pakistani women in Oslo.

To evaluate the vitamin D status in pregnant Pakistani women living in Oslo, we measured levels of serum calcidiol, calcitriol, vitamin D binding protein (DBP), osteocalcin, free calcium (Ca2+), phosphorous, alkaline phosphatase and intact parathyroid hormone (PTH). Thirty Pakistani and 23 Norwegian women who delivered vaginally after uncomplicated pregnancies were included. The serum levels of calcidiol were significantly lower in the Pakistani group (p < 0.0001) as compared with the Norwegians, the mean values being 15.1 nmol/l and 43.1 nmol/l, respectively. PTH levels were above 5.5 pmol/l in 13 of the Pakistanis, none of the Norwegians. There were no differences in calculated free calcitriol, free calcium and inorganic phosphorus between the groups. Alkaline phosphatase was high, while osteocalcin was low in both groups, but there were no significant differences between the groups. This study shows that there is a widespread vitamin D deficiency amongst pregnant Pakistani women living in Oslo, indicating the need for vitamin D supplementation to these women and their children.

The estimated free concentration of calcidiol is higher in venous cord blood than in maternal blood.

The serum levels of calcidiol (25-hydroxy-vitamin D3), calcitriol (1,25-dihydroxy-vitamin D3), albumin and vitamin D-binding protein (DBP) were measured in venous cord blood and in maternal blood at delivery. These results were used to calculate the free concentrations of calcidiol and calcitriol in maternal and fetal blood. Fifty three women participated in the study. Seventeen of the participants were excluded from the calculations because their calcidiol levels were below the limit of detection (< 5 nmoll-1). The estimated free concentration of calcidiol was on average 26% higher in cord serum than in maternal serum, the mean difference being 1.1 pmoll-1 (p = 0.001). The estimated free concentration of calcitriol, however, was 21% lower on the fetal side (p < 0.001). The difference was small, the mean value being 0.07 pmoll-1. A strong positive association existed between the serum levels of free calcidiol (r = 0.82, p < 0.001) and free calcitriol (r = 0.83, p < 0.001) in maternal blood and cord blood.

[Nutritional rickets--an old disease with new relevance]. / Alimentaer rakitt. En gammel sykdom med ny aktualitet.

Rickets caused by poor nutrition was widespread in Norway at the beginning of this century. Today it is a very rare disease among Norwegian children. During the last 20 years, however, it has become quite common among immigrant children who have come from developing countries to live in Norway. This is probably due to a combination of different factors such as material vitamin D deficiency, lack of vitamin D supplementation, long-lasting breast feeding, latitude (therefore little sunshine in winter) and lack of exposure to sunshine during the summer. The paper reviews the disease, with a special emphasis on clinical findings, diagnosis, treatment and prevention.

[Health problems among immigrant children in Norway]. / Helseproblemer blant innvandrerbarn i Norge.

BACKGROUND: There are approximately 54,500 immigrant children (< 16 years) in Norway, half of them from non-western countries. METHODS: The authors present an overview of different health problems that are more frequent in the migration population than in the general Norwegian population. RESULTS AND INTERPRETATION: Psychological problems are very frequent among immigrant children from war areas, and a special therapy programme should be designed for this group. A broad spectrum of diseases that are uncommon among Norwegians, are present in the migrant population, such as sickle cell disease, thalassaemia, malaria, typhoid fever and tuberculosis. Doctors dealing with migrant children should learn how to diagnose and treat these diseases. Iron deficiency and vitamin D deficiency are also prevalent among immigrant children. As many as 65 children with nutritional rickets have been treated at Norwegian hospitals in 1998 and 1999, 54 of them with an immigrant background. This demonstrates the need for a new programme against nutritional rickets in Norway.

[Light sedation in children. Midazole as nasal drops is a good alternative]. / Lett sedasjon av barn. Midazolam som nesedråper er et aktuelt alternativ.

Many of the procedures carried out on paediatric patients are both painful and frightening to the child. To increase the child's comfort and to promote good working conditions, it may be necessary and advisable to sedate the child. In this study, 125 children (63 boys and 62 girls) were sedated with midazolam. For most children (n = 110) the medication was administered as nose drops. The reasons for sedation were echocardiography (n = 51), venous or lumbar punction (n = 53) and computer tomography scan (n = 21). The overall success rate was 78%. Minor complications were registered in four children. Two children vomited and one child developed a facial rash. One child had prolonged sedation, but this did not affect its respiration. We conclude that midazolam given as nose drops is a safe and convenient way of sedating paediatric patients.

