Abish Sudhakar

Dynamics of growth and weight transitions in a pediatric cohort from India

BackgroundThere is paucity of information regarding time trends of weight status in children from rapidly developing economies like India. The aim of the study was to analyse the dynamics of growth and weight transitions in a cohort of school children from India.MethodsA population of 25 228 children was selected using stratified random sampling method from schools in a contiguous area in Ernakulam District, Kerala, India. Weight and height were measured at two time points, one in 2003-04 and another in 2005-06. The paired data of 12 129 children aged 5-16 years were analysed for the study.ResultsThe mean interval between the two surveys was 2.02 ± 0.32 years. The percentage of underweight, normal weight, overweight and obese children in the year 2003-04 were 38.4%, 56.6%, 3.7%, and 1.3% respectively. The corresponding figures in year 2005-06 were 29.9%, 63.6%, 4.8% and 1.7% respectively. Among the underweight children, 34.8% migrated to normal weight status and 0.1% migrated to overweight status. Conversion of underweight to normal weight predominated in urban area and girls. Among the normal weight children, 8.6% migrated to underweight, 4.1% migrated to overweight and 0.4% migrated to obesity. Conversion of normal weight to overweight status predominated in urban area, private schools and boys. Conversion of normal weight to underweight predominated in rural area, government schools and boys. Among the overweight children, 26.7% migrated to normal weight status, 16.4% became obese and 56.9% retained their overweight status. Of the obese children, 6.2% improved to normal weight status, 25.3% improved to overweight status and 68.5% remained as obese in 2005-06. There was significant difference in trends between socio demographic subgroups regarding conversion of underweight status to normal weight as well as normal weight status to overweight.ConclusionThe study population is experiencing rapid growth and nutritional transitions characterised by a decline in the underweight population coupled with an escalation of the overweight population. The heterogeneous nature of this transition appears to be due to differences in socio demographic factors.

Preoperative Determinants of Outcomes of Infant Heart Surgery in a Limited-Resource Setting

We studied the effect of preoperative determinants on early outcomes of 1028 consecutive infant heart operations in a limited-resource setting. Comprehensive data on pediatric heart surgery (January 2010-December 2012) were collected prospectively. Outcome measures included in-hospital mortality, prolonged ventilation (>48 hours), and bloodstream infection (BSI) after surgery. Preoperative variables that showed significant individual association with outcome measures were entered into a logistic regression model. Weight at birth was low in 224 infants (21.8%), and failure to thrive was common (mean-weight Z score at surgery was 2.72 ± 1.7). Preoperatively, 525 infants (51%) needed intensive care, 69 infants (6.7%) were ventilated, and 80 infants (7.8%) had BSI. In-hospital mortality (4.1%) was significantly associated with risk adjustment for congenital heart surgery-1 (RACHS-1) risk category (P < 0.001). Neonatal status, preoperative BSI, and requirement of preoperative intensive care and ventilation had significant individual association with adverse outcomes, whereas low birth weight, prematurity, and severe failure to thrive (weight Z score <-3) were not associated with adverse outcomes. On multivariable logistic regression analysis, preoperative sepsis (odds ratio = 2.86; 95% CI: 1.32-6.21; P = 0.008) was associated with mortality. Preoperative intensive care unit stay, ventilation, BSI, and RACHS-1 category were associated with prolonged postoperative ventilation and postoperative sepsis. Neonatal age group was additionally associated with postoperative sepsis. Although severe failure to thrive was common, it did not adversely affect outcomes. In conclusions, preoperative BSI, preoperative intensive care, and mechanical ventilation are strongly associated with adverse outcomes after infant cardiac surgery in this large single-center experience from a developing country. Failure to thrive and low birth weight do not appear to adversely affect surgical outcomes.

Micro-economic impact of congenital heart surgery: results of a prospective study from a limited-resource setting.

Introduction The microeconomic impact of surgery for congenital heart disease is unexplored, particularly in resource limited environments. We sought to understand the direct and indirect costs related to congenital heart surgery and its impact on Indian households from a family perspective. Methods Baseline and first follow-up data of 644 consecutive children admitted for surgery for congenital heart disease (March 2013 – July 2014) in a tertiary referral hospital in Central Kerala, South India was collected prospectivelyfrom parents through questionnaires using a semi-structured interview schedule. Results The median age was 8.2 months (IQR: 3.0– 36.0 months). Most families belonged to upper middle (43.0%) and lower middle (35.7%) socioeconomic class. Only 3.9% of families had some form of health insurance. The median expense for the admission and surgery was INR 201898 (IQR: 163287–266139) [I

Conotruncal anomalies in the fetus: Referral patterns and pregnancy outcomes in a dedicated fetal cardiology unit in South India.

11989 (IQR: 9696–15804)], which was 0.93 (IQR: 0.52–1.49) times the annual family income of affected patients. Median loss of man-days was 35 (IQR: 24–50) and job-days was 15 (IQR: 11–24). Surgical risk category and hospital stay duration significantly predicted higher costs. One in two families reported overwhelming to high financial stress during admission period for surgery. Approximately half of the families borrowed money during the follow up period after surgery. Conclusion Surgery for congenital heart disease results in significant financial burden for majority of families studied. Efforts should be directed at further reductions in treatment costs without compromising the quality of care together with generating financial support for affected families.

Elevated red cell distribution width is associated with delayed postoperative recovery after correction of Tetralogy of Fallot

Objective: To describe the referral patterns and pregnancy outcomes of fetuses with conotruncal anomalies (CTA) from a fetal cardiology unit in South India. Methods: Records of 68 women identified to have diagnosis of CTA on fetal echocardiography (mean gestational age 26.8 ± 5.9 weeks; range 17-38 weeks) during the period 2008-2011 were reviewed. Results: The most common indication for referral was suspected congenital heart disease during routine antenatal scan (89.7%). The various CTA diagnosed included Tetralogy of Fallot (TOF, 44.1%), Double outlet right ventricle (DORV, 27.9%), Transposition of great vessels (TGA, 8.8%), TOF with pulmonary atresia (TOF-PA, 8.8%), TOF absent pulmonary valve (TOF-APV, 7.4%) and truncus arteriosus (TA, 2.9%). Extra cardiac anomalies were reported in 4 fetuses (7.1%). Pregnancy outcomes included pregnancies not culminating in live-birth (54.4%), delivery at term (41.2%) with 3 patients (4.4%) being lost to follow-up. Proportion of pregnancies not culminating in live-birth lesion wise include: TOF (53.3%), DORV (52.6%), TGA (50%), TOF -APV (80%), TOF-PA (50%), and TA (50%). Twenty-four babies (35.3%) received post-natal cardiac care with 5 (7.4%) undergoing neonatal surgical procedures. Seven babies (10.3%) died in neonatal period, including 2 who underwent surgery. The accuracy of fetal echo was 96.4% for primary lesion and 67.9% for complete segmental diagnosis. Conclusions: Pre-natal diagnosis of CTA, despite a high diagnostic accuracy, prompted utilization of post-natal tertiary cardiac care in a limited proportion of patients, including those with reparable lesions. Focus in developing countries should shift towards earlier referral, improving awareness about treatment options and a comprehensive evaluation for associated anomalies.

Outcomes of Infants with Prenatally Diagnosed Congenital Heart Disease Delivered in a Tertiary-care Pediatric Cardiac Facility.

Objective: To study the impact of red cell distribution width (RDW) on postoperative recovery after correction of Tetralogy of Fallot (TOF). Background: Increased RDW indicates dysregulated erythropoiesis and predicts survival in critical illnesses that include idiopathic pulmonary artery hypertension and chronic heart failure. Myocardial injury and oxidative stress induced by cardiopulmonary bypass potentially contribute to prolonged recovery in post TOF repair patients. Materials and Methods: Retrospective analysis of data on 94 consecutive children with TOF undergoing corrective repair (January 2010-March 2011) was done. RDW was higher for the study population when compared to acyanotic patients with ventricular septal defect (17.7 ± 3.7 vs. 16.2 ± 4.2; P < 0.001). The mean RDW obtained from 100 separate age-, sex-, and weight-matched TOF patients (17.8) was chosen as a cut-off. Of 93 survivors (median age: 12 (4-204) months, weight: 8.6 (3.2-70) kg), 29 patients with higher RDW (> 17.8) had a longer ICU stay (155.6 ± 71.3 vs. 122.4 ± 61.3 hours, P = 0.02), hospital stay (18.6 ± 10.5 days vs. 13.4 ± 6.5 days, P = 0.01), ventilation time (57.9 ± 41.6 vs. 38.3 ± 30.8 hours, P = 0.01), and more surgical site infection (24.1% vs. 6.2%, P = 0.01). On multivariate analysis only elevated RDW (other variables included age, weight, hemoglobin, hematocrit, and surgical support times) showed a significant association with hospital stay. Conclusions: Elevated RDW appears to be associated with prolonged recovery after TOF repair, the precise underlying mechanisms are worth investigating.

Health-related quality of life in infants and toddlers with congenital heart disease: a cross-sectional survey from South India

ObjectiveTo report short-term outcomes of infants with prenatally diagnosed Congenital Heart Disease (CHD) delivered in a tertiary-care cardiac facility.DesignRetrospective study.SettingTertiary-care referral hospitalParticipantsChildren with prenatally diagnosed CHDs who underwent delivery at study centre during the period January 2008 - December 2013 were included. Outcomes tracked from hospital records and direct follow-up.ResultsOf the 552 fetuses diagnosed to have CHD, 121 (22%) were delivered at the study centre. Fetuses undergoing a planned delivery were diagnosed in late gestation (mean gestational age 31.5 ± 5.1 wk). 74 fetuses (61.2%) had simple CHD and rest were complex. 96 (79.3%) neonates received cardiac care; 30 (24.8%) required surgery while 5 received catheter-based interventions. 11 patients underwent surgery on follow-up. Neonatal survival in cardiac care group was 93.8%; on follow-up (12.5 ± 13.1 mo); 83 (86.4%) of these infants were alive. All infants undergoing neonatal surgery or catheter-based interventions survived. 25 patients (20.6%) received comfort care (Complex CHD, associated co-morbidities); 14 (56%) survived neonatal period and 6 (24%) were alive on follow-up.ConclusionInfants with prenatal diagnosis of CHD and planned delivery in a cardiac facility had satisfactory immediate outcomes, expecially in those receiving specialized post-natal cardiac care.