[Bacterial endocarditis in premature children. A complication caused by central venous catheters]. / Bakteriell endokarditt hos premature barn. En komplikasjon til sentralt venekateter.

During the last ten years, the literature has included an increasing number of reports of bacterial endocarditis in prematurely born neonates. We describe the cases of two prematurely born infants with structurally normal hearts who, when examined by echo cardiography, were shown to have intercardial vegetations. They were diagnosed as having infective endocarditis caused by coagulase negative staphylococci. Both infants had central venous lines and received total parenteral nutrition. Both infants were treated successfully with antibiotics. One of them died later of sudden infant death syndrome.

[Nutritional rickets. An old disease with new relevance]. / Alimentaer rakitt. En gammel sykdom med ny aktualitet.

Rickets caused by poor nutrition was widespread in Norway at the beginning of this century. Today it is a very rare disease among Norwegian children. During the last 20 years, however, it has become quite common among immigrant children who have come from developing countries to live in Norway. This is probably due to a combination of different factors such as maternal vitamin D deficiency, lack of vitamin D supplementation, long-lasting breast feeding, latitude (therefore little sunshine in winter) and lack of exposure to sunshine during the summer. The paper reviews the disease, with a special emphasis on clinical findings, diagnosis, treatment and prevention.

[Perinatal HIV-infection. Epidemiologic, social and ethical aspects]. / Perinatal HIV-smitte. Epidemiologiske, sosiale og etiske aspekter.

More HIV-infected women are becoming pregnant and delivering their baby. The rate of perinatal transmission is about 30-40%. Two thirds of the verified HIV-positive Norwegian women are infected by heterosexual contact. For this reason the obstetric interview is of major importance in order to identify women at risk. We discuss the HIV-screening programme now being run in Norway. Approximately 250,000 pregnant women have been tested and only 19 HIV-positive women have been detected. We discuss the ethical and social problems connected with day care centres, information to health services and the problems that arise when the mother or both parents develop AIDS and die.

[Vitamin D deficiency among pregnant women from Pakistan. How best to prevent it?]. / Vitamin D-mangel blant gravide fra Pakistan. Hvordan best forebygge?

Vitamin D deficiency is common among pregnant Pakistani women now living in Norway. This study was carried out to evaluate a health programme consisting of free samples of vitamin D (10 micrograms/day) combined with information about vitamin D deficiency. 38 pregnant women were included in the 18th week of pregnancy (study group) and blood samples were taken both at inclusion and after delivery. In addition, 18 other Pakistani women (control group) were included after giving birth at the same hospitals during the same period. 83% (30/36) of the pregnant women (study group) were vitamin D deficient (calcidiol < 30 nmol/l) at inclusion. Only 33% (11/33) of the women took more vitamin D than 5 micrograms/day. 19 of the women agreed to having a new blood sample taken after delivery, and 56% (10/18) of these women were still vitamin D deficient. 76% (13/17) of the women in the control group were vitamin D deficient at delivery. In conclusion the study demonstrates that it can be difficult to prevent vitamin D deficiency in the Norwegian immigrant population just by providing information and free samples of vitamin D.

Iron deficiency among pregnant Pakistanis in Norway and the content of phytic acid in their diet.

BACKGROUND: To test the hypothesis that iron deficiency is more common among pregnant Pakistani than pregnant Norwegian women in Oslo; and to determine whether differences in the diet can explain some of the differences in stored iron. METHODS: A cross sectional study in the 18th week of pregnancy. Thirty-eight Pakistani women and 38 Norwegian women referred to routine ultrasound examination at Aker and Ullevål Hospitals in Oslo participated. Analysis was undertaken of phytate (inositol hexaphosphate) and its degradation products in bread and chapatti. RESULTS: Twenty-six (68%) of the Pakistani and six (17%) of the Norwegian women had ferritin levels below 12 micrograms/l and a highly significant difference in serum ferritin was found between the groups (p < 0.001). Only one of the Pakistani and seven of the Norwegian women were supplemented with iron and there were no significant differences in the dietary intake of hem iron, non-hem iron, organic fiber, tea, ascorbic acid, meat or cereals. The content of inositol hexaphosphate (phytate) and inositol pentaphosphate, well known inhibitors of iron absorption, were measured in bread and chapatti and the estimated dietary intake was much higher in the Pakistani group, mean (95% CI) was 1175 mumol/day (933-1417) and 507 mumol/day (417-597) respectively, p < 0.001. CONCLUSIONS: Iron deficiency seems to be far more common among pregnant Pakistanis in Norway than among pregnant Norwegians. We speculate that the main reasons for this are a combination of a higher parity and a less common use of iron supplementation in pregnancy in the Pakistani group, and a higher content of phytate in the Pakistani diet.