Early Neurodevelopmental Outcomes After Corrective Cardiac Surgery In Infants.

Objective There are limited data on health-related quality of life (HRQOL) for infants and toddlers with congenital heart disease (CHD). We sought to compare generic HRQOL of infants and toddlers between CHD subjects and controls. Design Dual-setting, cross-sectional analytical survey. Setting We collected HRQOL data on infants and toddlers through a community survey for controls and through a hospital-based survey for those with CHD. Patients A total of 499 subjects with confirmed CHD in the age group of 1–24 months admitted for elective surgery in the study institution were selected by consecutive sampling. In addition, we selected 628 control children in the same age group from an area within the 10 km radius of the study institution. Main outcome measures The data contain parent proxy report of HRQOL. The Pediatric Quality of Life Inventory (PedsQL 4.0) was used to collect HRQOL data. Questionnaires were self-administered for parents. Results The mean total proxy HRQOL scores were significantly higher in control infants compared with infants with CHD (adjusted mean difference 5.0, 99% CI 2.5 to 7.5, p<0.001). Corresponding figure for toddlers was 7.6 (95% CI 5.0 to 10.2, p<0.001). There was no significant difference in total HRQOL scores across CHD functional classes among infants and toddlers (p=0.212 and p=0.502, respectively). Conclusions Infants and toddlers with uncorrected CHD have significant deficiency in proxy HRQOL compared with their controls. The functional class of CHD appears to have no differential impact on overall HRQOL deficiency in this age group.

Health-related quality of life in Indian children: A community-based cross-sectional survey

ObjectiveTo assess neurodevelopmental status in Indian infants undergoing corrective surgery for congenital heart disease (CHD) and to analyze factors associated with neurodevelopmental delay.DesignCross-sectional study.SettingTertiary-care pediatric cardiology facility.ParticipantsConsecutive infants undergoing corrective surgery for CHD (January 2013–December 2014). Palliative procedures, and patients with known genetic syndromes were excluded.Main outcome measuresNeurodevelopmental evaluation 3 months, and one year after surgery using Developmental Assessment Scales for Indian Infants (DASII); scores were categorized as delayed if ≤70.ResultsOf the 162 children enrolled, delayed PDI and MDI scores were observed in 33.5% and 19.6% of patients at 3 months, respectively; this reduced to 14.5 % on 1-year follow-up. On multivariate analysis, delayed PDI outcome at one year was predicted by early term birth and one-year postoperative head circumference Z-score <–2. Delayed MDI was associated with higher mean perfusion pressure on cardiopulmonary bypass. Cardiac diagnosis and peri-operative factors did not impact neurodevelopmental outcomes.ConclusionsNeurodevelopmental status is delayed in 14.5% of infants one year after corrective infant heart surgery.

Experiences in end-of-life care in the Intensive Care Unit: A survey of resident physicians

Background & objectives: There are limited data on health-related quality of life (HRQOL) related to Indian children. The objective of this study was to construct a generic HRQOL reference for children aged 2-18 yr from a community setting. Methods: The study was a community-based cross-sectional survey. A total of 719 children/adolescents in the age group of 2-18 yr were enrolled using stratified random cluster sampling. A total of 40 clusters (cluster size 18) were selected for the study. The data contained child self-report and parent proxy report from healthy children and their parents/caretakers. The Pediatric Quality of Life Inventory 4.0 (PedsQL4.0) Generic Core Scale was used to collect HRQOL data. Questionnaires were self-administered for parents and children aged 8-18 yr. In the age group of five to seven years, parents assisted the children in filling questionnaires. Results: The mean HRQOL total scores from child self-report and parent proxy report were 87.50±11.10 and 90.10±9.50 respectively, for children aged 2-18 yr. Social functioning had the highest scores and emotional functioning had the lowest scores for the entire sample and subgroups. The mean values for HRQOL in the current study were significantly different from the reference study for both child (87.39 vs. 83.91, P<0.001) and parent proxy reports (90.03 vs. 82.29, P<0.001) when compared between children aged 2-16 yr. Interpretation & conclusions: The study provided reference values for HRQOL in healthy children and adolescents from Kerala, India, that appeared to be different from existing international reference. Similar studies need to be done in different parts of India to generate a country-specific HRQOL reference for Indian children.