Congestive heart failure caused by vitamin D deficiency?

We describe a child, 3.5 months old, with severe vitamin D deficiency, profound hypocalcaemia, hyperphosphataemia, dilated left ventricle, severely reduced myocardial contractility and congestive heart failure. She also had depressed thyroid function with subnormal thyroxine and non-detectable serum thyrotropin (TSH) levels. The child promptly responded to calcium infusions, conventional anticongestive therapy and calcitriol. She is now 3 years old and received no medication. Myocardial function is normal but she has motor delay. We believe that her transitory congestive heart failure was caused by severe vitamin D deficiency with profound hypocalcaemia.

Vitamin D deficiency in pregnancy is not associated with obstructed labor. A study among Pakistani women in Karachi.

BACKGROUND: Vitamin D deficiency is widespread among pregnant Pakistanis in Norway. It may cause osteomalacia with destruction of maternal pelvis, and thus be a risk factor for cephalopelvic disproportion. This study was performed to determine whether vitamin D deficiency is common among pregnant Pakistanis in Pakistan, and to test the hypothesis that vitamin D deficiency in nulliparous pregnant women is associated with mechanical dystocia. METHODS: The study was carried out at the Civil Hospital, in a poor area of Karachi, and had a case-referent design. Thirty-seven nulliparous parturients with Cesarean section due to mechanical dystocia served as cases, and 80 nulliparous parturients with uncomplicated vaginal delivery were their referents. All blood samples were drawn before parturition. RESULTS: The mothers with obstructed labor were shorter (on average 150 vs. 155 cm, p= 0.0001) and lighter (on average 58 vs. 60.5 kg, p=0.005) than their referents. Seventy-one percent (83/117) of all the participants had marginal or low vitamin D status defined as serum level of calcidiol (25-OH vitamin D3) below 30 nmol/l. Vitamin D deficiency was, however, not more widespread among the mothers with obstructed labor (20/37 vs. 63/80). Furthermore, there were no significant differences in the serum levels of the carboxyterminal telopeptide of type I collagen, a sensitive biochemical marker of bone resorption, (7.2 vs. 6.6 microg/l), and bone specific alkaline phosphate (18.1 vs. 22.0 U/l) a sensitive marker of bone formation. CONCLUSIONS: Vitamin D deficiency in pregnancy is common in Karachi, but is not associated with mechanical dystocia.

PIP: Vitamin D deficiency, widespread among pregnant Pakistani women living in Norway, may cause osteomalacia and thus represent a risk factor for cephalopelvic disproportion. The present study investigated the prevalence of vitamin D deficiency among pregnant women in Karachi, Pakistan, in 1994-95 and its association with mechanical dystocia. 37 nulliparous women admitted to the Civil Hospital in a poor area of Karachi for cesarean section due to dystocia served as cases; 80 nulliparous parturients with uncomplicated vaginal delivery were enrolled as their controls. On average, mothers with obstructed labor were significantly shorter (50 vs. 155 cm) and lighter (58 vs. 60.5 kg) than their referents. Overall, 83 women (71%) had marginal or low vitamin D status (serum levels of calcidiol under 30 nmol/l). However, vitamin D deficiency was not more widespread among women with obstructed labor (20/37, or 54%) than controls (63/80, or 83%), even when logistic regression analysis including the risk factors of maternal height and birth weight was performed. In addition, there were no significant differences in serum levels of the carboxy-terminal telopeptide of type I collagen (a sensitive biochemical marker of bone resorption) or bone-specific alkaline phosphate (a marker of bone formation). The shorter height of Pakistani women with obstructed labor suggests that stunted growth in childhood--not vitamin D deficiency in pregnancy--is a major risk factor for cephalopelvic disproportion in low-income areas where vitamin D deficiency in pregnancy is widespread.

[Perinatal HIV-infection. Symptomatology, diagnosis and treatment]. / Perinatal HIV-infeksjon. Symptomatologi, diagnostikk og behandling.

Perinatally acquired HIV-infection is an increasing problem. Nine infants were born of HIV-infected mothers in Norway in 1988, and ten in 1989. Pediatric AIDS may involve a wide spectrum of clinical diseases with a high affinity to the central nervous system. The time from birth to development of clinical symptoms is relatively short. The overall mortality rate is extremely high in all age groups. Two children with perinatal HIV-infection are discussed in light of our treatment regimen. Children with immunosuppression and/or clinical symptoms are treated with zidovudine (azidotymidin/AZT) perorally. Children with repeated bacterial or opportunistic infections are also given immunoglobulin intravenously every 3rd to 4th week.